While hospital officials claim that the death of eight babies at the Neonatal intensive care unit (NICU) at the national referral hospital, Thimphu was not due to hospital-acquired infection (HIA), the parents claim otherwise.
Parents Kuensel talked to say that about eight babies died between March 11 and first week of April at the NICU.
Medical superintendent, Dr Gosar Pemba, said that the recent death of babies in the NICU reported in the media were not because of hospital-acquired infection.
According to the hospital records, seven babies died in March, two in February and nine in January.
“When you say outbreak, the cause of the death of all babies should be a particular bacterium like in the earlier case where it was Klebsiella,” Dr Gosar Pemba said. “This time, the cause of the death of all babies was their primary infection because of which they were admitted to the NICU; and primary infection could be from anywhere.”
During their stay at the NICU, the parents said that they noticed poor hand hygiene among health workers at the NICU.
A parent said that parents and attendants were advised and informed of hand hygiene by the hospital staff and the parents were strictly complying with it.
However, he said that the staff are observed to be touching one baby after another and not using hand sanitiser or hand rubs. This, the parent said, was transmitting infection among children causing sepsis, shock and death.
Another parent said there was excessive handling of babies by the staff. The parent said the babies were touched at least about two to three times an hour on an average, which increases their risk to infection and hypothermia.
The parents claimed that there was no dedicated specialist at the unit over a course of treatment and the examining health workers are either paediatricians or residents and not specialised in neonatal or preterm babies. “They carry out the treatment and intervention posing an increased risk of wrong diagnosis and wrong treatment.”
The parents also claimed that trainees from the Faculty of Nursing and Public Health were frequently carrying out some investigation without the supervision of seniors. “Newly passed out nurses should limit the insertion of needle (cannulation) on babies as their blood vessels are very small and they have difficulty to cannulate.”
Dr Gosar Pemba said specialist doctors are posted to the seven units of the pediatric department. The resident doctors, he said provides 24/7 service to the patients and this has improved service delivery at the hospital.
Parents also alleged that they were not informed of what was happening with their babies because of which they doubt the doctor’s competency. Delayed response to death/ serious health problem and harsh behaviours of some of the staff were other complaints.
When parents of babies admitted in NICU asked the staff regarding rampant deaths, a parent said that they did not respond well. The NICU was emptied and cleaned with some chemicals only after the death of the fourth or fifth baby.
A parent of the baby who died on April 4 had questioned the hospital staff for intubating his child without their permission. To this, Dr Gosar Pemba said that when the doctor was informed of the baby’s condition, the parents were not at the hospital.
The parent claimed that his baby’s health started deteriorating after the baby had a transfusion of a unit of blood for the second time. “After that, the baby started swelling and did not move.”
Dr Gosar Pemba said that after the doctor found that the baby was having difficulty breathing and turning blue due to lack of oxygen in the blood, the doctor immediately tried to help the baby to breath using a bag-mask ventilation but the baby’s condition did not improve.
The next step in such a situation is to insert a tube into the trachea of the baby and connect to a breathing machine to help the baby breath and increase oxygen in the blood, he said. “If quick intervention is not done the baby could suffer brain damage and the heart could stop from lack of oxygen within three to four minutes.”
He said this is an emergency situation and the doctor is duty bound to perform what is in the best interest of the patient.
Of the seven babies that died in NICU in March, four are delivered through caesarean, two referred from district hospitals and one baby had a normal delivery. All were born preterm before 33 weeks.
The hospital said that on an average about two to nine babies die every month, depending on how many babies with serious or complicated health problems were born in a month.
Dr Gosar Pemba said critical babies are referred to the hospital either by ambulance or helicopter and admitted at the NICU. All pregnant women with pregnancy-related complication are also referred to the hospital and most babies are delivered through C-section.
He said that babies who are born preterm and babies born to mothers with pregnancy-related complications are high-risk babies and develop complication. He said many such babies do not survive. “This is why the death rate among babies in JDWNRH is usually high.”
According to the hospital’s record, about 59 babies were admitted at the NICU between January and April, this year. Of this, about 17 babies (28 percent) died. Of a total of 208 babies admitted to the NICU last year, 53 preterm deaths (25 percent) were recorded.
Dr Gosar Pemba said that Bhutan Medical and Health Council is the right place to file a complaint and not the media. The Council, he said, has the authority and the mandate to investigate any issues related to clinical things in the hospital, not the media.
“They should consider the negative implication on the morale of the staff. While there may be some staff who are harsh to the patient and the attendants, more than 90 percent of the staff are doing a very good job,” he said.
Lyonchhen Dr Lotay Tshering said that while every death should be accountable, there was no increase in the number of deaths at the NICU. “For a super specialty hospital and a national referral hospital, one good indicator of the hospital’s performance is the performance of neonatology unit.”
During the AM to PM session with the JDWNRH management including the pediatricians last week, he said, the hospital management shared the problems they have had and the shortcomings in terms of infrastructure and human recourses affecting service delivery at the hospital.
He said JDWNRH has high neonatal deaths compared to international standards. Most of the babies that died at the NICU in the last two years were preterm and almost all were referral cases.
“There is no alarming increased death rate. Yet, I told the hospital administration that we cannot be complacent and to come up with strategies that will further minimise the death rate,” Lyonchhen said. “We are concerned.”
An independent investigating team with at least three heads including a doctor, a non-doctor and a paramedic would carry out the investigation into the case. Lyonchhen said the findings would be shared.
Lyonchhen said that none of the nurses working at the NICU is trained for the unit because of lack of fund. “Still, they are trying their best.”
He pointed out that after last years’ case where 11 deaths were reported at the NICU, some of the nurses went into depression and few are on medication. “They want to switch the unit saying they cannot work there but we cannot find a replacement. Given the choice, they all want to move out of the unit.”
“I don’t know how much good the media coverage last year made to the system but the damage is that the nurses there are thoroughly demoralised,” Lyonchhen said.
On the tracheal intubation that is done to help the baby breathe artificially, Lyonchhen said it has to be done very shortly and rapidly and when the indication is clear, consent is not sought because you are fighting for life.
Lyonchhen said the doctor who inserted the tube into the baby’s body was made to look like a killer. “I am sure the doctor lost a few nights sleep because deep down what he did was right. He did it with the intention to save the baby’s life but he couldn’t and the hospital is blamed”
Since the hospital doesn’t have a dedicated neonatologist, Lyonchhen requested the department to keep a paediatrician dedicated for the neonatal unit round the clock.
The hospital has only one operating room for emergency cases including the C-section. “If some emergency surgery is going on, the mother who requires to undergo C-section have to wait and that waiting will endanger a baby’s life. We call it fetal distress.”
Lyonchhen requested the hospital to have an operation theatre dedicated for C-section. “Even if we cannot do the routine cases, it is okay. The implication would be that gallstone and kidney stone patients would now have to wait longer for the surgery.”