1
|
Mitchell EJ, Aluvaala J, Bradshaw L, Daniels JP, Emadau C, Muthumbi B, Nabwera H, Ojee E, Opira J, Pallotti P, Qureshi Z, Sigei M, Su Y, Swinden R, Were F, Ojha S. A mixed-methods study to investigate feasibility and acceptability of an early warning score for preterm infants in neonatal units in Kenya: results of the NEWS-K study : Neonatal early warning scores in Kenya. BMC Pediatr 2024; 24:326. [PMID: 38734617 PMCID: PMC11088162 DOI: 10.1186/s12887-024-04778-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Preterm birth (< 37 weeks gestation) complications are the leading cause of neonatal mortality. Early-warning scores (EWS) are charts where vital signs (e.g., temperature, heart rate, respiratory rate) are recorded, triggering action. To evaluate whether a neonatal EWS improves clinical outcomes in low-middle income countries, a randomised trial is needed. Determining whether the use of a neonatal EWS is feasible and acceptable in newborn units, is a prerequisite to conducting a trial. We implemented a neonatal EWS in three newborn units in Kenya. Staff were asked to record infants' vital signs on the EWS during the study, triggering additional interventions as per existing local guidelines. No other aspects of care were altered. Feasibility criteria were pre-specified. We also interviewed health professionals (n = 28) and parents/family members (n = 42) to hear their opinions of the EWS. Data were collected on 465 preterm and/or low birthweight (< 2.5 kg) infants. In addition to qualitative study participants, 45 health professionals in participating hospitals also completed an online survey to share their views on the EWS. 94% of infants had the EWS completed at least once during their newborn unit admission. EWS completion was highest on the day of admission (93%). Completion rates were similar across shifts. 15% of vital signs triggered escalation to a more senior member of staff. Health professionals reported liking the EWS, though recognised the biggest barrier to implementation was poor staffing. Newborn unit infant to staff ratios varied between 10 and 53 staff per 1 infant, depending upon time of shift and staff type. A randomised trial of neonatal EWS in Kenya is possible and acceptable, though adaptations are required to the form before implementation.
Collapse
Affiliation(s)
- Eleanor J Mitchell
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Jalemba Aluvaala
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Lucy Bradshaw
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Caren Emadau
- Department of Paediatrics, Pumwani Maternity Hospital, PO Box 42849, Nairobi, 00100, Kenya
| | - Bernadine Muthumbi
- Department of Paediatrics, Thika Level 5 Hospital, PO Box 227, Thika, 001000, Kenya
| | - Helen Nabwera
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Ednah Ojee
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | | | - Phoebe Pallotti
- Maternal Health and Wellbeing Research Group, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Zahida Qureshi
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Mark Sigei
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Yuanfei Su
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Fredrick Were
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Shalini Ojha
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
2
|
Wainaina J, Ogero M, Mumelo L, Wairoto K, Mbevi G, Tuti T, Mwaniki P, Irimu G, English M, Aluvaala J. Hypothermia amongst neonatal admissions in Kenya: a retrospective cohort study assessing prevalence, trends, associated factors, and its relationship with all-cause neonatal mortality. Front Pediatr 2024; 12:1272104. [PMID: 38601273 PMCID: PMC11004247 DOI: 10.3389/fped.2024.1272104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 02/26/2024] [Indexed: 04/12/2024] Open
Abstract
Background Reports on hypothermia from high-burden countries like Kenya amongst sick newborns often include few centers or relatively small sample sizes. Objectives This study endeavored to describe: (i) the burden of hypothermia on admission across 21 newborn units in Kenya, (ii) any trend in prevalence of hypothermia over time, (iii) factors associated with hypothermia at admission, and (iv) hypothermia's association with inpatient neonatal mortality. Methods A retrospective cohort study was conducted from January 2020 to March 2023, focusing on small and sick newborns admitted in 21 NBUs. The primary and secondary outcome measures were the prevalence of hypothermia at admission and mortality during the index admission, respectively. An ordinal logistic regression model was used to estimate the relationship between selected factors and the outcomes cold stress (36.0°C-36.4°C) and hypothermia (<36.0°C). Factors associated with neonatal mortality, including hypothermia defined as body temperature below 36.0°C, were also explored using logistic regression. Results A total of 58,804 newborns from newborn units in 21 study hospitals were included in the analysis. Out of these, 47,999 (82%) had their admission temperature recorded and 8,391 (17.5%) had hypothermia. Hypothermia prevalence decreased over the study period while admission temperature documentation increased. Significant associations were found between low birthweight and very low (0-3) APGAR scores with hypothermia at admission. Odds of hypothermia reduced as ambient temperature and month of participation in the Clinical Information Network (a collaborative learning health platform for healthcare improvement) increased. Hypothermia at admission was associated with 35% (OR 1.35, 95% CI 1.22, 1.50) increase in odds of neonatal inpatient death. Conclusions A substantial proportion of newborns are admitted with hypothermia, indicating a breakdown in warm chain protocols after birth and intra-hospital transport that increases odds of mortality. Urgent implementation of rigorous warm chain protocols, particularly for low-birth-weight babies, is crucial to protect these vulnerable newborns from the detrimental effects of hypothermia.
