Reports published by the Health Information Quality Authority following unannounced visits by their inspectors have revealed a poor standard of hygiene in Irish hospitals.
Five hospitals were inspected during June and July by the Health Information and Quality Authority (HIQA) – an independent body which scrutinises the quality and safety of the health service in Ireland – and a general lack of hand hygiene was found in each.
Furthermore, inspectors discovered issues such as patients with suspected communicable diseases being treated in open bays of Accident and Emergency Departments and the doors of isolation units – where patients with transmittable diseases were being treated – being left open as standard practise.
Among a catalogue of issues, the poor standard of hygiene in Irish hospitals was exemplified by inspectors finding five hygienic gel dispensers empty at the Waterford Regional Hospital; with several more blocked by congealed soap, and mould growing in patients´ shower units and around toilet areas.
In addition to the Waterford Regional Hospital, a poor standard of hygiene at Irish hospitals was identified at:-
St Michael´s Hospital in Dun Laoghaire
Portiuncila Hospital in Galway
Louth County Hospital in Dundalk
Our Lady´s Hospital in Navan
Commenting on the damming report into hygiene standards at Waterford Regional Hospital, its Clinical Director – Rob Landers – said that the hospital was “extremely disappointed” with the findings of the inspectors, but added that the hospital´s Accident and Emergency Department was extremely busy on the day that the inspectors made their unannounced visit.
He said that compulsory hand hygiene training would be introduced for all workers at the hospital in the future and that future hygiene breaches would become a disciplinary matter. Mr Landers reassured patients that it was safe to attend Waterford Regional Hospital despite the finding in HIQA´s report.
A huge increase in the number of patients left overnight on Emergency Department trolleys could escalate hospital negligence claims made against the Health Service Executive (HSE).
According to the Irish Nurses and Midwives Organisation’s “trolley watch”, 6,624 patients were left overnight on trolleys in August due to a lack of beds, with 401 patients bed-less on August 31st alone. The figures indicate a 35 per cent rise on those from last year and are attributed, according to the Irish Nurses and Midwives Organisation General Secretary, Liam Doran, on the rising rate of bed closures due to the pruning of funds by the government and HSE.
“A Serious Negative Impact upon Patient Care”
Selecting Limerick as an example of how the situation has got out of control, Mr Doran noted that despite assurances in 2009 from the HSE that any reconfiguration of services “would not require any additional beds”, 50 acute beds were closed at Ennis General and Nenagh Hospitals, followed by 25 further bed closures at St. John´s Hospital in Limerick and – in the middle of the August crisis – the HSE closed 25 acute beds at Limerick Regional Hospital. This has had, according to Mr Doran, “a serious negative impact upon patient care”.
“An Unsafe Situation”
The Irish Nurses and Midwives Organisation’s claims that HSE cuts were resulting in “an unsafe situation” were echoed by Mr Fergal Hickey, President of the Irish Association for Emergency Medicine. Mr Hickey, quoting research conducted in Australia which was supported in the British Medical Journal, stated that Emergency Department overcrowding could be responsible for as many as 350 unnecessary deaths in Irish hospitals each year. He added that, for the first time ever, children admitted through the Emergency Department procedure were also facing delays in treatment due to the overcrowding situation.
“The Solution is Complex”
In response to the claims, Minister for Health James Reilly – who promised after his appointment in March that there would never again be 569 on trolleys in hospitals as there were earlier in the year -stated that “the solution is complex and will require an enhanced capacity by hospitals to deal with the inter-related issues involved”. Nonetheless, staff working in the country´s Emergency Departments are deeply concerned about the forthcoming months.
The Situation May Get Worse Before it Gets Better
The Irish Nurses and Midwives Organisation is concerned that the increase in bed shortages and subsequent high numbers of patients being left on hospital trolleys is occurring at the height of the summer – traditionally a “quiet” time of year – and has called on statutory bodies such as the Health Information and Quality Body (HIQA), An Bord Altranais and the Medical Council, to inspect all affected hospitals.
However, it is already known that HIQA has been unable to carry out independent hygiene inspections of hospitals throughout 2011 due to a lack of resources. This raises the fears for MRSA and other hospital infections being acquired by patients waiting in hospital corridors for a bed to become available. Furthermore, according to the HSE’s own performance system, five out of the six main Dublin hospitals are ranked as “unsatisfactory” in terms of the performance of their emergency departments.
