Fragile newborns in health care crisis

WHILE POLITICIANS have their mantra of developed country status by the year 2020, labour rooms and neonatal departments in Port-of-Spain (PoSGH), San Fernando General Hos-pital (SFGH) and Mt Hope are still lobbying for equipment to maintain a satisfactory level of health care, while expectant mothers deliver the nation’s future on rusty beds which seem to be there since colonial times.

Old equipment are still being used because there is a lack of new supplies and as one doctor said the old equipment can be used as a "back up" or for spare parts. When there is a high demand for ventilators and incubators these items are quickly sanitised to be used again.

The hospitals also lack basic equipment such as foetal monitors, ventilators and incubators.

Neonatal units at PoSGH, SFGH and Mt Hope are in need of refurbishment and expansion after decades of neglect.

Allocation of space for a neonatal unit was apparently an afterthought, since at PoSGH the unit is located downstairs from the labour ward, at SFGH a general ward was converted and at Mt Hope space was adapted.

As Neonatologist at Mt Hope Women’s Hospital, Dr Gary Yuille told the Commission of Enquiry into the Operation and Delivery of Health Care on May 20, there are "intrinsic problems" working in accommodations not designed for a Neonatal ICU (NICU).

Although the NICUs at Mt Hope, PoSGH and SFGH are sanitised regularly to prevent contamination, windows must be opened due to the absence of an internal ventilation system. Dr Yuille illustrated difficulties which ensue.

"Recently they were working on the roof outside the unit. We had just finished cleaning our entire unit and the breeze blew all the dust right back into the unit. This is in a unit that is supposed to take care of sick babies. The most fragile of patients."

Dr Kerryn Brahim, a paediatrician at the SFGH, said NICUs should be enclosed spaces with a ventilation system providing six air changes per hour. This is the recommendation of the American Academy of Paediatricians for infection control in neonatal units.

Neonatal nurseries in the US and UK are divided into levels according to the condition of the baby. Level one provides basic care for babies in a stable condition while level three caters for babies of low birth weight who require life support.

In TT levels one through three are also available.

There are only two specialists in newborn care in TT — consultant neonatologist Dr Petronella Manning-Alleyne at Port-of-Spain General Hospital and Dr Yuille. There are also paediatricians such as Dr Brahim and others with an interest in developing neonatal care in TT.

According to the British Association of Perinatal Medicine, in order to admit infants to the Neonatal Unit and maintain safety, services should be planned for an average occupancy of 70 percent. In TT the average is more than 80 percent. Each of the neonatal units have experienced overcrowding and this is when equipment is stretched.

At the San Fernando General Hospital there are six ventilators, nine incubators (three were supplied in 2003), two resuscitation units (one from 2003), four multi-sign monitors for heart rate, oxygen (two from 2003), three syringe pumps and four infusion pumps (two from 2003).

An order has been placed for three new ventilators, eight incubators, one resuscitation unit, five multi sign monitors, 16 syringe pumps and six infusion pumps.

Dr Brahim told Sunday Newsday that prior to 2000 the hospital had only two ventilators but after "justifying" the need for additional equipment, this was increased to five. He said the unit still has a five ventilator capacity and if necessary, an old ventilator is utilised. The SFGH is aiming to have ten intensive care cots equipped with ventilators, incubators and other accessories so there would be "less stress." Brahim said this would allow for more ICU beds to be opened without jeopardising babies’ health and allow regular maintenance of equipment.

Brahim said there were ventilators which have not gone through maintenance checks in three and five years. "After a number of man hours they need to go back to the manufacturer. We cannot do that now. We have to have all the equipment and the old on stand by."

While the Health Ministry has ensured that any contracts for equipment now include five years of maintenance, Brahim said workers in the biomedical department should be trained since equipment can break down at anytime.

Equipment are not calibrated for babies.

The Neonatal Unit as well as the paediatric department are awaiting new equipment since tenders have gone out.

The babies most in need of NICU care are those born at 34 weeks or less. Their weight can range between 1 kg and 1.5 kgs and they have a range of illnesses due to their premature state.

ICU care for adults or babies is not cheap. The cost of a baby on a ventilator on the first day when they are most critical, ranges between $2,500 and $4,000. This includes all the medical investigations necessary. From the second day onwards the cost ranges between $2,000 and $3,000. Babies spend an average of eight days on a ventilator.

Each ventilated baby should have one nurse assigned to it but due to the nationwide nursing shortage this has been impossible to achieve.

Brahim said in TT the ratio is one nurse to four babies and can reach one to eight or nine babies in the afternoons. At the Women’s Hospital, this ratio can reach as high as one nurse and nursing assistant caring for 20 babies.

He said more neonatal nurses are needed if the nursing ratio is to reach the required standard. Brahim said they must also be paid properly when they have completed their training in order to keep them in TT.

Asked if there has been an increase in the number of premature births (less than 37 and 32 weeks), he said there were no studies to show this. However, he said "anecdotal evidence" indicated an increase in 2003 and 2004.

Six to seven months after Carnival was the time when births usually increased but now it is year round.

Brahim said antenatal care (poor nutrition, teen pregnancies etc) was contributing to this trend.