Two days ago, HIQA, the Irish health and social care regulator, published their latest report on Holles St – the National Maternity Hospital in Holles, St, to give it its full title. This is a very busy maternity hospital, delivering 9,000 babies every year. I’ve just given an interview to Pat Kenny on Newstalk about this,
The core of the report is this ‘During the unannounced inspection on 7 October 2015, a number of high risks were identified, the composite of which presented an immediate high risk finding. Risks were identified regarding infrastructure and facilities, safe injection practices, environmental hygiene, the cleanliness of patient equipment and waste management. Cumulative findings were such that HIQA deemed that a re-inspection was necessary within six weeks’.
HIQA is a regulator, not prone to dramatic exaggeration, and this is very strong language by their standards.What prompted these remarks?
There are quite a number of findings in their report, some of which are common observations, familiar from previous reports, and from reports on other hospitals. These include failing to comply with best practice in preparing IV drugs, limited storage space, use of corridors for equipment, and cramped sluice rooms on wards. However, all of these are noted in many other Irish hospitals, as a glance over the many other hygiene reports on HIQA’s web site will confirm.
What stood out for me, in the Holles Street report, were phrases like ‘Overall environmental hygiene in the Delivery Ward was very poor with evidence of organic contamination on surfaces, insufficient dust control measures and suboptimal cleaning observed in most areas inspected‘. In a word, the Delivery Suite was notably, and visibly, dirty.
Previous reports on Holles St. had identified some hygiene problems, but the delivery suite had not previously been inspected. Worryingly, Holles St carries out regular internal environmental hygiene audits. To quote ‘Audit results indicated high levels of compliance in relation to environmental hygiene in the Delivery Ward in August and September 2015. A high level of compliance with desirable cleaning standards was not evident in the October HIQA inspection‘. This suggests a certain willful blindness on the part of the hospital
The management in Holles St. commented that they had two specific problems, first the building itself is old, and was not designed for anything like the current level of activity; second it is hard to clean the Delivery Suite, because the rooms are in constant use. The first is undoubtedly true, but as to the second, on the day of the inspection there were several unused rooms, and in the weeks following the first inspection, a thorough deep clean was done on the whole Delivery Suite.
HIQA were sufficiently concerned to take the unusual step of arranging another inspection within six weeks. This showed considerable improvements in cleanliness, although there was still some work to be done.
There are three messages here. The first is that Holles St is a safe place to have a baby. They have collected data for many years on outcomes for mothers and babies, and both are good. Whatever the extra risks of a dirty delivery suite, Holles St are getting away with it, so far. Equally HIQA are doing their job, pointing out problems.
The second is that they took their eye off the ball. It is, of course, difficult to arrange cleaning for places like delivery suites, and A/E, where patients come and go unpredictably. The rooms need to be easy to clean. Very specific measures, for example, a quick hit cleaning team, who can swoop in, clean a room, and get out fast, are needed. Such measures are not cheap, but they are necessary, and other places manage it. Holles St’s internal hygiene audits also need to be tougher and more realistic.
The third is a wider message. We tend to assume that hospitals last forever. They do not. What happens in hospitals changes over time, and the types of space needed also change. The new acute block in the Mater is a good example of what a modern hospital ought to look like. Ireland desperately needs a systematic review of our hospital estate, identifying buildings coming towards the end of their useful life, and replacing these in a reasonable time. As it happens, all three of the big Dublin maternity hospitals are due to move over the next decade, but the problem goes far wider. Too many Irish hospitals are lumbered with a completely out-of-date estate, and we need a far more radical approach to maintaining it and replacing it.