Authored by Augusto Sola*
Abstract
Background: The Iberoamerican Society of Neonatology (SIBEN) dedicates efforts to facilitate the dissemination of knowledge and contributes to the well-being of NB in the Latin American region. In the Dominican Republic, the neonatal mortality rate was 17‰ in 2018, among the highest in Latin America. Through an agreement between the National Health System (NHS) of the country and SIBEN, actions were planned, developed and implemented to improve care of sick newborns (NB) at risk of dying.
Objective: To describe the actions implemented and to present the results obtained in the first year of collaborative work.
Methods: Multidimensional interventions in the context of continuous quality improvement of care in all public hospitals of the country where neonatal care is delivered. The main components of the comprehensive program were: detailed monitoring of vital statistics; situational diagnosis working in the field, including assessment of clinical management and procedures, education, NB and family issues, staff issues, infrastructure, equipment, and legal/regulatory and ethical issues, in order to institute an appropriate “hierarchy of interventions”. In addition, we performed root cause analysis (RCA) in deceased NB and incorporated data collection system in the neonatal units through SIBEN’s neonatal network. Finally, we also performed a preliminary cost analysis.
Results: The country’s neonatal mortality rate decreased from 17‰ in 2018 to 12.1‰ in 2019, with a relative risk reduction of 26%. There were improvements in infrastructure, equipment and staffing, together with modifications in clinical management and procedures and education and training. More than 600 neonatal health care professionals were trained, including nurses, neonatologists and neonatology residents.
By root cause analysis (RCA), of 511 infants who died, 54% were <1500 grams and pulmonary hemorrhage (PH) was the most frequent cause.
During 2019, 3,347 NB were admitted to 11 neonatal intensive care units (NICU) hospitals and reported to SIBEN’s Network. Comparing data from the first semester of 2019 with the second semester, mortality in the NICU’s decreased from 22.5% to 19%, detection of significant patent ductus arteriosus improved and PH frequency decreased. The cost of the program was approximately 1,100 dollars per each of the newborn whose life was saved.
Conclusion: One year after the collaborative agreement between SIBEN and NHS started, organization and delivery of care to sick NB in public hospitals of the Dominican Republic improved, and has led to a significant increase in neonatal survival. This was due to education and to definite improvements in the provision of neonatal intensive care, in a cost-effective manner.
Keywords: Neonatal mortality; Education; Neonatal health services
Abbreviations: NHS: National Health Service of the Dominican Republic; SIBEN: Iberoamerican Society of Neonatology; NB: Newborn; PH: Pulmonary hemorrhage; RCA: Root cause analysis; NICU: Neonatal intensive care unit
Introduction
In the Dominican Republic the population is 11,000,000, the birth rate is 18‰, with about 180,000 births per year [1], and the neonatal mortality in previous years has been >18‰. Of all births, 14% of NB are of low birth weight (<2,500 grams) and 1.5-2.3% are <1,500 grams. These rates are higher than the average for Latin America and the Caribbean [1,2]. More than 74% of children who die before 12 months of age are ≤ 28 days old [1]. In the first half of 2018, of a total of 1,961 infant’s deaths, 1,461 (74.5%) occurred before 28 days of age [1].
In this country >98% of births occur in hospitals [1,2] and two years ago, two maternity hospitals with a high number of births reported a very high neonatal mortality rate, 31-39‰ [3]. Likewise, the caesarean section rate in the Dominican Republic is >65% [4], with higher rates in the private sector than in the public sector.
In its mission to implement actions to reduce neonatal mortality rates, the National Health System (NHS) incorporated concrete measures to improve neonatal care. Among them, on October 31, 2018, they called upon SIBEN to collaborate in the efforts to improve the care of sick and at-risk neonates through various actions, including education of neonatal health care professionals. The agreement was signed by the general director of the NHS, Mr Chanel Rosa Chupany and the medical director of SIBEN, Augusto Sola.
