sto­ries by Gail Alexan­der

Se­nior Po­lit­i­cal Re­porter

The Pan Amer­i­can Health Or­gan­i­sa­tion (PA­HO) team’s in­ves­ti­ga­tion in­to ba­by deaths at Neona­tal In­ten­sive Care Unit (NICU) in April has high­light­ed de­fi­cien­cies in the op­er­a­tions at the Port-of-Spain Gen­er­al Hos­pi­tal.

These range from in­ad­e­quate staffing, the ab­sence of per­son­al sani­ti­sa­tion pro­to­cols and breach­es in per­son­al pro­tec­tive equip­ment (PPE) pro­to­cols, to the lack of pro­ce­dures for the high-lev­el dis­in­fec­tion of equip­ment.

Over­all, the PA­HO team, which ex­am­ined the clin­i­cal events at the NICU af­ter sev­en new­borns died be­tween April 2-9, gave the spe­cial­i­ty ba­by unit a 29 per cent com­pli­ance rat­ing, not­ing the high­light­ed ar­eas showed a need for im­proved com­pli­ance mon­i­tor­ing and train­ing.

“Use of mul­ti-dose saline vials was ob­served which could lead to an in­creased risk of in­fec­tions among pa­tients. Use of sin­gle-dose saline vials on­ly must be done,” the re­port said in one seg­ment.

“In­fec­tions at sur­gi­cal and pro­ce­dur­al sites were linked to in­con­sis­tent or in­ad­e­quate skin prepa­ra­tion prac­tices, sug­gest­ing a need for stan­dard­ised, pre-pack­aged 2% chlorhex­i­dine so­lu­tions to en­sure ef­fec­tive an­ti­sep­sis. Use of pre-pack­aged 2% chlorhex­i­dine skin prepa­ra­tion for pre­op­er­a­tive skin prep, NICU pro­ce­dures, and for cae­sare­an sec­tions must be done,” the re­port added.

PA­HO al­so raised alarm that “there are no per­son­nel re­spon­si­ble for In­fec­tion Pre­ven­tion and Con­trol at high lev­els with­in the hos­pi­tal” and that “goals are not mon­i­tored and eval­u­at­ed an­nu­al­ly by hos­pi­tal man­age­ment.”

How­ev­er, in its re­port sub­mit­ted to the Health Min­istry on June 21, it said epi­demi­o­log­i­cal sur­veil­lance of in­fec­tion was at 80 per cent even though the stan­dard­ised de­f­i­n­i­tion of blood­stream in­fec­tions (BSI) is not con­sis­tent­ly used and stan­dard­ised de­f­i­n­i­tion, in­clud­ing de­nom­i­na­tor da­ta, is not col­lect­ed.

“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,” the re­port added.

In ad­di­tion to a se­ries of hos­pi­tal vis­its, the three-mem­ber PA­HO team of ex­perts, which was on the ground in Trinidad from April 22-26, con­duct­ed an ex­ten­sive re­view of doc­u­ments and in­ter­views, “aimed to for­ti­fy the hos­pi­tal and pos­si­ble na­tion­al ef­forts in pre­vent­ing hos­pi­tal-ac­quired in­fec­tions with a par­tic­u­lar fo­cus on the NICU.”

The team in­clud­ed Pro­fes­sor of Pae­di­atrics, Glob­al Health and Epi­demi­ol­o­gy at George Wash­ing­ton Uni­ver­si­ty in Wash­ing­ton DC, Dr Nali­ni Singh MD, MPH; Clin­i­cal Mi­cro­bi­ol­o­gist and head of Mi­cro­bi­ol­o­gy at Cen­tro de Asis­ten­cia Med­ica So­ri­ano in Uruguay, Dr Grisel Ro­driguez, MD, PH; and New­born In­ten­sive Care Spe­cial­ist and head of the Neona­tal Care In­ten­sive Unit at the Queen Eliz­a­beth Hos­pi­tal in Bar­ba­dos, Dr Gillian Birch­wood, MD.