Collapse
Affiliation(s)
- John Wainaina
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Livingstone Mumelo
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Kefa Wairoto
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - George Mbevi
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Oxford, United Kingdom
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| |
Collapse
|
3
|
Ekpenyong EE, Akpan UM, Oloyede IP, Ebiekpi IU, David UD. An Audit of Mortality Pattern in the Neonatology Unit of the University of Uyo Teaching Hospital, Uyo, Nigeria: A Seven-Year Review. Niger Med J 2024; 65:213-221. [PMID: 39005554 PMCID: PMC11240200 DOI: 10.60787/nmj-v65i2-410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Background Most neonatal deaths occur in low and middle-income countries (LMICs). These deaths can be prevented through universal access to basic high-quality in-patient health services. Prematurity, neonatal sepsis, and perinatal asphyxia have been reported as the leading causes of in-patient neonatal deaths. This study aimed to assess the trend of neonatal mortality in our hospital, determine the pattern and causes of neonatal mortality, and evaluate the factors associated with neonatal mortality in our facility. Methodology This was a retrospective cross-sectional descriptive study conducted in the Special Care Babies Unit (SCBU) and Sick Babies Unit (SBU) of the University of Uyo Teaching Hospital, over seven years (2015-2021). Demographic, clinical, and mortality data was extracted from the case record files of patients into a structured proforma and analysed. Results There was a total of 228 deaths comprising 130 males (57.02%) and 98 (42.98%) females. The median age at demise was 4.00 (IQR = 1.00 - 12.00) days for both genders. The majority (71.50%) of deaths occurred in the Sick Babies Unit. More males died than females (57% vs 43%). The three leading causes of death were: prematurity (38.60%), neonatal sepsis (38.16%), and birth asphyxia (13.60%). Conclusion The leading causes of neonatal mortality in our environment are prematurity and neonatal sepsis. There is a need for increased community education on antenatal care, training of traditional birth attendants, improved newborn transportation facilities, and provision of neonatal intensive care facilities.
Collapse
Affiliation(s)
- Enobong Edet Ekpenyong
- Department of Paediatrics, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Usenobong Morgan Akpan
- Department of Paediatrics, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Iso Precious Oloyede
- Department of Paediatrics, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | | | - Utibe David David
- Department of Paediatrics, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| |
Collapse
|
4
|
Muinga N, Tuti T, Mwaniki P, Gicheha E, Paton C, Beňová L, English M. Evaluating the documentation of vital signs following implementation of a new comprehensive newborn monitoring chart in 19 hospitals in Kenya: A time series analysis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002440. [PMID: 37910489 PMCID: PMC10619831 DOI: 10.1371/journal.pgph.0002440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
Multi-professional teams care for sick newborns, but nurses are the primary caregivers, making nursing care documentation essential for delivering high-quality care, fostering teamwork, and improving patient outcomes. We report on an evaluation of vital signs documentation following implementation of the comprehensive newborn monitoring chart using interrupted time series analysis and a review of filled charts. We collected post-admission vital signs (Temperature (T), Pulse (P), Respiratory Rate (R) and Oxygen Saturation (S)) documentation frequencies of 43,719 newborns with a length of stay > 48 hours from 19 public hospitals in Kenya between September 2019 and October 2021. The primary outcome was an ordinal categorical variable (no monitoring, monitoring 1 to 3 times, 4 to 7 times and 8 or more times) based on the number of complete sets of TPRS. Descriptive analyses explored documentation of at least one T, P, R and S. The percentage of patients in the no-monitoring category decreased from 68.5% to 43.5% in the post-intervention period for TPRS monitoring. The intervention increased the odds of being in a higher TPRS monitoring category by 4.8 times (p<0.001) and increased the odds of higher monitoring frequency for each vital sign, with S recording the highest odds. Sicker babies were likely to have vital signs documented in a higher monitoring category and being in the NEST360 program increased the odds of frequent vital signs documentation. However, by the end of the intervention period, nearly half of the newborns did not have a single full set of TPRS documented and there was heterogenous hospital performance. A review of 84 charts showed variable documentation, with only one chart being completed as designed. Vital signs documentation fell below standards despite increased documentation odds. More sustained interventions are required to realise the benefits of the chart and hospital-specific performance data may help customise interventions.
Collapse
Affiliation(s)
- Naomi Muinga
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Timothy Tuti
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Paul Mwaniki
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Edith Gicheha
- Rice360 Global Health Institute, Rice University, Texas, United States of America
| | - Chris Paton
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Mike English
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
| |
Collapse
|
5
|
Tette EMA, Nartey ET, Nyarko MY, Aduful AK, Neizer ML. Trends in Neonatal Mortality at Princess Marie Louise Children's Hospital, Accra, and the Newborn Strategic Plan: Implications for Reducing Mortality in Hospital and the Community. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1755. [PMID: 38002846 PMCID: PMC10670549 DOI: 10.3390/children10111755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND In low and middle-income countries, close to half of the mortality in children under the age of five years occurs in neonates. OBJECTIVES We examined the trend, medical conditions and factors associated with newborn deaths at the Princess Marie Louise Children's Hospital (PML), Accra, from 2014 to 2017 (4 years). METHODS The study was a cross-sectional study. Data on age, sex, date of admission, date of discharge, cause of death and place of residence of these babies were obtained from the records department. This was transferred into an Access database and analyzed. Components of the Newborn Strategic Plan implemented at the hospital were described. RESULTS Neonatal sepsis, pneumonia and kernicterus were the major causes of death. Admissions increased and 5.4% of the neonates died, declining from 6.5% in 2014 to 4.2% in 2017 due to deliberate actions to reduce neonatal death. The highest mortality occurred in babies residing in an area more than 1 hour's drive away from the hospital. CONCLUSION Implementing the Newborn Strategic Plan was associated with a drop in mortality. A preponderance of community-acquired infections was observed. Thus, locality-specific interventions targeted at known determinants and implementing the newborn strategic plan are essential for reducing neonatal mortality.
