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Implementation of a Bubble CPAP Treatment Program for Sick Newborns in Nakuru, Kenya: A Quality Improvement Initiative.

ABSTRACT: Introduction. Respiratory distress (RD) contributes to common causes of neonatal mortality. Bubble continuous positive airway pressure (bCPAP) is a safe, low-cost therapy for RD; however, adoption of bCPAP programs remains challenging. Aim. To increase the percentage of neonates with RD treated with bCPAP from 2% to 25% by January 2019. Methods. In the newborn unit (NBU) at the Nakuru County and Referral Hospital in Kenya, a pre-initiative (pre) period (March 2016 to December 2017) and a post-initiative (post) period (January 2018 to December 2018) were defined. Tests of change included organization of infrastructure, staff trainings, development of a nurse educator role, and treatment protocols. Clinical and outcome data were abstracted from all available medical records. Results. A total of 405 infants were included in the pre group, with 2% bCPAP use. A total of 1157 infants were included in the post group, with 100 (17.6%) treated with bCPAP. bCPAP use increased during the post period. Rates of RD (49.9% pre, 49.0% post, P = .64) and mortality (30.9% pre, 29.1% post, P = .35) were similar. Neonates treated with bCPAP had lower mean birth weight and a higher risk of death (relative risk = 1.41, 95% confidence interval = 1.21-1.65) compared with those not treated with bCPAP. Conclusion. It was possible to build capacity for the use of bCPAP to treat neonates in this low-resource setting. Gaps in the delivery bCPAP remain, and the current capacity in the PGH NBU allows for application of bCPAP to smaller, likely, sicker neonates.

SUBMITTER: Switchenko N

PROVIDER: S-EPMC7412892 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Implementation of a Bubble CPAP Treatment Program for Sick Newborns in Nakuru, Kenya: A Quality Improvement Initiative.

Switchenko Nora N Kibaru Elizabeth E Tsimbiri Pamela P Grubb Peter P Anderson Berry Ann A Fassl Bernhard B

Global pediatric health 20200730

Introduction. Respiratory distress (RD) contributes to common causes of neonatal mortality. Bubble continuous positive airway pressure (bCPAP) is a safe, low-cost therapy for RD; however, adoption of bCPAP programs remains challenging. Aim. To increase the percentage of neonates with RD treated with bCPAP from 2% to 25% by January 2019. Methods. In the newborn unit (NBU) at the Nakuru County and Referral Hospital in Kenya, a pre-initiative (pre) period (March 2016 to Decembe ...[more]

PMID: 32821774

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Project description:BACKGROUND: With the use of medicines being a broad and extensive part of health management, mechanisms to ensure quality use of medicines are essential. Drug usage evaluation (DUE) is an evidence-based quality improvement methodology, designed to improve the quality, safety and cost-effectiveness of drug use. The purpose of this paper is to describe a national DUE methodology used to improve health care delivery across the continuum through multi-faceted intervention involving audit and feedback, academic detailing and system change, and a qualitative assessment of the methodology, as illustrated by the Acute Postoperative Pain Management (APOP) project. METHODS: An established methodology, consisting of a baseline audit of inpatient medical records, structured patient interviews and general practitioner surveys, followed by an educational intervention and follow-up audit, is used. Australian hospitals, including private, public, metropolitan and regional, are invited to participate on a voluntary basis. De-identified data collected by hospitals are collated and evaluated nationally to provide descriptive comparative analyses. Hospitals benchmark their practices against state and national results to facilitate change. The educational intervention consists of academic detailing, group education, audit and feedback, point-of-prescribing prompts and system changes. A repeat data collection is undertaken to assess changes in practice.An online qualitative survey was undertaken to evaluate the APOP program. Qualitative assessment of hospitals' perceptions of the effectiveness of the overall DUE methodology and changes in procedure/prescribing/policy/clinical practice which resulted from participation were elicited. RESULTS: 62 hospitals participated in the APOP project. Among 23 respondents to the evaluation survey, 18 (78%) reported improvements in the documentation of pain scores at their hospital. 15 (65%) strongly agreed or agreed that participation in APOP directly resulted in increased prescribing of multimodal analgesia for pain relief in postoperative patients. CONCLUSIONS: This national DUE program has facilitated the engagement and participation of a number of acute health care facilities to address issues relating to quality use of medicine. This approach has been perceived to be effective in helping them achieve improvements in patient care.

