Highlights — 31 May 2013 — by Miriam Longsworth
“No one” responsible!!

13 infant deaths at KHMH, but investigation only blames “several factors”

The Karl Heusner Memorial Hospital (KHMH) management held its second press conference today, Thursday, to update the public on the investigation into the multiple neonatal deaths caused by an organism outbreak in the neonatal intensive care unit during the first 22 days of this month.

The key messages of the meeting were that no one is to be blamed for being the source of the bacteria outbreak and that the investigation is ongoing.

Within the first 22 days of May, 13 babies died at the KHMH. The initially reported number of deaths was 12, but one more baby died on May 22, increasing the toll to 13. We were told that that baby was admitted into the hospital already ill and was tested negative for the organism.

The first organism outbreak-related death occurred on May 10. The NICU was not allowed to admit any more babies into the unit after that date.

Dr. Adrian Coye, Director of Medical Services at KHMH, said they are still trying to put together a list of factors related to the outbreak. But some of those factors are obvious and include overcrowding of the unit and the lack of specially trained nurses to work in the unit.

He added that risk factors of pregnancies also contributed to the situation. Coye said 92 percent of the babies were pre-term, meaning that they were born before reaching 38 weeks of gestation, and 46 percent of them had very low birth weight, some being less than one kilogram.

Coye said a lack of antenatal care also contributed to the condition of some of the babies. Poor antenatal care can cause urinary tract infections in the mothers, putting the babies at risk for prematurity.

“It was recognised by members of the [medical] team that babies were becoming septic and becoming unwell very quickly,” Coye said. “‘Sepsis’ meaning they weren’t feeding well, having short[ness] of breath. It was recognised [that] all these babies that come to our unit were sick babies and they can’t not go to unit because they’re sick, because it’s a special care unit. So they were treated empirically to rule out what we presumed [to be] sepsis and as the clinical course became evident, more babies were becoming septic and dying,” he further explained.

Coye said that they began to look into the situation after the third death, but during their testing, more babies died.

Coye defended his staff’s work, saying that they are not given enough recognition for the good they do.

“It is easy to see the wrong; it is easy to say they don’t have this, they don’t have that, and I’m challenging you as a country to see the other side,” he said. “This is a small unit; we’re asked to do so much – 450, 500 babies a year with a capacity that should be for 10 babies but we do 20 sometimes and I’ve seen miracles, I’ve seen excellent work. And when all those successes are happening, no one says anything,” Coye went on to say.

Epidemiologist for the Infection Control Program in the Ministry of Health in Chile, Dr. Ricardo Bustamente, was sent by PAHO to be a part of the investigation team. He said that the hospital reacted to the situation in a timely manner.

“Sometimes it is not easy to identify an outbreak and here you had an outbreak that started in a very short span of time,” he said. “Most of the time it happens that doctors start treating them but not really aware that this would correspond to a common source of infection. The approach done here was done in a timely manner,” he said.

We were told that this is not the first time that the bacteria has been detected among patients in the hospital, but the situation had never escalated to the point where there were fatalities. All the other cases were treatable because the organism can appear in sub-forms.

For this year, the first appearance of the organism was in February, but the baby was treated and discharged. The unit was closed and cleaned before more babies were admitted.

Due to the outbreak this month, the unit was officially closed for operations on May 20. We were told that the unit will remain closed for about another two months while upgrades are ongoing.

The management has informed us that the hospital is working toward meeting several recommendations to improve the overall operations of the institution.

Also present on the panel at the press conference were Prime Minister Dean Barrow, Minister of Health Hon. Pablo Marin, CEO of KHMH Dr. Francis G. Longsworth and Chairlady of the Board of Governors at KHMH Chandra Nisbet-Cansino.

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