Hygiene in medical centres across Ireland will come under fresh scrutiny with the announcement that a new strain of methicillin resistant Staphylococcus aureus (MRSA) has been discovered in two Dublin hospitals. MRSA is bacteria which enter the bloodstream through cuts, surgical wounds and invasive devices such as catheters or implanted feeding tubes, causing infection to hospital patients with weak immune systems. Difficulties exist treating these infections, as MRSA are resistant to penicillin based antibiotics and, although some MRSA infections manifest as boils or abscesses, MRSA may cause pneumonia, endocarditis (inflammation of the heart chambers) and septicaemia (blood poisoning).
A report published in 2010 entitled “MRSA in Ireland” revealed that patients who contract MRSA infections in Irish hospitals are seven times more likely to die in hospital than those that do not have secondary infections.
The report further disclosed that secondary MRSA infections meant that patients spent on average an extra 11 days in hospital, costing the Health Service Executive (HSE) more than 23 million Euros each year.
By law, doctors have to report any MRSA infection to the HSE, and statistics produced by the Health Protection Surveillance Centre have shown that as many as 2,500 patients per year contract MRSA blood stream infections in Irish hospitals.
Alarmingly, doctors are not obliged to disclose if an MRSA infection is a contributory factor in a patient´s death and, based on international fatality levels throughout Europe, it is possible that as many as 250 deaths in Ireland per year are directly attributable to a hospital acquired MRSA infection.
Now that a new strain of MRSA has been discovered – that was so different that existing test kits could not recognise it as being an MRSA-type bacterium – new treatments will have to be found to counter the illnesses and deaths caused by the bacteria.
It is claimed in the medical journals “Antimicrobial Agents and Chemotherapy” and the “Lancet Infectious Diseases” that the organism can share its genetic make-up and its antibiotic resistance with other bacteria. This raises the fears of a new generation of superbugs that hospitals will have no answer to. Only through improved standards of hygiene and public awareness will hospitals and other medical centres be able to prevent a new epidemic of MRSA, and the claims for compensation which will inevitably follow.
A member of a High Court working group, commissioned to investigate provision for the victims of catastrophic injury and chaired by Mr Justice John Quirke, has announced that the working group is considering the introduction of pre-action protocols to reduce the financial burden to the State of clinical negligence compensation claims.
Mr Michael Boylan was speaking in Dublin at a conference on catastrophic birth and child injuries organised by the charity “Action Against Medical Accidents”. He said that a legal “duty of candour” should be introduced to require medical practitioners to advise a patient as soon as they are aware that a clinical error as occurred.
Quoting from a Health Service Executive report, Mr Boylan stated that there was evidence to suggest that patients often forgave the clinical error when it is disclosed promptly, fully and compassionately, and not only would this action reduce the trauma and distress of patients and their families upon discovery, but also reduce the amount of legal costs arising from contested medical negligence actions.
The first proposal from the working group was contained in a report published in November 2010. The report recommended that people who sustain catastrophic injuries would benefit more from periodic compensation payments than one lump sum. Mr Boylan hoped that the report would be acted upon and legislation introduced, although he acknowledged that the overall cost to the State could be greater and feared that this might prevent it from being adopted into law.
A new superbug called CRE (Carbapenem Resistant Enterobacteriaceae) has been discovered in Irish hospitals for the first time. The new superbug is potentially fatal and can cause kidney infection and pneumonia. Four cases have been discovered so far in Ireland, causing concern with medical professionals because it is difficult to eliminate once it takes hold in a country’s medical system (which has already occurred in Greece and parts of the United States).
One of the problems with treating the superbug is that the general population is less responsive to treatments for CRE because of the widespread using of board spectrum antibiotics.
If CRE spreads in Irish hospitals, it it likely to be for the same reasons as the recent MRSA outbreak – contaminated surfaces, especially medical equipment.
The Health Service Executive (HSE) is launching a new complaints procedure called “Your Service, Your Say” that is aimed at obtaining both positive and negative feedback. The HSE is presumably looking for opportunities to improve the health service. The HSE is aiming to provide a 30-day turnaround on complaints.
There was a 63 percent increase in complaints in 2009, with the total reaching 8,000. Interestingly, despite the surge in complaints, the director of advocacy in the HSE, Mary Culliton, still believes there is under reporting of complaints due to patient’s reluctance to question medical decisions.
