TRACKING NEW BORN DISCHARGED FROM SCNU Dr. Gagan Gupta Health Specialist , UNICEF

Background……..

2002- 2006 : IMR reduced by 11 points with out a single point drop in Neonatal Mortality

Highest IMR in the Country at 67 per 1000 (SRS 2009)

Government Sector: Special Care was Non Existent

Key Strategy : Guna ModelKey Strategy : Guna ModelContinuum of Care from Community to FacilityContinuum of Care from Community to Facility

Community:-IMNCI

-Immunization.

-ORS & Zinc in Diarrhea.

-ASHA for Social Mobilization

-Maternal Death Audit

Facility:-SCNU

-NRC

-Model Labour Rooms

-24 x 7 Safe Delivery Centers at Sub - Block level

-Staff trained in Skilled Birth attendance and Essential Newborn Care

24 x 7 Referral Transport

Piloted in Guna in 2007,Replicated in Shivpuri being Scaled up State Wide

Strengthening Facility Based New Born Care

To ensure Continuum of Care with IMNCI in community and SCNU at the Facility.

First 2 Units established by UNICEF at Guna and Shivpuri.

Establishment cost of each unit Rs. 45 Lakhs.( Civil work 25 lakh, Equipments 20 lakh)

Running cost of pilot units and scale up entirely through NRHM. SCNU Shivpuri

Scale Up Under NRHM : SCNU Vidisha District Hospital

New-Born being treated at SCNU

Backed Up By….

Model Maternity wing at District Hospital …..

Model Labor Room : Shivpuri

Maternity Ward : Shivpuri District Hospital

Free 24 x 7 Referral transport with Call Centre

Saving Life on Wheels : 24 x 7

BTL

SVP

SNI

SDH

SA

CDWBLG

CTP

KRG

RSN

MDL

STN

VDS

DHRJBA

PAN

SJP

KND

DMH

SHE

SOP

UJN

RJGSDL

DWS

JBP

HSB

GUNRWATKM

NSP

MDS

KTN

DDR

AKN

BHD

IDR

GLR

MRN

RTM

ANP

BRW

UMR

NMC

HRD

BHP

BPL

DTA

31 Functional

09 to start by 31st January

Status of Special Care New Born Units : M.P

10 under construction

What Happens After Discharge ??

Objective….

Determine survival at One year in babies discharged from SCNU

To follow this cohort for Neurological Development

Learn and put in place system for prospective follow up of

discharged new born with Community – Facility linkages.

Generate evidence for justifying continued investments of large

funds on SCNU amongst other competing priorities

Methodology….

Study Area : SCNU Guna and Shivpuri

- First 2 units in the State were established in these districts.

- Presence of Call Centre, Block Coordinators for support

Study Sample : All New Born discharged from SCNU since

inception till 31st December 2008.

Guna : 1617 (14th Dec. 2007 – 31st Dec.2008 )

Shivpuri : 557 (1st July 2008- 31st December 2008)

Methodology….

Type of Study : Retrospective in 3 phases.

- Phase 1 : Desk review, Data entry, Telephonic Tracking.

- Phase 2 : Visit to community for verification

- Phase 3 : Clinical evaluation for developmental assessment.

Follow up Stages..…..

Phase 1 : Screening of Records

Phase 2 : Verification by Home visit

Phase 3 : Developmental Assessment

ADMISSIONS – FOR WHAT ??

Respiratory Distress

681

Septicemia

603

Birth Asphyxia

748

258 10467 20 30

67 620

423

INDICATIONS OF ADMISSION

Respiratory Distress (HMD,TTNB,MSL,PNEUMONIA) Septicemia Birth Asphyxia

Hyperbilirubinemia Low Birth Wt. Congenital Anomaly

Hypothermia Feeding difficulties Pre term

Tetanus Convulsion Polycythemia

IUGR

N= 2681

FOLLOW UP FINDINGSDISTRICT SHIVPURI

ISO : 9001 Certified Unit

TRACKING OUTCOME

466

5833

433(92.9%)

55 (94.8%)29(87.9%)

SUCESSFULLY DISCHARGED LAMA/DOR TERTIARY REFERRAL

TOTAL TRACKED

SURVIVAL OUTCOME433

55

29

392(90.5%)

39 (70.9%)16 (55.2%)

SUCESSFULLY DISCHARGED LAMA/DOR TERTIARY REFERRAL

TRACKED SURVIVED

TIME DISTRIBUTIONTotal deaths = 70

URBAN RURAL DISTRIBUTION

Total deaths = 70

CASTE WISE DISTRIBUTION

Total deaths = 70

WEIGHT ON ADMISSION

46

84

175

212

17(37%) 19(23%) 18(10%) 16(7.5%)

0

50

100

150

200

250

< 1500 GM 1500-2000 GM 2000 -2500 GM > 2500 GM

DISCHARGE PLUS LAMA PLUS TERTIARY REFERRAL

DEATHS

Total deaths = 70

FOLLOW UP OUTCOME DISTRICT

: GUNA

ISO : 9001 Certified Unit

SURVIVAL OUTCOME1169

194

31

1048 (89.6 %)