Collapse
Affiliation(s)
- Edem M. A. Tette
- Department of Community Health, University of Ghana Medical School, Accra P.O. Box 4236, Ghana
- Princess Marie Louise Children’s Hospital, Accra P.O. Box GP 122, Ghana; (M.Y.N.); (M.L.N.)
| | - Edmund T. Nartey
- Centre for Tropical Clinical Pharmacology and Therapeutics, University of Ghana Medical School, Accra P.O. Box 4236, Ghana;
| | - Mame Yaa Nyarko
- Princess Marie Louise Children’s Hospital, Accra P.O. Box GP 122, Ghana; (M.Y.N.); (M.L.N.)
| | - Abena K. Aduful
- Family Medicine Department, Korle-Bu Teaching Hospital, Accra P.O. Box GP 4236, Ghana;
| | - Margaret L. Neizer
- Princess Marie Louise Children’s Hospital, Accra P.O. Box GP 122, Ghana; (M.Y.N.); (M.L.N.)
| |
Collapse
|
6
|
Irimu G, Okwaro F, Coleman J, Waiyego M, Murila F, Chomba D, Parsimei M, Shitote C, Ochieng R, Shah J, Ogero M, Ginsburg AS, Ansermino JM, Macharia W. Developing and testing a clinical care bundle incorporating caffeine citrate to manage apnoea of prematurity in a resource-constrained setting: a mixed methods clinical feasibility study protocol. Implement Sci Commun 2023; 4:80. [PMID: 37461120 PMCID: PMC10351121 DOI: 10.1186/s43058-023-00455-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Apnoea of prematurity (AOP) is a common condition among preterm infants. Methylxanthines, such as caffeine and aminophylline/theophylline, can help prevent and treat AOP. Due to its physiological benefits and fewer side effects, caffeine citrate is recommended for the prevention and treatment of AOP. However, caffeine citrate is not available in most resource-constrained settings (RCS) due to its high cost. Challenges in RCS using caffeine citrate to prevent AOP include identifying eligible preterm infants where gestational age is not always known and the capability for continuous monitoring of vital signs to readily identify apnoea. We aim to develop an evidence-based care bundle that includes caffeine citrate to prevent and manage AOP in tertiary healthcare facilities in Kenya. METHODS This protocol details a prospective mixed-methods clinical feasibility study on using caffeine citrate to manage apnoea of prematurity in a single facility tertiary-care newborn unit (NBU) in Nairobi, Kenya. This study will include a 4-month formative research phase followed by the development of an AOP clinical-care-bundle prototype over 2 months. In the subsequent 4 months, implementation and improvement of the clinical-care-bundle prototype will be undertaken. The baseline data will provide contextualised insights on care practices within the NBU that will inform the development of a context-sensitive AOP clinical-care-bundle prototype. The clinical care bundle will be tested and refined further during an implementation phase of the quality improvement initiative using a PDSA framework underpinned by quantitative and qualitative clinical audits and stakeholders' engagement. The quantitative component will include all neonates born at gestation age < 34 weeks and any neonate prescribed aminophylline or caffeine citrate admitted to the NBU during the study period. DISCUSSION There is a need to develop evidence-based and context-sensitive clinical practice guidelines to standardise and improve the management of AOP in RCS. Concerns requiring resolution in implementing such guidelines include diagnosis of apnoea, optimal timing, dosing and administration of caffeine citrate, standardisation of monitoring devices and alarm limits, and discharge protocols. We aim to provide a feasible standardised clinical care bundle for managing AOP in low and middle-income settings.
Collapse
Affiliation(s)
- Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
| | | | - Jesse Coleman
- The University of British Columbia, Vancouver, Canada
| | - Mary Waiyego
- Division of Paediatrics, Kenyatta National Hospital, Nairobi, Kenya
| | - Florence Murila
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Dorothy Chomba
- Department of Paediatrics, Aga Khan University, Nairobi, Kenya
| | | | - Cynthia Shitote
- Department of Paediatrics, Aga Khan University, Nairobi, Kenya
| | | | - Jasmit Shah
- Department of Paediatrics, Aga Khan University, Nairobi, Kenya
| | - Morris Ogero
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | |
Collapse
|
7
|
Ogola M, Wainaina J, Muinga N, Kimani W, Muriithi M, Aluvaala J, English M, Irimu G. Development of a small and sick newborn clinical audit tool and its implementation guide using a human-centred design approach newborn clinical audit process and design. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001577. [PMID: 36963070 PMCID: PMC10021839 DOI: 10.1371/journal.pgph.0001577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023]
Abstract
Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the clinical audit process must use a structured tool that comprehensively covers the continuum of newborn care from immediately after birth to the period of newborn unit care. The objective of the study was to co-design a newborn clinical audit tool that considered the key principles of a Human Centred Design approach. A three-step Human Centred Design approach was used that began by (1) understanding the context, the users and the available audit tools through literature, focus group discussions and a consensus meeting that was used to develop a prototype audit tool and its implementation guide, (2) the prototype audit tool was taken through several cycles of reviewing with users on real cases in a high volume newborn unit and refining it based on their feedback, and (3) the final prototype tool and the implementation guide were then tested in two high volume newborn units to determine their usability. Several cycles of evaluation and redesigning of the prototype audit tool revealed that the users preferred a comprehensive tool that catered to human factors such as reduced free text for ease of filling, length of the tool, and aesthetics. Identified facilitators and barriers influencing the newborn clinical audit in Kenyan public hospitals informed the design of an implementation guide that builds on the strengths and overcomes the barriers. We adopted a Human Centred Design approach to developing a newborn clinical audit tool and an implementation guide that we believe are comprehensive and consider the characteristics of the context of use and the user requirements.
