|Year : 2019 | Volume
| Issue : 4 | Page : 357-361
Onsite mentoring of special newborn care unit to improve the quality of newborn care
YN Prashantha1, A Shashidhar2, BC Balasunder3, B Pradeep Kumar4, P N Suman Rao5
1 Assistant Professor, Department of Neonatology, St. John's Medical College, Bengaluru, Karnataka, India
2 Associate Professor, Department of Neonatology, St. John's Medical College, Bengaluru, Karnataka, India
3 Senior Specialist (Pediatrics), S.N.R. District Hospital, Kolar, Karnataka, India
4 Consultant, Department of Pediatrics, SSNMC, Bengaluru, Karnataka, India
5 Professor and Head, Department of Neonatology, St. John's Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||18-Dec-2019|
Dr. A Shashidhar
Department of Neonatology, St. John's Medical College, Sarjapur Road, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: It has been possible to set up special newborn care units (SNCUs) and to improve the survival of newborns in India. However, several challenges remain affecting their effective functioning. Different approaches have been attempted and several policies have also been implemented to address this issue. Objectives: To evaluate the feasibility of implementing best practices in neonatal care by onsite mentoring in an SNCU over 4 months. Methods: The mentoring team was from a tertiary care hospital in Karnataka. The SNCU was functioning at the district hospital, catering to approximately 3500 live births per year. Onsite mentoring was carried out from August 2016 to November 2016. This was a prospective implementation research. Framework focused on infection control, preterm care, care at birth, advocacy for infrastructure and resources, and facility-based refresher training. Results: A total of 16 visits were done by the mentoring team and 2 weeks of in-house residency. There were improvements in hand hygiene compliance from 0% to 87.5%, in cleaner IV site (from 50% to 100%), decreased unnecessary oxygen administration (from 75% to 33.3%), decreased antibiotic usage (from 70.5% to 35.5%), decrease in the number of babies receiving >5 days of antibiotics (from 41.6% to 0%), and increased kangaroo mother care initiation rate from 0% to 41.6%. The facility got level IIA accreditation by the end of the intervention period. Conclusions: Onsite mentorship program of SNCU is feasible and planning should be contextual. With the problems being uniform across most facilities, the model could be replicated across the country.
Keywords: Infant mortality, mentoring, quality of health care, special newborn care unit
|How to cite this article:|
Prashantha Y N, Shashidhar A, Balasunder B C, Kumar B P, Rao P N. Onsite mentoring of special newborn care unit to improve the quality of newborn care. Indian J Public Health 2019;63:357-61
|How to cite this URL:|
Prashantha Y N, Shashidhar A, Balasunder B C, Kumar B P, Rao P N. Onsite mentoring of special newborn care unit to improve the quality of newborn care. Indian J Public Health [serial online] 2019 [cited 2020 Jul 10];63:357-61. Available from: http://www.ijph.in/text.asp?2019/63/4/357/273364
| Introduction|| |
It is estimated that about 70% of neonatal deaths could be prevented if proven interventions are implemented effectively with high coverage. It is further estimated that health facility-based interventions can reduce neonatal mortality by 23%–50% in different settings. The major causes of newborn mortality in India are prematurity/preterm (35%), neonatal infections (33%), intrapartum-related complications/birth asphyxia (20%), and congenital malformations (9%).
Community-based neonatal interventions aim for increased referral of sick newborns to facilities, largely to be catered by the special newborn care units (SNCUs). To achieve the goal of India Newborn Action Plan of ending preventable newborn deaths to achieve “single-digit Neonatal Mortality Rate” by 2030, the facility-based newborn care (FBNC) has a major role to play.
It has been possible to set up and manage the quality of SNCUs and improve the survival of newborns. However, several challenges relating to human resources, maintenance of equipment, and maintenance of asepsis remain challenging their effective functioning. Various approaches have been tried and several policies have also been implemented to address this issue., Despite this, lacunae still exist. Onsite mentoring at primary health centers has shown improvements in quality of care in the facilities. We evaluated the feasibility of implementing best practices in neonatal care by a model of onsite mentoring of an SNCU functioning in a district hospital over 4 months.
The outcome measures used were hand hygiene compliance, appropriate peripheral line maintenance, antibiotic usage, appropriate oxygen usage, kangaroo mother care (KMC) initiation, and SNCU survival rates.
| Materials and Methods|| |
This was a prospective implementation research study. A memorandum of understanding for mentoring the SNCU of a district hospital in South Karnataka was entered between the Department of Health and Family Welfare, Government of Karnataka (GOK), and a tertiary care neonatal intensive care unit (NICU) of a medical college recognized for DM neonatology training program.
