BABY- FRIENDLY NURSERIES

How to prevent and manage infection outbreaks in the nursery

By Michelle Ciriacruz

When you talk of an infection outbreak in the nursery, we need to consider two things," University of Perpetual Help Hospital medical director Arcadio Tamayo points out: that the microorganisms or agents causing the infection may have either come from the hospital surroundings, equipment, personnel or it may have come from the mother herself.

    Textbook of Pediatrics and Child Health by del Mundo et al. confirms that in babies who died of infection and were autopsied, the infections were diagnosed to be either intrauterine infection or acquired, during delivery or after birth.

    If the infection was transmitted maternally, either the mother was already suffering from an infection like hepatitis A, or the microorganisms normally present in her vaginal tract, upon contact with the baby's less adequate immune system, suddenly turned opportunist.

    Common microbes like Escherichia coli, Klebsiella, Enterobacter, Proteus species, and Pseudomonas aeruginosa also become common agents in the infection of the newborn, as nursery equipment become inadvertent carriers.

    Infections usually involve the skin, bacteremia, and pneumonia, with low-birth-weight infants in neonatal intensive care units more susceptible to nosocomial infections than normal full-term infants.

    Tamayo cites, however, the difficulty in ascertaining which of these likely sources of infectious agents is the real culprit. "The pediatricians (or neonatologists), as well as many hospital administrators, find it very difficult, even with its infection control committee, to distinguish whether it is a hospital-[acquired] or nosocomial infection, or it is the mother."

    Generally, early onset infections are likely contracted from the mother, but if the infection develops later than 48 to 72 hours after birth, it is viewed as nosocomial.

    Tamayo says there is still lack of precision in the delineation of infections; so to simplify matters, the US Center for Disease Control and Prevention has "defined all neonatal infections, whether acquired during delivery or during hospitalization as nosocomial-unless evidence indicates acute acquisition."

    Which policy our own Department of Health has adopted, he reports.

    This places much of the burden of guilt for any infection contracted by a newborn during hospital stay on the hospitals. But Tamayo explains that strict implementation of the policies for prevention of infection in the nursery could and does minimize the incidence of infection among newborns.

    These precautions, in a way, also help hospital personnel rule out which infection was transmitted maternally and which was truly nosocomial.

    Tamayo emphasizes the observance of basic infection control, like handwashing, and nursery design, which has evolved through the years towards where overcrowding is avoided and proper equipment and nursery procedures take integral roles.

    "The way we design the nursery now is so that cross-infection will be prevented," he clarifies.

    UPMHC's infection control policies and procedures manual stresses the importance of providing adequate space between and around the newborn's crib or bassinet. This is to allow free movement for the nursery personnel and to give way for the necessary equipment and strategically placed sinks.

    In the design of the nursery, these should be observed:

•     For normal newborns: a space of 30 square feet per neonate with at least three feet between bassinets; for infants requiring intensive care: a space of 50 to 60 square feet per neonate with at least five feet between bassinets.

•     A sink to be placed for six to eight normal newborns; three to four in the intensive care unit (ICU).

•     Proper ventilation with efficient filters against dust.

•     An isolation room in each nursery for special cases.

    Adequate staffing should be prioritized as well:

•     One nurse for every three to four normal newborns; one for every two in the ICU.

•     Strict adherence to routine procedures:

•     Initial hand washing lasting two to three minutes; 15 to 20 seconds in between patient care (hand, arms to above the elbows).

•     Wearing of special attire-For nursery personnel: scrub suits, caps, an overcoat upon leaving the nursery; a separate footwear inside the nursery; For mothers who will breastfeed: clean gown and cap.

•     Decontamination and cleaning of all equipment in contact with the infants; keeping equipment, furniture, and fixtures dust-free; daily cleaning plus a twice-a-month general cleaning; changing of linen twice daily, especially if soiling occurs.

    Surveillance and monitoring involve the daily review of the newborn's progress. Measures of quality care are also taken daily.

    Tamayo explains that each hospital should have an infection control committee that makes sure these policies are enforced and that could recommend additional preventive measures. He says UPHMC's committee recommends fumigation of the hospital's nursery once a month.

    Before the babies are evacuated, however: "We have to fumigate another private room. It takes us about two to three days at the most to have the nursery again prepared."

    Ultraviolet light is also one of the things the hospital uses to keep the room sterile.

    And if, indeed, a case of nosocomial infection is detected in the nursery, like an outbreak of salmonella: "Scrub-down kami talaga, which means we have to scrub the walls all the way, and the floor."

    Isolating the infected infants from the other infants and the appropriate antibiotic treatment also quickly follow. The purpose of isolating the patients is to limit the transmission of the infection, relates Tamayo.

    Tamayo says the health of nursery personnel must also be screened and monitored to prevent cross-infection between personnel and their nursery wards. Even those with just the common cold will not be allowed any direct contact with the newborns.

    Tamayo says they are advised to take a leave of absence. However, there will always be those, he concedes, who will deny their ill health and still come to work. "This is where the supervisors (head nurses and department heads) will have to be very keen in observing people who are now hiding all of these (symptoms of ill health) from them."

    In terms of responsibility, if upon investigation by the hospital administrators and the infection control committee, the personnel was found to have intentionally and maliciously disregarded the hospital's policies, appropriate sanctions would take into effect.

    "Of course, the sanctions will have to be varied from whatever the situations were," Tamayo qualifies.

    He points out that it makes it a different story if the personnel acquired his illness suddenly or in the course of his hospital duty. There is also the additional complication of incubation periods, making it sometimes difficult to catch the disease before it enters the infectious stage.

    "In other words, the measures are in place, the policies are set. Whether these are 100-percent-to-the-letter being implemented, I can only speculate and tell you, we try our very best," he comments.

    Presumably, tertiary hospitals would be the ones with the resources and the discipline to strictly follow and maintain these safety rules, but Tamayo says he is worried more whether some government hospitals, where babies are being born in ever increasing numbers, are able to carry out the necessary procedures with regards to infection control.

    He says primary or secondary medical care institutions do not experience the influx of babies that government hospitals are forced to endure. "They will not even have the nurseries filled up," he points out.

    But in a more crowded scenario: "Imagine mo na lang, if you have like 50 babies in one nursery, tapos iilan lang kayong staff. Then if you have like 10 or 15 babies [in your care], you have to wash your hands 10 or 15 times, every time you will care for the babies-but that's supposed to be the rule," stresses Tamayo.

    With the current state of our health care and delivery system, and funds for the maintenance of our government hospitals running low, the answer to this dilemma could very well echo what Tamayo stated earlier: they will try their very best.

    Whether this proves sufficient in the nursery care setting, unfortunately, the lives of our newborns are the stakes.