ATC110811: Report Oversight Visit to Cecilia Makiwane Hospital in the Eastern Cape
Report of the Portfolio Committee on Health on an oversight visit to Cecilia Makiwane Hospital in the Eastern Cape, dated 11 August 2011
The Portfolio Committee on Health having undertaken an oversight visit to Cecilia Makiwane Hospital in the Eastern Cape on 28 March 2011 reports as follows:
An infection outbreak at Cecilia Makiwane Hospital culminated in a reported 29 infant fatalities by the end of February 2011. The Portfolio Committee resolved on the 23 March 2011, to conduct an oversight visit to the hospital on 28 March 2011. This report presents key briefings by the hospital management and activities at various visited wards at Cecilia Makiwane Hospital as well as the findings and recommendations by the Committee.
Health is one of the priorities of the country. The Committee visited Cecilia Makiwane Hospital to assess what caused the outbreak and to establish what strategies were used by the hospital to curb the infection in order to prevent it from spreading to other hospitals. One of the Millennium Development Goals is to curb child mortality and maternal mortality by 2015. The Committee thus also wanted to assess if the hospital would meet the Millennium Development Goals as they relate to health, as it was not the first time that a number of infant fatalities had been reported at this hospital.
Dr MB Goqwana, Committee Chairperson (ANC)
Ms TE Kenye (ANC)
Mr M Waters (DA)
Mr DA Kganare (COPE)
The following officials accompanied the delegation:
Ms V Majalamba, Committee Secretary
Mr Z Rahim, Committee Researcher
4.1 WALK ABOUT AT THE HOSPITAL
4.1.1 LABOUR WARD
The Committee visited the labour ward. The Committee learnt that the ward accommodated patients from the whole of Amatole region. The sister in charge of the labour ward informed the Committee that the staff was using very old CTG (cardiotocography) or foetal monitoring machines that were bought in 2007. When asked about human resources at the ward, the sister informed the Committee that the labour ward was short staffed. She indicated that sometimes, the ward only had five professional nurses, instead of ten professional nurses allocated to it. The ward also only had 20 midwives allocated to it, instead of the required 30 midwives. She also informed the Committee that sometimes one midwife had to take care of six patients. The Committee was also shown an old room, that used to be a labour ward, but which was at the time used as a ward for patients who were in the fourth stage of labour.
4.1.2 DELIVERY ROOM
In the delivery room the Committee observed that there were CTG machines and baby receivers for each bed. The delivery room was integrated with the Prevention of Mother to Child Transmission (PMTCT) programme. The Committee learnt that all pregnant women were given the option to have an HIV test. If the test proved positive they were given treatment and follow-ups were made. The sister responsible for the PMTCT programme highlighted that they were dealing with problems of referrals of patients who were never tested early in their pregnancy so that relevant treatment could be prescribed if they tested positive. The Committee expressed concern that referrals that were not tested early in their pregnancy was a sign that primary healthcare was not working well.
4.1.3 NEONATAL WARD 17
The Committee enquired what the causes of fatalities were of the babies that were admitted to the ward in 2006. The doctor in charge of paediatrics informed the Committee that the babies had been on ventilators which stopped working as a result of a power failure thereby causing the demise of the babies. In response to a query about the human resource capacity of the ward, a nurse complained that they were short staffed with only 24 professional nurses allocated to the ward, instead of the required 40 professional nurses. Due to poor infrastructure the nursery unit was also part of the neonatal ward instead of being a ward on its own.
4.14 HIGH CARE UNIT
At the high care unit, the staff informed the Committee that they were always running out of consumables like antiseptic soap and gloves. They indicated that they had to leave the work they were doing in the wards in order to go to other hospitals to ask for consumables. The staff further indicated that they had written numerous letters and raised the issue with the hospital manager but no intervention had been made. The staff also raised their displeasure that they sometimes had to do a management job instead of doing their own. The staff also raised a challenge that they were having with the medical depot which did not deliver on time.
4.15 VENTILATED ICU
On the day of the visit, the Committee observed that there was no ventilated patient in the ICU. Here too the staff raised their dissatisfaction with the unit being short staffed. There was no duty room and sometimes staff had to have their tea next to the babies and monitor them at the same time. The Committee observed that there was a pile of files that were not properly filed in the same ward as the babies. When asked about what implications that had on infection control measures and cleanliness the sister informed the Committee that they did not have space at the time but were trying to get space so that they could move the files and have a proper filling system.
