Venkata Padma Hospital is a privately owned children’s hospital in the Vizianagaram district of Andhra Pradesh. It caters to people living in the nearby tribal districts. The majority of the babies admitted to the hospital are born outside of the hospital facility and are referred to the unit from surrounding areas. Each month, the hospital has about seventy to eighty newborn admissions, with ninety percent of those admissions being babies born outside the hospital facility. In November 2014 Venkata Padma Hospital became part of the Safe Care, Saving Lives program. Safe Care, Saving Lives is a program created by the public health insurance program in Andhra Pradesh, Aarogyasri Health Care Trust, and ACCESS Health International to reduce neonatal and perinatal mortality through quality improvement.
Administrators at Venkata Padma Hospital were eager to see how an ongoing process to improve the quality of healthcare services delivery at the hospital could improve health outcomes for newborns. Dr. Venkateshwar Rao is the Chief Pediatrician and Managing Director of the hospital. He attended a learning session organized by ACCESS Health International that explained the basics of quality improvement and how to use data to identify areas for improvement and monitor the impact of changes made to correct areas of concern. Armed with this information, Dr. Rao and his team conducted a thorough analysis of the mortality and morbidity data in their newborn care unit and decided, based on that analysis, to focus on improving the identification and management of hypothermia.
Hypothermia is one of the greatest risks to a newborn’s life. When inside the womb, a fetus is entirely dependent on its mother for all its needs, including regulating its core internal temperature. As the fetus reaches full term, it starts developing self adaptive mechanisms for thermoregulation and survival but when babies are born too soon these mechanisms for survival are not yet fully developed. In addition to being an independent risk, hypothermia acts as a trigger in accelerating other primary causes of morbidity and mortality, like sepsis and birth asphyxia. As such, early identification and management of hypothermia is one of the key interventions for reducing neonatal mortality and morbidity. However, identifying hypothermia in newborns is quite complex and difficult since preterm newborns often are at risk of experiencing large fluctuations in temperature.
Dr. Rao wanted to tackle this enormous problem by taking a few small but important steps. First, he and his team decided that the temperature of every baby must be noted within fifteen minutes of admission to the emergency room. If there was an issue with the temperature, it should be properly addressed and the temperature stabilized. Dr. Rao and his team created a standard protocol and made sure all staff were aware of the changes. From start to finish, the process of identifying the area for quality improvement and implementing change took roughly one month.
Diving deep to find the root cause
A key part of the Safe Care, Saving Lives process of quality improvement is ongoing collection and analysis of data to fully understand the impact of changes made and where further improvements can be made. Dr. Rao and his team were all anxiously awaiting the first set of data coming out of emergency rooms following their change to standard protocol. The initial analysis of the data revealed that ninety three percent of cases were compliant with the protocol. The quality improvement team was skeptical of these results however, as they had not seen much improvement in the profiles of the newborns who were admitted from the emergency rooms to the Neonatal Intensive Care Unit. When they dived deeper into the data, they were surprised to find that almost eighty six percent of babies coming to the emergency room had temperatures outside the normal range. This was an eye opener for the team and helped them realize the critical importance of data collection. After brainstorming, the Dr. Rao and his team decided to collect more information on the hospitals referring these babies, how the babies were transported, and the temperature of each baby arriving at the Neonatal Intensive Care Unit.
What the data revealed
The additional data analysis revealed that nearly one quarter of newborns identified as hypothermic in the emergency room continued to be hypothermic when they were transferred to the Neonatal Intensive Care Unit. This meant that the management of hypothermia in the emergency room was not appropriate. The team was excited, as they now had a much better understanding of the whole process areas to improve.
Fixing the root cause
The team identified key areas for quality improvement. The first was to improve how the temperature of premature babies was monitored and managed upon referral, in the emergency rooms, and in the Neonatal Intensive Care Unit. The second was to ensure that every baby’s temperature was stabilized before being transferred to the newborn care unit.
The team developed a protocol to keep babies with hypothermia in the emergency room until their temperature was stabilized and then shift the baby to the Neonatal Intensive Care Unit. A triage area was created in the emergency room and a trained nurse was posted to manage hypothermia. The team also started recording the temperature of all babies who arrived via ambulance and the duration of each baby’s stay in the emergency room, as they suspected that the longer the stay in the emergency room the greater the temperature fluctuations.
The next review of data coming out of the emergency rooms showed significant improvements. Compliance in recording temperature had risen to ninety six percent and ninety one percent of newborns with hypothermia were stabilized in the emergency room before being transferred to the Neonatal Intensive Care Unit. There was a direct correlation noted between time spent in the emergency room and temperature fluctuations, which gave insight into further improvements that could be made by reducing the length of stay. The data also showed ongoing issues with babies who arrived via ambulance, as sixty percent of these babies still had abnormal temperatures.
In response to these findings, ambulance staff were trained on management of hypothermia and the length of time babies stayed in the emergency room was reduced by shifting babies to the intensive care unit before completing the health insurance claim paperwork. Previously, babies stayed in the emergency room until all the paperwork was finalized.
Fruits of labor
The results from the Safe Care, Saving Lives work in the hospital are very encouraging. Emergency room stays were reduced from sixty nine minutes to eleven minutes, in ninety-six percent cases the temperature was recorded within fifteen minutes of arrival in the emergency room, and ninety one percent of newborns with hypothermia were stabilized before being transferred to the Neonatal Intensive Care Unit. Most importantly, these changes led to a seventy percent reduction in neonatal mortality, from 1.1 percent to 0.32 percent. Deaths due to prematurity are now a rare event in the hospital.
Dr. Rao and his team learned many lessons from their Safe Care, Saving Lives work, not the least of which is the importance of data collection and analysis to draw meaningful inferences on quality improvement. This hospital is an example now for all other hospitals on how to use data to identify and fix the small problems at the root of neonatal mortality.
This article was written by Dr. M Venkateshwar Rao (Pediatrician and Managing Director, Venkata Padma Hospital), Dr. Ananth Sagar (Neonatologist, Consultant Pediatrician), Sandesh Sibinath (Senior Associate, Safe Care, Saving Lives), and Vikrant Prabhakar (Technical Leader, Safe Care, Saving Lives)