While the general principle of collecting feedback with the objective of improving services is an extremely positive development for the HSE, patients should be cautious regarding medical negligence and other types of hospital negligence. The prudent approach is to speak to a solicitor before making any accusations regarding medical malpractice. It’s not just a question of defamation, but also because the victim may wish to make a compensation claim at a later date.
The State Claims Agency has already paid out 20% more in compensation in the first eight months of the year compared with the whole of the 2009. The State Claims Agency had already paid compensation of €59.9 million up to August 2010, compared with total compensation payments of €48 million in 2009. At the current rate, the Agency will make compensation payments of nearly €90 million in 2010. This represents an increase in compensation of nearly 50% in 2010 compared with 2009.
The Minister for Health, Mary Harney, has announced some measures to improve patient safety. The most significant are draft healthcare standards developed by the Health Information and Quality Authority (Hiqa), which has now entered into a public consultation phase.
Minster Harney has said that about 10% of people admitted to hospital experienced an ‘adverse event’, and about 1% of the adverse events would result in injury or death. Speaking about the adverse events, the minister said “Many of them are systemic failings and many of them are avoidable”.
It should also be pointed out that although the rate of adverse events in HSE run hospitals is particularly high, the HSE is not always responsible, such as the recent DePuy recall.
A Medical Council fitness-to-practice committee ruling has attracted significant media comment over the past few days in the case involving the removal of the wrong kidney from a young child. After hearing most of the evidence in the case, the committee had decided to invoke Section 67 of the Medical Practitioners Act 2007 that allows doctors to undertake not to repeat their errors while avoiding being found guilty of professional misconduct. The incident occurred at Our Lady’s Hospital for Sick Children in Crumlin, Dublin, in March 2008 when junior doctor Sri Paran, under the supervision of Professor Martin Corbally, removed a perfectly healthy kidney while leaving in place a barely functioning kidney.
The young boys’ parents, Jennifer Stewart and Oliver Conroy, repeatedly asked hospital staff to confirm which kidney was scheduled to be removed before the operation. Despite this, it was revealed that nobody had reviewed the X-rays that were available in the operating theatre before the operation. The boy, now 8 years old, is left with a right kidney with 9 per cent functionality, leaving him requiring regular dialysis until he obtains a kidney transplant.
Professor Corbally immediately met with the parents of the boy and apologised.
This type of medical error happens all the time as is known as a “wrong-site operation”. The problem is mainly due to poor procedures in operating theatre, where surgeons seem to resist the ‘checklist’ approach to operations that are common in other professions. A good example is the pre-flight checklist used by all pilots all over the world, where they check even the most obvious things like fuel levels and radio signals.
Since there were no proper checklists in place for a kidney removal operation, there was no medical malpractice resulting from not following the non-existent checklist. It was a simple case of human error.
There has been much commentary in the media about the new Health Services Executive (HSE) chief executive Cathal Magee facing a difficult first year implementing significant budget cuts. However, he also has a significant challenge changing the internal staff culture of the HSE, which was most recently criticised by the Ombudsman for its “rotten culture of secrecy” when dealing with medical malpractice.
Cathal Magree should start by reading the paper in August 17th issue of the Annals of Internal Medicine about a program launched by the University of Michigan Health System that encouraged health workers to report medical mistakes. The program included a procedure for telling victims about errors, who exactly made the error, what steps were made to prevent similar mistakes in the future, and mostly importantly, making a sincere apology to the patient or family. The procedure also included a process for offering fair compensation.
Reporting and explaining errors honestly to patients obviously leads to faster resolution of disputes, but also reduced the number of lawsuits by 36%.
A survey by Red C on behalf of the Health Information and Quality Authority (Hiqa) has found that over 40 percent of Irish people feel that healthcare services they or their families have received are below the expected standards. The survey statistics were obtained using a representative sample of over 1,000 adults.
But only one third of the people that were dissatified with the healthcare they received actually made a complaint about the below-standard level of care. One of the primary reasons was that 52 percent felt too intimidated to make a complaint. Over 80 percent of survey respondents said it was difficult to know where to make a complaint. The actual number of complaints received in 2009 by the Health Services Executive (HSE) was 7,984 which is an increase of 63 percent on 2008.