The mentoring team comprised the two faculties from the Department of Neonatology and two senior residents of a tertiary care hospital in Karnataka. One faculty with a senior resident visited the facility every week.
The SNCU was chosen by the GOK for mentoring and it was functioning at the district hospital catering to approximately 3500 live births per year and covering 25 subcenters, with a bed strength of 16. The facility provided care to all newborns not requiring assisted ventilation. It was located approximately 70 km from Bengaluru. Human resources consisted of two pediatricians, two resident doctors, 13 staff nurses, one data entry operator, one counselor, and one housekeeping staff.
Onsite mentoring of the SNCU was carried out from August 2016 to November 2016.
A frame work was conceptualized aiming to decrease the neonatal mortality based on the principles of quality improvement (QI) and onsite mentoring, which focused on the major causes of neonatal mortality, namely
- Infection control
- Preterm care
- Care at birth
- Advocacy for infrastructure and resources.
Mentoring was divided into three time frames as described in [Table 1].
Interventions were carried out in all aspects of newborn care in the facility as summarized in [Table 2] and [Table 3]. [Table 2] summarizes the indicators of the process and outcomes.
Interventions and the approach to the mentorship
Various tools and approaches were used.
- Workshops: Following workshops were conducted for the nurses and the doctors, simplified as both theory and hands-on sessions with audio-visual aids making sure all the staff in the facility attend these workshops. Each of these was organized by 3–4 experts including a consultant
- Neonatal Resuscitation Program (NRP) – A 1-day course based on Basic NRP of NRP First Golden Minute Program, for which all the four faculties were national trainers. The doctors were also trained in Advanced NRP
- KMC and Human Lactation Workshop – A full-day workshop was conducted by the mentoring faculty
- Infection Control and Housekeeping Workshop was conducted by the Hospital Infection Committee experts from the mentoring unit.
- Refresher training: It was based on the FBNC protocols  along with the classes on equipment demonstration. A quiz program for the doctors and the staff nurses based on the FBNC protocols was conducted at the end of the intervention period.
The mentors attended Clinical rounds along with the nurses and resident doctors which was intended to solve clinical problems and also reinforce classroom teaching. During rounds, observation of practices and policies as mentioned in [Table 2], which would provide feedback for policy-makers, was focused upon. However, clinical decision-making was with the local faculty.
Various audit tools were designed and utilized as process indicators [Table 3]. Each staff nurse and the resident doctors were made champions for a particular area of newborn care, to increase the accountability and improve self-auditing. Regular auditing was also done with each visit by the mentoring faculty.
The DM resident was posted in the SNCU for 2 weeks as a part of external posting. The responsibilities included taking rounds, teaching, attending emergency calls, and audits of the processes.
Descriptive feedback which included the perception of system changes during the mentoring, suggestions, and requests from all the staff nurses and the doctors was taken at the end of the intervention period, which aimed to identify deficits and improve the scope of the mentoring process.
Structure of the mentoring visit
A typical mentoring visit plan included attending rounds, conducting training sessions, auditing, and discussion with the various stakeholders of the facility. Each visit also included addressing the problems, evaluation, and formal assessment of the facility and discussion with the administrators (district surgeon). A detailed report was prepared at the end of the day with an action plan to be followed up at the next visit, including the timeline and person responsible for the job.
Department of Health and Family Welfare, GOK, sponsored the mentoring program financially. Karnataka State Neonatal and Child Health Consultant, UNICEF, assisted the program by facilitating the mentoring and meetings with the administration.
Qualitative variables are expressed in percentages, while quantitative variables are expressed in mean and standard deviation. Knowledge assessment was done by assessing mean paired difference using paired t-test. Difference in the NICU survival was analyzed by repeated measures ANOVA. The process indicator results were depicted in run charts. The data was captured in MS-Excel version 16.16.9 and analyzed using SPSS v.24 software (IBM, Chicago, Illinois, USA).
| Results|| |
A total of 16 visits were done by the mentoring team and 2 weeks of in-house residency by the DM neonatology resident.
The mean number of admissions was 101 ± 9.6/month during the mentoring period. Process indicator results are depicted in [Table 4], which shows increased hand hygiene compliance (0%–87.5%), cleaner IV site (50%–100%), decreased antibiotic usage (70.5%–35.5%), and decrease in the number of babies receiving >5 days of antibiotics (41.6%–0%). Initiation of KMC increased from 2% to 41.6% for eligible babies. The percentage of babies on oxygen in the unit during the mentoring period varied from 6.6% to 33.3%. A decrease in unnecessary oxygen administration (75%–33.3%) was observed. The NICU survival had increased from 80.7% to 84.2% (P < 0.01). Posttest assessment after workshops showed significant increase in the knowledge, after NRP 6 ± 2.75 (P < 0.001), infection control and housekeeping workshop 3.3 ± 1.27 (P < 0.001), and KMC and lactation 3.3 ± 1.27 (P < 0.001). Feedback from the healthcare providers was positive, and they felt empowered at the end of the intervention. They requested more frequent training and deputation to the mentor unit along with onsite training.