The doctors informed the Committee that there were no towels in ICU at Frere Hospital which is one of the hospitals that forms the East London Complex.
4.1.6 ASSESSMENT WARD
The Committee was taken to an assessment ward. The assessment ward was a 24 hour out-patient ward. It was used for babies that were born small, to have follow-ups and to establish if the babies were coping due to their low birth weight.
4.1.7 NEONATAL WARD 22
The Neonatal ward 22 was moved from ward 18 because it was going to be demolished. The staff also raised the challenge of short staffing. The Committee was informed that there were nine sisters covering the day shift instead of the required 15. The nursing staff also informed the Committee that the ideal situation would be to have one nurse for each occupied bed. The ward was also used as a nursery. The Committee was also shown the Kangaroo Mother Care Unit, which was also part of ward 22. Babies who did not need ICU were admitted to the ward. The challenge that was highlighted by staff was that mothers were coming to the hospital without being referred. They also informed the Committee that they sometimes had very young mothers, most of them 16 years of age, but some were 12 years old.
4.18 LODGER MOTHER ROOM
Mothers who were at the lodger mother room were the discharged mothers who were waiting for their babies who were still admitted in hospital. They were waiting closer to their babies so that they could take care of them and breast feed them. The Committee observed that the sister who was responsible for the ward seemed very passionate about what she was doing. The only challenge that the staff mentioned was that because they sometimes admitted Somalian mothers who were now living in South Africa, they also had to provide temporary lodgings for their husbands who acted as interpreters as the mothers could not speak English. This was raised as a serious challenge for other patients who were all females and who had to share the ward with men.
Having completed the tour of the different wards, the Committee had a formal meeting with the nurses and doctors working at the above wards.
4.2 MEETING WITH THE DOCTORS AND NURSES AT THE HOSPITAL
The Committee met with the following doctors and nurses at the hospital:
Ms N Nyundo: Professional Nurse
Ms B Neti: Professional Nurse
Mrs F Jakeni-Gomba: PMTCT Coordinator
Dr Selanto: Specialist (Maternity)
Miss P Barney: Operational Manager
Ms L Madosi: Professional Nurse
Ms T Mazamisa: Nursing Manager (ICU)
Ms N Wellel: Neonatal Sister
Ms N Binqela: Professional Nurse
4.2.1 CHALLENGES RAISED BY THE DOCTORS AND NURSES
The doctors and nurses raised the following challenges:
- There was a shortage of staff in all the wards visited by the Committee.
- The wards were always out of consumables, such as gloves, paper towels, soap and sprays. Sometimes they had to wash gloves and re-use them. The Doctor complained that she had to go to Keiskamahoek with her car to ask the hospital there for gloves and CTG paper.
- The hospital had a shortage of supplies, such as syringes and ET cubes. Sometimes staff had to wash, sterilise and re-use them.
- There were always no CTG papers which made it difficult to induce patients. Beds were always full because of the patients who were waiting to be induced.
- There were no Ivec pumps.
- The hospital had a shortage of drugs, like Betamol.
- There was no budget for the PMTCT programme.
- The HIV directorate in the province was not supporting the PMTCT programme.
- Sometimes the PMTCT programme did not have nevaripine and patients sometimes had to be discharged without it.
- There was overcrowding at Frere and Cecilia Makiwane Hospitals.
- The issue of not having a proper family planning clinic was raised as a serious challenge. The hospital was dealing with unplanned pregnancies and had to do 4000 terminations every year. The doctor indicated that even those patients who delivered their babies, had not planned their pregnancies. Mr Mosana urged the Committee to look at the whole health system and to consider the issue of having an onsite midwife unit at both Frere and Cecilia Makiwane hospitals.
There was a sense of high frustration amongst the staff over the unavailability of the Pharmacy Deputy Director, who was frequently unavailable, which impacted negatively on patients because they couldn’t get hold of important drugs like Betamol which was used to reduce high blood pressure in pregnant women.
The staff also felt that the hospital management did not support them, as they had not received any responses to the letters that they had written to the management raising their challenges with the bad condition of the hospital.