Collapse
Affiliation(s)
- Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Pumwani Maternity Hospital, Nairobi, Kenya
| | - John Wainaina
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Naomi Muinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| |
Collapse
|
8
|
Talbert A, Ngari M, Obiero C, Nyaguara A, Mwangome M, Mturi N, Ouma N, Otiende M, Berkley J. Trends in inpatient and post-discharge mortality among young infants admitted to Kilifi County Hospital, Kenya: a retrospective cohort study. BMJ Open 2023; 13:e067482. [PMID: 36631234 PMCID: PMC9835934 DOI: 10.1136/bmjopen-2022-067482] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To describe admission trends and estimate inpatient and post-discharge mortality and its associated exposures, among young infants (YI) admitted to a county hospital in Kenya. DESIGN Retrospective cohort study. SETTING Secondary level hospital. PARTICIPANTS YI aged less than 60 days admitted to hospital from January 2009 to December 2019: 12 271 admissions in 11 877 individuals. YI who were resident within a Kilifi Health and Demographic Surveillance System (KHDSS): n=3625 with 4421 admissions were followed-up for 1 year after discharge. PRIMARY AND SECONDARY OUTCOME MEASURES Inpatient and 1-year post-discharge mortality, the latter in KHDSS residents. RESULTS Of 12 271 YI admissions, 4421 (36%) were KHDSS-resident. Neonatal sepsis, preterm complications and birth asphyxia accounted for 83% of the admissions. The proportion of YI among under-5s admissions increased from 19% in 2009 to 34% in 2019 (Ptrend=0.02). Inpatient case fatality was 16%, with 66% of the deaths occurring within 48 hours of admission. The introduction of free maternity care in 2013 was not associated with a change in admissions or inpatient mortality among YI. During 1-year post-discharge, 208/3625 (5.7%) YI died, 64.3 (95% CI 56.2 to 73.7) per 1000 infant-years. 49% of the post-discharge deaths occurred within 1 month of discharge, and 49% of post-discharge deaths occurred at home. Both inpatient and post-discharge deaths were associated with low admission weight. Inpatient mortality was associated with clinical signs of disease severity, while post-discharge mortality was associated with the length of hospitalisation, leaving against advice and referral to a specialised hospital. CONCLUSIONS YIs accounted for an increasing proportion of paediatric admissions and their overall mortality remains high. Post-discharge mortality accounts for a lower proportion of deaths but mortality rate is higher than among children aged 2-59 months. Services to address post-discharge mortality are needed and should focus on infants at higher risk.
Collapse
Affiliation(s)
| | - Moses Ngari
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christina Obiero
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Amek Nyaguara
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Neema Mturi
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Nelson Ouma
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - James Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, Oxfordshire, UK
| |
Collapse
|
9
|
Imam A, Gathara D, Aluvaala J, Maina M, English M. Evaluating the effects of supplementing ward nurses on quality of newborn care in Kenyan neonatal units: protocol for a prospective workforce intervention study. BMC Health Serv Res 2022; 22:1230. [PMID: 36195863 PMCID: PMC9530438 DOI: 10.1186/s12913-022-08597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data from High Income Countries have now linked low nurse staff to patient ratios to poor quality patient care. Adequately staffing hospitals is however still a challenge in resource-constrained Low-middle income countries (LMICs) and poor staff-to-patient ratios are largely taken as a norm. This in part relates to limited evidence on the relationship between staffing and quality of patient care in these settings and also an absence of research on benefits that might occur from improving hospital staff numbers in LMICs. This study will determine the effect on the quality of patient care of prospectively adding extra nursing staff to newborn units in a resource constrained LMIC setting and describe the relationship between staffing and quality of care. METHODS This prospective workforce intervention study will involve a multi-method approach. We will conduct a before and after study in newborn units of 4 intervention hospitals and a single time-point comparison in 4 non-intervention hospitals to determine if there is a change in the level of missed nursing care, a process measure of the quality of patient care. We will also determine the effect of our intervention on routinely collected quality indicators using interrupted time series analysis. Using three nurse staffing metrics (Total nursing hours, nursing hours per patient day and nursing hours per patient per shift), we will describe the relationship between staffing and the quality of patient care. DISCUSSION There is an urgent need for the implementation of staffing policies in resource constrained LMICs that are guided by relevant contextual data. To the best of our knowledge, this is the first study to evaluate the prospective addition of nursing staff in resource-constrained care settings. Our findings are likely to provide the much-needed evidence for better staffing in these settings. TRIAL REGISTRATION This study was retrospectively registered in the Pan African Clinical Trial Registry ( https://pactr.samrc.ac.za/Default.aspx?Logout=True ) database on the 10th of June 2022 with a unique identification number-PACTR202206477083141.