148(76..3%)

15(48.4%)

SUCESSFULLY DISCHARGED LAMA/DOR TERTIARY REFERRAL

TRACKED SURVIVED

TIME DISTRIBUTION114

23

125 2 5 4 5 2 0 0 1

10

0

20

40

60

80

100

120

1 Month

2 Month

3 Month

4 Month

5 Month

6 Month

7 Month

8 Month

9 Month

10 Month

11 Month

12 Month

>12 Month

Total deaths = 183

WEIGHT ON ADMISSION

115

287358

634

45 (39.1%) 54 (18.8%) 36 (10.1%) 48 (7.6%)

0

100

200

300

400

500

600

700

< 1500 GM 1500-2000 GM 2000 -2500 GM > 2500 GM

DISCHARGE PLUS LAMA PLUS TERTIARY REFERRAL DEATHS

Total deaths = 183

Phase 3 :Developmental Screening

District Shivpuri (M.P.)

Developmental Screening : Protocols

Neurodevelopmental , Visual and Hearing screening done

Neurodevelopmental : Pathaks modification of Baroda Scale.

Hearing : American Academy of Pediatrics criteria

Visual : American Academy of Pediatrics guidelines

Developmental Screening…

Head Circumference

Screening for Visual Deficits

SUMMARY : FOLLOW UP OUTCOME

Survival in New Born discharged after successful completion of treatment was 90% at 1 year of age

Deaths were higher in new born who were discharged against medical advise and tertiary referrals.

More than 60 % Deaths occurred in 1st month after discharge.

Deaths were higher in excluded and rural population .

SUMMARY : FOLLOW UP OUTCOME

Survival in < 1500 gram birth wt. was 61 % against 93% in

> 2500gm.

Deficits were seen in 11 % of Children who survived with Neurological deficit being commonest.

SAM prevalence was unusually low on follow up.

LESSONS LEARNED….

Strong tracking system should be in place.

Vital information on admission should be recorded (Postal Address ,Mobile numbers)

Need to develop follow up protocols with community and facility linkages. (Extending continuum of care)

Local resources are best suited for follow up and tracking. (AWW, ASHA)

First month after discharge is most critical with need to focus on very low birth wt babies < 2000 grams

Action Initiated :Tracking System….

SCNU Software developed and all vital information on admission / discharge recorded in it by data operator.

On discharge Parents are counseled & provided contact of IMNCI worker along with a community follow up card.

Data operator sends SMS to IMNCI trained worker to enroll the discharged child.

SMS reminders are sent to Parents as well as worker on day of Follow up.

Community Follow up card

Actions Initiated : Tracking System

IMNCI trained AWW to make Six home visits as per IMNCI schedule in first month.

At least one home visit to be done by ANM

SCNU follow up at 15 days, 1,3,6 & 12 months or in case of complications

Status upgraded at the end of the day of visit.

Admission Entry Form

Entry after Treatment Outcome

Daily Follow - up List

SCNU Software Generated Graphs : 2010

DISTRICT SHIVPURI

District Hospital Delivery Vs Inborn Admission SNCU Shivpuri (M.P.)

8276

6734

8292

891 (10.8%)607 ( 9%) 725 ( 8.7%)

0

13000

2008-09 2009-10 2010-11

Adm

issi

ons

in N

umbe

rs

DH DeliveryInborn Admission

SNCU functioning since June 2008

SCNU Case Record Sheets & Monitoring Formats

Case Record File

Neonatal Admission Sheet

Discharge Card

SCNU Follow-up Statistics 2011

District Shivpuri (M.P.)

Facility Follow-up Statistics: 2010- 2011, SCNU Shivpuri

Total Facility Follow-up done since start : 2184

Community Follow-up Statistics , Shivpuri : 2011( Till Oct.)

Mainstreaming and Scaling Up….

Mainstreamed under NRHM for State wide use.

Data operators sanctioned and on board in all units

SCNU Software installed in all SCNUs across the State.

Case Record sheets and SCNU stationary compatible with software developed and put in use Statewide

Both Software and Case record sheets in line with GOI guidelines on FBNC

Support to Other States : Orissa / Haryana / Uttaranchal / Andhra Pradesh / Maharashtra

Work Under Progress…… Mentoring visits to New Born corners & Stabilization units

by SCNU / Maternity team

Work Under Progress……

Linkage of Software and Neonatal case sheets with

Maternity records

Setting up online monitoring system for centralized

monitoring

Neonatal transport system

Early intervention clinic for limiting disability

Sharing Across States…..

States being Supported :

• Haryana• Andhra Pradesh• Uttaranchal• Tamilnadu• Orissa• Maharashtra

Justified Investment For Tomorrow…

BABY 2

New Born Discharged from SCNU….

N = 42

TREATMENT OUTCOME

STATUS UNCLEAR =2

N = 53

New Born Corners till Sub Block level ….

24 x 7 Sub Centre at Shivpuri