Michael Harty (Clare, Independent)
Link to this: Individually | In context | Oireachtas source

I thank the Minister for taking this matter. The incidence of multidrug resistant infections in University Hospital Limerick has not been adequately controlled, according to the Health Information and Quality Authority. It may have been a contributing factor in 29 deaths and is associated with increasing numbers of new cases. This is a cause of great concern to patients and their families, and requires an urgent examination of the infection control policies in the hospital. I ask the Minister of State, Deputy Corcoran Kennedy, to direct an investigation into this matter.

As background, in June 2014 HIQA found there were risks to patient safety when it reviewed the governance structure of University Hospital Limerick. In particular, overcrowding in emergency departments of the hospital resulted in significant compromises in maintaining adequate levels of environmental cleanliness, which in turn increased risk of health care-associated infections, including multidrug resistant infections. These infections are life-threatening if contracted by frail elderly patients who are placed at risk in trolley queues for prolonged periods of time in the emergency department or placed in congested, overcrowded wards.

Multidrug resistant infections pose a problem in all acute hospitals and their origin is multifactorial. Antibiotic resistant infections arise from overuse and misuse of antibiotics both in hospital and in the community, resulting in increased numbers of new multiresistant bacteria. This poses huge challenges for hospitals where these infections predominate and require intense efforts to control and eradicate. However, University Hospital Limerick seems to have a much higher incidence of infections than other hospitals. In July 2014, the infection prevention and control team at University Hospital Limerick wrote to the executive management team to highlight its serious ongoing concerns regarding the management of patients with multidrug resistant micro-organisms. They highlighted the difficulties with identification of patients who are infected, lack of single rooms to isolate infected patients, serious environmental hygiene concerns with current cleaning standards and lack of basic education of cleaning staff in their role in controlling the spread of infection. The cleaning of patient equipment was sub-optimal and poor environmental cleaning, hand hygiene and antibiotic prescribing contributed to clusters of infection in the hospital. Finally, it was stated there should be a dedicated infection prevention and control clinical nurse specialist for the management of infected patients.

Between 2009 and 2014, there are were in excess of 50 cases of CPE-produced enterobacteria. As a result, in 2014, a member of the infection control team at University Hospital Limerick became so concerned about the escalation of multidrug resistant infections in the hospital that she made a protected disclosure to HIQA.

Subsequently, the Health Information and Quality Authority, HIQA, carried out an unannounced inspection in November 2014 whose findings were summarised as especially poor standards of environmental hygiene; ward maintenance not carried out in a timely fashion; long-standing extra beds in wards; and inappropriate bed spacing which led to increased risk of spread of infection between patients. This has a knock-on effect on planned admissions and elective procedures. Given the incidence of multidrug-resistant infection in Limerick University Hospital, an external investigation needs to be urgently carried out to identify the cause of this cluster of infection.

Marcella Corcoran Kennedy (Offaly, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I thank Deputy Harty for raising this very important matter today. Multidrug-resistant infections and resistance to antibiotics are an ongoing and evolving international risk for all health care providers. I can assure the House that the prevention and control of health care associated infections, HCAIs, and antimicrobial resistance, AMR, is a significant patient safety and public health priority for the Government.

I am advised that Irish hospitals, like other hospitals internationally, are taking steps to reduce health care associated infections and antimicrobial resistance including the prudent use of antibiotics. I am aware of the challenges in tackling multidrug-resistant superbug infection rates in all hospitals including at University Hospital Limerick. The hospital has confirmed that it has a focused quality improvement plan in place to tackle the issues of control of HCAIs and AMR. This is in line with recommendations of the HIQA unannounced inspection reports at the hospital on 28 November 2014 and 13 January 2015. This includes an intensive screening programme for the detection of carbapenem resistant enterobacteriaceae, CRE, as it is known, among high risk patients. An isolation ward for the mitigation of any risk of cross-transmission of newly detected or known positive patients; adoption of strict contact precautions, dedicated equipment and a highly intensive cleaning regimen; speedy laboratory procedures to ensure results regarding infections available within 24 hours; good communication among microbiologists and with all relevant parties on detection of a new case; and good communication with patients and GPs and other health care worker contacts to inform GPs of their patients’ status.