Other achievements during the mentorship period included establishment of a KMC ward and lactation clinic in the facility. Assessments for accreditation were done by the experts from National Neonatology Forum (NNF) in December 2016 and were accredited level IIA – the first for an SNCU in Government Sector in Karnataka State.
| Discussion|| |
Different approaches to improve newborn care at the public health facilities located have been used in low- and middle-income countries with success.,, Onsite mentoring has been successfully utilized in improving the quality of emergency newborn care in the first referral units in North Karnataka. We tried to implement this model to improve the overall quality standards of the SNCU.
There was increased hand hygiene compliance from 0% to 87.5% during the intervention. In a study by Chhapola and Brar, from India, it had improved to 46% after similar intervention. Although it was an observation over a small period, the improvement was significant. Initial poor compliance could partly be attributed to nonavailability of hand rub as reflected in the audits as well as the number of hand rub containers used. The asepsis practices in the peripheral line handling also improved during the intervention probably as a result of increased awareness. The advocacy for procurement of the essentials for the control of sepsis, i.e., hand rubs, sterile gloves, use of a closed system for intravenous fluid administration, also helped in the achievement of increased infection control processes.
Antibiotic usage decreased from 70.55% to 35.5% and the number of antibiotic use ≥5 days had decreased to 0% by the end of the intervention period. Increased sensitization regarding antibiotic stewardship and consensus on antibiotic policy could have helped to optimize the antibiotic utilization. However, the nonavailability of the sepsis screen and the blood culture facilities may still hinder the appropriate antibiotic usage.
Appropriate use of oxygen though had improved, the overuse of oxygen had not decreased significantly, which may be attributed to nonavailability of other modalities of respiratory support and the lack of pulse oximeters for monitoring.
Increased KMC for the eligible newborns was also observed (2%–41.6%). The increased awareness, establishment of KMC ward, and acceptance by the mothers and the staff were reflected in the feedback by health care personnel and parents. Das et al. did a capacity building and QI program in three districts of Uttar Pradesh, India. This before and after study showed marked improvement in KMC (27%) at these facilities.
The NICU survival rate had increased from 80.7% to 84.2% in the postintervention period. Although we did not evaluate disease-specific mortality, this could reflect the overall impact of the regular mentoring visits. However, the intervention was of short duration to show a significant effect on sustainability over time.
The accreditation of the SNCU as level IIA by the NNF, which happened at the end of the intervention, reflected the success of the mentorship program.
Strengths of the study were that we demonstrated that onsite mentoring was possible despite the limiting factor of distance of the facility. There was a structured plan before the interventions which targeted the core areas of improvement and was tailored to the facility. The tools utilized during the study could be used to sustain and improve the quality of care by the SNCU and could be replicated and adopted for similar projects. Training program being run in the same setup helped to involve all the healthcare personnel.
We also showed that the principles of QI could be integrated into the mentorship programs. The active participation of the hospital administration and the attitudes of the doctors and the staff nurses to bring about improvement were also noted to be the strength of the project.
As a part of the curriculum, neonatology DM/DNB residents and postgraduate residents should take up community interventions to ignite their interest, and this could help in understanding the ground realities and the problems encountered in caring newborns at the community level. This would also help cater to the unmet need of mentorship and support for the SNCUs across India.
Although the study integrated the principle of QI, the mentorship was for a short duration; audits were not stringent and only few audit tools were validated. There was limited scope for evaluation of each Plan-Do-Study-Act cycle. We intended to continue the mentorship to consolidate and sustain the changes for the next 2 months. However, in view of lack of continued logistic support from the government, the project had to conclude in 4 months. These were the limitations of the current study.
Consolidation of gains in terms of assessment of the outcome measures to look into the impact of the mentorship program in each core area would need projects to span across years and commitment from the government and the healthcare system.
| Conclusion|| |
Onsite mentorship program of SNCU facility is feasible, and planning should be contextual. With the problems being uniform across most of SNCU in our country, the model could be replicated across other facilities.
We would like to acknowledge Office of the Deputy Director, Department of Health and Family Welfare, GOK, for the logistic support for the study; the Secretary, C.B.C.I. Society for Medical Education, St. John's Medical College, for the permission for mentoring visits; and UNICEF, Karnataka, for facilitating the mentoring program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]