Hiqa is preparing draft national standards for better and safer healthcare that will eventually apply across the entire health sector. The Hiqa survey found that 99 percent of people wanted to be informed when there was a problem with their treatment so it seems likely that Hiqa will propose better disclosure procedures in the new national standards. It remains to be seen if the HSE, which has a reputation for secrecy, will accept a more open approarch to patient disclosure when it comes to medical negligence.
Professor John Crown, a consultant oncologist, writing recently in The Irish Independent, said that the HSE and Department of Health and Children together “comprise one of the least ethical organisations that I have ever dealt with”. Professor Crown goes on to describe the HSE as “secretive, self-serving, dishonest, incompetent and unintelligent.” He concludes, with an interesting historical comparison, that the “corruption and incompetence” of the HSE is effectively a form of Stalinism.
These comments are interesting from the point of view of anyone trying to make a medical negligence claim or hospital negligence claim related to one of the HSE’s services. The management problems that increase the likelihood of negligence are compounded by the way the HSE deals with its own negligence. It’s really no surprise that the Injuries Board Ireland refuses to deal with cases against the HSE.
Jim Reilly of Patient Focus has claimed today that international figures show that 4-16% of patients in hospitals are exposed to “potentially dangerous adverse events”. Mr Reilly was speaking at a conference organised by the charity Action Against Medical Accidents. Peter Walsh, chief executive of Action Against Medical Accidents, claimed that more people are killed or permanently disabled in hospitals due to medical incidents than were injured in road traffic accidents.
State Claims Agency data for 2008 reveals that there were 83,661 “adverse incidents” recorded by Irish hospitals, where an medical incident could range from something as simply as slips, trips, and falls to more serious treatment errors such as medication errors.
The figures include both major and minor incidents ranging from slips, trips and falls to medication and treatment errors. The figures also demonstrate how badly exposed the Irish health services are to medical negligence claims and hospital negligence claims.
Data from the State Claims Agency reveal that there were 8,250 ‘medication incidents’ (incorrect dosages or simply wrong medication given to patients), some 5,559 ‘treatment incidents’ (which includes mistakes like leaving surgical swabs in patients’ bodies after operations), and poor documentation (which lead to anything from a simple ‘near miss’ to a catastrophic incident).
The State Claims Agency runs a clinical indemnity scheme for Irish hospitals that paid out almost €50 million in medical negligence claims and hospital negligence claims last in 2009, with an average award of €63,000.
The MRSA Group, multidisciplinary advisory group including microbiologists, hospital pharmacists, and patient advocates with funding from Pfiizer, has published a report “Meticillin-Resistant Staphylococcus aureas (MRSA) in Ireland: Addressing the Issues” . Shockingly, the report finds that patients who acquire infections in Irish hospitals are 7.1 times more like than uninfected patients to die in hospitals.
The report estimates that patients who acquire an infection in hospital stayed in hospital 2.5 times longer than other patients and that the cost of healthcare associated infections (HCAI) totalled €233.75 million a year. This cost estimate does not include the cost of hospital negligence claims. The report states that approximately one third of HCAIs are preventable, therefore the potential savings from all HCAI is €77 million. Again, this illustrates the potential level of liability for medical negligence claims for infections that should never have happened if the hospitals were properly run.
European Antimicrobial Resistance Surveillance System data ranks Ireland fourth in Europe for MRSA bloodstream infection (BSI) rates at 33.1%. This infection rate is significantly higher than in many other EU countries.
There are some factors causing HCAI that are specific to individual patients such as age, surgical wounds, use of medical devices, illness severity, and length of stay in hospital. These factors are the same in all countries in Europe, so Ireland’s high rate of hospital infections is due to the way the hospitals are managed. The factors under the control and responsibility of the hospitals include poor hand-hygiene, overuse of antimicrobials, contaminated equipment, delays in patient isolation, low staff-patient ratios (which strongly influences quality of care), and the availability of isolation facilities (for patients at risk).
There is a lot of discussion about the degradation of hygiene in Irish hospitals. The cleaning staff are now heavily unionised and often blamed for a work-to-rule attitude. The nursing staff are now considerably better educated than previous generations and appear more focussed on medical issues less inclined to help with cleaning duties.
In fact, it was well known that while hospitals were run by religious orders, the hospital matron regularly terrorised nursing staff with meticulous inspections. The matrons famously used a handkerchief to search for any dirt or dust. The unholy wrath of the matrons was Ireland’s most effective defence against hospital infections!