Improving neonatal outcomes through a Continuous Quality Improvement approach: A retrospective hospital data review from a tertiary hospital in Zimbabwe Masanga J D 1, MukoraF N 2, Mafaune P 1, Mashizha S 1, Chideme M 3, Mutede B 3 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: , InTech, Available from: ‘ 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: , InTech, Available from:

Zimbabwe neonatal mortality rate over the last 15 years

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) 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 Admissions Admissions 1356

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 VariableCategory2013 Admissions N 1 = Admissions N 2 = 1165 p-value Sex: no (%)Males635 (56.6)524 (44.9)0.08 Females483 (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/Other111 (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

Comparison of Admission indication by Year of Admission

Changes Noted p-value Mean 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 2013 n (%) 2014 n (%) p-value Discharged962 (86.1)1039 (89.2)0.014* Transferred out7 (0.6)9 (0.8) Died149 (13.3)117 (10.0) *died against other categories

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

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 2013 PredictoraHRp- value 5 min APGAR <7 2.70<0.001 Bwt 4kg Sick on admission Referred from elsewhere PredictoraHRP-value 5 min Apgar <7 2.86<0.001 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): 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 identifiedRecommendation Fetal heart not being monitored. FHHRNurses to document the actual number and grade Time lapse in managing patient was too longPatient to be seen by the doctor within 30 min Anaesthetist to respond within 20 min Poor monitoring of patients in labourFrequent meeting of maternity staff. Weekly Monday ward meetings Laboratory results for referring hospitalsTo be capacitated so that they have their own lab Use of two partographSession on the use of a partograph SIC maternity to continue strengthening Referring institutions to attach their partograph to avoid using another partograph Inappropriate care by attending GMOMidwife can bypass and call consultant, head of institution

Process cont Gaps identifiedRecommendation Referred patient sent back by attending GMOOnce 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 transportUse of private cars Bypassing referral protocol Delay in receiving care when main theatre is in useCapacitation of maternity theatre

Systemic and Process Strengthening milestones Nov 2013 to Dec 2014 Process Strengthening/ModificationTargetedAchieved Resuscitation of hospital perinatal audit committee11 Creation of Neonatal Database10 Documentation and reporting of fresh still births100% Documented Fresh still birth investigations100%60% Clinical audit meetings (2014 only)1312 Skills reinforcement/transfer sessions62 Changes/modifications followed through106