Collapse
Affiliation(s)
- Abdulazeez Imam
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Michuki Maina
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Kamau PT, Koech M, Hecht SM, McHenry MS, Songok J. Assessment of neonatal resuscitation skills among healthcare workers in Uasin Gishu County, Kenya. SAGE Open Med 2022; 10:20503121221119296. [PMID: 36051784 PMCID: PMC9424879 DOI: 10.1177/20503121221119296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Neonatal resuscitation is key in preventing neonatal mortality. The objective of this study was to assess the competence of healthcare workers in basic neonatal resuscitation at six hospitals in Uasin Gishu County in Kenya. Methods This was a cross-sectional study of healthcare workers based on the labor and delivery wards. Results Of the 46 healthcare workers who were assessed with a written examination and skills assessment, 85% were nurses. While 46% were able to pass the written examination, none demonstrated all required steps of newborn resuscitation during the skills assessment by simulation. No significant associations were present between the pass rate of the written examination and years of experience, role, or prior in-service training. All of the hospitals had the basic equipment required for neonatal resuscitation. Conclusion There is a need to further develop the neonatal resuscitation skills among healthcare workers in the labor and delivery wards in Uasin Gishu County, Kenya.
Collapse
Affiliation(s)
| | - Myra Koech
- Department of Pediatrics and Child Health, School of Medicine, Moi University, Eldoret, Kenya
| | - Shaina M Hecht
- Division of Pediatric Infectious Diseases and Global Health, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Megan S McHenry
- Division of Pediatric Infectious Diseases and Global Health, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Julia Songok
- Department of Pediatrics and Child Health, School of Medicine, Moi University, Eldoret, Kenya
| |
Collapse
|
11
|
Obiero CW, Williams P, Murunga S, Thitiri J, Omollo R, Walker AS, Egondi T, Nyaoke B, Correia E, Kane Z, Gastine S, Kipper K, Standing JF, Ellis S, Sharland M, Berkley JA. Randomised controlled trial of fosfomycin in neonatal sepsis: pharmacokinetics and safety in relation to sodium overload. Arch Dis Child 2022; 107:802-810. [PMID: 35078765 PMCID: PMC9411916 DOI: 10.1136/archdischild-2021-322483] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/24/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess pharmacokinetics and changes to sodium levels in addition to adverse events (AEs) associated with fosfomycin among neonates with clinical sepsis. DESIGN A single-centre open-label randomised controlled trial. SETTING Kilifi County Hospital, Kenya. PATIENTS 120 neonates aged ≤28 days admitted being treated with standard-of-care (SOC) antibiotics for sepsis: ampicillin and gentamicin between March 2018 and February 2019. INTERVENTION We randomly assigned half the participants to receive additional intravenous then oral fosfomycin at 100 mg/kg two times per day for up to 7 days (SOC-F) and followed up for 28 days. MAIN OUTCOMES AND MEASURES Serum sodium, AEs and fosfomycin pharmacokinetics. RESULTS 61 and 59 infants aged 0-23 days were assigned to SOC-F and SOC, respectively. There was no evidence of impact of fosfomycin on serum sodium or gastrointestinal side effects. We observed 35 AEs among 25 SOC-F participants and 50 AEs among 34 SOC participants during 1560 and 1565 infant-days observation, respectively (2.2 vs 3.2 events/100 infant-days; incidence rate difference -0.95 events/100 infant-days (95% CI -2.1 to 0.20)). Four SOC-F and 3 SOC participants died. From 238 pharmacokinetic samples, modelling suggests an intravenous dose of 150 mg/kg two times per day is required for pharmacodynamic target attainment in most children, reduced to 100 mg/kg two times per day in neonates aged <7 days or weighing <1500 g. CONCLUSION AND RELEVANCE Fosfomycin offers potential as an affordable regimen with a simple dosing schedule for neonatal sepsis. Further research on its safety is needed in larger cohorts of hospitalised neonates, including very preterm neonates or those critically ill. Resistance suppression would only be achieved for the most sensitive of organisms so fosfomycin is recommended to be used in combination with another antimicrobial. TRIAL REGISTRATION NUMBER NCT03453177.
Collapse
Affiliation(s)
- Christina W Obiero
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Phoebe Williams
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sheila Murunga
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnstone Thitiri
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Raymond Omollo
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | | | - Thaddaeus Egondi
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | - Borna Nyaoke
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | - Erika Correia
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Zoe Kane
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia.,Analytical Services International (ASI) Ltd, St George's - University of London, London, UK
| | - Joseph F Standing
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, University of London, London, UK
| | - James Alexander Berkley
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | | |
Collapse
|
12
|
A mixed-methods study on evaluating an updated, francophone version of ETAT+ training in Madagascar. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2022; 38. [PMID: 36284927 PMCID: PMC9549591 DOI: 10.7196/sajcc.2022.v38i2.535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 11/08/2022] Open
Abstract
Background
Madagascar needs major efforts to achieve the UN Sustainable Development Goals, despite the considerable reduction of child
mortality during past years. In this context, implementation of emergency triage assessment and treatment (ETAT) plays an important role. In
recent years, ETAT training activities rarely took place in Madagascar. To strengthen ETAT in Madagascar, a pilot training course was conducted
in December 2019 at the University Hospital Mahajanga.