Project description:IntroductionThere is growing evidence that parental participation in the care of small and sick newborns benefits both babies and parents. While studies have investigated the roles that mothers play in newborn units in high income contexts (HIC), there is little exploration of how contextual factors interplay to influence the ways in which mothers participate in the care of their small and sick newborn babies in very resource constrained settings such as those found in many countries in sub-Saharan Africa.MethodsEthnographic methods (observations, informal conversations and formal interviews) were used to collect data during 627 h of fieldwork between March 2017 and August 2018 in the neonatal units of one government and one faith-based hospital in Kenya. Data were analysed using a modified grounded theory approach.ResultsThere were marked differences between the hospitals in the participation by mothers in the care of their sick newborn babies. The timing and types of caring task that the mothers undertook were shaped by the structural, economic and social context of the hospitals. In the resource constrained government funded hospital, the immediate informal and unplanned delegation of care to mothers was routine. In the faith-based hospital mothers were initially separated from their babies and introduced to bathing and diaper change tasks slowly under the close supervision of nurses. In both hospitals appropriate breast-feeding support was lacking, and the needs of the mothers were largely ignored.ConclusionIn highly resource constrained hospitals with low nurse to baby ratios, mothers are required to provide primary and some specialised care to their sick newborns with little information or support on how undertake the necessary tasks. In better resourced hospital settings, most caring tasks are initially performed by nurses leaving mothers feeling powerless and worried about their capacity to care for their babies after discharge. Interventions need to focus on how to better equip hospitals and nurses to support mothers in caring for their sick newborns, promoting family centred care.

Project description:BackgroundAdmission hypothermia (AH, < 36.5℃) remains a major challenge for global neonatal survival, especially in developing countries. Baseline research shows nearly 89.3% of very low birth weight (VLBW, < 1500 g) infants suffer from AH in China. Therefore, a prospective multicentric quality improvement (QI) initiative to reduce regional AH and improve outcomes among VLBW neonates was implemented.MethodsThe study used a sequential Plan-Do-Study-Act (PDSA) approach. Clinical data were collected prospectively from 5 NICUs within the Sino-Northern Neonatal Network (SNN) in China. The hypothermia prevention bundle came into practice on January 1, 2019. The clinical characteristics and outcomes data in the pre-QI phase (January 1, 2018- December 31, 2018) were compared with that from the post-QI phase (January 1, 2019-December 31, 2020). Clinical characteristics and outcomes data were analyzed.ResultsA total of 750 in-born VLBW infants were enrolled in the study, 270 in the pre-QI period and 480 in the post- QI period, respectively. There were no significant differences in clinical characteristics of infants between these two phases. Compared with pre-QI period, the incidence of AH was decreased significantly after the QI initiative implementation in the post-QI period (95.9% vs. 71.3%, P < 0.01). Incidence of admission moderate-to-severe hypothermia (AMSH, < 36℃) also decreased significantly, manifesting a reduction to 38.5% in the post-QI (68.5% vs 30%, P < 0.01). Average admission temperature improved from after QI (35.5 [Formula: see text] 0.7℃ vs. 36.0 [Formula: see text] 0.6℃, P < 0.01). There was no increase in proportion the number of infants with a temperature of > 37.5 °C or thermal burns between the two groups. The risk ratio of mortality in infants during the post-QI period was significantly lower in the post-QI period as compared to the pre-QI period [adjusted risk ratio (aRR): 0.26, 95% confidence interval (CI): 0.13-0.50]. The risk ratio of late-onset neonatal sepsis (LOS) also significantly lowered in the post-QI period (aRR: 0.66, 95% CI: 0.50-0.87).ConclusionImplementation of multicentric thermoregulatory QI resulted in a significant reduction in AH and AMSH in VLBW neonates with associated reduction in mortality. We gained a lot from the QI, and successfully aroused the attention of perinatal medical staff to neonatal AH. This provided a premise for continuous quality improvement of AH in the future, and might provide a reference for implementation of similar interventions in developing countries.Trial registrationTrial registration number: ChiCTR1900020861 . Date of registration: 21 January 2019(21/01/2019). Prospectively registered.

Project description:BackgroundDespite efforts to incorporate experience of care for women and newborns in global quality standards, there are limited efforts to understand experience of care for sick newborns and young infants. This paper describes the manifestations, responses, and consequences of mistreatment of sick young infants (SYIs), drivers, and parental responses in hospital settings in Kenya.MethodsA qualitative formative study to inform the development of strategies for promoting family engagement and respectful care of SYI was conducted in five facilities in Kenya. Data were collected from in-depth interviews with providers and policy makers (n = 35) and parents (n = 25), focus group discussions with women and men (n = 12 groups), and ethnographic observations in each hospital (n = 64 observation sessions). Transcribed data were organized using Nvivo 12 software and analyzed thematically.ResultsWe identified 5 categories of mistreatment: 1) health system conditions and constraints, including a) failure to meet professional standards, b) delayed provision of care; and c) limited provider skills; 2) stigma and discrimination, due to provider perception of personal hygiene or medical condition, and patient feelings of abandonment; 3) physically inappropriate care, including providers taking blood samples and inserting intravenous lines and nasogastric tubes in a rough manner; or parents being pressured to forcefully feed infants or share unsterile feeding cups to avoid providers' anger; 4) poor parental-provider rapport, expressed as ineffective communication, verbal abuse, perceived disinterest, and non-consented care; and 5) no organized form of bereavement and posthumous care in the case of infant's death. Parental responses to mistreatment were acquiescent or non-confrontational and included feeling humiliated or accepting the situation. Assertive responses were rare but included articulating disappointment by expressing anger, and/or deciding to seek care elsewhere.ConclusionMistreatment for SYIs is linked to poor quality of care. To address mistreatment in SYI, interventions that focus on building better communication, responding to the developmental needs of infants and emotional needs for parents, strengthen providers competencies in newborn care, as well as a supportive, enabling environments, will lead to more respectful quality care for newborns and young infants.

