THE DIRECTOR OF Ireland’s busiest maternity hospital has warned of an “intolerable patient safety crisis” due to overcrowding and poor infrastructure. 

The Master of the Rotunda in Dublin’s north city centre said the hospital’s “patient safety situation has deteriorated”, raising concerns about the institution’s ability to contain further risks and the ability to guarantee the safety of premature babies in its care. 

Professor Fergal Malone’s warnings to Health Minister Simon Harris were included in a letter obtained under Freedom of Information by Noteworthy, the investigative journalism platform from TheJournal.ie.

In the letter dated 10 May 2019, Malone describes how the Rotunda’s neonatal intensive care unit (NICU) was forced to close due to “another” outbreak of a multi-drug resistant organism. At the time of writing the letter, he said the hospital had been struggling to contain this infection, identified as “ESBL-producing Klebsiella”, for six weeks.

In the letter to the Minister, Malone states;

• Eight premature babies have been affected to date
• One baby which had been infected had died after 25 weeks’ gestation – the exact cause of death is yet to be determined by the Dublin City Coroner
• Three other babies developed an invasive infection with this bacteria – two with meningitis, and one with sepsis and necrotizing enterocolitis – an inflammatory bowel condition

The principal factor in the spread of this infection, according to Malone, is overcrowding. 

‘Major concerns’ 

Speaking about the lack of space, Malone described how many of the Rotunda’s most critically-ill premature babies are being nursed in incubators less than one metre apart, making repeated infectious outbreaks “virtually inevitable”.

Each NICU cot area should have 16m2 of space but according to Malone, the Rotunda can only provide 5m2 of space for each baby’s care.

Given the mortality and severe morbidity that has already occurred, we have major concerns regarding our ability to contain further risks and our ability to guarantee the safety and wellbeing of babies admitted to the Rotunda.

The NICU at the Rotunda is a tertiary referral centre and provides specialist care not only
to babies born in the Rotunda but also to small and/or sick babies delivered at other hospitals throughout the state.

According to the HSE’s model of care for Neonatal Services, adequate space is important to reduce cross-infection between babies, and there are minimum acceptable distances between intensive care cots.

Rotunda Annual Report 2017 Rotunda Annual Report 2017

The issue of incubators being spaced too close together appeared in the Rotunda’s annual report back in 2017, which made it an “exciting yet challenging year for the neonatal intensive care unit”.

“The difficulties of running a very busy NICU within the confines of very outdated physical infrastructure really came to the fore,” the report states.

It goes on to detail how, despite the highest levels of hospital hygiene practices, the hospital “suffered multiple serious infection outbreaks” over the year.

With incubators spaced too close together, it is almost inevitable that further infectious outbreaks will occur. These major infrastructural challenges are compounded by low nurse-to-baby ratios within the unit.

It was also a challenge mentioned in the annual report for 2016.

We continue to operate in a unit not fit-for-purpose with significant infrastructural challenges including inadequate spacing between cots, a lack of isolation rooms, a lack of a parent counselling room.

In August 2017, work began on a new four-bed extension to the special care area, followed in January 2018 by a renovation and modernisation of the remaining NICU which was completed by December. 

Despite these recent refurbishments, ideal incubator and cot spacing could not be achieved in the NICU due to “space restrictions”, according to the latest edition of the Rotunda’s newsletter, Rotunda Delivery.

‘Precarious position’

The Rotunda’s NICU remains closed to babies under 32 weeks’ gestation. This has led to many mothers and babies being transferred to the National Maternity hospital at Holles Street and the Coombe Women and Infants’ University hospital.

Malone stressed in his letter to Simon Harris that the Rotunda’s sister hospitals will not be able to support the volume of patient transfers for much longer due to their own clinical demands.

“The national neonatal intensive care capacity is therefore in an extremely precarious position due to out infectious outbreaks and physical infrastructure limitations,” Malone said. 

Over the last three years, he says the Rotunda has introduced a number of innovations and quality improvement projects to mitigate these risks, but the hospital has arrived at a situation “where infrastructural works remain the key patient safety piece remaining to be implemented”.

With additional reporting from Ken Foxe and the team at Noteworthy.ie – find out more about their work here.