What-You-See-Is-What-You-Get Computer-Interpretable Guidelines: The Case of NoviGuide Neonatal.

Complex clinical decision support (CDS) that goes beyond representing simple clinical flowcharts to supporting the totality of a care encounter may help improve care quality and consistency. However, integrating a large volume of clinical guidelines applicable to a care encounter poses unique design and safety considerations. We present the visual and technical methods employed in developing NoviGuide, a platform for complex CDS. Assuring safe functioning required transparency of all outputs, which we achieved using a JSON formalism for capturing logic. Unlike raw computer code, logic-as-data can be presented clearly in context to non-informatician reviewers. Two different styles for visualizing CDS logic, random-access and narrative, support different review contexts. We assess the fitness of these solutions for encoding hundreds of neonatal-care guidelines into integrated multi-topic CDS.

The utilization of clinical decision support tools to identify neonatal hypothermia and its associated risk factors: A prospective observational study.

Hypothermia (axillary temperature less than 36.5°) is a major source of neonatal morbidity and mortality, with a disproportionate burden of disease in low- and middle-income countries. Despite the importance of thermoregulation on newborn outcomes, the global epidemiologic landscape of neonatal hypothermia is poorly characterized. Clinical decision support (CDS) software provides point-of-care recommendations to guide clinical management and may support data capture in settings with limited informatics infrastructure. Towards this end, we conducted a prospective observational study of the NoviGuide, a novel CDS platform for newborn care, at four health facilities in Uganda between September 2022 to May 2021. Data were extracted from clinical information (e.g. axillary temperature, birth weight, gestational age) entered into the NoviGuide by nurses and midwives on newborns within 24 hours of delivery. Descriptive statistics and multivariable logistic regression were used to evaluate neonatal temperature profiles and the association between hypothermia and clinical features. Among 1,027 completed assessments, 30.5% of entries had neonatal hypothermia with significant variation across study sites. On multivariable logistic regression analysis, we found that hypothermia was independently associated with pre-term birth (Adjusted Odd's Ratio [aOR] 2.62, 95% Confidence interval [CI] 1.38-4.98), sepsis/concern for sepsis (aOR 2.73, 95% CI 2.90-3.94), and hypoglycemia/concern for hypoglycemia (aOR 1.78, 95% CI 1.17-2.72). Altogether, neonatal hypothermia was commonly entered into the NoviGuide and associated clinical characteristics aligned with previous studies based on conventional data collection instruments. Our results should be contextualized within unique technical and operational features of CDS tools, including a bias towards acutely ill patients and limited quality control. Nonetheless, this study demonstrates that a CDS used voluntarily by clinicians has the potential to fill key data gaps and drive quality improvement towards reducing neonatal hypothermia in low resource settings.

Implementation of a Newborn Clinical Decision Support Software (NoviGuide) in a Rural District Hospital in Eastern Uganda: Feasibility and Acceptability Study.

BACKGROUND: Lack of trained health care workers and nonadherence to national guidelines are key barriers to achieving high-quality newborn care in health care facilities in low- and middle-income countries. Traditional didactic approaches addressing these barriers fail to account for high staff turnover rates and result in temporary behavior change. NoviGuide, a clinical decision support software designed to standardize neonatal care through point-of-care assessments, has the potential to align bedside practice to national guidelines in settings lacking subspecialty neonatal providers. OBJECTIVE: This study aims to determine the adaptation, adoption, feasibility, acceptability, and sustainability of NoviGuide and its impact on nurse-midwives' knowledge in a rural hospital in eastern Uganda. METHODS: This mixed methods observational study was guided by the Proctor framework. Experts reviewed the clinical content of NoviGuide to ensure fidelity to Uganda guidelines. We enrolled nurses and midwives providing newborn care at Tororo District Hospital, trained them on NoviGuide use, and followed them for 12 months. We assessed adoption, feasibility, acceptability, and sustainability by analyzing NoviGuide use data, comparing it with maternity registry data and administering the System Usability Scale (SUS) and the Center for Health Care Evaluation Provider Satisfaction Questionnaire. We compared the mean knowledge assessment score at baseline, 6 months, and 12 months using a two-tailed t test. RESULTS: Five Ugandan experts suggested two minor changes to NoviGuide: the inclusion of an unsterile birth environment as an indication for empiric antibiotics and the addition of a reminder to follow-up with newborns with temperatures between 37.7°C and 37.9°C. Of the 19 nurse-midwives enrolled in February 2017, 74% (n=14) completed the follow-up in March 2018. The participants entered a total of 1705 assessments of varying newborn characteristics into NoviGuide throughout the day, evening, and night nursing shifts. The SUS score at the end of the study was very high (93.5, above the average of 68). Participants had a positive perception about NoviGuide, reporting that NoviGuide saved time (mean 5, SD 0) and prevented mistakes (mean 5, SD 0), and that they felt more confident in taking care of newborns when they used NoviGuide (mean 5, SD 0). Participants were highly satisfied with NoviGuide (mean 4.86, SD 0.36), although they lacked medical supplies and materials needed to follow NoviGuide recommendations (mean 3.3, SD 1.22). The participants' knowledge scores improved by a mean change of 3.7 (95% CI 2.6-4.8) at 6 months and 6.7 (95% CI 4.6-8.2) at 12 months (P<.001). CONCLUSIONS: NoviGuide was easily adapted to the Uganda guidelines. Nurse-midwives used NoviGuide frequently and reported high levels of satisfaction despite challenges with medical supplies and high staff turnover. NoviGuide improved knowledge and confidence in newborn care without in-person didactic training. NoviGuide use has the potential to scale up quality newborn care by facilitating adherence to national guidelines.

