Although infant mortality rates in India have come down significantly over the last decade, the country still reports the highest infant mortality rate in the world. Of the three million neonatal deaths which happened globally in 2012, thirty three percent occurred in India alone.
The survival of a newborn in India is not simply a matter of luck. Adherence to standard operating procedures and basic norms for hygiene could save a significant number of newborns, as failure to comply with these procedures is often what leads to illness and death.
Raising the Red Flag in Andhra Pradesh
Nandyal is a small town in the south of India, with a population of about two hundred thousand people. At the Nandyal District Hospital Neonatal Intensive Care Unit (NICU) there are more than one hundred admissions each month. Thirty five percent of these admissions are babies who were born in other healthcare facilities who were referred to Nandyal due to complicated health problems. In 2014 the hospital reported nine percent neonatal mortality. The hospital has an acute shortage of neonatal intensive care unit staff but does what it can with available resources. As part of the Safe Care, Saving Lives program, key members of the hospital staff – Dr. Oruganti Lalitha, NICU in Charge; Dr. Achavelli Kutti Parimala, pediatrician; Mary Jasmin, senior staff nurse; Malipeddi Manohar, data entry operator; and Sr. Palnati Ramadevi, senior staff nurse – decided to reduce the high rate of neonatal mortality by focusing on one of the leading causes of newborn death, sepsis. The task was to bring down sepsis cases from thirty three percent to less than ten percent.
Rigorous Hand Hygiene
Through the Safe Care, Saving Lives quality improvement process, the staff members determined that the high numbers of neonatal sepsis were likely due to a lack of adherence by nurses in delivery rooms and neonatal wards to standard practices when washing and sanitizing their hands. The Quality Improvement Team worked in coordination with the hospital administrators to ensure that hand hygiene facilities were always available to staff nurses. Following this, they trained and supervised to ensured that nurses either used sanitizers or washed their hands. By this, the compliance to hand sanitization reached sixty seven percent.
Identifying the Bottlenecks
Besides hand hygiene, the team explored Aseptic Non Touch Technique to prevent sepsis. This is a technique used when inserting a cannula or tube intravenously. The special technique helps prevent infection and the spread of bacteria from healthcare worker to the patient and vice versa. The Quality Improvement Team decided to ensure Aseptic Non Touch Technique for all line insertion cases. The first change was to have Aseptic Non Touch Technique trays, packed and sterilized the day before every procedure. A new tray was used for each procedure. At first, Aseptic Non Touch Technique compliance for line insertion was poor, and compliance to the technique did not increase. The staff hit upon the idea of separating the elective and emergency cannulations, and rescheduled planned cannulations to points in the day where there was less overall work. Thus, by simply rescheduling the day’s activity, the team could reduce the work pressure on each staff member. Within two months of implementing the changes, the overall percentage score for Aseptic Non Touch Technique compliance hit eighty three percent for elective insertion events.
Follow the Data
With every new decision made by the Quality Improvement Team, like ensuring hand hygiene and Aseptic Non Touch Technique adherence, the team collected robust data to analyze the impact of their efforts on the incidence of sepsis. This process of data analysis exposed a new problem: cases of septic arthritis were being reported at an alarming rate. The babies reporting with septic arthritis were usually premature babies that had been recently discharged from the intensive care unit. The Quality Improvement Team mapped the process of management in the intensive care units to find out the root cause of the problem.
Solving Problems, the Simple Way
The Quality Improvement Team found that IV cannulation was difficult in newborns, especially in those born prematurely. Because of this, the staff sometimes did deep venous perforator cannulations. This, coupled with missing the Aseptic Non Touch Technique in some babies could have resulted in septic arthritis of the knee and the hip. Thanks to this discovery, the hospital stopped performing deep venous perforations and adhere to the Aseptic Non Touch Technique for all IV line insertions.
Within one year, septic arthritis cases were eliminated altogether, from an average of three to four cases per month to zero cases.
This reduction in septic arthritis cases not only was a relief for the families, but also for the facilities and the Insurance Trust. Such babies are usually kept in intensive care for twenty one days and require costly antibiotics for their care. The average cost of treatment is around thirty to forty five dollars per day. Each case of septic arthritis can cost up to one thousand dollars over twenty one days.
The takeaways from this experience are simple. The ability to address most problems in newborn health can be solved by the staff members within the facility itself. Improving camaraderie between individuals and teams, building communication channels, empowering staff, and trusting people to deliver are among the best motivators for staff. The bottlenecks can be identified by looking at data, and simple, ongoing analysis of the data can lead to solutions. Even with limited resources, improvements can be made. Safe Care, Saving Lives and its partners are working hard to ensure that the learnings from Nandyal Hospital are widely understood and incorporated at other hospitals as well.
The success is authored by Dr. Dr. Oruganti Lalitha, Dr. Achavelli Kutti Parimala, Dr. Katakam Venkata Sudhakar, ,Sister Peddamari Mary Jasmin and Mr. Malipeddi Manohar and Sister Palnati Rama Devi from District Hospital, Nandyal, and supported by Dr. Manish Singh, Dr. Satyanarayana Bhamidapati and Vikrant Prabhakar of the Safe Care, Saving Lives Project. The Safe Care, Saving Lives Program is funded by the Children’s Investment Fund Foundation.
 According to a National Health Survey Report conducted across thirteen states including Andhra Pradesh, the national average was about fifty one deaths among one thousands births.