A wide range of initiatives has been put in place in the Irish health system over several years to tackle HCAIs and AMR, covering improved surveillance of infections, prescribing, infection prevention and control processes. It also includes antimicrobial stewardship initiatives and public and professional awareness-raising with a significant emphasis on the education and training of health care professionals. Ireland is also developing a national action plan on AMR in line with the World Health Organization’s 2015 global action plan on AMR and the European Council’s 2016 conclusions, "The next steps under a 'One Health' approach to combat antimicrobial resistance". The national action plan is being developed with the oversight and guidance of the interdepartmental AMR consultative committee. The committee was established in 2014 by our Department’s Chief Medical Officer and the Chief Veterinary Officer of the Department of Agriculture, Food and the Marine in recognition of the need for a whole of Government approach to tackling the issue of AMR. This intersectoral approach crosses the health, veterinary and environmental spheres to encompass all stakeholders' efforts to address what is a worldwide concern. This work will continue in 2017. It is intended that the national action plan will be published in 2017. Tackling AMR will require the whole system to prioritise key initiatives, working with our international colleagues. Ireland is fully committed to, and engaged in, addressing resolution of the problem of AMR and will continue to collaborate at international, EU and national levels to this end.

Nationally, I expect that the HSE will place particular emphasis on prevention and management of HCAIs and AMR in its service planning for 2017.

Michael Harty (Clare, Independent)
Link to this: Individually | In context | Oireachtas source

As the Minister of State mentioned, there were unannounced inspections in November 2014 and January 2015, yet the incidence of multidrug resistant infections continues to increase in the hospital in spite of many of the deficiencies identified in the HIQA inspection being addressed. The incidence of CPE infection, which is just one of several multidrug resistant infections, is increasing at an alarming rate in the hospital and new cases continue to occur. An internal report dated July 2016 highlighted the extent of the problem. In 2009, there was one case; in 2010, two; in 2011, 11; in 2012, nine; in 2013, three, yet in 2014 there were 33 and in 2015, 53, and in the first two quarters of this year 19 new cases were identified. Those charged with identification of infected patients are obviously efficient in detecting and identifying the problem, yet infection prevention measures in the hospital are failing to adequately control the spread of multidrug infection. Inappropriate antibiotic prescribing is undoubtedly an underlying factor. However, factors which contribute to the spread of the infection continue to be poor quality of cleanliness in the environment, inattention to hand hygiene, overcrowding in the emergency departments and overcrowding in the corridors and wards with lack of isolation rooms. The physical capacity of the hospital to accommodate the population of the catchment area and the number of frail elderly patients exposed to the high risk of infection is inadequate.

All these factors contribute to infection risk and lead to failure to control the problem. Overcrowding in University Hospital Limerick and presumably in other hospitals is putting patients’ health and lives at risk for many reasons, in particular exposing patients to multidrug resistant infections. An external independent investigation needs to be carried out urgently, especially in the light of information that at least 29 patients may have had multidrug resistant infection as a contributory cause in their deaths.

Marcella Corcoran Kennedy (Offaly, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I can hear that Deputy Harty is concerned as any of us would be. However, I am advised that, based on the unannounced HIQA reports, the hospital has put in place the recommendations I outlined earlier. I will certainly bring the Deputy’s suggestion that there be an independent report to HIQA and the Minister and see what can be done.

The Deputy has put his finger on the bigger global picture in that this is not just an issue for one hospital in this country; AMR is of global concern. Those of us who have been a few decades on this planet can recall that 20 years ago we were given an antibiotic for a cold. Over-prescription of antibiotics has brought us to this situation globally. The HSE’s website www.undertheweather.ieis a great resource. It is well worth people’s while to look at it.

The HIQA report, which is a review of the antimicrobial stewardship in public acute hospitals, found that overall a progressive approach is being taken in the hospitals. I will certainly raise the matter at higher levels.