Impact of Quality Improvement Bundle on Neonatal Mortality in a District Hospital in Tanzania
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Setting
2.3. Patients
2.4. Interventions
2.5. Outcome Measures
2.6. Data Collection
2.7. Definitions
2.8. Statistical Analysis
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Area of Intervention | Year | Action |
---|---|---|
Infrastructures | January 2017 | A Neonatal ward was constructed near the Maternity Ward, divided into three areas: Neonatal Intensive Care Unit (one room), Neonatal Sub-intensive Care Unit (one room) and Kangaroo Mother Care Unit (two rooms) |
Equipment | January 2017 | Four oxygen concentrators (increased over the years up to 10), two phototherapy machines, four infusion pumps and a syringe pump, a capillary hemoglobin dosing machine and an electric aspirator were purchased. The staff received training on their use. |
Protocols | 2017 and 2019 | Operational protocols were updated and presented to the staff in dedicated training sessions. Laminated copies of the most commonly used protocols were displayed for quick consultation even by on-call staff during night shifts and holidays. A further update of the ward guidelines was carried out in 2019, in light of the publication of the first edition of the national neonatal guidelines. |
Procedures | January 2017 | New procedures were introduced: antenatal administration of dexamethasone for lung maturity and magnesium sulfate for neuroprotection, positioning of an umbilical venous catheter in newborns weighing <1200 g, administration of paracetamol in newborns with suspected patent ductus arteriosus, administration of hydrocortisone in newborns with oxygen dependence and suspected bronchopulmonary dysplasia. |
Staff | 2017 | A dedicated nursing team was created, consisting of 5 nurses (increased over the years up to 8). From February 2017, a Tanzanian doctor started working in Neonatology. |
Training activity | 2017–2019 | Over years, the Neonatal Unit and Maternity Ward staff were periodically trained on partogram use and interpretation, management of a complicated pregnancy (gestational hypertension, gestational diabetes, prolonged rupture of the membranes); management of labor and delivery (1st, 2nd, 3rd stage), prolonged rupture of the membranes, complicated labor and the most common maternal peripartum complications, neonatal resuscitation, management of common neonatal severe conditions (sepsis, jaundice, asphyxia, prematurity, respiratory distress syndrome), essential newborn care and care of low-birth-weight and very-low-birth-weight infants. |
Pre-Intervention | Post-Intervention Period: | p-Value | |
---|---|---|---|
Period: | |||
Deliveries | N = 2901 | N = 2732 | - |
Mode of delivery: | <0.0001 | ||
Caesarean section | 1056/2901 (36.4%) | 840/2732 (30.7%) | |
Vaginal delivery | 1845/2901 (63.6%) | 1892/2732 (69.3%) | |
Twin deliveries | 50/2901 (1.7%) | 55/2732 (2.0%) | 0.48 |
Neonates | N = 2952 | N = 2790 | |
Inborn neonates | 2890/2952 (97.9%) | 2675/2790 (95.6%) | <0.0001 |
Males | 1472/2952 (49.9%) | 1370/2790 (49.1%) | 0.58 |
Birth weight: | <0.0001 | ||
≤1499 g | 24/2952 (0.8%) | 63/2790 (2.3%) | |
1500–2499 g | 282/2952 (9.6%) | 318/2790 (11.4%) | |
≥2500 g | 2646/2952 (89.6%) | 2409/2790 (86.3%) | |
5-min Apgar score < 7 (only inborn) | 121/2890 (4.2%) | 109/2675 (4.1%) | 0.89 |
Outcome Measure | Pre-Intervention Period: | Post-Intervention Period: | Post vs. Pre Comparison: Odds Ratio (95% Confidence Interval) | p-Value |
---|---|---|---|---|
All neonates | N = 2952 | N = 2790 | - | - |
Overall mortality | 87/2952 (2.9%) | 92/2790 (3.3%) | 1.05 (0.78 to 1.41) | 0.49 |
Mortality in BW categories: | ||||
≤1499 g | 13/24 (54.2%) | 31/63 (49.2%) | 0.81 (0.32 to 2.10) | 0.86 |
1500–2499 g | 34/282 (12.1%) | 20/318 (6.3%) | 0.49 (0.27 to 0.87) | 0.02 |
