1. Initiation of a Plan-Do-Study-Act quality improvement program supports sustainability of Helping Babies Breathe in Kenya
Janet Rukunga KRCHN1, Sherri Bucher2, PhD, Sreelatha Melenth, PhD 3, Fabian Esamai4 MD, PhD, MPH
1Moi Referral and Teaching Hospital, Eldoret, Kenya; 2Indiana University School of Medicine, Indianapolis Indiana; 3RTI International, North Carolina; 4Moi University School of Medicine, Eldoret, Kenya
BACKGROUND
OBJECTIVES
PDSA cycle: Sustain HBB capacity
Plan: Build infrastructure to support adequate and sustainable capacity for neonatal resuscitation.
Do: Identify threats to sustainable HBB capacity.
Equipment  Minor issues
Personnel  Multiple challenges identified
Study: (1) Maintenance of skills/knowledge among trained BAs; (2) Frequent ward rotations and chronic understaffing; (3) Large teaching hospital = many inexperienced students; (4) Staff worry about QI adding “extra work;” (5) QI monitoring viewed as punitive.
Act: (1) BAs develop BMV practice schedules specific to their wards; (2) BAs are encouraged to record staffing challenges as “data” on QI forms, which the QI monitor then utilizes to advocate for improved scheduling; (3, 2) QI monitor utilizes “low-dose, high-frequency” on-the-job HBB training with students to convert them from “inexperienced” to “HBB helpers;” (4, 2) When BAs are overwhelmed, the QI monitor offers a “2nd pair of hands” prior to performing QI duties; (5) Supportive mentoring and guided self-reflection techniques, underpinned by QI processes such as Resuscitation Debriefing and Perinatal Death Audit, are employed.
Helping Babies Breathe (HBB) is a neonatal resuscitation training program launched in 75 countries.
Feasible, affordable, and acceptable programmatic models for HBB are needed.
Quality Improvement (QI) efforts can contribute to the design of effective and sustainable HBB programs.
Describe methods used in a QI program to support HBB at a large African referral hospital.
Highlight key findings of PDSA cycles.
Investigate impact of HBB + QI on stillbirth rates.
METHODS
PDSA cycle:
Assess HBB impact
Plan: Ensure that the impact of HBB program implementation on neonatal mortality can be measured.
Do: Survey existing data collection processes and indicators for newborn mortality.
Study: (1) FSB and MSB rates collected; (2) “neonatal death” collected, not disaggregated between early vs. late; (3) asphyxia not listed as possible cause of newborn death.
Act: (1) Operationalize definitions of FSB, MSB among wards and staff; (2) Introduce “Delivery Room Death” indicator; (3) resuscitation debriefings and perinatal death audits.
Setting: Riley Mother Baby Hospital (RMBH) in Eldoret, Kenya is the maternity hospital of Moi Teaching and Referral Hospital, which serves a catchment area of 17 million persons. RMBH has 15,000 deliveries per year.
Methods: A pre/post design was used to investigate the impact of HBB underpinned by QI on resuscitation practices and stillbirth rates over time.
No HBB (standard practice; July 2013-December 2013): Total number of deliveries was collected monthly for labor, operating theater, and private wards. Total stillbirth, fresh stillbirth (FSB) and macerated stillbirth (MSB) rates were assessed.
HBB training only (January 2014-June 2014): Same data collection as described above. HBB training was conducted from January – March among 149 health workers in 7 newborn care areas: Labor/delivery; Operating theater; Newborn Unit/Newborn Intensive Care Unit (NBU/NICU); Postnatal; Private ward; Sick child clinic; MCH clinic.
HBB + QI (July 2014 – March 2015): QI strategies and data collection activities.
QI Procedures: We implemented 5 primary QI processes: (1) Regular practice of bag- and-mask ventilation skills (BMV) among in-service staff and frequent “on the job” HBB training sessions specifically targeted students and new staff; (2) Debrief every BMV resuscitation event; (3) Delivery Room Death Audits; (4) QI visits (actual deliveries observed; delivery registers, admission logbooks, and QI data forms reviewed); (5) Continuous supportive supervision and mentoring. We utilized frequent Plan-Do-Study-Act (PDSA) cycles to identify barriers and bottlenecks, to elicit potential solutions, and to implement effective strategies for sustainable implementation of HBB. Process variables, qualitative data, and mortality data were collected bi-weekly.
Analysis: Descriptive statistics used for QI process measures; Wilcoxon rank sum tests and general linear modeling were used to assess impact of HBB + QI on FSB and MSB over time.
Table 1: Total deliveries and stillbirth rates by study period
Total deliveries (% total)
Total MSB
(% total)
Total FSB
Total stillbirth rate
MSB rate
FSB rate
Overall totals
22904
230
172
18/1000
10/1000
8/1000
No HBB (Standard practice)
6775
(30%) 67
(29%) 37
(22%)
15/1000
5/1000
HBB Training
7117
(31%) 82
(36%) 72
(42%)
22/1000
12/1000
HBB + QI
9012
(40%) 81
(35%) 63
(37%)
16/1000
9/1000
7/1000
No significant differences detected in total, MSB, or FSB rates over time.
CONCLUSIONS
PDSA cycles enabled us to identify, and respond to, key threats to sustainability of HBB implementation in a large African teaching and referral hospital.
HBB + QI has not resulted in statistically significant impact on overall rates of stillbirth. Further study, within the context of standardized definitions for early newborn mortality, is needed.
There may be indirect benefits of HBB + QI, in regards to improving the abilities of BAs to recognize and refer women with delivery complications.