Feasibility, Sustainability, and Effectiveness of the Implementation of "Facility-Team-Driven" Approach for Improving the Quality of Newborn Care in South India.

OBJECTIVES: The primary objective of the study was to assess the feasibility and sustainability of the implementation of the point of care quality improvement (POCQI) methodology for improving the quality of neonatal care at the level 2 special newborn care unit (SNCU). Additional objective was to evaluate the effectiveness of the quality improvement (QI) and preterm baby package training model. METHODS: This study was conducted in a level-II SNCU. The study period was divided into baseline; intervention and sustenance phases. The primary outcome i.e., feasibility was defined as completion of training for 80% or more health care professionals (HCPs) through workshops, their attendance in subsequent review meetings and, successful accomplishment of at least two plan-do-study-act (PDSA) cycles in each project. RESULTS: Of the total, 1217 neonates were enrolled during the 14 mo study period; 80 neonates in the baseline, 1019 in intervention and 118 in sustenance phases. Feasibility of training was achieved within a month of initiation of intervention phase; 22/24 (92%) nurses and 14/15 (93%) doctors attended the meetings. The outcomes of individual projects suggested an improvement in proportion of neonates being given exclusive breast milk on day 5 (22.8% to 78%); mean difference (95% CI) [55.2 (46.5 to 63.9)]. Neonates on any antibiotics declined, proportion of any enteral feeds on day one and duration of kangaroo mother care (KMC) increased. Proportion of neonates receiving intravenous fluids during phototherapy decreased. CONCLUSIONS: The present study demonstrates the feasibility, sustainability, and effectiveness of a facility-team-driven QI approach augmented with capacity building and post-training supportive supervision.

Hydrostatic reduction of acute intussusception. A prospective study.

Data were collected prospectively on 57 Jamaican children presenting with 62 episodes of acute intussusception over a two year period, for whom operative and hydrostatic methods of reduction were employed. 31 (54%) of 57 episodes were reduced successfully using barium (42), saline (11) and air (4) hydrostatically. Among the 31 other episodes, 15 had ileo-colic intussusception, seven caeco-colic, six ileo-ileo-colic and one ileo-ileal. Two patients had spontaneous reduction discovered at surgery. There were two episodes of barium hydrostatic perforation of the colon leading to death in one patient. Hydrostatic reduction is recommended as the first therapeutic option for acute intussusception because it spares the patient a major operative procedure when successful.

Hydrostatic reduction of acute intussusception. A prospective study

Data were collected prospectively on 57 Jamaican children presenting with 62 episodes of acute intussusception over a two year period, for whom operative and hydrostatic methods of reduction were employed. 31 (54) of 57 episodes were reduced successfully using barium (42), saline (11) and air (4) hydrostatically. Among the 31 other episodes, 15 had ileo-colic intussusception, seven caeco-colic, six ileo-ileo-colic and one ileo-ileal. Two patients had spontaneous reduction discovered at surgery. There were two episodes of barium hydrostatic perforation of the colon leading to death in one patient. Hydrostatic reduction is recommended as the first therapeutic option for acute intussusception because it spares the patient a major operative procedure when successful.

Ileocaecal atresia.

Meconium ileus is one of the commonest causes of distal small bowel obstruction in neonates. Within the last six years at our hospital two newborns presented with identical signs and symptoms of meconium ileus. Abdominal x-rays showed distal small bowel obstruction with ground glass opacity in the right lower quadrant. Gastrografin enema in both cases demonstrated a microcolon, but there was no reflux of this contrast material into the terminal ileum. Laparotomy in both babies revealed atresia of the ileocaecal valve with dilatation of the terminal ileum loops which contained normal meconium. Ileocolic resection was carried out in both neonates. Sweat chlorides and eventual recovery were normal. Pathology in one of the specimens showed muscularis passing across the atretic area with a telescoped pattern of the muscularis propria suggesting intussusception in utero. Although the presentation of a newborn may be that of meconium ileus, the fact that the Gastrografin enema is unable to enter the terminal ileum in a retrograde fashion should be an indication for immediate laparotomy rather than persisting in this mode of treatment. It is obvious that occasionally the radiological diagnosis of meconium ileus is incorrect.

Meconium ileus: laparotomy without resection, anastomosis, or enterostomy.

During the 14 yr from 1965 through 1978, 49 infants presented shortly after birth with intestinal obstruction due to impacted meconium. Three of these patients did not have fibrocystic disease. Eight patients were cured by a Gastrografin enema. There were 18 patients who had complications that included associated atresia, volvulus, and/or peritonitis. Various operations were done including resection with either primary anastomosis or enterostomy or varieties of the foregoing. Twenty-three babies had the simple uncomplicated form of meconium ileus. Eleven of these underwent resection and six patients died. Twelve patients were treated by laparotomy, ileotomy through a purse-string suture and prolonged irrigations using acetylcysteine. Of this group only one succumbed. This latter course of management is recommended for patients with simple uncomplicated meconium ileus as it involves no resection, no enterostomy, nor any primary anastomosis.