Early Initiation of Emergency Management of Sick Neonate Point of Care Quality Improvement WHO Collaborating Center for Training and Research in Newborn Care Early Initiation of Emergency Management of Sick Neonate Prof. Dr. Asim Kumar MallickIn-charge Neonatal Unit, NRS Medical College and HospitalKolkata, West Bengal, India www.pocqi.org

Background Context & Problem Statement Initiation of emergency treatment of sick new born within 30 minutes will reduces mortality and provide timely treatment . Early treatment will reduce complications ( like organ damage ) thus reduces hospital stay of neonate. It also reduces morbidity and long term sequale in neonate. It reduces the financial burden of the family and as a whole cost of therapy.

In a prospective cohort study of 91 infants and children presenting to community hospitals with septic shock (defined by hypotension or delayed capillary refill), each hour delay in initiation of appropriate resuscitation or persistence of hemodynamic abnormalities was associated with a clinically significant increased risk of death (odds ratio [OR] 1.5 and 2.3, respectively)** **Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003; 112:793.

Problems Delay in receiving the sick neonate in triage by Sisters. No Dedicated person posted in triage. Delay in processing of admission ticket. No Separate Emergency tray in triage hence delay.

Run Charts on base line data Senior Residents (who is assigned) measure the time by using stop clock and record.

Aim Statement To initiate emergency management of all Sick Newborn admitted in our SNCU before 30 minutes (from two hours now) within 8 weeks from current of 20% to 80 % (within 30/04/2017)

Team Members Dr. Asim Kumar Mallick (Leader ) Dr. Biswajit Mondal (Analyser) Dr. Gopal Pandey (Time Keeper) Dr. Mahammad Kalam (Communicator) Bina Acharya(Sister In-charge) Archana Ghosh(Staff Nurse) Sunipa Pramanik(Staff Nurse) Samaresh Kar (DEO)

Process flow ** Intervention Point Register at Triage Neonate Received at SNCU Register at Triage Baby Placed in Radiant Warmer Asking the Doctor for Examination of the Baby Examination done by the Doctor Emergency Signs Present Discharge with advice Advice given by the Doctor Emergency Treatment given Baby Stable Admission in SNCU Yes NO **20 Min 5 Min 2 Min **20 Min (Variable) ** Intervention Point

Fish Bone Analysis

Driver Diagram

Change Idea(s) & PDSAs 1)Posting or assigning responsibility in each shift of Doctors and Nurses in SNCU triage. 2) Immediate receiving of sick neonate at triage by the nurses. 3) Separate emergency tray in triage. 4) Use of Stopwatch for measuring time. 5) Use of Sticker

Measurements Outcome- Proportion of babies receiving emergency management within 30 minutes Process: 1)Percentage of receiving baby immediately by nurses 2) Percentage of time of Posting of dedicated Sisters and Doctors in triage. 3) Percentage of Doctors and nurses following the emergency protocol. Balancing Measures: Over crowding at triage area.

PDSA –I assigning responsibility in each shift of Doctors and Nurses Assigned Doctor Assigned Nurse Time Keeper Team

PDSA-I Triage Sticker

PDSA-II Separate emergency tray in triage. Doctor and Nurse checking the List at each shift

CHECK LIST

PDSA-III Training of Doctors and Nurses for protocol treatment plan for Sick New Born. Emergency cases – Hypothermia (temp < 360C) -Apnea or gasping respiration -Severe respiratory distress (rate>70, severe retractions, grunt) -Central cyanosis -Shock (cold periphery, CFT>3secs, weak& fast pulse) -Coma, convulsions or encephalopathy

Run Chart in Morning Shift BASE LINE DATA PDSA -1 BASE LINE MEDIAN EXPECTED MEDIAN PDSA -2 PDSA -3

Run Chart in Evening Shift BASE LINE MEDIAN EXPECTED MEDIAN BASE LINE DATA

Run Chart in Night Shift BASE LINE MEDIAN EXPECTED MEDIAN

Comparative Run Chart(Morning, Evening and Night)

Our observations…. Looking at benefits of Triaging in morning shift and sharing the data with other shift nurses/doctors despite heavy rush in evening On duty Doctors and Nurses of Evening and night shift are inspired by seeing the morning shift staff success. Implement these change ideas to other shifts (Evening & Night) soon by sharing the success story among other health professionals and leadership of Hospital.

Thank You