Port of Spain General Hospital NICU source: Morale low but staff continue their work

The Neonatal Intensive Care Unit (NICU) at the Port of Spain General Hospital (PoSGH) has been running more or less normally since April 10, and has been admitting sick babies and sending home its healthy and stable patients since then.

The unit has been under intense scrutiny since the North West Regional Health Authority issued a media release on April 11 saying there had been a "rapid deterioration in the clinical status of several neonates" from April 4-7. It later transpired that seven babies had died in a "cluster" of deaths between April 4 and 9, reportedly of bacterial infections.

The NWRHA is doing its own internal investigation, as is routine in such eventualities, and the Health Ministry asked the Pan American Health Organization also to do an investigation. The PAHO team of experts arrived this week and on Friday a source close to the NICU reported that its three members have visited the unit.

Since the revelation of the cluster of deaths, the parents of some babies have sent pre-action protocol letters warning of intended legal action over their children's deaths. They have been joined by the parents of other babies who have died at the unit. As of Friday this number stood at 21 babies, of whom 17 died in the past four months.

The source said, "We're always alert and vigilant about the possibility of infection."

But if there is an outbreak in the unit, the source pointed out, "We can't move anybody out; we have to assume they all have it already."

So moving the babies might lead to spreading the infection further; and most of them would not survive being moved from the NICU in any case.

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The PoSGH NICU has a capacity of about 24, but has an average of 16-20 inpatients, and sees 12-15 outpatients a day – babies who have "graduated" and no longer need dedicated hospital care.

"We've treated thousands of patients. We treat 400-600 a year. Thousands have been saved by passing through our hands of care...If they weren't admitted to the NICU they'd be dead."

The longer they have to stay in hospital, the more likely it is that babies will be "colonised by the hospital bacteria." In addition, bacteria may be brought in by parents coming from outside the hospital to visit babies in the NICU.

Parents are told what precautions they should observe, and are supposed to wear personal protective equipment to touch their babies, although, said the source, "We may allow skin-to-skin contact sometimes."However, "There are parents who may not adhere to the policies. We'll probably start swabbing parents (for possible infections)."

Even NICU staff can't always predict what may happen to any particular baby.

"Sometimes you think a patient is going to make it and they don't. I don't know if you read about the baby (a case reported this week) with necrotising enterocolitis – the whole gut dies. It happens in the US, Canada – there's no cure. The baby can be dead in a few hours.

"People aren't aware how sick these babies can get. These (premature) babies aren't supposed to be out of the womb. Their gastrointestinal system can cause them problems just because of the normal gut bacteria."

The source said the policy at the unit is to admit babies from 26 weeks' gestation up to full term (40 weeks). (The unit does not care only for premature babies, but also for babies born on their due dates but who may need hospital care for conditions such as respiratory distress.)

Full-term babies who are not very ill may only need to stay in the NICU for two-three days; others may be there for as long as four months. The smallest babies admitted may weigh less than 1,000 grams.

The source pointed out that the age set as the national standard for viability (ability to survive) in TT is the World Health Organization standard of 28 weeks' gestation.

Below that age, the source said, babies have approximately a 50-50 chance of survival at the PoSGH NICU, the highest rate in the country.

This policy, the source said, is different from that followed in other places, such as Guyana, saying the practice there is for babies born at under 28 weeks' gestation to be treated as miscarriages and given only palliative care (that is, to relieve distress rather than with the aim of alleviating or curing their condition).

According to a pull-out advertisement the NWRHA published in the daily newspapers on April 22, in 2023 the mortality rate among the 403 babies admitted to the PoSGH NICU in 2023 was eight per 1,000 live births. This ranked equal with Barbados among the 2021 figures given for other Caribbean countries (Jamaica's figure was given as ten per 1,000 live births, Suriname's as 11, Guyana's as 17 and small regional states' as 11).

In addition, the younger the premature babies are, the source said, the higher the chance that even if their lives are saved, they may have a lifelong or long-term developmental disability. These may include cerebral palsy, deafness or blindness, delayed milestone achievements such as walking or speech development, or impaired learning.

STAFF MORALE LOW

After being discharged from the NICU, these babies will need additional treatment such as occupational or speech therapy or physiotherapy – none of which is available in the public health service.

Parents, the source said, are counselled extensively about their babies' condition and prognosis, and may be referred to medical social workers if they are having difficulty in coming to terms with the outcome of their babies' treatment.

"We are very, very meticulous about speaking to parents."

Sometimes if staff have not seen the parents for the day, owing to lack of time, said the source, they will call to update them on their babies' condition, and in some cases, "Staff buy things for the babies if the parents can't afford them."

The source said staff at the unit feel under attack at present – "Even the cleaners feel attacked" – and morale is low.

"People don't get to see how hard they work."

They feel they are being "tried in the court of public opinion."

The source also said the way some of the staff have been reported as speaking to parents of sick babies was "insulting to the staff."

Even at normal times, the staff have access to an employee assistance programme for counselling; emotional trauma is not uncommon in those who work with sick babies, not all of whom will survive.

"It's 100 per cent traumatic for staff," said the source.

Not only nursing staff in the unit but also the doctors may often need therapy.

"It's sad. You're trying your best for an individual, using all the latest things available in Trinidad, but sometimes you have a bad outcome.

"And you're dealing with other people's emotions too. Babies carry the hopes of generations. You feel that pressure. It's challenging."

Like Nursing Association head Idi Stuart, the source praised CEO of the NWRHA Anthony Blake, who was alerted early on to the crisis in the NICU. Blake, said, the source, "has spoken to (NICU) staff himself several times."

The source admitted the PoSGH NICU has its shortcomings: there are issues of equipment and staffing, and procurement and funding are handled by the hospital, which must often choose between a number of pressing needs among different departments competing for limited resources.

"Everyone has a need."

On staffing levels, the source said, "They could be improved: (the staff) get tired and burned out. We could have better patient-to-staff ratios."

The source also said despite "all the ribbon-cutting" and having several relatively new hospitals, the country does not have a single purpose-built NICU. Instead, NICUs are fitted into existing spaces.

A purpose-built unit, the source explained, would include, among other things, single-patient rooms, which would reduce the risk of the spread of infection, give parents and their babies more privacy and would mean patient-staff ratios would have to be improved.

Globally, the source said, one of the determinants of a country's health status is maternal and child health.

The source stressed the importance of NICUs in improving the health of babies who will then grow up to be healthy adults, arguing that investing in NICUs would give the best value when deciding how to allocate healthcare funding