Objectives
This study aims to evaluate if the ETAT+ pilot training content matches clinical needs in Madagascar and whether participants achieved
their learning objectives.
Methods
In this cross-sectional mixed-methods study, a 41-item questionnaire was used at the end of the ETAT+ training to evaluate their
learning experience from the 12 participants (paediatricians, physicians, nurses and midwives). Six weeks after the training, guided interviews were
conducted among five participants to describe how training content could be transferred into clinical practice in five health facilities.
Results
Results suggest that this pilot project designed to contribute to the re-establishment of ETAT in Madagascar meets participants’ needs
and is adapted to clinical realities in terms of transmitted knowledge, skills and competencies. However, results also show that considerable multi-disciplinary efforts are needed to advance ETAT+ implementation in Madagascar.
Conclusion
Implementation processes of ETAT training programmes need re-evaluation to assure their validity to contribute to quality of
care improvements efficiently. Further operational research is required to evaluate sustainable, innovative implementation strategies adapted to
contexts in Madagascar.
Contributions of the study
This study aims to evaluate an updated Malagasy version of the Emergency Triage Assessment and Treatment Plus (ETAT+). The training met the
participants’ needs and was adapted to the clinical realities in Madagascar relating to transmitted knowledge, skills and competencies.
Collapse
|
13
|
Tuti T, Collins G, English M, Aluvaala J. External validation of inpatient neonatal mortality prediction models in high-mortality settings. BMC Med 2022; 20:236. [PMID: 35918732 PMCID: PMC9347100 DOI: 10.1186/s12916-022-02439-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Two neonatal mortality prediction models, the Neonatal Essential Treatment Score (NETS) which uses treatments prescribed at admission and the Score for Essential Neonatal Symptoms and Signs (SENSS) which uses basic clinical signs, were derived in high-mortality, low-resource settings to utilise data more likely to be available in these settings. In this study, we evaluate the predictive accuracy of two neonatal prediction models for all-cause in-hospital mortality. METHODS We used retrospectively collected routine clinical data recorded by duty clinicians at admission from 16 Kenyan hospitals used to externally validate and update the SENSS and NETS models that were initially developed from the data from the largest Kenyan maternity hospital to predict in-hospital mortality. Model performance was evaluated by assessing discrimination and calibration. Discrimination, the ability of the model to differentiate between those with and without the outcome, was measured using the c-statistic. Calibration, the agreement between predictions from the model and what was observed, was measured using the calibration intercept and slope (with values of 0 and 1 denoting perfect calibration). RESULTS At initial external validation, the estimated mortality risks from the original SENSS and NETS models were markedly overestimated with calibration intercepts of - 0.703 (95% CI - 0.738 to - 0.669) and - 1.109 (95% CI - 1.148 to - 1.069) and too extreme with calibration slopes of 0.565 (95% CI 0.552 to 0.577) and 0.466 (95% CI 0.451 to 0.480), respectively. After model updating, the calibration of the model improved. The updated SENSS and NETS models had calibration intercepts of 0.311 (95% CI 0.282 to 0.350) and 0.032 (95% CI - 0.002 to 0.066) and calibration slopes of 1.029 (95% CI 1.006 to 1.051) and 0.799 (95% CI 0.774 to 0.823), respectively, while showing good discrimination with c-statistics of 0.834 (95% CI 0.829 to 0.839) and 0.775 (95% CI 0.768 to 0.782), respectively. The overall calibration performance of the updated SENSS and NETS models was better than any existing neonatal in-hospital mortality prediction models externally validated for settings comparable to Kenya. CONCLUSION Few prediction models undergo rigorous external validation. We show how external validation using data from multiple locations enables model updating and improving their performance and potential value. The improved models indicate it is possible to predict in-hospital mortality using either treatments or signs and symptoms derived from routine neonatal data from low-resource hospital settings also making possible their use for case-mix adjustment when contrasting similar hospital settings.
Collapse
Affiliation(s)
- Timothy Tuti
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya.
| | - Gary Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya.,Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya.,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| |
Collapse
|
14
|
Ouma PO, Malla L, Wachira BW, Kiarie H, Mumo J, Snow RW, English M, Okiro EA. Geospatial mapping of timely access to inpatient neonatal care and its relationship to neonatal mortality in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000216. [PMID: 36962323 PMCID: PMC10021833 DOI: 10.1371/journal.pgph.0000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 05/27/2022] [Indexed: 11/18/2022]
Abstract
Globally, 2.4 million newborns die in the first month of life, with neonatal mortality rates (NMR) per 1,000 livebirths being highest in sub-Saharan Africa. Improving access to inpatient newborn care is necessary for reduction of neonatal deaths in the region. We explore the relationship between distance to inpatient hospital newborn care and neonatal mortality in Kenya. Data on service availability from numerous sources were used to map hospitals that care for newborns with very low birth weight (VLBW). Estimates of livebirths needing VLBW services were mapped from population census data at 100 m spatial resolution using a random forest algorithm and adjustments using a systematic review of livebirths needing these services. A cost distance algorithm that adjusted for proximity to roads, road speeds, land use and protected areas was used to define geographic access to hospitals offering VLBW services. County-level access metrics were then regressed against estimates of NMR to assess the contribution of geographic access to VLBW services on newborn deaths while controlling for wealth, maternal education and health workforce. 228 VLBW hospitals were mapped, with 29,729 births predicted as requiring VLBW services in 2019. Approximately 80.3% of these births were within 2 hours of the nearest VLBW hospital. Geographic access to these hospitals, ranged from less than 30% in Wajir and Turkana to as high as 80% in six counties. Regression analysis showed that a one percent increase in population within 2 hours of a VLBW hospital was associated with a reduction of NMR by 0.24. Despite access in the country being above the 80% threshold, 17/47 counties do not achieve this benchmark. To reduce inequities in NMR in Kenya, policies to improve care must reduce geographic barriers to access and progressively improve facilities' capacity to provide quality care for VLBW newborns.