Staff at the NICU had ob­served a rapid de­te­ri­o­ra­tion in the sta­tus of sev­er­al new­borns. Treat­ment was trig­gered for late-on­set neona­tal sep­sis. Lab­o­ra­to­ry in­ves­ti­ga­tions re­vealed the pres­ence of three dif­fer­ent or­gan­isms - Ser­ra­tia marce­sens, ES­BL Kleb­siel­la pneu­mo­ni­ae, and Kleb­siel­la aero­genes, all known to pose sig­nif­i­cant risks to vul­ner­a­ble neonates(ba­bies).

Health Min­is­ter Ter­rence Deyals­ingh laid PA­HO’s re­port in Par­lia­ment yes­ter­day, not­ing the min­istry is seek­ing ur­gent clar­i­fi­ca­tion on cer­tain of its find­ings.

The re­port’s ex­ec­u­tive sum­ma­ry stat­ed that PA­HO’s tech­ni­cal as­sis­tance was re­quest­ed by the min­istry and that PA­HO and the min­istry agreed to con­duct a re­view of the cur­rent IPC prac­tices.

Find­ings: Room for Im­prove­ment

The re­port stat­ed that an as­sess­ment of the na­tion­al IPC pro­gramme was car­ried out on May 2, by ap­ply­ing the World Health Or­gan­i­sa­tion (WHO) tool for pe­ri­od­ic eval­u­a­tion of in­fec­tion pre­ven­tion and con­trol pro­grammes through an elec­tron­ic ques­tion­naire by the na­tion­al au­thor­i­ties.

Six WHO core com­po­nents were eval­u­at­ed: IPC pro­gramme, IPC guide­lines, ed­u­ca­tion and train­ing in PCI, sur­veil­lance of Health­care Ac­quired In­fec­tions, mul­ti­modal strate­gies, mon­i­tor­ing, au­dit­ing of PCI prac­tices, feed­back and con­trol ac­tiv­i­ties.

“Over­all, the In­fec­tion Pre­ven­tion and Con­trol As­sess­ment tool as­sess­ment re­veals strengths in most of the six ar­eas eval­u­at­ed. How­ev­er, there is room for im­prove­ment in de­vel­op­ment, dis­sem­i­na­tion, and im­ple­men­ta­tion of na­tion­al tech­ni­cal guide­lines and in in­for­ma­tion analysed and time­ly feed­back pro­vid­ed to all rel­e­vant stake­hold­ers,” the re­port stat­ed. “Ad­dress­ing these ar­eas is es­sen­tial to en­hance the ef­fec­tive­ness of the IPC pro­gramme at the na­tion­al lev­el,” the re­port added.

“At hos­pi­tal lev­el, com­pli­ance with In­fec­tion Pre­ven­tion Con­trol (IPC) as­sess­ment var­ied from 29 per cent to 80 per cent.”

The find­ings of PA­HO’s Rapid Eval­u­a­tion Tool al­so showed de­fi­cien­cy in the fol­low­ing ar­eas:

Or­gan­i­sa­tion com­pli­ance - 66 per cent

There are no per­son­nel re­spon­si­ble for In­fec­tion Pre­ven­tion and Con­trol at high lev­els with­in the hos­pi­tal; goals are not mon­i­tored and eval­u­at­ed an­nu­al­ly by hos­pi­tal man­age­ment.

How­ev­er, epi­demi­o­log­i­cal sur­veil­lance of in­fec­tion was said to be at 80 per cent even though the stan­dard­ised de­f­i­n­i­tion of blood­stream in­fec­tions (BSI) is not con­sis­tent­ly used and stan­dard­ised de­f­i­n­i­tion, in­clud­ing de­nom­i­na­tor da­ta, is not col­lect­ed.

Ad­di­tion­al­ly, PA­HO high­light­ed that ac­tive sur­veil­lance for month­ly Health­care Ac­quired In­fec­tions/Blood Stream In­fec­tion (BSI) rates is not con­duct­ed and out­break iden­ti­fi­ca­tion and num­ber of out­breaks in the last year da­ta are not read­i­ly re­port­ed.