4.2.2 MEETING WITH AND RESPONSES BY THE HOSPITAL MANAGEMENT
The Committee met with the following senior hospital management officials:
Mr L Mosana: CEO, East London Hospital Complex
Dr G Boon: Head of Department – Paediatrics and Child Health
Dr L Galo: Manager - Medical Services
Dr NN Qangule: Director - Hospital Services Manager
Ms N Mnyamana: Assistant Director - O&G Department
Ms E Tonono: Director – Facilities Management
Ms N Mabele: Director – CSL
Ms N Tyalisi: Assistant Manager
Ms N Tshangana: Assistant Manager
Ms L Maqaqa: Deputy Director
Ms N Nxelewa: Deputy Director
Ms M Ndwandwe: Deputy Director
Ms J Scholl: Senior Deputy Director - Clinical Support Services
Mr PM Mhlaba: Information Manager
Ms T Nonhonho: Manager - Hospital Services Manager
Ms N Ntushelo: Human Resource Manager
Ms L Vara: Human Resource Development Manager
Ms P Fongoqa: Assistant Manager - Infection Control
Mr D Sixishe: Nurse Manager
Ms D Matebeni: Nursing Manager Complex
Ms M Mazamisa: Nurse Manager - ICU
Mr M Bomeni: Manager - Labour Relations
Mr M Nkwali: Administrative Officer - Security Management
At the meeting with the Management officials of the hospital, the above challenges cited by the hospital staff were raised. The following formed part of the hospital management’s responses to the challenges raised by the staff:
a. In responding to the issue of staff shortages, the CEO informed the Committee that it was a long bureaucratic process to fill positions. He stated that the hospital had lost some nurses because they had accepted other job offers because the filling of vacancies took too long.
b. In responding to the budget constraints faced by the hospital, the CEO informed the Committee that, the budget was taken from the hospital and allocated to the Frontier Hospital which was facing a crisis at the time. He stated that the hospital management had not agreed with the process but the money was taken anyway. He also indicated that their request that funds be shifted back to the hospital had not been acceded to.
c. In responding to the issue of the medical depot, the CEO informed the Committee that they had written proposals to the head office about the dysfunctional pharmaceutical depot. He also mentioned that some of the challenges faced by the depot were pure organisational issues.
d. In responding to self referrals, the CEO indicated that there was only one community health centre in the area of Mdantsane.
e. Ms Maqaqa, who was the Deputy Director responsible for health quality assurance informed the Committee that they were committed to serving the people. She told the Committee that infection control was a priority and indicated that the hospital management had introduced stakeholder meetings on infection control in January 2011.
When asked by the Committee if the management of the hospital had an open door policy where staff could report at any given time, the CEO indicated that the management did interact with staff. He also highlighted that maybe due to the high levels of frustrations experienced with work challenges, staff may tend to do things as per normal and not report them on time. He mentioned that sometimes he also went out personally and borrowed consumables from other hospitals.
THE FOLLOWING WERE PRESENTED BY THE CEO AS CHALLENGES FACING THE INSITUTION:
Ø Funds taken from institutional budget to other institutions.
Ø Funds shifts not done instantly.
Ø Staff shortages and lengthy bureaucratic appointment processes and even appointment of nurses going to head office.
Ø Dysfunctional Pharmaceutical Depot.
Ø Dysfunctional Primary Health Care and only 33% provided in the catchment area.
Ø Family planning lacking.
Ø Work overload impacting badly on staff.
Ø Patient self referral and the general burden of disease.
The following solutions were proposed:
Ø Implementation of a Referral Strategic Operations Procedure.
Ø Implementation of the outreach programme.
The Committee having finalised its oversight visit concludes that the baby deaths happened and could have been prevented. These happened due to the following:
Ø Staff shortages in all visited wards.
Ø Equipment shortages.
Ø Running out of consumables which could lead to infections spreading from one patient to another.
Ø Overcrowding in the wards which also results in the spreading of infections.
Ø No infection control strategies.
Ø Patients going to the hospital without being referred.
Ø Significant numbers of teenage pregnancies.
Ø High numbers of termination of pregnancies due to unplanned pregnancies.
Ø Primary health care not functioning well.
Ø Budget constraints.
7. RECOMMENDATIONS BY THE COMMITTEE
The Committee recommends the following:
Ø The Department should attend to the issue of staff shortages as a matter of urgency.
Ø The Hospital should make sure that it has the relevant equipment.
Ø Running out of consumables should be avoided at all costs and the hospital must always make sure that there are enough consumables to run the hospital. This will also assist in the prevention of the spreading of infections.
Report to be considered
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