Mt Hope still worried about outbreak

AT THE end of last year, attempts were made to transfer a premature baby from the Sangre Grande Hospital (SGH) to the Neonatal Intensive Care Unit at Mount Hope Women’s Hospital (MHWH), Mt Hope. When the request was made, however, there were no available ventilators, incubators, or intravenous pumps in the unit.

Another baby was due to go into theatre and nurses tried to make accommodations for the new admission. A doctor on duty expected that two babies would be well enough to be taken off a ventilator, and suggested the transfer would be possible the next day. On this day a doctor from SGH called the Neonatal Unit and spoke to a colleague, also a doctor.

He was informed that only one nurse and a nursing assistant (NA) were on duty. The nurse was monitoring six babies in critical condition who were on ventilators, and another six who were oxygen dependent. Meanwhile, the NA was helping resuscitate another baby who was being admitted to the hot room (for critical babies). The baby had stopped breathing and his lungs had collapsed while he was in the cool room (for stabilised babies). A ventilator was being set up for him to use.

There were no available intravenous pumps and functioning syringe pumps. As a result, several infants were on uncontrolled infusion of intravenous fluid. The result was that one premature baby’s blood sugar reached a dangerously high level — 550-575 mg/dl due to being overloaded with fluids. The normal blood sugar level for premature babies ranges between 60-150mg/dl.

All incubators, including the transport incubator and an old incubator, were being used to accommodate babies. Babies were wrapped in disposable theatre gowns to keep warm because of a shortage of incubators and blankets. The baby from Sangre Grande was not accepted since conditions were not favourable for survival. It was subsequently sent to Port-of-Spain General Hospital (POSGH). The scenario is not unique to the NICU at Mt Hope, as it happens at PoSGH and SFGH (San Fernando General Hospital) where conditions are the same, but it was the Enterobacter outbreak at the MHWH which thrust conditions at the nation’s NICUs into the spotlight.

The Enterobacter species, which include Enterobacter cloacae and Enterobacter aerogenes, are hospital acquired pathogens which cause a variety of infections including bacteremia, lower respiratory tract infections, skin and soft tissue infections. Prolonged hospitalisation, especially in an ICU, makes patients susceptible to infections with "ICU bugs".

It was NICU consultant Dr Jennifer Delamore who alerted the authorities about the Enterobacter (cloacae) outbreak after the results from routine tests (on September 5) showed a 100 percent presence of Enterobacter "at various stages" in babies. The Health Minister at the time, Colm Imbert, threatened action against "those responsible" for the unsanitary condition which led to the increased incidence of Enterobacter. Investigations were ordered into conditions at the NICU, and whether the baby deaths in August were due to unsanitary conditions. The North West Regional Health Authority (NWRHA) hired a private company to do an extensive sanitation exercise from ceiling to floor on the unit.

The neonatal unit was temporarily relocated while this happened. The quality control procedures at the NICU were revisited with the aim of improving and preventing subsequent outbreaks. An Infection Control committee was established, sinks and toilets changed, and additional neonatal equipment purchased.

In early December 2003, Health Minister John Rahael announced that the MHWH would be relocated to the Eric Williams Medical Sciences Complex (EWMSC).

At a media briefing at the Health Ministry on December 24, the unsatisfactory condition of TT’s neonatal units was revealed. Speaking about the findings of a report compiled by consultants from the Pan American Health Organisation (PAHO), country representative Lilian Reneau-Vernon said they looked at the infrastructure of neonatal units at PoSGH, San Fernando, Sangre Grande and Mt Hope, and found the facilities were not designed to be ICUs.

The Health Ministry was advised to expedite the plan to refurbish and extend nurseries and the NWRHA (under whose authority MHWH fell) to institute a preventive maintenance schedule for infrastructure and equipment, introduce internal auditing of neonatal nurseries and infection control systems.

Lab tests results released in September indicated that only four of 13 babies who died in August 2003 died because of Enterobacter, but women were afraid to go to Mt Hope to have their babies. They rushed and crowded Port-of-Spain and San Fernando — facilities which have had to battle their own share of infections.

Despite the positive outcomes from the 2003 episode, including a significant drop in Enterobacter infection rates, the head of the NICU, Dr Gary Yuille last month told the Commission of Inquiry into the Operation and Delivery of Health Care Services that existing conditions could contribute to another outbreak.

He spoke of limited space, overcrowding, and inadequate equipment. (Neonatal equipment which was purchased in 2003 was shared between Mt Hope, SFGH and PoSGH in the aftermath of the Enterobacter scare).

Consumables — items intended for one time use are repeatedly used because of erratic supply.

The nursing shortage can also compromise child care and increase infection rates since nurses had to interact with several babies.

"There is no time to sanitise your hands, running back and forth all night and day," Dr Yuille said.

The Guidelines for Hand Hygiene in Health Care Setting produced by the US National Centre for Infectious Diseases states: "Outbreak investigations have indicated an association between infections and under staffing or overcrowding, the association was consistency linked with poor adherence to hand hygiene."