Improving neonatal outcomes through a Continuous Quality Improvement approach: A retrospective hospital data review from a tertiary hospital in Zimbabwe

• Masanga J D1, MukoraF N2, Mafaune P1, Mashizha S1, Chideme M3, Mutede B3

1.Ministry of Health and Child Care(MOHCC)2. Maternal and Child Health Integrated Program(MCHIP)3. Elizabeth Glaser Paediatric AIDS Foundation(EGPAF)

Sajjad ur Rahman and Walid El Ansari (2012). Neonatal Mortality: Incidence, Correlates and Improvement Strategies, Perinatal Mortality, Dr. Oliver Ezechi (Ed.), ISBN: 978-953-51-0659-3, InTech, Available from: http://www.intechopen.com/books/perinatal-mortality/neonatal-mortality

‘ Every minute 7 new-born babies die world wide ….’

Background

• Neonatal mortality is a strong indicator of neonatal, perinatal and maternal health• Highest in Africa compared to other regions

• African region NMR 36/1000 • Europe 7/1000 • Japan 1/1000

• For African settings, most causes are preventable and strongly health systems related yet• Reduction of neonatal mortality remains the most significant challenge in reducing under

5 mortality

• Sajjad ur Rahman and Walid El Ansari (2012). Neonatal Mortality: Incidence, Correlates and Improvement Strategies, Perinatal Mortality, Dr. Oliver Ezechi (Ed.), ISBN: 978-953-51-0659-3, InTech, Available from: http://www.intechopen.com/books/perinatal-mortality/neonatal-mortality

Zimbabwe neonatal mortality rate over the last 15 years

10 - 15 yrs ago 5 - 9 yrs ago 0 - 4 yrs0

5

10

15

20

25

30

35

20

25

29NMR

Background

• Zimbabwe has good ANC coverage of 93% • Skilled birth attendance of 80% of as institutional deliveries • However, neonatal mortality rates remain high at 29 per 1000 live births (MICS 2014)• Recent reviews identify lack of quality of care received as the most significant barrier

to reducing neonatal mortality• Interventions have been developed to reduce maternal and child mortality

• Data on impact of these interventions for the local setting remains scanty

• For Mutare Provincial Hospital Fresh Still Births were 2.2% and 3.6% of total deliveries in 2011 and 2012 respectively• These remain the main source of neonatal mortality

Zimbabwe National Statistics Agency (ZIMSTAT). 2014. Multiple Indicator Cluster Survey 2014, Key Findings. Harare, Zimbabwe: ZIMSTAT.

Merali et al. Audit- identified avoidable factors in maternal and perinatal deaths in low resource settings – a systematic review. BMC Pregnancy and Childbirth 2014, 14:280

Causes of Mortality in SCBU: Mutare Provincial Hospital 2011 and 2012

2011 Admissions 1373

prematurity63%

low apgar 28%

other9%

n = 167

prematurity low apgar other

2012 Admissions 1356

prematurity 51%low apgar

37%

other12%

n = 194

prematurity low apgar other

What are we doing about it?

• Started a Continuous Quality Improvement process to Systematically improve the quality of care • Maternity• SCBU

• Main Elements• Regular Maternal and Perinatal Audit meetings

• Institutional• Departmental

• Systematic follow through of recommendations• Health worker capacitation• Management of the referral system and process

• Within the facility• Between MPH and feeder units

PDSA cycle

Main Interventions

• The main CQI interventions were:• Expedited patient care

• MPH and feeder units• Patient triaging

• Referred clients from feeder units• Patient management protocols

• Provider-client interface • Availability of SOPs• Clear and functional chain of command for patient care

• Provider education to improve quality and scope of neonatal care• Practical skills and knowledge transfer• Systematic support and supervision

• These aimed to address the third delay – delay in receiving adequate care

Lessons Learnt

It is a process ….

• Initially some resistance , excuses• ‘Not a witch hunt…’• Inspiration

if you want to go fast go alone, if you want to go far go together you can not change what you will not confront it always seems impossible until it is done Success comes from doing the small things well

• Team building – what happens to one affects all, when a mother or baby dies we have failed collectively

Selection of Records for Analysis

Total admissions to the NNU Jan 2013 to Dec 2014, n= 2726 (100%)

Total number of records with complete and consistent data, n= 2325 (85%)

Total number of admissions within the neonatal period (analysed records),

n= 2283 (84%)

2013 neonatal admissions, n= 1118 (41%)

2014 neonatal admissions, n= 1165 (43%)

401 (15%) records incomplete & inconsistent

42 (1%) post neonatal

admissions

Comparison of 2013 & 2014 Neonatal Admissions Profiles

Variable Category 2013 AdmissionsN1=1118

2014 AdmissionsN2= 1165

p-value

Sex: no (%) Males 635 (56.6) 524 (44.9) 0.08

Females 483 (43.4) 642 (53.1)

Referring Zone: no (%)

Provincial Hospital

647 (57.9) 549 (47.1) 0.04

District/Mission Hospital

236 (21.1) 380 (32.6)

Rural Health Centre

124 (11.1) 131 (11.2)

