quality of care for essential newborn care and neonatal
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Quality of Care for Essential Newborn Care and Neonatal Resuscitation
in selected districts Jharkhand Experience
Dr. Anju Puri, Senior Advisor, Newborn Health
USAID- MCHIP
Uttar Pradesh
Gonda
Deoghar
Jamtara
Jharkhand
Giridih Simdega
Chaibasa
Lucknow
Knowledge base posts
ENCR - Essential and Universal
Technical focus: Essential newborn care: Immediate newborn care and neonatal resuscitation (QOC) Approach that has been used to analyse the delivery of service; understand the
performance of the providers during training; and thereafter using systematic effort to
improve the competence for the skill proficiency on ENC/R for improved outcomes.
Core of our understanding is direct implementation and observation to assess
quality of care at the select facilities, both for delivery and newborn care
3
NSSK
2 day training Neonatal Resuscitation Basic newborn care - Care of the baby at birth, Prevention of infection, Thermal
protection, Feeding of normal & LBW, transport of neonates
NO CHANGE IN PRACTICE ? Who got trained? Plan? Provider mapping? ? How was training conducted? Block/ district? Complete or
Incomplete? ? What did the training result? ? What was missing? ? What can be done to improve?
4
During Training - adaption Quality Assurance Checklist Been used to assess and
adhere to a minimum standard for quality of process during the training.
10 observation questions Score less than 80,
training is repeated.
Ensure Pre-Post Performance checklist shared with each participant
Pre-post test scores are used to rate the training and provide feed-back to the providers.
Measure changes in both the knowledge and skill acquisition by the health providers as a result of the training.
S no
Field for scoring. Scoring by observer/participants Total
score Average
score Ideal score Trainee 1 2 3 4 5 6
1 Facilitator to participants ratio
District A 5 5 5 5 5 - 25 4.2 5
District AI 0 0 0 0 0 0 0 0.0 5
District B 5 5 5 5 5 5 30 5.0 5
District BI 5 5 5 5 5 25 4.2 5
2 Whether planning session conducted before the start of the training?
District A 0 NA NA NA NA 0 0.0 5
District AI 5 NA NA NA NA NA 5 0.8 5
District B 5 0 NA NA NA NA 5 0.8 5
District BI 5 NA NA NA NA 5 0.8 5
3 Items present at the training
District A 2 2 2 2 2 10 1.7 5
District AI 2 2 2 2 2 2 12 2.0 5
District B 2 2 2 5 5 5 21 3.5 5
District BI 2 2 2 2 2 10 1.7 5
4 Number of participant’s for whom both pre & post test was conducted
District A 5 5 5 5 5 25 4.2 5
District AI 5 5 5 5 5 5 30 5.0 5
District B 5 5 5 5 5 5 30 5.0 5
District BI 5 5 5 5 5 25 4.2 5
5 Whether the performance list was correctly used
District A 5 0 5 5 5 20 3.3 5
District AI 5 5 5 5 5 5 30 5.0 5
District B 5 0 5 5 5 5 25 4.2 5
District BI 5 5 5 0 5 20 3.3 5
6 Feedback given using performance checklist
District A 0 0 5 5 5 15 2.5 5
District AI 5 5 0 5 5 5 25 4.2 5
District B 5 0 5 5 5 5 25 4.2 5
District BI 5 5 5 0 5 20 3.3 5
7 List of skill demonstrations
District A 45 35 45 50 50 225 37.5 50
District AI 40 35 40 40 40 40 235 39.2 50
District B 40 45 45 50 50 45 275 45.8 50
District BI 45 45 45 40 40 215 35.8 50
8 Good quality video used in the training (Thermal protection and feeding)
District A 10 10 10 10 10 50 8.3 10
District AI 5 5 5 5 5 5 30 5.0 10
District B 10 10 10 0 10 10 50 8.3 10
District BI 0 0 0 0 0 0 0.0 10
9 Mega code score conducted correctly (Performed for all 5 bold items)
District A - 10 10 - - - 20 3.3 10
District AI 10 10 - 10 10 10 50 8.3 10
District B - - - - 10 10 20 3.3 10
District BI 10 0 - 10 - - 20 3.3 10
10 Number of participant’s with less than minimum passing score (optional)
District A 4 4
District AI 3 3
District B 3 3
District BI 3
Total score
District A 72 67 87 82 82 - 390 65 100
District AI 77 72 62 77 77 82 447 70 100
District B 72 62 72 70 90 85 451 80 100
District BI 82 77 70 85 72 386 57 100
Gear Changers : Capacity Building Approach
Modified cascade approach used to promote continuity & quality
Quality care at key times during delivery and postpartum care, integrating components (assessment, care and counseling) care and follow up a) core group of trainers/supervisors and nurses,
b) physicians - orientation sessions
Basic Care of NSSK adapted to improved action based components: Immediate essential care (within the first 6 hours of
delivery)
Pre-discharge care (including providing appointment for 1st visit)
Early postnatal visit (within 1 week as recommended for visit within 3 days)
Subsequent PN visits during next 4 weeks
8
B. Organizational Changes
Physical space (room) and basic equipment/supplies
Introduction of record and review mechanism
Appropriate organization of the labor room
C. Supportive Supervision and M & E
Baseline and mid line readiness evaluations by observations of client-provider interactions and the job-corrections and capacity building
Findings from on-going monitoring during monthly supportive supervisory visits facilitated by MCHIP staff
Modeling with in facilities
District Supportive supervision
A structured guide & training methodology for supportive supervision was prepared
An “yes and no “simple checklist” is being used for regular supervision & feedback.