Pre­ven­tion & Con­trol strate­gies -71 per cent

In­sti­tu­tion­al poli­cies for cen­tral line in­ser­tion and main­te­nance in NICU aren’t used con­sis­tent­ly.

Poli­cies and pro­ce­dures for pre­ven­tion of sur­gi­cal site wound in­fec­tion in OB the­atre isn’t done.

An­timi­cro­bial stew­ard­ship pro­gramme isn’t im­ple­ment­ed.

Hos­pi­tal En­vi­ron­ment & San­i­ta­tion - 64 per cent

Use of al­co­hol-based hand rub from hands-free dis­pensers is not be­ing done.

Ap­pro­pri­ate bed spac­ing (at least 1m be­tween beds) is not present

Neona­tal ICU - 29 per cent

In­ad­e­quate ra­tio of nurs­ing pro­fes­sion­als to pa­tient ra­tio is present con­sis­tent­ly.

Ear­ly breast milk feeds are not be­ing in­sti­tut­ed.

Poli­cies and pro­ce­dures for use of mul­ti­dose med­ica­tions on NICU need to be de­vel­oped.

NICU unit dose med­ica­tions are not pre­pared in ster­ile con­di­tions by phar­ma­cy. Ster­ile unit dose prepa­ra­tion of all NICU med­ica­tions by phar­ma­cy must be done.

There are no poli­cies nor pro­ce­dures for high-lev­el dis­in­fec­tion for equip­ment such as laryn­go­scopes. Poli­cies and pro­ce­dures for high-lev­el dis­in­fec­tion e.g. laryn­go­scopes must be de­vel­oped.

Lim­it­ed hands-free al­co­hol-based hand rub dis­pensers in NICU. More ac­ces­si­ble hands-free al­co­hol-based hand rub dis­pensers need to be in­stalled on NICU.

Lack of im­ple­men­ta­tion of time­ly con­tact pre­cau­tions for pa­tients af­fect­ed by mul­ti­ple drug-re­sis­tant or­gan­isms. Con­tact pre­cau­tions for pa­tients har­bour­ing MDROs must be prompt­ly in­sti­tut­ed.

Breach­es in per­son­al pro­tec­tive equip­ment (PPE) pro­to­cols ob­served in the NICU, in­di­cat­ing a need for im­proved com­pli­ance mon­i­tor­ing and train­ing. Com­pli­ance mon­i­tor­ing of don­ning & doff­ing pro­ce­dures for PPE and con­tact pre­cau­tions on NICU us­ing the WHO tool should be done.

Use of mul­ti-dose saline vials was ob­served which could lead to an in­creased risk of in­fec­tions among pa­tients. Use of sin­gle-dose saline vials on­ly must be done.

In­fec­tions at sur­gi­cal and pro­ce­dur­al sites were linked to in­con­sis­tent or in­ad­e­quate skin prepa­ra­tion prac­tices, sug­gest­ing a need for stan­dard­ized, pre-pack­aged 2% chlorhex­i­dine so­lu­tions to en­sure ef­fec­tive an­ti­sep­sis. Use of pre-pack­aged 2% chlorhex­i­dine skin prepa­ra­tion for pre­op­er­a­tive skin prep, NICU pro­ce­dures, and for cae­sare­an sec­tions must be done.

Skin ir­ri­ta­tion and ad­verse re­ac­tions were fre­quent­ly not­ed in neonates fol­low­ing the use of chlorhex­i­dine baths, in­di­cat­ing a need for gen­tler, pH-neu­tral or mild­ly acidic cleansers.

Use in­di­vid­ual pH neu­tral/mild­ly acidic gen­tle cleansers for neonates, dis­con­tin­ue chlorhex­i­dine baths.

Prepa­ra­tion, stor­age and use of agents for used for skin prep pri­or to pro­ce­dures is done in the phar­ma­cy un­der un­sat­is­fac­to­ry cir­cum­stances.

In­ef­fec­tive prac­tices: Ces­sa­tion of shav­ing of sur­gi­cal site.