≥2500 g | 40/2646 (1.5%) | 41/2409 (1.7%) | 1.12 (0.72 to 1.75) | 0.67 |
Mortality for prematurity | 21/2952 (0.7%) | 36/2790 (1.3%) | 1.82 (1.03 to 3.29) | 0.04 |
Mortality for asphyxia: | ||||
Overall | 44/2952 (1.5%) | 40/2790 (1.4%) | 0.96 (0.62 to 1.47) | 0.94 |
≤1499 g | 0/24 (0.0%) | 0/63 (0.0%) | NA | NA |
1500–2499 g | 15/282 (5.3%) | 7/318 (2.2%) | 0.40 (0.16 to 1.00) | 0.07 |
≥2500 g | 29/2646 (1.1%) | 33/2409 (1.4%) | 1.25 (0.75 to 2.07) | 0.45 |
Mortality for infection: | ||||
Overall | 12/2952 (0.4%) | 6/2790 (0.2%) | 0.52 (0.19 to 1.40) | 0.29 |
≤1499 g | 0/24 (0.0%) | 0/63 (0.0%) | NA | NA |
1500–2499 g | 5/282 (1.8%) | 2/318 (0.6%) | 0.35 (0.06 to 1.82) | 0.26 |
≥2500 g | 7/2646 (0.3%) | 4/2409 (0.2%) | 0.62 (0.18 to 2.14) | 0.55 |
Inborn neonates | N = 2890 | N = 2675 | - | - |
Overall mortality | 77/2890 (2.7%) | 73/2675 (2.7%) | 1.02 (0.74 to 1.41) | 0.94 |
Mortality in BW categories: | ||||
≤1499 g | 10/15 (66.7%) | 22/30 (73.3%) | 1.37 (0.35 to 5.27) | 0.90 |
1500–2499 g | 29/249 (11.6%) | 18/287 (6.3%) | 0.50 (0.27 to 0.93) | 0.04 |
≥2500 g | 38/2626 (1.4%) | 33/2358 (1.4%) | 0.96 (0.60 to 1.54) | 0.98 |
Mortality for prematurity | 15/2890 (0.5%) | 26/2675 (1.0%) | 1.88 (0.99 to 3.55) | 0.07 |
Mortality for asphyxia: | ||||
Overall | 43/2890 (1.5%) | 33/2675 (1.2%) | 0.82 (0.52 to 1.30) | 0.48 |
≤1499 g | 0/15 (0.0%) | 0/30 (0.0%) | NA | NA |
1500–2499 g | 15/249 (6.0%) | 6/287 (2.1%) | 0.33 (0.12 to 0.87) | 0.03 |
≥2500 g | 28/2626 (1.1%) | 27/2358 (1.1%) | 1.07 (0.63 to 1.82) | 0.90 |
Mortality for infection: | ||||
Overall | 10/2890 (0.3%) | 5/2675 (0.2%) | 0.53 (0.18 to 1.57) | 0.38 |
≤1499 g | 0/15 (0.0%) | 0/30 (0.0%) | NA | NA |
1500–2499 g | 4/269 (1.5%) | 2/287 (0.7%) | 0.46 (0.08 to 2.55) | 0.44 |
≥2500 g | 6/2626 (0.2%) | 3/2358 (0.1%) | 0.55 (0.13 to 2.22) | 0.51 |
Outborn neonates | N = 62 | N = 115 | - | - |
Overall mortality | 10/62 (16.1%) | 19/115 (16.5%) | 1.02 (0.44 to 2.37) | 0.99 |
Mortality in BW categories: | ||||
≤1499 g | 3/9 (33.3%) | 9/33 (27.3%) | 0.75 (0.15 to 3.65) | 0.69 |
1500–2499 g | 5/33 (15.2%) | 2/31 (6.5%) | 0.38 (0.06 to 2.15) | 0.42 |
≥2500 g | 2/20 (10.0%) | 8/51 (15.7%) | 1.67 (0.32 to 8.66) | 0.71 |
Mortality for prematurity | 6/62 (9.7%) | 10/115 (8.7%) | 0.88 (0.30 to 1.57) | 0.99 |
Mortality for asphyxia: | ||||
Overall | 1/62 (1.6%) | 7/115 (6.1%) | 3.95 (0.47 to 32.89) | 0.26 |
≤1499 g | 0/9 (0.0%) | 0/33 (0.0%) | NA | NA |
1500–2499 g | 0/33 (0.0%) | 1/31 (3.2%) | 3.29 (0.12 to 89.97) | 0.48 |
≥2500 g | 1/20 (5.0%) | 6/51 (11.8%) | 2.53 (0.28 to 22.49) | 0.66 |
Mortality for infection: | ||||
Overall | 2/62 (3.2%) | 1/115 (0.9%) | 0.26 (0.02 to 2.96) | 0.28 |
≤1499 g | 0/9 (0.0%) | 0/33 (0.0%) | NA | NA |
1500–2499 g | 1/33 (3.0%) | 0/31 (0.0%) | 0.34 (0.01 to 8.76) | 0.99 |
≥2500 g | 1/20 (5.0%) | 1/51 (2.0%) | 0.38 (0.02 to 6.38) | 0.48 |
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Pietravalle, A.; Brasili, L.; Cavallin, F.; Piquè, M.; Zavattero, C.; Azzimonti, G.; Maziku, D.M.; Leluko, D.E.; Putoto, G.; Trevisanuto, D. Impact of Quality Improvement Bundle on Neonatal Mortality in a District Hospital in Tanzania. Children 2022, 9, 1060. https://doi.org/10.3390/children9071060
Pietravalle A, Brasili L, Cavallin F, Piquè M, Zavattero C, Azzimonti G, Maziku DM, Leluko DE, Putoto G, Trevisanuto D. Impact of Quality Improvement Bundle on Neonatal Mortality in a District Hospital in Tanzania. Children. 2022; 9(7):1060. https://doi.org/10.3390/children9071060
Chicago/Turabian StylePietravalle, Andrea, Luca Brasili, Francesco Cavallin, Margherita Piquè, Chiara Zavattero, Gaetano Azzimonti, Donald Micah Maziku, Dionis Erasto Leluko, Giovanni Putoto, and Daniele Trevisanuto. 2022. "Impact of Quality Improvement Bundle on Neonatal Mortality in a District Hospital in Tanzania" Children 9, no. 7: 1060. https://doi.org/10.3390/children9071060