Apr 24, 2015 — University of Utah researchers and international experts are looking into how developing countries can expand best practices to save the lives of newborns. Through their work, Bernhard Fassl, M.D. and his team have developed ten quality measures for lowering the mortality rate aboard. Their work was recently presented at the 2015 Pediatrics Academic Societies conference in San Diego, California.

Interview

Interviewer: Infant mortality in third world countries, what we can do about it. Plus some of the lessons we've learned over there could be applied to health care here in the United States. That's coming up next on The Scope.

Announcer: These are the conversations happening inside health care that are going to transform health care. The Health Care Insider is on The Scope.

Interviewer: Dr. Bernhard Fassl is an assistant professor of pediatrics at University of Utah Health Care and his presentation on platform establishing benchmarks for the quality of care for newborns in developing countries, very interesting. Tell me a little bit of the story and study and what you discovered.

Dr. Fassl: As part of a global health program, we work in a children's hospital in rural India. What we found is that about 80% of our mortality and morbidity occurs in the neonatal period. Observation of the practitioners we noted that there are several gaps in care delivery that stem from individual performance of practitioners but in general they have to operate in an environment that is not supporting our best practice.

We tried to measure and analyze the causes of where the system fails and we ran into several obstacles, such as, well we don't really know what constitutes best practice. What should actually those people in developing countries where resources are limited be doing to save lives of children.

Our group performed a literature review and identified things that constitute best practice in developing countries. Interestingly, no other publications were available that would have summarized the evidence and that would have published quality measures for the newborn period.

So as we got a local steering group together that consisted of international experts but also local physicians who work in the environment on a daily basis, we developed 10 quality measures for newborns that they define best to settings where resources are limited. What we sort of decided on was really three groups of measures, one big area of pathology occurs right around child birth. If you envision yourself in a delivery room where you have plenty of kids coming and going but no infrastructure to support care, inevitably you're stuck with preventable death.

So, we identified four measures that are based on [inaudible 00:02:30] American Academy of Pediatrics and Indian national guidelines that define immediate newborn care. Those are that the delivery room should be ready and set up to receive a newborn with oxygen and equipment, that the equipment should be checked and should be functional. Then there should be an immediate assessment of the newborn to see if they have established breathing and then if they're not, they should be ventilated within 30 seconds.

So none of these are high tech interventions and most people that I've talked to think that's way too simple. But then when you actually collect information about what the current practice is, you see that, well, even those simple interventions are not getting done.

And that continues throughout the hospitals today. We get newborns who get discharged with a fever of 104 degrees with obvious sign of infection and well, it is because nobody checks the vital signs. So it's very simple steps in nursing care and physician care that set you up for failure that contribute greatly to poor outcomes.

Almost 50% of newborns in India are born with low birth weight, meaning less than 2,500 grams. Causes are many, most of it due to malnutrition that comes from the parents. So 20% of low birthed infants die within six months for various reasons. The truth is that we failed them. We do not have systems in place in the hospital to actually transition them successfully from the neonatal to the postnatal period.

So part of the benchmarks that we developed are focused around low birth weight care which include, that should have been established feeding pattern, they should be able to maintain a body temperature and that they should not be discharged unless they reach a certain weight goal.

Again, none of this is high tech and it appears almost too simple to be true, but when you immerse yourself in the system I think only then will you realize how difficult it is to get those simple things done.

Interviewer: So you have these new benchmarks that you've developed, have you actually implemented them and tested to see how successful they are in this situation?

Dr. Fassl: So the publication that you see here is baseline data collection. What we have done after this is we have identified areas of poor performance and we have implemented targeted interventions to mitigate those weaknesses. This is usually a combination of educational effort such as health worker training, but also includes infrastructure, includes logistics, and a big part is ongoing data collection.

What we found is the most powerful weapon against preventable newborn death is to make people aware of the magnitude and the preventability. This is the first time that those people who we work with, our partners in India, really conceptualize the magnitude of preventable deaths. So they embrace that idea as something that they actually can do. By giving them feedback every three to six months where we collect follow-up data, they see progress. And we continue to monitor gaps and we continue to tailor our interventions to make improvement.

So the next abstracts you're going to see are going to look vastly different, we're going to be performing much better.

Interviewer: What's the big takeaway, what's the one takeaway that somebody should take from your research study?

Dr. Fassl: Guidelines are only as good as long as they are implemented on the front line. There are thousands of guidelines that define proper newborn care but if you never check what is being done and what is being followed, a guideline lives in the drawer of a desk. But I think what this study does it helps people translate guidelines into a real project.

Announcer: Be a part of the conversation that transforms health care, leave a comment and tell us what you're thinking. The Health Care Insider is a production of TheScopeRadio.com, University of Utah's Health Science Radio.


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