Delivering integrated care after sexual violence in the Democratic Republic of the Congo.

In the eastern Democratic Republic of the Congo, ongoing armed conflict increases the incidence of gender-based violence (GBV) and presents a distinct and major barrier to care delivery for all survivors of GBV. A specific challenge is providing emergency contraception, HIV prophylaxis and treatment for sexually transmitted infections to all survivors within 72 hours of violence. To address the multiple barriers to providing this time-sensitive medical care, Global Strategies and Panzi Hospital implemented the Prevention Pack Program. The Prevention Pack is a pre-packaged post-rape medical kit containing antiretroviral post-exposure prophylaxis, antibiotics for treatment of sexually transmitted infections and emergency contraception. The Prevention Pack Program combines community sensitisation about post-rape medical care with the provision of Prevention Packs and the implementation of a cloud-based and Global Positioning System (GPS)-enabled inventory management system. The Panzi Hospital gender-based violence team implemented the Prevention Pack Program at Panzi Hospital and 12 rural clinics in the South Kivu Province. The data manager took GPS coordinates of each site, provided an initial stock of Prevention Packs and then called all sites daily to determine demand for post-rape care and Prevention Pack consumption. Inventory data were entered into the GPS-enabled cloud-based inventory management system. Project personnel used the consumption rate, trends and geolocation of sites to guide Prevention Pack restocking strategy. Between 2013 and 2017, a total of 8206 individuals presented for care following rape at the study sites. Of the 1414 individuals who presented in the rural areas, 1211 (85.6%) did so within the first 72 hours of reported rape. Care was delivered continuously and without a single stockout of medication across all sites. The Prevention Pack Program provided timely and consistent access to emergency contraception, HIV prophylaxis and treatment for sexually transmitted infections for rape survivors in the eastern Democratic Republic of the Congo.

Sources of drug information in neonatal guidelines of low- and middle-income countries.

OBJECTIVE: Identify drug information (DI) resources used in neonatal practice guidelines in low- and middle-income countries. METHODS: Individuals with knowledge of national neonatal guideline development completed a descriptive, cross-sectional survey. KEY FINDINGS: Eighty-five per cent (33/39) of respondents fully completed the survey. Physicians from university hospitals in Africa were primary respondents. Forty-five per cent (15/33) used a single national neonatal guideline. Primary neonatal resources for drug dosing and preparation were as follows: (1) World Health Organization Pocketbook of Hospital Care for Children, (2) Pediatric & Neonatal Dosage Handbook and (3) National Institute for Health and Care Excellence for Infants and Neonatal pathways. CONCLUSION: Low- and middle-income countries with single national neonatal guidelines cite a finite range of DI resources.

Agreement of decision analyses and subsequent clinical studies in infectious diseases.

PURPOSE: Decision analysis techniques can compare management strategies when there are insufficient data from clinical studies to guide decision making. We compared the outcomes of decision analyses and subsequent clinical studies in the infectious disease literature to assess the validity of the conclusions of the decision analyses. METHODS: A search strategy to identify decision analyses in infectious disease topics published from 1990 to 2005 was developed and performed using PubMed. Abstracts of all identified articles were reviewed, and infectious disease-related decision analyses were retained. Subsequent clinical trials and observational studies that corresponded to these decision analyses were identified using prespecified search strategies. Clinical studies were considered a match for the decision analysis if they assessed the same patient population, intervention, and outcome. Agreement or disagreement between the conclusions of the decision analysis and clinical study were determined by author review. RESULTS: The initial PubMed search yielded 318 references. Forty decision analyses pertaining to 29 infectious disease topics were identified. Of the 40, 16 (40%) from 13 infectious disease topics had matching clinical studies. In 12 of 16 (75%), conclusions of at least 1 clinical study agreed with those of the decision analysis. Three of the 4 decision analyses in which conclusions disagreed were from the same topic (management of febrile children). CONCLUSIONS: There was substantial agreement between the conclusions of decision analyses and clinical studies in infectious diseases, supporting the validity of decision analysis and its utility in guiding management decisions.