Collapse
Affiliation(s)
- Paul O. Ouma
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Hellen Kiarie
- Health Sector Monitoring and Evaluation Unit, Ministry of Health, Nairobi, Kenya
| | - Jeremiah Mumo
- Health Sector Monitoring and Evaluation Unit, Ministry of Health, Nairobi, Kenya
| | - Robert W. Snow
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
15
|
Stylianou A, Blanks KJH, Gibson RA, Kendall LK, English M, Williams S, Mehta R, Clarke A, Kanyuuru L, Aluvaala J, Darmstadt GL. Quantitative decision making for investment in global health intervention trials: Case study of the NEWBORN study on emollient therapy in preterm infants in Kenya. J Glob Health 2022; 12:04045. [PMID: 35972445 PMCID: PMC9185187 DOI: 10.7189/jogh.12.04045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Partners from an NGO, academia, industry and government applied a tool originating in the private sector – Quantitative Decision Making (QDM) – to rigorously assess whether to invest in testing a global health intervention. The proposed NEWBORN study was designed to assess whether topical emollient therapy with sunflower seed oil in infants with very low birthweight <1500 g in Kenya would result in a significant reduction in neonatal mortality compared to standard of care. Methods The QDM process consisted of prior elicitation, modelling of prior distributions, and simulations to assess Probability of Success (PoS) via assurance calculations. Expert opinion was elicited on the probability that emollient therapy with sunflower seed oil will have any measurable benefit on neonatal mortality based on available evidence. The distribution of effect sizes was modelled and trial data simulated using Statistical Analysis System to obtain the overall assurance which represents the PoS for the planned study. A decision-making framework was then applied to characterise the ability of the study to meet pre-selected decision-making endpoints. Results There was a 47% chance of a positive outcome (defined as a significant relative reduction in mortality of ≥15%), a 45% chance of a negative outcome (defined as a significant relative reduction in mortality <10%), and an 8% chance of ending in the consider zone (ie, a mortality reduction of 10 to <15%) for infants <1500 g. Conclusions QDM is a novel tool from industry which has utility for prioritisation of investments in global health, complementing existing tools [eg, Child Health and Nutrition Research Initiative]. Results from application of QDM to the NEWBORN study suggests that it has a high probability of producing clear results. Findings encourage future formation of public-private partnerships for health.
Collapse
Affiliation(s)
- Annie Stylianou
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | | | - Rachel A Gibson
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | - Lindsay K Kendall
- GlaxoSmithKline R&D, Gunnels Wood Road, Stevenage, Hertfordshire, UK
| | - Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Clinical Medicine, Oxford, UK
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | | | - Lynn Kanyuuru
- Save the Children International, Kenya Country Office, Nairobi, Kenya
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
16
|
Tuti T, Aluvaala J, Malla L, Irimu G, Mbevi G, Wainaina J, Mumelo L, Wairoto K, Mochache D, Hagel C, Maina M, English M. Evaluation of an audit and feedback intervention to reduce gentamicin prescription errors in newborn treatment (ReGENT) in neonatal inpatient care in Kenya: a controlled interrupted time series study protocol. Implement Sci 2022; 17:32. [PMID: 35578243 PMCID: PMC9109356 DOI: 10.1186/s13012-022-01203-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/10/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medication errors are likely common in low- and middle-income countries (LMICs). In neonatal hospital care where the population with severe illness has a high mortality rate, around 14.9% of drug prescriptions have errors in LMICs settings. However, there is scant research on interventions to improve medication safety to mitigate such errors. Our objective is to improve routine neonatal care particularly focusing on effective prescribing practices with the aim of achieving reduced gentamicin medication errors. METHODS We propose to conduct an audit and feedback (A&F) study over 12 months in 20 hospitals with 12 months of baseline data. The medical and nursing leaders on their newborn units had been organised into a network that facilitates evaluating intervention approaches for improving quality of neonatal care in these hospitals and are receiving basic feedback generated from the baseline data. In this study, the network will (1) be expanded to include all hospital pharmacists, (2) include a pharmacist-only professional WhatsApp discussion group for discussing prescription practices, and (3) support all hospitals to facilitate pharmacist-led continuous medical education seminars on prescription practices at hospital level, i.e. default intervention package. A subset of these hospitals (n = 10) will additionally (1) have an additional hospital-specific WhatsApp group for the pharmacists to discuss local performance with their local clinical team, (2) receive detailed A&F prescription error reports delivered through mobile-based dashboard, and (3) receive a PDF infographic summarising prescribing performance circulated to the clinicians through the hospital-specific WhatsApp group, i.e. an extended package. Using interrupted time series analysis modelling changes in prescribing errors over time, coupled with process fidelity evaluation, and WhatsApp sentiment analysis, we will evaluate the success with which the A&F interventions are delivered, received, and acted upon to reduce prescribing error while exploring the extended package's success/failure relative to the default intervention package. DISCUSSION If effective, these theory-informed A&F strategies that carefully consider the challenges of LMICs settings will support the improvement of medication prescribing practices with the insights gained adapted for other clinical behavioural targets of a similar nature. TRIAL REGISTRATION PACTR, PACTR202203869312307 . Registered 17th March 2022.