Home/Other 111 (9.9) 105 (9.0)

Mean age in days at admission (sd)

0.69 (2.6) 0.89 (3.0) 0.09

Mean birth weight: kg (sd)

2.56 (0.80) 2.54 (0.81) 0.56

Comparison of Birth Weight Categories by year of Admission

ELBWt VLBWt LBWt NBWt HBWt0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

3.3%7.3%

30.1%

58.4%

0.9%2.4%

7.5%

35.3%

53.5%

1.3%

20132014

Birth weight category

Perc

enta

ge o

f adm

itted

neo

nate

s

Chi-square 8.97, p = 0.06

Comparison of Admission indication by Year of Admission

Congenital M

alform

ation

Jaundice/A

naemia

Prematurit

y

Birth Asp

hyxia

Sepsis

Caring (N

ot sick

)

Miss

ing0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

2.9% 2.9%

22.4%

36.6%

18.0%16.5%

0.9%

3.8% 4.0%

26.0%

33.5%

18.9%

12.5%

1.2%

20132014

Admission Indication

Perc

enta

ge o

f Adm

itted

Neo

nate

s

Changes Noted

2013 2014 p-valueMean Hospital Stay: days (sd)

4.87 (7.5) 5.95 (7.9) << 0.05

Mean APGAR at 5 mins (sd)

8.0 (1.9) 8.5 (1.8) 0.07

Process Related

Outcomes

Outcomes 2013n (%)

2014n (%)

p-value

Discharged 962 (86.1) 1039 (89.2) 0.014*

Transferred out 7 (0.6) 9 (0.8)

Died 149 (13.3) 117 (10.0)

*died against other categories

Comparison of Mortality Events among Neonates admitted to NNU 2013 and 2014

2013 20140

5

10

15

20

25

3026.9

16.71

Year

Mor

talit

y Ev

ents

per

100

0 H

ospi

tal d

ays

Comparison of Mortality Events among Neonates admitted to NNU 2013 and 2014

2013 20140

5

10

15

20

25

3026.9

16.71

Year

Mor

talit

y Ev

ents

per

100

0 H

ospi

tal d

ays

37.9% reduction

Comparison of Survival Probability of Neonates admitted to Neonatal Care Unit between 2013 and 2014

Hazard Ratio=0.68 (0.53, 0.87), p=0.002

Comparison of Significant Mortality Predictors

2013Predictor aHR p- value

5 min APGAR <7

2.70 <0.001

Bwt<1.5kg or Bwt>4kg

2.92 0.01

Sick on admission

7.89 0.06

Referred from elsewhere

1.58 0.02

2014Predictor aHR P-value

5 min Apgar <7

2.86 <0.001

Bwt<1. 5kg or Bwt>4kg

3.5 <0.001

Discussion

• Decline in maternity admissions from Mutare Hospital• Decline by condition• Birth asphyxia• Caring

• Significant increase in hospital stay• Significant reduction in mortality

• Perinatal deaths can be reduced by 30% through conducting audits• Audits have not been scaled up in sub Saharan Africa • It is a process that needs ‘drivers’• There is need for team work to achieve sustainability• The impact depends on how effectively the solutions are implemented• It requires limited resources• Nakibuuka VK1 et al Perinatal death audits in a peri-urban hospital in Kampala, Uganda African Health Sciences 2012; (4): 435 - 442

• Belizán et al. Stages of change: A qualitative study on the implementation of a perinatal audit programme in South Africa BMC Health Services Research 2011, 11:243

Conclusion

Audits are a LOW COST, EFFECTIVE intervention that REDUCES neonatal mortality if ACTIVELY implemented in our setting

What is the community doing?

Thank you!

Process….

Gaps identified Recommendation

Fetal heart not being monitored. FHHR Nurses to document the actual number and grade

Time lapse in managing patient was too long Patient to be seen by the doctor within 30 minAnaesthetist to respond within 20 min

Poor monitoring of patients in labour Frequent meeting of maternity staff. Weekly Monday ward meetings

Laboratory results for referring hospitals To be capacitated so that they have their own lab

Use of two partograph Session on the use of a partographSIC maternity to continue strengtheningReferring institutions to attach their partograph to avoid using another partograph

Inappropriate care by attending GMO Midwife can bypass and call consultant, head of institution

Process cont

Gaps identified Recommendation

Referred patient sent back by attending GMO Once referred no patient shall be returned

Nurse anaesthetist not willing to do an operation without FBC

Expedition of blood samples by maternity staff

Delays within institutions due to lack of transport Use of private carsBypassing referral protocol

Delay in receiving care when main theatre is in use Capacitation of maternity theatre

Systemic and Process Strengthening milestones Nov 2013 to Dec 2014

Process Strengthening/Modification Targeted Achieved

Resuscitation of hospital perinatal audit committee 1 1

Creation of Neonatal Database 1 0

Documentation and reporting of fresh still births 100%

Documented Fresh still birth investigations 100% 60%

Clinical audit meetings (2014 only) 13 12

Skills reinforcement/transfer sessions 6 2

Changes/modifications followed through 10 6