The Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) said it has taken several measures to control the recent outbreak of Healthcare Associated Infection (HCAI) at the Neonatal Intensive Care Unit and prevent similar outbreak in future.

According to a press release from JDWNRH, the hospital’s management met on October 1 to discuss the implementation of the recommendations of the Interim Government (IG). This was in response to the IG’s letter to the hospital for immediate implementation of short-term recommendations related to the recent outbreak of HCAI.

It states that the mothers of all nine babies who died in the NICU because of HCAI in the hospital between July 23 and August 6 this year, were referred from district hospitals due to pregnancy related complications. They had to undergo emergency caesarean section.

The babies were born preterm with low birth weight of less than 2kgs, which required them to be admitted in the NICU. The babies were in severe medical conditions and increased medical procedures performed as required would have put the babies at higher risk of acquiring infections, the press release states.

“Cleaning environment with substandard disinfectant,  understaffing and less trained staff, overcrowding with visitors, inadequate infrastructure and poor compliance of the parents in sterilising feeding materials could have been some of the contributing factors which have put babies at higher risk of infection,” it states. “The other probable cause was water contamination in JDWNRH.”

Daily chlorination of its water tank and regular monitoring of the water quality by the Royal Centre for Disease Control (RCDC), installation of three-stage UV water filter in NICU, strengthened monitoring and supervision on compliance of infection prevention and control practices among staff and attendants are some of the measures taken by the hospital to prevent future outbreak.

The other measures include frequent meetings of the stakeholders to update the outbreak situation and implementation status of the recommendations, environmental surveillance with help of RCDC, restrictions of visitors by deploying security personnel at the entrances of all ICUs, antibiotics stewardship, and liaising with other stakeholders.

Interim Government’s recommendations

The following are the IG’s short-term recommendations for immediate actions, which the hospital had discussed and endorsed:

Considering the urgent need of infection control unit at JDWNRH, the press release states that the hospital wrote to the Royal Civil Service Commission (RCSC) for the approval of setting up the unit and the required staff strength in 2017. The commission instructed the hospital to wait for the approval of the 12th Plan Human Resources standard.

While the hospital had trained six nurses in infection control for a week to 10 days, currently, infection prevention and control practices of JDWNRH was being looked after by a focal person, Deputy Nursing Superintendent. It is an additional responsibility to her daily overseeing of nursing administration and management, it states.

“There was no dedicated nurse to look after the infection control practices in the wards and other units while the focal person had to carry out patient care like other nurses. This could have led the focal person to be less effective,” it states. “Therefore, an infection control unit has to be institutionalised as early as possible to prevent such incidences occurring in future.”

The hospital already has a Standard Operating Procedure (SOP) for cleaning and the ward and unit in-charges would strengthen the monitoring of the cleaning and compliance of the SOP.

The in-charges of the concerned unit and maintenance division would work together to ensure that water stagnation and blockage of drainages were cleared immediately. The press release states that with the current hospital infrastructure design, it is difficult to relocate the handwashing basin as recommended by the IG because of lack of space in the critical units.

“To install a dedicated handwashing basin inside the unit would require closing of the unit for at least seven to 10 days which may cause inconvenience to the babies requiring admission both within Thimphu and from the districts,” it states. “However, the maintenance division will revisit the space and explore ways to do this if possible.”

The hospital’s maintenance division would ensure that daily chlorination of the reservoir tank and water quality testing by RCDC is being carried out without fail. The division would develop SOP on maintaining safe drinking water in coordination with RCDC and Quality Assurance and Standardisation Division at the hospital.

The IG recommended to accelerate procurement of infection control material and provide consistent and adequate supply. Regarding the inconsistent supply of bleaching powder, the press release states that the problem in supply had occurred due to some packaging problem. “The procurement division places the purchase order based on the annual requisition put up by the Unit and ward In-charges with certain percentage added to that in order to last for the whole year.”

However, it states that often, quantity purchased of few items like hand sanitiser is not adequate for the whole year. The problem occurs when the additional quantity is ordered where the procurement cycle has to be followed as per procurement rules which delays the supply of the item on time. To prevent such shortages, it states that the procurement division would strictly monitor the stock balance and maintain buffer stock within the maximum permitted limit, recommend alternative disinfectant to be included in the standard list of consumables, infection control focal person and the ward in-charges would be responsible for the effective management and monitoring of the usage of the disinfectants.

During a meeting yesterday, the hospital recommended the chief procurement officer to include bleaching powder in the drugs list to ensure quality.

“Bleaching powder had been removed from the 2016-2017 essential drug list since it does not fit in the definition of essential drugs and also that Bhutan Health Trust Fund supports fund only for essential drugs.”

It states that since bleaching powder is procured by the health ministry, the hospital would write to the ministry to consider re-including bleaching powder under drug list so that like any other drugs, bleaching powder is also tested regularly for quality.

Strict crowd control measures have also been put in place with additional security guards in different designated areas of the hospital.

Besides the security services, biometric doors and CCTV cameras installed, it was difficult to control the access of people to the ICUs, wards and cabins.

“During the recent bacterial outbreak, we had to pull out some security guards from some other areas to the ICU as an interim measure,” it states. The hospital would soon deploy some additional security guards for the ICUs, psychiatric ward and other critical areas to strengthen the security services. “Required staff will also be recruited to work as lift operator to monitor the bed lift. Visitor lift will be made available only during visiting hours to restrict the visitors.”

The maintenance division would ensure that all biometric doors are functioning including closing well on its own because people often do not bother to close the door properly.

Dechen Tshomo