The lack of personnel last winter at the Birthing Pavilion of the Anna-Laberge Hospital Center in Châteauguay forced the arrival of several inexperienced nurses. The supervision of these new professionals “was not sufficient to ensure safe care and services for users and newborns,” concludes a new report from the Québec Ombudsman, which notes, among other things, an increase in epidurals.
Posted at 5:39 p.m.
The Québec Ombudsman conducted an investigation between the 4e and the 5e pandemic wave, last winter, at the Anna-Laberge Hospital Birth Pavilion. This investigation was triggered following “worrying reports” evoking a “lack of staff training” which “would compromise the quality of services”, can we read in the report.
The document, dated April 26, 2022 but released on Tuesday, explains that there was a lack of qualified personnel at the Birth Pavilion at Anna-Laberge Hospital. The pandemic had forced the shedding of employees, especially those in advisory positions. There have been retirements and sick leave. The newly hired staff lacked training, which led to various problematic situations.
Not the right oxygen mask
The report explains, for example, that the 20 rooms in the birth pavilion were not always well prepared. There was sometimes a lack of equipment, such as tubing to suck the baby’s secretions after birth. When a slightly premature newborn was born, “we couldn’t find an oxygen mask in the room that suited his size.” “As he needed resuscitation care, the staff had to find a smaller mask on the spot,” writes the Protector, who adds that “this situation is worrying since it inevitably led to a delay in the care of this newborn in respiratory distress”.
The organization of work in the Birthing Pavilion meant that two nurses could together take care of a woman giving birth and 5 to 6 postpartum patients. This way of doing “does not ensure continuous monitoring of the mother during childbirth”, it is written.
The Protector points out that of the 40 medical records he analyzed, 85% of women who gave birth without a caesarean had recourse to an epidural. “The establishment confirmed to the Québec Ombudsman an increase in the number of epidurals in the last year and mentioned that it was necessary to train new staff more about the assessment and relief of pain during childbirth. », is it written.
Lack of follow-up
The lack of follow-up on certain important postpartum elements was observed by the Québec Ombudsman. For example, “on more than one occasion, a bottle-fed newborn did not drink enough in a 24-hour period, due to lack of follow-up by nursing staff and education to parents “.
In one of the files analyzed, a baby who had to have his blood sugar checked every three hours did not have checks until after ten o’clock, then seven o’clock. “The medical notes state that the newborn did not have his last blood sugar check ‘because they rang and no answer.’ The staff note explains this delay by an increase in work. However, it is essential to answer the call bells of families in order to verify the urgency of the request, ”it is written.
The lack of training of staff at the Birthing Pavilion also meant that some blood samples taken from the heels of newborns were performed incorrectly and had to be repeated. However, this blood test is described as “traumatic and painful for newborns […]. It is therefore essential not to repeat it unnecessarily,” notes the Québec Ombudsman.
The latter points out that during the pandemic, the new nurses had learned the technique of taking blood from the foot by teleconference. “Staff lacked practical training,” it says.
In his conclusions, the Québec Ombudsman emphasizes the hospital’s full cooperation in the procedures. Changes have already taken place. For example, a synthetic foot is now used to train nurses in taking blood. The Québec Ombudsman nevertheless made 15 recommendations to the establishment.
CISSS reaction
The CISSS de la Montérégie-Ouest says it takes the report of the Québec Ombudsman “very seriously”, but specifies that the investigation took place in the midst of a pandemic, when the staff shortage was “exacerbated”. “The quality and safety of care being a priority, our teams are in action to implement all the recommendations as soon as possible”, indicates the head of media relations, Jade St-Jean.
It emphasizes that “actions have been identified for all the recommendations and the majority are in progress, particularly with regard to the development of clinical tools and the improvement of the training offered to staff”. Audits are also planned to “ensure the sustainability of actions”.