HIQA’s infection prevention and control inspections in hospitals during January and March 2019

Date of publication:

Five inspection reports on infection prevention and control practices in public acute hospitals have been published today. 

Inspections were carried out between January and March 2019 in:

  • Wexford General Hospital
  • University Hospital Waterford
  • Beaumont Hospital
  • Louth County Hospital
  • Mater Misericordiae University Hospital.

HIQA’s inspections evaluate how hospitals organise themselves to minimise the spread of healthcare-associated infections, and the approach taken to reduce the risk of reusable medical device-related infection in satellite decontamination facilities. These two areas are internationally recognised as being major contributors to potentially preventable patient harm as a consequence of healthcare provision. 

Inspectors found that only one hospital, Louth County Hospital, was in compliance with the Health Service Executive’s (HSE’s) February 2018 guideline on screening patients for Carbapenemase-Producing Enterobacteriales (CPE). HIQA sought assurances from hospital management in Wexford General Hospital, University Hospital Waterford, Beaumont Hospital and Mater Misericordiae University Hospital that this risk would be managed, and assurances were provided. All hospitals were endeavouring to move towards automated validated systems for reprocessing of all critical and semi-critical reusable medical devices used. Academic training and education for staff working in decontamination was progressing across all hospitals inspected. 

Overall, HIQA found recurring challenges faced by hospitals to effectively prevent and control the CPE outbreak, such as design of and aging hospital infrastructure, a lack of isolation facilities and high occupancy rates.

To concur with HSE national recommendations, each hospital group must identify a group decontamination lead and each hospital should progress the centralisation of decontamination activity. Microbiological testing of environment and equipment also needs to be implemented.

A summary of additional key findings from each inspection are outlined below.

Leadership, governance and management arrangements in relation to infection prevention and control had been strengthened and a decontamination lead position had been put in place since the last HIQA inspection. A risk management system for identifying and managing risk was also in place. 

HIQA acknowledges the hospital’s compliance levels in relation to, for example: 

  • application of appropriate transmission-based precautions 
  • environmental hygiene standards in areas inspected
  • decontamination-related process maps at point of use and embedding a culture of continuous audit and quality improvement.

Management of Wexford General Hospital need to address: 

  • screening and microbiological testing arrangements 
  • equipment hygiene and oversight for same 
  • enhance and develop the antimicrobial stewardship programme 
  • management of clinical waste at ward level
  • hospital hand hygiene compliance.

University Hospital Waterford was experiencing an ongoing hospital outbreak of CPE since March 2016. The outbreak control committee had implemented multi-model infection prevention and control strategies to manage the ongoing outbreak. 

Hospital management need to address issues identified in a satellite decontamination facility inspected, including: 

  • decontamination systems and processes used 
  • competency assessment of staff operatives following training 
  • embedding regular auditing and improvement plans into routine practice. 

Inspectors found that there were clear lines of accountability and responsibility in relation to governance and management arrangements for the prevention and control of healthcare-associated infection at the hospital. However, the degree to which these were coordinated in the hospital could be improved.

Beaumont Hospital had experienced an ongoing outbreak of CPE on one ward since August 2018. Although a number of mitigating measures had been implemented on the outbreak ward, new cases of CPE continued to be identified over the following six months. 

This inspection identified that the hospital was continuing to admit patients to a CPE outbreak ward which had been closed to admissions; this was contrary to advice from the infection prevention and control team. It was also of significant concern to HIQA, who escalated concerns to the hospital related to this finding following the inspection. The ward was closed to admissions on the week beginning 18 February 2019.

HIQA acknowledges the hospital’s compliance levels in relation to the oversight of performance across all clinical areas in relation to infection prevention and control  and of environmental and patient equipment hygiene. In relation to decontamination service provision, HIQA found:

  • strong leadership, management and oversight arrangements 
  • standardised processes with up-to-date standard operating procedures 
  • a culture of audit, feedback and quality improvement. 

Louth County Hospital had commenced universal screening for CPE in October 2018 and was screening in line with national guidance. However, there was an underdeveloped approach to antimicrobial stewardship at the hospital, which was contrary to national guidance.

HIQA found clear lines of accountability, responsibility and managements arrangements in place in relation to decontamination and reprocessing practices, environmental and patient equipment hygiene audit results.

Hospital management need to ensure:

  • risks in relation to decontamination equipment are escalated 
  • ongoing training-needs assessment of staff working in satellite facilities 
  • audit of decontamination processes and procedures. 

Inspectors found that governance arrangements for the prevention and control of healthcare-associated infection needed to be strengthened. Key positions in the infection prevention and control team were vacant in 2018, but a programme was in the process of being re-established. 

HIQA acknowledges the outbreak control committee had had successfully controlled two outbreaks of CPE transmission in critical care areas.  Nothwithstanding this positive finding, inspectors also found that the local infection prevention and control risk register was not being managed and escalated in line with national guidance. 

While the hospital had defined leadership and management arrangements in place for decontamination service provision, inspectors found that governing and oversight structures to support the service were not clearly defined. Additionally, decontamination-related risks had not been effectively managed. There was a need to embed a culture of continuous audit, feedback and quality improvement cycles in relation to decontamination and reprocessing procedures across the hospital. 

Notes to Editors
  • HIQA’s approach to monitoring against the National Standards for the prevention and control of healthcare-associated infections in acute healthcare services was revised in 2017.
  • HIQA focused in the first instance on decontamination facilities outside of designated controlled decontamination units to ensure that structures, systems, processes and outcomes were aligned to national guidelines.
  • A National Public Health Emergency Plan was declared on 25 October 2017 by the Minister for Health in response to the increase and spread of Carbapenemase-Producing Enterobacteriales (CPE) in Ireland. As a result a National Public Health Emergency Team was convened. Further details as to the work of this team may be viewed on the Department of Health website.
  • Carbapenemase-Producing Enterobacteriales (CPE) is the newest in a long line of 'superbugs' (bacteria that are hard to kill with antibiotics). Of all the superbugs, CPE is among the most difficult to kill with antibiotics. It is carried in the bowel and can cause infection in people who are vulnerable, such as the elderly and those with low immunity. In some outbreaks more than half of all patients who develop blood stream infections with CPE died as a result of their infection. Further details may be found on the HSE website.
  • The HSE has developed detailed national screening guidelines that are available to view on the HSE website.
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