Other factors also added to neonatal deaths at JDWNRH
The recent nine neonatal deaths at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) were also added by other factors to hospital-acquired infections (HAI).
Medical Superintendent of Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Gosar Pemba said that out of the nine cases, two were not because of HAI rather it was due to other factors.
The press release from the JDWNRH states that two babies were born at only six months of pregnancy weighing around one kg and another four babies were born at only seven months of pregnancy weighing little over one kg with predisposing conditions in the mother; six out of nine mothers had severe pregnancy induced hypertension which is well established risk factor for neonatal deaths and additional three babies had congenital heart diseases and blood related diseases.
The press release stated that all babies were born preterm with mean delivery period of 7.3 months of pregnancy and with predisposed conditions. The rate of HAI increases with the degree of both prematurity and low birth weight.
However, HAI is common in all health facilities, and in spite of all the necessary Infection Control measures, outbreak could occur due to many external factors.
“HAI is a common problem among neonates in Neo-natal Intensive Care Unit (NICU) and globally, it is one of the leading causes of death in this group of patients. In South East Asia, HAI related mortality in neonates is as high as 75 percent and Bhutan is no exception.”
The new-born babies admitted to NICU usually have many risk factors which predisposes them to HAI. In this group of new-born babies that succumbed to infection, the babies were born premature with risk factors such as immaturity of the immune system, barrier function of the skin and gastrointestinal tract, and the invasive diagnostic and therapeutic procedure which our new-born undergo and therefore, easily become susceptible to one of the commonly found bacteria causing HAI, Klebsiella Pneumonia.
The first signs of the bacteria Klebsiella Pneumonia were observed on 16th July 2018 in the NICU when the blood report of a few neonates showed presence of the bacteria. The matter was reported to the infection prevention and control focal person of JDWNRH. The Focal person immediately enforced the infection prevention and control practices and the infected babies were segregated from the noninfected ones.
The press release from the ministry of health stated that the Ministry of Health and the JDWNRH has taken immediate interventions through mass cleaning, steaming and fogging, treatment of hospital water reservoir, environmental surveillance in NICU and Neonatal Ward, additional deployment of staff and sanitary supplies, quality check for antibiotics, isolation of infected children and sterilization of feeding equipment.
Independent investigations conducted by the JDWNRH, Drug Regulatory Authority and the Ministry of Health recommended the JDWNRH management to strictly abide by the standards and practices for infection control, improve management through assignment of appropriate health workers especially in the critical care areas and ensure safety of water.
“All necessary measures have been undertaken and it is said that the outbreak is effectively under control.”
The Ministry of Health has also reminded all health facilities to strictly enforce the standards and practices for infection control to improve quality and safety of health services across the country.
In NICU, generally four to six babies die every month of which one to two is related to HAI. In the 3rd week of July 2018, there were five neonatal deaths related to HAI due to which the outbreak was declared as it met the outbreak criteria. Several life saving measures were put in place soon after the outbreak was notified on 26th July 2018, due to which we were able to save 15 babies out of the total 24 confirmed cases admitted during the period. The first death occurred on 23rd July and the last one was on 6th August.
Meanwhile, the press release states that the possible cause for this outbreak was found to be contaminated hospital water supply which was used for cleaning the units, washing hands, feeding materials and other equipment.
The report from the Royal Centre for Disease Control (RCDC) carried out on 31st July 2018 showed presence of high level of Coli Form. Other factors which contributed to aggravation of the HAI, could be attributed to the shortages of doctor and nurses, limited facility to segregate patients, complacency of the parents in sterilizing the feeding materials, poor hand hygiene, and uncontrollable patient visitors, who despite installation of biometric system to restrict visitors, shows very poor compliance and even quarrel with security guard and staff on daily basis.
The standard requirement of nurses in the Neonatal Intensive Care Unit (NICU) and other ICUs is 1:1 (1 nurse per 1 patient), whereas, the current ratio in JDWNRH is 1:4. In the Nursing department, JDWNRH have a shortage of 173 nurses. Similarly, the hospital has a shortage of ward boy/girl and cleaners. There is only one Neonatologist in JDWNRH while there should have been at least 3 Neonatologist as per the norm.