Two inspection reports on infection prevention and control practices in public acute hospitals have been published today by the Health Information and Quality Authority (HIQA). HIQA monitors infection prevention and control in hospitals against the National Standards for the prevention and control of healthcare-associated infections in acute healthcare services. Inspections were carried out in September 2017 at University Hospital Waterford and University Hospital Limerick.

University Hospital Waterford

An unannounced inspection of University Hospital Waterford was carried out on 5 September 2017. On the day of inspection, HIQA found that University Hospital Waterford had put in place some of the elements of an infection prevention and control programme. Although the hospital had demonstrated consistently high compliance results in national hand hygiene audits, the monitoring and evaluation of healthcare-associated infection processes and outcomes at the hospital was relatively limited. Inspectors also found that more needed to be done to ensure required policies, procedures and guidelines were both up to date and readily available to staff.

In addition, it was noted that the hospital provided a microbiology service to five hospitals in two hospital groups. This service included twenty four hour a day, seven day a week microbiological clinical advice. HIQA determined that in light of the span and scope of this service, there is a requirement for the hospital to review this arrangement to ensure that the necessary resources are in place to deliver a safe sustainable service in all settings.

A combination of factors identified on the day of inspection, including insufficient bed capacity and overcrowding, insufficient isolation facilities and poor hospital infrastructure in some inpatient clinical areas increase the risk of transmission of infection. Hospital management was working to address this risk, and the hospital was in the process of building a new five story block with single room patient accommodation at the time of inspection. 

University Hospital Limerick

An announced inspection of University Hospital Limerick took place on 22 September 2017. This inspection was prompted by consideration of previous HIQA inspection findings at the hospital and subsequent unsolicited information provided to HIQA relating to infection prevention and control issues. 

During previous inspections, HIQA has identified risks at University Hospital Limerick relating to the management of Carbapenemase Producing Enterobacteriaceae (CPE). HIQA has previously highlighted that comprehensive management of these risks requires effective management within the hospital coupled with parallel efforts to address this issue in both community and residential care settings. HIQA has also previously emphasised the need for national support from the HSE to further assist the hospital in dealing with this serious issue.

A number of high risks were identified during this inspection in relation to the prevention and control of healthcare-associated infection which required HIQA to officially raise concerns with the hospital. HIQA found that despite the implementation of a significant number of measures by hospital management and staff to manage this issue more needs to be done to effectively prevent and control the spread of CPE. 
Inadequate infection prevention and control resources at the UL Hospitals Group, including an identified lack of required specialised trained staff, has impeded the ability of the team to perform in the face of an increased workload imposed as a consequence of a major CPE outbreak. This has also impacted on the delivery of the wider infection prevention and control programme. 

Despite efforts to improve hospital hygiene, HIQA found during this inspection that recommended standards of patient equipment and environmental hygiene were not consistently achieved in the areas inspected. 
Continued overcrowding at the hospital, and an ongoing reliance on using large multi-occupancy rooms to accommodate patients in some part of the hospital increases the risk of the continued spread of CPE. 

These risk factors have persisted at the hospital, despite repeated concerns raised in prior HIQA inspection reports. In light of the findings of this inspection, HIQA immediately escalated concerns both to the hospital, and through national governance arrangements, in order to properly address these risks in the short term. 

It is imperative that efforts to address the serious findings of this inspection are urgently implemented in order to reduce current risks for patients. This will require more effective local management of to ensure full compliance with National Standards, coupled with urgently required external support to deal with hospital overcrowding, infrastructural deficiencies and infection prevention specialist staff and laboratory staff resourcing levels. 

Notes for Editors

• HIQA’s infection prevention and control monitoring programme aims to examine and positively influence the adoption and implementation of evidence-based practice in public acute hospitals regarding infection prevention and control. 
• HIQA’s approach to monitoring public acute hospitals against the National Standards was revised in 2017 in consideration of infection risk factors for patients, previous HIQA inspections and review findings and increasing antimicrobial resistance in Ireland. The revised monitoring programme seeks to determine if service providers have essential elements in place in order to prevent and control healthcare-associated infections. 
• HIQA’s Guide to the Health Information and Quality Authority’s Infection Prevention and Control Monitoring Programme in Public Acute Hospitals outlines the requirements for service providers in this programme.
• Enterobacteriacea are a type of bacteria which may harmlessly live in the human gut. However in some instances, including as a possible consequence of medical treatment, they may pass into sterile parts of the human body such as the bloodstream, the urinary tract, the lungs, or open wounds, and cause infection. Carbapenemase producing Enterobacteriacea (CPE) are a type of Enterobacteriacea which are resistant to nearly all antibiotics, are very difficult to treat, and in some outbreaks internationally have caused the death of over 50% of patients infected. This resistant strain may be passed between humans via an unclean environment, through poorly cleaned equipment or through poor hand hygiene practices. 
• CPE has begun to emerge in many different countries internationally. Due to the difficulty associated with treating CPE infection, preventing its spread and the knock on impact these efforts can have on delivering health services, it is seen as a key public health priority. In October 2017, the Irish Minister for Health declared CPE a National Public Health Emergency. Further details in relation to this declaration may be found here. 
• Ensuring both good infection prevention and control practice and prudent antimicrobial usage - through what is known as Antimicrobial Stewardship - are critical to prevent the spread of CPE. In July 2016, HIQA published a comprehensive review of Antimicrobial Stewardship in Public Acute Hospitals. This review report is available to view here.