Each skill is only scored, if all the steps is followed for the skill.
The checklist has two copies, one for the health provider being supervised and the other for the one who supervises the activity. By this mean we assured that the provider who was supervised knows the misses and can be motivated to improve his performance.
55
82
100
64
100
82
45
55
73
73
73
100
73
73
Preparation of birth
Hand washing
Drying
Cord clamping & cutting
Skin to Skin
Breast feeding with in 1 hr
Vitamin K
Examination of the newborn
Temperature recording
Weighing
Neonatal immunization
Cheking of B & M
Steps of resuscitation
Vetilation by Bag & mask
Supportive supervision
Newborn Resuscitation Simulations
11
(1) Adjustment is any proper adjustment: check neck position, check seal, repeat suction, squeeze harder (2) Ventilation: place correct size mask covering chin, moth and nose, squeeze bag with 2 fingers or hand – appropriately, ventilate at 40 breathes/min (all items) (3) Initial steps: drying, place on warm clean surface, head in slightly extended position, suction with bulb or catheter in mouth or nose (all items)
Dip-stick tests – Regular and measurable
Questionnaire and exercise methodology developed to focus on the “preparedness” of the health facilities to deliver newborn care services as per the national guidelines.
The results framework is quantifiable in operational terms rather than health systems framework.
The analysis tool works on 75 broad indicators to generate color- codes to map the status of 8 parameters – Infrastructure, Delivery and Newborn Care services, Human resource, Essential drugs, equipment and supply, Register and client case record, Protocols and guidelines, universal precautions & infection prevention and Provider‟s knowledge & competency on core skills.
A computerized SQL based analysis system has been developed to generate score based color-codes.
Implementing a planning exercise based after this exercise is found very useful and allowed us to bench mark the health facilities over a period of time.
Score-card and improvement scores
37 43 43
57
67 64
54
75
Palajori Pabia Sadar Jamtara Mahupur
Facility readiness scores of the demo sites
Oct-2010 Feb-2012
Reporting and recording system
Simple, coded, integrated maternal and newborn register 94% percent of the total deliveries are live born and 3% are neonatal and still
births. 9.38% increase in the institutional delivery load between Oct 2011 and Sept
2012 There is 4.57% reduction in the reported neonatal deaths from 5.68% of all
live births in October 2011 to 1.12% in September 2012
15
Reported Data Reduction in still birth
rates is 5.44% from 6.53% of all deliveries to 1.09% in September 2012
On an average 21% newborns were low birth weight, 10.9% newborns had birth asphyxia and 0.9% newborns were preterm.
16
Resuscitation at NBCC D
istri
ct N
ame
Faci
lity
Nam
e
Num
ber o
f stil
l bor
ns re
susc
itate
d (X
)
Stil
l bor
ns b
roug
ht b
ack
to li
fe (B
V-C
U)
Num
ber o
f ne
wbo
rns
with
asp
hyxi
a (A
J)
Num
ber o
f ne
wbo
rns
with
mec
oniu
m
(AI)
Num
ber o
f ne
wbo
rns
who
had
flo
ppin
ess
(AK
)
Num
ber r
esus
cita
ted
by s
timul
atio
n on
ly
Num
ber r
esus
cita
ted
by s
timul
atio
n an
d su
ctio
n
Num
ber r
esus
cita
ted
by s
timul
atio
n ,s
uctio
n an
d ba
g an
d m
ask
Num
ber r
esus
cita
ted
by s
timul
atio
n ,s
uctio
n an
d ba
g an
d m
ask
and
oxyg
en
Tota
l num
ber o
f new
born
s on
who
m b
ag
and
mas
k ha
s be
en u
sed
Tota
l num
ber o
f new
born
s w
ith a
sphy
xia
or m
econ
ium
or f
lopp
ines
s (A
J+AI
+AK
)
JAM DH 33 2 43 75 11 3 37 13 14 27 67
JAM Pabia 36 0 8 10 0 0 4 8 0 8 10
DEO Palajori 7 1 8 18 12 0 1 5 2 7 29
DEO Madhupur 30 0 6 15 3 4 2 3 2 5 18
All sites total 84 3 82 125 36 8 44 29 18 47 124
Tracked newborn care at NBCC resuscitation data
18
Out of a total of 369 birth asphyxia newborns 189 newborns were reported to be have managed by bag and mask. While it is encouraging finding of increase in use of bag and mask; the proportion remains very high*
So what?
