Eliminating Sepsis in Khammam District Hospital Through Low Cost Quality Improvement
India is home to advanced innovations in healthcare services, yet it has the highest burden of newborn deaths in the world. The main causes of neonatal death in India are sepsis, low birth weight, premature births, and asphyxia. A newborn is most susceptible during the first month of its life. This is the period when the baby needs focused care and attention, though this may not always be possible due to a variety of challenges, including limited financial and manpower resources. However, despite these challenges, many facilities are able to work collectively to discover simple solutions that can save the lives of newborn babies at little to no additional cost.
A case in point here is the Special Newborn Care Unit (SNCU) at the District Hospital in Khammam, Telangana. This unit treats around a hundred newborn infants each month; nearly one third of these newborns are born outside of the hospital and admitted to the special newborn care unit after birth, often with serious health complications. One of the biggest dangers facing babies admitted to the SNCU is sepsis, a condition in which blood infections occur either when the mother has complications during pregnancy or delivery, or after a baby is born due to coming into contact with an infected person or object.
A team made up of nursing staff, administrators, and doctors at Khammam District Hospital were determined to reverse the trend of newborn deaths by preventing neonatal sepsis among newborns in the SNCU.
The SNCU staff decided to work on a four step plan of action. First, they examined the causes of sepsis in the unit; second, they tried to find low or no cost solutions to reduce the chances of infection; third, they implemented the new solutions, often without any extra funding or staff support; finally, they analyzed the data and measured the impact of their solutions. The team working on this initiative are dubbed the Quality Improvement Team within the hospital, and were given the authority to decide how to put these simple quality improvement procedures into practice and implement it in the hospital.
The Quality Improvement team at Khammam District Hospital conducted an initial evaluation to ascertain why newborn babies were becoming infected. The team concluded that there were three high risk zones when babies became infected:
- when babies were still in the womb and their mothers had to undergo vaginal examinations;
- when neonates were given intravenous insertions;
- when hospital staff who had not washed their hands came in contact with the newborns.
As a result of their initial findings, the staff came up with three ideas to improve hospital procedures to protect newborns from infection:
Hand Hygiene: The Quality Improvement Team worked with hospital administrators to ensure that basic facilities for hand washing and hand hygiene were available to all staff nurses in the SNCU. Additionally, the team refurbished the nursing station counter by installing a wash basin with elbow operated taps, promoted the use of autoclaved newspaper for drying hands, and placed hand wash dispensers beside each newborn warmer. The staff were encouraged to wash their hands with an alcohol based hand rub before entering the SNCU and before and after touching the babies. Compliance to these hand hygiene measures have increased to eighty five percent.
Intravenous Insertions: The Quality Improvement Team also implemented an improved process for inserting intravenous lines into newborns. They mandated aseptic insertion of peripheral intravenous lines and adopted the use of alcohol-based hand-rubs as part of the process. The hospital team identified and trained two nurses to do the procedure. This helped ensure compliance to standard operating procedures. The team also decided to prepare sterilized trays for intravenous procedure one day prior to expected procedures, to improve efficiency and ensure that all intravenous insertions used the aseptic insertion technique.
Vaginal Examinations: The Quality Improvement Team prescribed the use of medicated vaginal washes during labor that would help guarantee that all examinations were undertaken in sterile and aseptic conditions. The team also made sure that gloves, running water, hand wash dispensers, and tissues were readily available in the labor wards.
The results were dramatic. Over a period of two years, from 2015 to 2017, data analysis revealed that cases of sepsis fell from thirty percent among newborns to nine percent. Newborns deaths due to sepsis were nearly eliminated, falling from a high of twelve percent in 2015 to under one percent this year.
Kudos to the Quality Improvement Team in the hospital, which is made up of the Medical Superintendent, who is in charge of special newborn care unit and obstetrics and gynecology, and the nursing staff in charge of the special newborn care unit and labor room. The success of this program is intrinsically linked to the support that is provided by Aarogyasri Health Care Trust.
Motivated and trained staff at the District Hospital at Khammam took many positive steps to reverse the trend of newborn deaths due to sepsis. As expected the change ideas implemented were fruitful and continue to give positive results. Better outcomes and reliable processes do not require large investments in infrastructure or equipment. Healthcare providers and Doctors should be able to identify, share and scale no cost and frugal solutions. It is important for the country that such learnings are shared across hospitals.