Quality Improvement Study With Low-Cost Strategies to Reduce Neonatal Admission Hypothermia.

Background Admission hypothermia is still an underappreciated major challenge for new-born survival in low-resource settings. The WHO recommends skin-to-skin contact as the simplest and safest way for maintaining the body temperature even during transportation. Quality improvement initiatives for hospitalised new-borns have shown benefits like a reduction in neonatal morbidity and mortality. This study was undertaken in a resource-constrained public hospital in southern India with an aim to reduce neonatal hypothermia at admission to <20%. Method It was a prospective, quality improvement study undertaken over 20 weeks. All neonates born in the selected delivery room (DR), requiring transportation to the neonatal intensive care unit, were included. The primary outcome indicators were the mean axillary temperature of neonates measured upon arrival at the neonatal intensive care unit and the percentage of neonates with hypothermia at admission. Improving the thermoregulatory practices and ambient DR temperature to >25˚C, transportation by the kangaroo method, and a portable infant warmer (PIW) were implemented in three successive Plan-Do-Study-Act (PDSA) cycles. Result In the third PDSA cycle, the mean admission temperature (36.51˚C ±0.82) was significantly (p<0.0001) higher when compared with the baseline phase (35.41˚C ±1.09), and there was a significant (p<0.001) reduction in hypothermia (33.33%). The aim was achieved in the last two weeks of the third cycle with a reduction in hypothermia to 17.6%. Conclusion Implementation of appropriate thermoregulatory practices and low-cost strategies like the kangaroo method and PIW using quality improvement methodology significantly reduced admission hypothermia.

A Study of the Clinical Profile and Respiratory Index of Severity in Children (RISC) Score in Infants Admitted With Acute Respiratory Infections at a Tertiary Care Hospital.

Background Pneumonia is a major infectious cause of mortality in young children worldwide. The Respiratory Index of Severity in Children (RISC) score was designed with the intent to provide an objective mean to quantify the severity of lower respiratory tract infection in young children based on their risk of mortality. Knowledge about the clinical profile of acute respiratory infections and the scoring system predicting the risk of mortality helps in modifying treatment strategies. This study was undertaken at a resource-limited, tertiary-care public hospital in southern India with the objectives of describing the clinical profile of infants admitted with acute respiratory infections and determining the association of the RISC score with mortality. Method This was a retrospective observational study conducted over six months. Case records of infants admitted with acute respiratory infections were reviewed. The socio-demographic and clinical details of each case were recorded. The RISC score was calculated using clinical parameters which included the history of refusal of feeds, oxygen saturation lower than 90%, chest in-drawing, wheezing, and low weight-for-age. The maximum score was six. Descriptive data was represented using mean, standard deviation, and percentage or proportion. The association between any two categorical variables was analyzed using the chi-square test. The differences between any two continuous variables were analyzed using the independent sample t-test. A p-value of < 0.05 was considered statistically significant. Results A total of 75 infants were admitted with a diagnosis of acute respiratory infection during the study period. Of these, 68 were included in the study. The mean age of infants was 6.69 ± 3.96 months; 58.8% were male, 41 (60%) were exclusively breastfed, and 51 (75%) were up-to-date immunized. Twenty (29.4%) infants had a history of exposure to indoor smoke. The majority (67.6%) had pneumonia. Nine (13.2%) were mechanically ventilated. The mean duration of hospital stay was 8.16 ± 5.45 days. Sixty-three (92.64%) infants recovered and there were five deaths. The presence of less than 90% oxygen saturation (p-value=0.004), a diagnosis of severe pneumonia (p-value <0.001), and the need for mechanical ventilation (p-value <0.001) were significantly associated with mortality. A statistically significant (p-value=0.001) association was observed between the RISC score and mortality. Conclusions Addressable factors like the absence of exclusive breastfeeding, partial-immunization status, exposure to indoor smoke, and malnutrition were observed in infants with acute respiratory infections, which reinforces the importance of protective and preventive strategies for the control of pneumonia. The RISC score was observed to be beneficial in predicting mortality in an infant with acute respiratory infection. Triaging and early identification of infants at risk of mortality using this score could be very helpful in initiating timely treatment to reduce mortality, especially in resource-limited settings.