PAHO report submitted to Parliament identifies dozens of violations in neonatal intensive care units

Health Minister Terrence Deyalsingh presented to Parliament on Friday, June 28, the Pan American Health Organization (PAHO) report on clinical events at the Neonatal Intensive Care Unit (NICU) of the Port of Spain General Hospital.

In a June 23 statement, the Ministry of Health confirmed that the report was received from PAHO officials on June 21. The ministry also noted that clinical and technical staff from the Ministry of Health and the North West Regional Health Authority (NWRHA) were to undertake an internal review of the findings before they were made public.

The PAHO team commissioned its investigation in April this year, following the deaths of several premature babies in the hospital's neonatal intensive care unit over a short period of time.

In his statement to Parliament on Friday, Deyalsingh said his ministry and the NWRHA, having reviewed the report, including the findings and recommendations, note that many of the recommendations contained in the report were already an integral part of the standard operating procedure national and regional.

He added: “We are, however, of the opinion that certain conclusions require urgent clarification. Since receiving the report on June 21, 2024, the Ministry has been actively communicating and collaborating with PAHO through its country office. This allows PAHO to have the opportunity to quickly address and resolve these concerns, as the report provides for the submission of additional data and information. »

According to the 35-page PAHO report, a copy of which was made available to the media, the organization's external assessment of PoSGH's infection prevention and control (IPC) practices was conducted from April 22 to 26, 2024, and aimed to achieve the following objectives:

1. Strengthen the IPC program at PoSGH, with particular emphasis on neonatology.

2. Assess the capacity of bacteriology laboratories to compile and analyze data on antimicrobial resistance, thereby improving the use of quality-assured data microbiological data for HAI surveillance.

The report explains that data were collected for the review period of January to April 2024, during which NICU mortality rates were calculated and causes of death were analyzed, stratified into sepsis and other causes.

He said: “With the available information, an increase in NICU mortality during the month of The month of April can be observed, perhaps in connection with the increase in cases of sepsis.

The report also provided a breakdown of the microbiological data collected.

The study noted: “During the study period, a total of 367 specimens were received from the NICU, of which 230 were blood cultures, of which 34 were positive (positivity rate of 15%). The most frequently isolated pathogens were Candida spp (12 isolates), Klebsiella pneumoniae (11 isolates), and Serratia marcenses (5 isolates).”

The PAHO team further suggested that in light of the results, a thorough laboratory evaluation be considered at POSGH:

“In light of these findings, the PoSGH would benefit from a thorough laboratory assessment as a baseline for developing an improvement plan in terms of clinical diagnosis and AMR surveillance. The country would benefit from a strong national reference laboratory that would assume national leadership and work towards continuous improvement in the quality of laboratory diagnostics.”

Regarding actual results regarding the hospital: “There is no staff responsible for PCI at a high level within the hospital. The objectives are not monitored and evaluated annually by the hospital management.

Furthermore, in terms of epidemiological surveillance of the infection, which stands at 80 percent compliance with the IPC, the report states:

1. The standardized definition of bloodstream infections (BSI) is not used consistently.

2. No standardized definition including data on denominators is collected.

3. Active surveillance of monthly rates of nosocomial infections/bloodstream infections (BSIs) is not conducted.

4. Data on outbreak identification and number of outbreaks over the last year are not taken into account. easily reported.

Regarding microbiology, which was at 40% compliance:

1. Identification of aerobic bacterial species in blood cultures is not performed.

2. No external performance assessment is carried out.

3. No internal quality assessment is carried out.

4. A regularly updated (every 3 years) sample collection and shipping manual is not finished.

5. A laboratory staff member must be part of the infection control committee to provide real time for MDRO is not done.

Additionally, it was also found that institutional policies for central line insertion and maintenance in the NICU are not used consistently; surgical site wound infection prevention policies and procedures in the delivery room are not enforced; and the antimicrobial stewardship program is not implemented.

The report also notes that the use of alcohol-based hand sanitizer from hands-free dispensers is not carried out and that appropriate spacing between beds (at least 1m between beds) is not carried out. assured.

Concerning the hospital's neonatal unit, the report indicates that several shortcomings were identified:

1. The ratio between the number of nursing professionals and the number of patients is systematically insufficient.

2. Early breastfeeding is not instituted.

3. Policies and procedures regarding the use of multidose medications in the NICU should be developed.

4. Unit dose medications in the NICU are not prepared under sterile conditions by the pharmacy.

5. There is no high-level disinfection policy or procedure for equipment. like laryngoscopes.

6. Limited hands-free hand sanitizer dispensers in NICUs.

Additionally, the report states that violations of personal protective equipment (PPE) protocols were observed in the NICU, indicating the need for improved compliance monitoring and training.

It also noted: “The use of multidose saline vials has been observed, which may lead to an increased risk of infections in patients; infections at surgical and procedural sites have been linked to inconsistent or inadequate skin preparation practices; skin irritation and adverse reactions have been commonly observed in neonates following the use of chlorhexidine baths, indicating the need for milder, pH-neutral or slightly acidic cleansers; and that the preparation, storage, and use of agents used for skin preparation before procedures are made at the pharmacy under unsatisfactory circumstances.