Community follow up; Birth asphyxia children were followed with at least three visits- Visit 1 on day3, Visit 2 on day 7, and visit 3 on day 28 and an extra visit „4‟ and an additional visit is made on day 14 if the newborn is found sick or reported ill by Sahiya‟s.
477 facility delivered newborn have been tracked with all the 3 follow ups completed in the community. Highest mortality 58.3% were found within 1st 3 days of birth.
19
Mortality up-to 28 days on the community follow up visit
Change in knowledge on diagnosis of birth asphyxia
67.9
0.0
71.4
0.0 3.6
53.6
89.3
78.6
100.0
89.3
78.6
67.9
Depressed
breathing
Floppiness
Not cried at birth
Delayed crying (1
or 5 minutes)
Heart rate below 100 beats per minutes
Central cyanosis
(blue tongue)
Deoghar Oct 10
Deoghar Jan 12
Change in provider’s knowledge & practice in using chronology of steps during resuscitation process
0.0 0.0
16.7 4.2
70.2
4.2
0.0
40.0 70.0
44.0
66.0
90.0
80.0
60.0
Explain to mother
condition of baby
Place the newborn face
up
Wrap or cover baby except for face and
chest
Position baby’s head so neck is
slightly extended
Suction mouth then
nose
Start ventilation using using
bag and mask
Were the steps in
sequential order
Deoghar Oct 10
Deoghar Jan 12
0.0
50.0
22.2 5.6
83.3
61.1
0.0
80.0
90.0
62.0
74.0
94.0
98.0
88.0
Explain to mother
condition of baby
Place the newborn face
up
Wrap or cover baby except for face and
chest
Position baby’s head so neck is
slightly extended
Suction mouth then
nose
Start ventilation using using
bag and mask
Were the steps in
sequential order
Jamtara Oct 10
Jamtara Jan 12
Sustaining and scaling efforts
Resuscitation indicators
Non - breathing
Non - breathing or meconium or floppiness
% newborns with birth asphyxia 3.5 5.3
Proportion of "Non - breathing" newborns resuscitated with stimulation alone 9.8 6.5
Proportion of "Non - breathing " newborns resuscitated with stimulation and suction 53.7 42.2
Proportion of " Non- Breathing" resuscitated with stimulation, suction and bag and mask 35.4 48.2
Proportion of "Non-breathing" newborns resuscitated successfully 98.8 96.9
Landscape of program inputs
Facility readiness assessment using 8 parameters was conducted in
Oct 2010 using a structured questionnaire and 75 indicators generated. KAP performance for maternal and newborn care especially neonatal
resuscitation was mapped. District mapping of the gaps generated and facility wise plan made for
realistic program. Based on this implementation included provider
mapping, 3- Day skill based training in essential newborn care and resuscitation
skills of all district level primary providers conducted (250) Job-aides and skill lab of key providers (28) in the demo-facilities. Supportive supervision involving quantitative and qualitative checklists
was used to provide on-going hand holding. Involving district authorities
at each step was critical to success of the program. Strengthening of health information systems by improved reporting and
feedback mechanism,
Follow up of facility births of birth asphyxia newborns conducted in the
community.
ENCR program Operational Model Framework
Tools Key Management Cycle Needs assessment
Planning Monitoring Evaluation
Basic Information Basic Data x x x x Facility Needs Facility Readiness x x Planning Facility Plan x Implementation Training, Supportive Supervision,
Information Management x x
Service & Management quality*
Training QA, logistic management, Quality of Care, Neonatal death audit
x
Surveillance Management information system x Monitoring indicators & feedback x x Cost analysis Not Included x Sustainability Key Parameters x x X x
25
Conclusions
Assumption that skilled birth attendance equals quality newborn care is obviously not true
There is a need to improve the quality of newborn care for infants delivered at health facilities
No ENC R program in place Training is not synonymous with practice Supportive national policies absent Lack of supplies for immediate newborn care A sizable percentage of health facilities had newborn
resuscitation equipment Routine monitoring of newborn care in health facilities, in addition
to periodic comprehensive health facility assessments, will assist in addressing some of the observed deficiencies
State and district ownership
27
Self learning tools – Rotating mentors
Practice exercises at skill labs
Leaders and excellence within the districts – cross learning
30
6
CROSS-LEARNING -ENCR
Practical skill station and peer learning and supervision
31
ASKS
SIGNATURE PROGRAM FOR ENCR Operational plan for roll-out of ENCR
–District as a unit (perinatal network) Adaptation of current training guidelines –
NSSK to ENCR ( at least 3 days) Supportive supervision Neonatal task groups in ALL states Linkages with Maternal Health especially
Intra-partum care
32
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