SIBEN is a non-profit and public charity organization registered in the United States, under the federal tax and legal regulations of that country. Its main mission is to collaborate to improve neonatal care through education in the Latin American region [5]. In accordance with its bylaws, SIBEN dedicates its efforts to the diffusion of knowledge with an ethical approach, including equity, intersectoral and interdisciplinary methodologies, in order to identify and implement medical, human and social solutions for sick NB and their families. This has been done through various faceto- face and interactive educational methods in multiple regions of Latin America as demonstrated in multiple publications, some of which are listed in the bibliographic references [6,9].
The social, economic, preventive and nutritional actions that can have an effective impact in improving neonatal morbidity and mortality, if properly implemented, are multiple and have been described in detail [10-12]. Within this exhaustive and comprehensive framework, SIBEN focuses fundamentally on one aspect, aiming its actions directly towards improving the quality of intra-institutional care in three key periods for NB’s at risk of dying: the immediate prenatal period, the fetal-neonatal transition period and during the stay in neonatal intensive care. To do this, it implements and adapts, according to local needs and possibilities, programs to improve the quality of direct care, which have been widely described by others [13-19].
Objective
Describe the actions implemented by SIBEN in the Dominican Republic within the agreement with the NHS and present results obtained that led to the improvement of neonatal quality of care and neonatal survival in a cost-effective manner.
Methods
The program started at the end of 2018 within the framework of the SIBEN-NHS agreement and was based on the search for strategies and the implementation of actions to improve neonatal survival in the Dominican Republic by 2019.
All complex health interventions require a multidimensional approach and for this we established stages of diagnosis, planning and specific actions. The modality of the interventions was developed following the procedures described for the continuous improvement of quality of care [13-19]. As proposed by Deming and Shewhart, the “PDSA” cycle involves planning, doing, studying and acting [12]. These iterative cycles are based on the application of the best available evidence, the comparative evaluation of the results with permanent feedback and a collaborative process of mutual learning across all institutions. For all the stages we planned a dynamic interaction in order to adapt the strategies to the reality of each institution, to the identified findings and to the feasibility of change. We developed a “road map” that included the components described in this manuscript, actions to be implemented for each and their expected results. We summarize below the methods used related to vital statistics and neonatal survival, situational diagnosis, education, and information systems.
Vital statistics and neonatal survival
Number of births, neonatal mortality and prematurity rates were obtained from the General Epidemiology System (GEPIS) of the Ministry of Public Health (MPH) of the Dominican Republic [1]. We used these data to compare 2018 (pre-intervention) with 2019 (intervention in course). Statistical analysis included measures of effect with their respective confidence intervals.
Situational diagnosis
We planned to evaluate various basic aspects related to quality of neonatal care in the following areas: a) infrastructure, equipment and supplies (availability of O2 and compressed air, blenders, continuous positive airway pressure (CPAP), surfactant, respirators and others; b) human resource endowment and education (doctors, nurses and residents); c) use of protocols and procedures (name of the NB, family access, and diagnosis and treatment of prevalent diseases, including neonatal sepsis). This was carried out by SIBEN neonatologists and nurses in the maternity wards with the highest number of deliveries, in order to identify priority situations to be modified. The analysis of all the reports was carried out together with the local responsible MD’s and RN’s.
Education (October 2018 - December 2019)
Educational actions were planned according to SIBEN programs. The following were adapted locally so that most doctors and nurses could participate:
Dialogues SIBEN: An educational activity for doctors and nurses with an interactive and participatory approach.
Field activities (hospital visits): Sequential visits to all maternity wards to improve and modify management guidelines in inpatient care.
Residents: In agreement with the Ministry of Public Health and the Autonomous University, a training program was developed for all neonatology residents, in person or remotely, for training in neonatal topics relevant to neonatal survival.
Nursing: the SIBEN nursing chapter designed educational activities in practical workshops and in the field to improve the care of the NB and the performance of procedures.
Information systems
As the continuous improvement cycles require a fairly rapid sequence of “data - information - action”, we established two additional mechanisms for information, in addition to the evidence provided by GEPIS: i) analysis of neonatal deaths according to the standardized techniques of root cause analysis method [20,21], and ii) systematized data through SIBEN’s Neonatal Network.
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