Collapse
Affiliation(s)
- Timothy Tuti
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Lucas Malla
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- London School of Hygiene and Tropical Medicine, London, UK
| | - Grace Irimu
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - George Mbevi
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - John Wainaina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Kefa Wairoto
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Christiane Hagel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
17
|
Tuti T, Aluvaala J, Chelangat D, Mbevi G, Wainaina J, Mumelo L, Wairoto K, Mochache D, Irimu G, Maina M, English M. Improving in-patient neonatal data quality as a pre-requisite for monitoring and improving quality of care at scale: A multisite retrospective cohort study in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000673. [PMID: 36962543 PMCID: PMC10021237 DOI: 10.1371/journal.pgph.0000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/20/2022] [Indexed: 03/11/2023]
Abstract
The objectives of this study were to (1)explore the quality of clinical data generated from hospitals providing in-patient neonatal care participating in a clinical information network (CIN) and whether data improved over time, and if data are adequate, (2)characterise accuracy of prescribing for basic treatments provided to neonatal in-patients over time. This was a retrospective cohort study involving neonates ≤28 days admitted between January 2018 and December 2021 in 20 government hospitals with an interquartile range of annual neonatal inpatient admissions between 550 and 1640 in Kenya. These hospitals participated in routine audit and feedback processes on quality of documentation and care over the study period. The study's outcomes were the number of patients as a proportion of all eligible patients over time with (1)complete domain-specific documentation scores, and (2)accurate domain-specific treatment prescription scores at admission, reported as incidence rate ratios. 80,060 neonatal admissions were eligible for inclusion. Upon joining CIN, documentation scores in the monitoring, other physical examination and bedside testing, discharge information, and maternal history domains demonstrated a statistically significant month-to-month relative improvement in number of patients with complete documentation of 7.6%, 2.9%, 2.4%, and 2.0% respectively. There was also statistically significant month-to-month improvement in prescribing accuracy after joining the CIN of 2.8% and 1.4% for feeds and fluids but not for Antibiotic prescriptions. Findings suggest that much of the variation observed is due to hospital-level factors. It is possible to introduce tools that capture important clinical data at least 80% of the time in routine African hospital settings but analyses of such data will need to account for missingness using appropriate statistical techniques. These data allow exploration of trends in performance and could support better impact evaluation, exploration of links between health system inputs and outcomes and scrutiny of variation in quality and outcomes of hospital care.
Collapse
Affiliation(s)
- Timothy Tuti
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - George Mbevi
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - John Wainaina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Kefa Wairoto
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Grace Irimu
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
18
|
Muinga N, Abejirinde IOO, Benova L, Paton C, English M, Zweekhorst M. Implementing a comprehensive newborn monitoring chart: Barriers, enablers, and opportunities. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000624. [PMID: 36962452 PMCID: PMC10021603 DOI: 10.1371/journal.pgph.0000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/20/2022] [Indexed: 11/19/2022]
Abstract
Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised paper-based charts. We report on a process of implementing a comprehensive newborn monitoring chart and the perceptions of health workers in a network of hospitals in Kenya. The chart was launched virtually in July 2020 followed by learning meetings with nurses and the research team. This is a qualitative study involving document review, individual in-depth interviews with nurses and paediatricians and a focus group discussion with data clerks. The chart was co-designed by the research team and hospital staff then implemented using a trainer of trainers' model where the nurses-in-charge were trained on how to use the chart and they in turn trained their staff. Training at the hospital was delivered by the nurse-in-charge and/or paediatrician through a combined training with all staff or one-on-one training. The chart was well received with health workers reporting reduced writing, consolidated information, and improved communication as benefits. Implementation was facilitated by individual and team factors, complementary projects, and the removal of old charts. However, challenges arose related to the staff and work environment, inadequate supply of charts, alternative places to document, and inadequate equipment. The participants suggested that future implementation should be accompanied by mentorship or close follow-up, peer experience sharing, training at the hospital and in pre-service institutions and wider stakeholder engagement. Findings show that there are opportunities to improve the implementation process by clarifying roles relating to the filing system, improving the chart supply process, staff induction and specifying a newborn patient file. The chart did not meet the need for supporting documentation of long stay patients presenting an opportunity to explore digital solutions that might provide more flexibility and features.
Collapse
Affiliation(s)
- Naomi Muinga
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Ibukun-Oluwa Omolade Abejirinde
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Canada
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Chris Paton
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, GB, England
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Mike English
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, GB, England
| | | |
Collapse
|
19
|
English M. Improving Emergency and Admission Care in Low-Resource, High Mortality Hospital Settings - Not as Easy as A, B, C. Health Policy Plan 2021; 37:808-810. [PMID: 34673985 PMCID: PMC9189608 DOI: 10.1093/heapol/czab128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/20/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust, Nairobi, Kenya.,Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, UK
| |
Collapse
|