Infection-control failures put Kerry patients at risk

Poor cleaning of reusable bedpans and failure to test water outlets for the bacteria that causes Legionnaire’s Disease were among the multiple infection-control failures that left patients at University Hospital Kerry (UHK) exposed to significant risk.

Infection-control failures put Kerry patients at risk

Hiqa inspectors were so concerned about ongoing failure to test water for legionella bacteria that they referred the matter to the Health and Safety Authority (HSA).

They also wrote twice to Gerry O’Dwyer, CEO of the South/Southwest Hospital group (SSWHG), warning of “serious risk to the health or welfare of patients”.

Among the high-level risks identified in an unannounced inspection in June were:

  • Poor practice in relation to the cleaning of reusable equipment, particularly reusable bedpans, urinals and measuring jugs;
  • Insufficient isolation facilities for patients with transmissible infection, and absence of isolation facilities with specialised ventilation for patients with airborne infection;
  • Unsafe practice in relation to the preparation and storage of medication for injection in the intensive care unit;
  • Incomplete screening of patients for multi-drug resistant organisms, thereby increasing the risk of transmission to other patients.

Other serious deficits included inability of the microbiology lab to perform rapid testings of specimens for influenza virus because of a lack of resources — instead they had to be sent to Dublin.

A review of outbreak reports showed staff had limited advice from a consultant microbiologist during an outbreak of a resistant strain of Staphylococcus aureus among newborns in 2016 — a bacteria that can prove fatal if it spreads to the bloodstream, and during a measles outbreak, where lack of isolation facilities contributed to the outbreak.

Hiqa wrote to Mr O’Dwyer on June 19 on foot of its findings, which included concerns that the hospital was without a consistent consultant microbiologist contractual arrangement over the course of several years, which had hindered the progression of an effective infection prevention and control programme.

Hospital management said ongoing financial deficits had impeded improvements such as legionella water testing and additional cleaning resources.

While Mr O’Dwyer provided a number of assurances to Hiqa in terms of mitigating identified risks, Hiqa sought further assurances and informed Mr O’Dwyer that the failure to test for legionella had been referred to the HSA.

In a statement yesterday, the SSWHG said it acknowledged the issues raised in the Hiqa report “and are currently putting in place key actions to mitigate risks identified”, including that legionella testing and environmental monitoring commenced at the UHK site in August 2017.

To date, pathogenic strains have not been detected.

“Staff training and re-training in patient equipment de-contamination is already underway,” the SSWHG statement said, and “plans are in place to undertake minor capital works including the procurement of additional bedpan washers”.

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