Improving the Quality of Health Care in Special Neonatal Care Units of India: A Before and After Intervention Study

Ashok K. Deorari; Praveen Kumar; Deepak Chawla; Anu Thukral; Sonika Goel; Rajashree Bajaj; Manish Singh; Clare Gilbert; Rajan Shukla; for the Retinopathy of Prematurity-Quality Improvement India Study Group

doi:10.9745/GHSP-D-22-00085

Key Findings

Combining a training package to improve the knowledge and skills of health care workers in managing sick and preterm neonates with point-of-care quality improvement skills successfully reduced the unindicated use of oxygen, antibiotics, and phototherapy while increasing the use of enteral feeds.
Despite a significant reduction in the use of 2 lifesaving medical interventions—oxygen and antibiotics—no increase in mortality or short-term adverse outcome was observed, indicating an overuse of these interventions in the preintervention period.

Key Implication

A strategy of combining professional training activities and coaching in continuous quality improvement methods can successfully improve the health care of sick and preterm neonates. With the rapid expansion of access to facility-based neonatal care, it is important to monitor for both overuse and underuse of evidence-based interventions.

ABSTRACT

Background:

We evaluated the efficacy of training health care workers (HCWs) in point-of-care quality improvement (POCQI) and a preterm newborn health care package (PHCP), followed by remote mentoring and supportive supervision in improving health care practices, neonatal survival, and morbidities in special neonatal care units (SNCUs).

Methods:

This pre- and postintervention quality improvement study was conducted at 3 SNCUs in Madhya Pradesh, India from February 2017 to February 2019. Clinical care teams comprising doctors and nurses from the study sites were trained in POCQI and the PHCP. The teams identified, prioritized, and analyzed problems and designed quality improvement initiatives at their respective health facilities. Change ideas were tested by the local teams using sequential plan-do-study-act cycles. Facilitators maintained contact with the teams through quarterly review meetings, fortnightly videoconferencing, on-demand phone calls, and group chat service. State SNCU coordinators made follow-up visits to supplement coaching. Study research staff independently collected data on admissions, health care practices, and outcomes of neonates.

Findings:

A total of 156 HCWs were trained in the POCQI methodology and PHCP. Sixteen quality improvement projects were formulated and implemented. Among 13,821 enrolled neonates (birth weight 2275±635 g; gestation: 35.8±2.8 weeks), improvement was seen in reduction of use of oxygen (36.1% vs. 48.0%; adjusted odds ratio [aOR]=0.60, 95% confidence interval [CI]=0.55, 0.66), antibiotics (29.4% vs. 39.0%; aOR=0.76, 95% CI=0.68, 0.85), and dairy milk (33.8% vs. 49.4%; aOR=0.34, 95% CI=0.31 to 0.38). Enteral feeds were started within 24 hours of admission in a larger number of neonates, resulting in fewer days to reach full feeds. There was no effect on survival at discharge from the hospital (aOR=0.93; 95% CI=0.80, 1.09).

Conclusion:

A collaborative cross-learning quality improvement approach with remote mentoring, coaching, and supportive supervision was successful in improving the quality of care at SNCUs.

Received: March 3, 2022.
Accepted: September 13, 2022.
Published: October 31, 2022.

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