An unannounced inspection was carried out at the Midland Regional Hospital Portlaoise on 11 April 2018. The hospital had not successfully ensured that national HSE patient screening guidelines for CPE were fully implemented. In light of the current national public health emergency, HIQA considered this to be a high risk and escalated the issue to hospital management. It is acknowledged that the hospital had identified this issue as an area of concern prior to this inspection. The general manager provided assurances to HIQA that the hospital was actively managing this risk in the interim of additional resources required to support the full implementation of CPE screening guidelines.

It was apparent that the hospital had strengthened governance and operational arrangements since the previous HIQA infection prevention and control inspection. However, due to legacy regional hospital group arrangements, the hospital was not fully aligned to the current hospital group governance structure.

The hospital had systems in place to identify and manage risk in relation to the prevention and control of healthcare-associated infections. A number of infrastructural and maintenance issues, which had the potential to impact on infection prevention and control measures, were identified during the course of the inspection. HIQA acknowledges that these issues had been highlighted as an area of concern by local hospital management and escalated accordingly.

The consultant microbiologist provided cover to three acute hospitals over two hospital groups, including 24-hour seven-days-a-week clinical advice. Management stated that formalised cover arrangements were in place for periods of leave. The challenge associated with ensuring sustainability of this service had been highlighted in a previous HIQA inspection in 2012. It is acknowledged that the hospital had escalated this issue to the hospital group; however, to date this matter has not been addressed.

The patient environment inspected was generally clean with few exceptions. Opportunities for improvement were identified in relation to the cleaning and storage of patient equipment. HIQA found that a more comprehensive systematic approach to Aspergillus controls during building or renovation works at the hospital was required.

An unannounced inspection was carried out at Tallaght University Hospital on 19 April 2018. HIQA identified that screening for CPE was in line with the latest national guidance. The hospital has experienced an ongoing outbreak of CPE since August 2016 and had a high degree of visibility in relation to this as a consequence of the extensive level of CPE screening conducted. While the hospital has not seen a reversion to zero cases of CPE colonisation, due to the extensive level of CPE screening conducted, the hospital has seen a significant reduction in the prevalence of new CPE cases and has identified a very low number of CPE related bloodstream infections. The hospital has also identified background rates of CPE in the community which may indicate it may not be possible to fully eradicate CPE in the hospital.

Tallaght University Hospital had an established infection surveillance programme and had implemented a number of evidence-based care bundles.

HIQA recommends that the hospital puts measures in place to address the deficiencies identified during this inspection with particular emphasis on:

• communication to all relevant staff concerning revised governance structures and arrangements for the infection prevention and programme
• a review of environmental hygiene auditing
• improvements in equipment hygiene and oversight of same
• systems analysis of healthcare infections be carried out in line with national guidelines
• review arrangements regarding ventilated isolation rooms to ensure that there are appropriate facilities for patient isolation.

While inspectors identified that rates of CPE acquisition had reduced and improvements had been made, outstanding areas of challenge had been identified by the hospital and were reflected in the hospital’s risk register; including capacity and infrastructure. Management stated they had sought external assistance in dealing with same from the Dublin Midlands Hospital Group.

An unannounced inspection was carried out at Kilcreene Regional Orthopaedic Hospital on 25 April 2018. Inspectors found that the hospital had not ensured that screening patients for CPE was fully aligned to the latest national guidelines. In light of the national public health emergency, HIQA considered this to be a high risk that required escalation to hospital management. The general manager provided written assurance in response to HIQA, stating that the hospital had reverted to compliance with screening guidelines in the immediate aftermath of HIQA’s inspection.

Overarching governance and management arrangements for the infection prevention and control programme at Kilcreene Regional Orthopaedic Hospital and at a wider hospital group level required considerable improvement. The multi-faceted and complex governance arrangements had been highlighted as an area of concern by local hospital managers and escalated accordingly. A corporate group response is required from the South/South West and Ireland East Hospital Groups to put structures and processes in place for Kilcreene Regional Orthopaedic Hospital that provide clear lines of accountability and responsibility in relation to the infection prevention and control programme. Such a response needs to consider the following issues:

• the governance and management arrangements around the prevention and control of healthcare-associated infection at the hospital were confusing, fragmented and not fully aligned to the revised South/South West Hospital Group hospital group structure
• legacy arrangements for some services were still in place; the Infection Prevention and Control Team reported to both the Ireland East Group and South/South West Group
• the hospital was not formally linked with either hospital group in relation to some committees
• oversight and governance of infection prevention and control-related incidents and risks at Kilcreene Regional Orthopaedic Hospital, and between St Luke’s General Hospital and University Hospital Waterford were not formalised
• current arrangements in relation to a consultant microbiologist position for the hospital need to be risk-assessed and reviewed.

HIQA acknowledges the hospital’s positive progress and compliance levels in relation to hand hygiene, care bundle implementation and hospital hygiene standards despite infrastructural challenges.

An unannounced inspection was carried out at Galway University Hospitals out on 10 May 2018. The hospital had put governance arrangements, systems, processes and practices in place to support infection prevention and control in the hospital. HIQA had identified that screening for CPE was in line with the latest national guidance. The hospital had been proactively managing an outbreak since June 2017.

While the hospital had not seen a reversion to zero incidents of CPE, efforts to date had succeeded in containing the number of new CPE cases and maintaining CPE-related bloodstream infections at very low levels. A CPE multidisciplinary outbreak committee oversaw actions to contain the outbreak and had implemented additional measures to prevent, detect and contain the spread of CPE. Examples of measures included but were not limited to:

• full compliance with national CPE screening guidelines
• environmental screening in areas where there was evidence of cross transmission and remedial action taken where positive environmental samples were obtained
• opening of a dedicated infection prevention and control cohort ward located in the newly build hospital wing.

Notwithstanding the many good practices that HIQA identified during the inspection, areas for further improvement include:

• oversight of equipment hygiene
• patient discharge communication
• infrastructural deficits
• compliance with mandatory hand hygiene training among all staff groups
• review and update of infection prevention and control policies, procedures and guidelines.

An unannounced inspection was carried out on 15 May 2018 at Mayo University Hospital, Castlebar. HIQA found that the hospital had made significant progress since the previous inspection and screening for CPE was in line with the latest national guidance. Prior to the HIQA inspection, the hospital had identified a potential high risk in relation to blood cultures not being processed between 12 midnight and 8am and were working to address this. HIQA sought assurances following the inspection around the management of this risk, and the hospital was able to outline subsequent control measures that were enacted to remove this risk.

The hospital had many elements of an infection prevention and control programme which included the following:

• strengthened governance and management arrangements
• additional resources allocated to the Infection Prevention and Control Team
• systems to identify, manage incidents and risk pertaining to infection prevention and control
• 100% of consultants and non-consultant hospital doctors at the hospital were up to date with hand hygiene training.

The hospital monitored compliance with healthcare-associated infection key performance indicators. However, invasive-device related and surgical site infection surveillance programmes require progression. Evidence-based care bundles need to be fully implemented at the hospital. Overall, the hospital environment and patient equipment on both clinical areas inspected was generally clean.