A recent unannounced inspection at St Luke's General Hospital in Kilkenny found that key elements of infection prevention and control were absent due to frequent overcrowding, poor inpatient accommodation, and a lack of isolation facilities.
The Health Information and Quality Authority (HIQA) has today published the report arising from that inspection, which was carried out at the local hospital on May 25. It identifies multiple issues with infection prevention and control measures in the local hospital arising from factors such as overcrowding and infrastructural deficits.
Inspectors reviewed documents and data, and observed practices in a number of clinical areas, including a surgical ward and the Intensive Care Unit.
Among the findings:
Review of documentation and discussion with staff did not indicate there was a 'clear strategic plan' for the prevention and control of healthcare-associated infection. HIQA also found there was a 'lack of clarity' in relation to the Infection Prevention and Control Committee and other hospital committees and departments, in relation to areas such as hygiene and decontamination.
The HIQA inspectors were told that finding inpatient accommodation for patients with transmissible infections was a 'day to day challenge due to busy patient throughput' coupled with insufficient numbers of hospital beds and isolation rooms. Staff education sessions were not delivered due to workload pressures, and staffing levels had also impacted the delivery of infection prevention and control.
The report also notes the overcrowding problems at the hospital, at a time of year when 'Trolleywatch' figures have traditionally been lower. The day before the inspection, there were 44 patients on trolleys according to INMO figures.
The practice of patients being kept on corridors is identified as a risk issue when it comes to overcrowding, as well as insufficient isolation facilities for people with a transmissible infection and poor inpatient accommodation. The HIQA report says it was reported by hospital management that 'extra patients were frequently accommodated on the corridors of the hospital's wards'.
"Collectively, these findings in tandem with high patient activity levels do not facilitate effective prevention and control in an acute hospital setting and are not in line with current national standards or evidence-based best practice guidelines," finds the report.
Furthermore, the documentation reviewed showed multiple factors were restricting the hospital's ability to effectively prevent and control infection. HIQA also identified that documentation relating to incidents or outbreaks of infection showed 'common recurring deficiencies' in relation to hospital infrastructure, resources and bed numbers.
On the day of inspection, 21 patients required single-room isolation for infection control reasons. The hospital's own information showed there were 18 single rooms at the hospital, all of which were occupied by people who required infection control precautions. Only five of these rooms had ensuite toilets, however, and one of them was in the coronary care unit.
"The lack of isolation facilities likely meant that patients with transmissible infection were frequently moved throughout the hospital whenever a single room was available," finds the report.
As outlined in a previous HIQA report, the Intensive Care Unit infrastructure 'did not facilitate effective infection and control' due to several reasons, including limited space between beds, and a lack of sufficient isolation facilities and ancillary rooms. Inspectors also learned that due to insufficient facilities, people with 'transmissible microorganisms' were often accommodated in the open plan area of the unit.
At the surgical ward inspected, there were two patients in beds outside on the corridor. It was reported that this practice of accommodating patients on this corridor was a regular occurrence.
As with ICU, the infrastructure of the surgical ward 'did not facilitate effective infection prevention and control'. Single rooms did not have ensuite toilets or a handwash sink for patients. Environmental surfaces and patient equipment inspected in the surgical ward were found to be unclean, with dust present on several surfaces. Checklists reviewed indicated that the weekly cleaning of patient equipment had not been consistently performed - and it was reported that staff responsible for cleaning the equipment were not regularly allocated the time to perform routine cleaning.
HIQA's report notes that, to address the identified risks, the hospital has made a capital submission for a new building with 75 rooms (including six with specialised ventilation and scope for an ICU. However, the hospital has not yet received confirmation regarding funding for this.
It notes the plans to renovate an older ward to facilitate patients while clinical areas were being refurbished - a scenario which unfolded in July, and is currently under way. The closed ward is not expected to reopen until the end of September.
Some of the risks impeding effective infection prevention and control as they exist cannot be sufficiently mitigated at local hospital management level. Mitigation of these risks will require support at senior HSE and hospital group level to address the infrastructural deficiencies and capacity.
Notwithstanding the identified areas for improvement found during this inspection, inspectors found that the infrastructure of some facilities for people attending the hospital had been improved since the last HIQA inspection.
The hospital had opened a newly built Emergency Department and day and out-patient facilities one year prior to this inspection. This is a welcome development.
The HIQA report also notes that environmental surfaces and patient equipment in the ICU were visibly clean, and hygiene audit results reviewed for 2017 showed compliance with standards consistently greater than 85%.
The hospital participates in the national hand hygiene audits, results of which are published twice a year. Since 2015, the hospital has consistently achieved the required HSE national hand hygiene compliance target of 90%.
In addition, reviewed documents showed there had been a number of infection outbreaks in the hospital over the past year. Reports showed that these outbreaks had been effectively managed and contained.