PAHO on 7 deaths: Poor care for newborns at Port of Spain General Hospital

THE deaths of several babies at Port of Spain General Hospital (PoSGH) in April were linked to poor infection prevention and control, said the PAHO report that Health Minister Terrence Deyalsingh laid in the House of Representatives on June 28.

The report rated the precautionary measures in the hospital’s Neonatal Intensive Care Unit (NICU) at just 29 per cent.

The report said the deaths of the seven babies were “possibly related to the increase in cases of sepsis,” referring to bacterial infections.

Based on available information, while admitting to a low sample size, the report blamed an increase in NICU mortality of newborns or neonates.

“Regarding the variables gestational age and birth weight, both show the vulnerability and clinical complexity of the neonates.

“Of note, 17 out of 20 (85 per cent) fatal neonates were very or extremely pre-term and had extremely low or very low weight at birth.”

Extremely pre-term meant less than 28 weeks of gestation and very pre-term meant 28-31 weeks of gestation. Full-term babies are born at 40 weeks.

Extremely low birth weight meant under 1,000 grammes (2.2 pounds) and very low birth weight meant less than 1,500 grammes (3.3 pounds).

The report listed five aspects of infection prevention control (IPC) at PoSGH which were respectively rated at 29-80 per cent. Among these, neonatology was rated lowest, at 29 per cent. The PAHO recommendations included breast-feeding within 24 hours of birth, better hand hygiene, active screening of bacteria cultures during outbreaks, better nurse-patient ratios, policies and procedures for cleaning and for high-level disinfection and external performance evaluation of the laboratory.

Deyalsingh told the House, “I once again take this opportunity to extend my deepest condolences to the affected families.”

He quoted the report’s executive summary: “A significant strength identified in PoSGH is the presence of a dedicated IPC programme and a knowledgeable microbiology laboratory team capable of identifying pathogens. The commitment from both hospital administration and national authorities to enhance IPC measures was clearly evident and commendable.”

He said the report said Trinidad and Tobago’s National Action Plan on Antimicrobial Resistance for 2023-2027 aligned with the WHO Global Action Plan.

“The Ministry of Health and the North West Regional Health Authority (the RHA under whose aegis the hospital falls) having gone through the report, inclusive of the findings and recommendations, note that many of the recommendations contained within the report were already integral parts of the national and regional standard operating procedure.

“We are of the view, however, that there are certain findings that require urgent clarification.”

Deyalsingh said since getting the report on June 21, his ministry had actively communicated and collaborated with PAHO via its country office.

“This is to ensure that PAHO has the opportunity to address and resolve these concerns promptly as the report anticipates the submission of additional data and information.”

He thanked PAHO and again offered his personal condolences and those of the Government to the affected families.

PAHO: Faults and fixes at PoSGH NICU

The report noted 12 shortcomings at the PoSGH NICU.

It lamented an inadequate ratio of nursing professionals to patients.

“Early breast milk feeds are not being instituted,” the report added. Breast milk is known to help babies’ immune systems fight infections.

The report said policies and procedures for using multidose medications at the NICU must be developed.

“NICU unit dose medications are not prepared in sterile conditions by pharmacy.

“Recommendation: Sterile unit dose preparation of all NICU medications by pharmacy must be done.” PAHO said there were no polices nor procedures for high-level disinfection for equipment such as laryngoscopes, but recommended those be developed.

The report noted “limited hands-free alcohol-based hand-rub dispensers in NICU.” More dispensers must be installed, PAHO recommended.

The report lamented a “lack of implementation of timely contact precautions for patients affected by multi-drug-resistant organisms.”

Such precautions must be promptly instituted, PAHO said.

There were “breaches in personal protective equipment (PPE) protocols observed in the NICU, indicating a need for improved compliance monitoring and training.

“Recommendation: Compliance monitoring of donning and doffing procedures for PPE and contact precautions on NICU using the WHO (World Health Organization) tool should be done.”

The report warned the use of multi-dose saline vials was observed and could lead to an increased risk of infections among patients.

“Recommendation: Use of single-dose saline vials only must be done.” PAHO said infections at surgical and procedural sites were linked to inconsistent or inadequate skin-preparation practices.

“Recommendation: Use of pre-packaged two per cent Chlorhexidine skin preparation for preoperative skin prep, NICU procedures, and for caesarean sections must be done.”

However, the report also said skin irritation and adverse reactions were often seen in babies after the use of Chlorhexidine baths.

PAHO recommended, “Use individual pH neutral/mildly acidic gentle cleansers for neonates, discontinue Chlorhexidine baths.”

Lastly, the report said the preparation, storage and use of agents for skin prep prior to procedures was done in the pharmacy under unsatisfactory circumstances.

The report noted ineffective practices, urging: “Cessation of shaving of surgical sites.”