Project description:BackgroundGiven the high mortality associated with neonatal illnesses and severe malnutrition and the development of packages of interventions that provide similar challenges for service delivery mechanisms we set out to explore how well such services are provided in Kenya.MethodsAs a sub-component of a larger study we evaluated care during surveys conducted in 8 rural district hospitals using convenience samples of case records. After baseline hospitals received either a full multifaceted intervention (intervention hospitals) or a partial intervention (control hospitals) aimed largely at improving inpatient paediatric care for malaria, pneumonia and diarrhea/dehydration. Additional data were collected to: i) examine the availability of routine information at baseline and their value for morbidity, mortality and quality of care reporting, and ii) compare the care received against national guidelines disseminated to all hospitals.ResultsClinical documentation for neonatal and malnutrition admissions was often very poor at baseline with case records often entirely missing. Introducing a standard newborn admission record (NAR) form was associated with an increase in median assessment (IQR) score to 25/28 (22-27) from 2/28 (1-4) at baseline. Inadequate and incorrect prescribing of penicillin and gentamicin were common at baseline. For newborns considerable improvements in prescribing in the post baseline period were seen for penicillin but potentially serious errors persisted when prescribing gentamicin, particularly to low-birth weight newborns in the first week of life. Prescribing essential feeds appeared almost universally inadequate at baseline and showed limited improvement after guideline dissemination.ConclusionRoutine records are inadequate to assess newborn care and thus for monitoring newborn survival interventions. Quality of documented inpatient care for neonates and severely malnourished children is poor with limited improvement after the dissemination of clinical practice guidelines. Further research evaluating approaches to improving care for these vulnerable groups is urgently needed. We also suggest pre-service training curricula should be better aligned to help improve newborn survival particularly.

Project description:OBJECTIVE:To assess whether a multiphase, departmental quality improvement effort decreases opioid prescribing and increases multimodal analgesic use after cesarean delivery. METHODS:This is a prospective quality improvement study. In phase 1 of the protocol, discharge providers implemented counseling regarding expectations for pain, typical need for opioids, and importance of multimodal nonopioid analgesic use and used shared decision-making to determine the number of opioids prescribed. Patients could select up to a maximum of 30 tablets of 5 mg oxycodone (or equivalent opioid), lower than the previous routine discharge prescription of 40 opioid tablets. The primary outcome was the mean (SD) number of opioid tablets prescribed on discharge with secondary outcomes including opioid refill rate within 30 days of discharge and rates of nonopioid analgesic prescriptions on discharge. In phase 2, using these results, we adjusted the protocol's maximum opioid prescription to 25 opioid tablets, but no other aspects of the protocol were changed. All data were analyzed with t test and ? analyses. RESULTS:Data from 624 women who underwent cesarean deliveries were analyzed. Opioids, most commonly oxycodone, were prescribed after 95% of all cesarean deliveries. The mean (SD) number of opioid tablets prescribed decreased from 33.2 (9.3) to 26.5 (6.7; P<.01) with the implementation of phase 1 having no effect on the opioid refill rate, 8.9% vs 8.1% (P=.79). These results allowed adjustment of the maximum recommended prescription to 25 opioid tablets, introducing phase 2 of the study, during which the mean (SD) number of opioid tablets prescribed further decreased from 24.9 (7.5) to 21.5 (6.3; P<.01) with no effect on the opioid refill rate, 6.3% vs 5.1% (P=.72). Overall, this represents a 35% decrease in opioid prescribing (P<.01). Rates of ibuprofen prescribing were 98% or higher throughout the study, but rates of acetaminophen prescribing increased from 32.6% before phase 1 to 92.0% after phase 2 (P<.001). CONCLUSION:Implementation of a multiphase quality improvement protocol to decrease opioid prescribing, combined with iterative review of discharge data, resulted in a significant decrease in the number of opioid tablets prescribed after cesarean delivery.

Dataset Information

Implementation of a Bubble CPAP Treatment Program for Sick Newborns in Nakuru, Kenya: A Quality Improvement Initiative.

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Implementation of a Bubble CPAP Treatment Program for Sick Newborns in Nakuru, Kenya: A Quality Improvement Initiative.

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