Harmonization of guidelines for hospital care of sick and small newborns

The Uganda Paediatric Association (UPA) together with the Centre of Excellence for Maternal and Newborn Health Research – School of Public Health Makerere University are in the process of harmonizing and improving the guidelines on hospital care of newborns. The guidelines are intended to act as a job aid when managing sick and small newborns, and will also be used as a resource for training health workers.

As part of the process, UPA visited four regional referral hospitals (Jinja, Mbale, Soroti, Hoima, Masaka) and Mulago national referral hospital in Uganda. The aim was to interact and discuss with the frontline health workers in newborn care in order to understand the current newborn care services, opportunities and challenges. This information was deemed necessary for the development of locally-relevant guidelines.

During the discussions, the health workers were able to propose topics/ areas that should be included in the new guidelines, drawn from their experiences in caring for high risk babies. Such areas included discharge planning and follow up especially for the preterm babies.

Quality improvement of neonatal care at Jinja Hospital through enhanced surveillance and needs directed mentorship and training

Background

Neonatal mortality remains a big problem in Uganda, contributing up to 45% of overall deaths among children less than five years of age. The current neonatal mortality is estimated to be 23 per 1000 live births. Although this is an improvement from 29 per 1000 live births 10 years ago, the rate of reduction is generally slow Focus on the care of small and ill neonates would prevent 600,000 newborn deaths per year by 2025. Improved quality of care in hospitals can prevent up to 90% of deaths among the sick and small neonates Therefore high impact and cost-effective interventions that can contribute to neonatal care in hospitals are very crucial. In Uganda, like many countries in Sub-Saharan Africa, there is still a gap in collecting significant information that is important in understanding the burden of newborn morbidity and mortality. Yet, this information is very important in planning and implementing locally –relevant interventions.

It is against this background that Uganda Paediatric Association (UPA) in collaboration with Jinja hospital, and Centre for Health Research and Programs designed a project aimed at improving neonatal data quality and neonatal health care in Uganda. The main strategy neonatal disease surveillance, whereby data on neonates admitted in Jinja regional referral hospital is collected using a standardized neonatal medical record form (NMRF) that was developed by the project team. The NMRF is a comprehensive tool that is used to assess and manage the sick and small neonates. It also has a section for capturing and delivering prevention and health promotion interventions such as immunization, prevention of mother to child transmission of HIV and breastfeeding. The data is entered into an electronic database and analyzed on a monthly basis. The results are then disseminated to the team at Jinja hospital and used to generate discussions and plans for making local improvements in the quality of neonatal care at the hospital.

A pilot project was implemented in Jinja regional referral hospital from 2014 to 2015. The overarching goal of this project was to improve clinical care outcomes of neonates admitted in Jinja hospital. Overall, the results showed that hospital-based neonatal disease surveillance is disease is a very good intervention with a lot of potential to improve the neonatal outcomes. Specifically, the NMRF was very comprehensive and ensured a holistic approach to hospital newborn care. The data also revealed the true neonatal disease burden and facilitated planning for improvements especially in the context of training and mentorship, drugs and supplies and addressing some of the local administrative issues like staff duty rosters.

Some challenges were also noted. For example, the NMRF was not user-friendly and staff had difficulties in completing it and, data was only captured for sick babies and there was no information about well babies delivered in the hospital. Using the data, it was possible to identify lower level units that refer very sick babies without providing them with critical care before referral and this contributed to their poor outcomes. It was against this background that a second phase was planned to address the challenges highlighted by the pilot phase. Implementation of the second phase covers Jinja regional referral hospital, Bugembe Health Centre IV and Budondo Health Centre IV, and started in January 2016. Below is a summary of the activities and findings

Jinja regional referral hospital

• Revision of the NMRF to make it more user-friendly and include more relevant information. This was spearheaded by the project team in consultation with the front-line health workers (midwives, nurses, doctors, and Paediatricians) in Jinja hospital.
• Orientation of the staff in Department of Paediatrics and Obstetrics on the revised NMRF
• Analysis of the data that was collected during the period between pilot phase and phase II. This information was very useful in providing insight into implementation of disease surveillance without project support.
• Daily data collection and entry
• Monthly data analysis
• Feedback meetings. The feedback meeting focused on providing and overall picture of neonatal disease burden right from the pilot phase to second phase. There were also discussions on how to improve on data quality and completeness because this is very important in obtaining the true picture of status of neonatal disease burden and care at the hospital. Improvements in the user-friendliness of the revised form were noted. The data also highlighted the equipment needs and re-organization in one of the neonatal care points (Nalufenya Children’s hospital). Procurement of this equipment (Baby cribs, oxygen concentrator, resuscitation set and thermometers) has been completed and re-organization has been done. Significantly, there has been tremendous improvement data completeness since the form was revised, with most of the indicators scoring above 80% and a number of them having 100% data completeness. Data quality has also improved tremendously.
• New health workers in the neonatal care points were also oriented on the use of NMRF and neonatal disease surveillance in general by the onsite team.

Bugembe and Budondo Health Center IVs

A baseline survey was done to establish the current status of newborn care services and identify opportunities, needs and challenges. Many gaps were found but specifically, it was noted that in both health centres, there were no clear records on the newborns. The newborn information was very scanty and recorded in the mother’s medical file. There were no registers for newborns. Important medicines, supplies and basic equipment for newborn care were also lacking, largely because it was not prioritized.

The NMRF was introduced in both sites. The health workers received one-day training on disease surveillance in general, the project goal, objectives and activities, and how to use the NMRF. Neonatal registers were also provided. Follow up visits were also made to help the teams on kick-starting the use of the NMRF and capturing data on all newborns in the health centres.

Feedback on the data that was collected was done. The strengths and challenges were discussed. The training and equipment needs arising from the data collected were also discussed. Key findings included the fact that the staff was now more aware of the neonatal services in the unit, the drugs for newborn care were procured, and data collection on all newborns was improving. During the meeting, the health workers were re-oriented on management of neonatal sepsis.

Other relevant findings

The Preterm Birth Initiative (PTBi) is a research project which is implementing activities on preterm care in Busoga region (Jinja hospital inclusive). During their planning phase, the research team noted the importance of the NMRF, especially the scope of the newborn health data. It was also noted to be an easy and standardization of information on newborns in Jinja hospital, and the subsequent changes that it stimulated. PTBi project is currently using the same tool (NMRF) to collect data on newborn care in all their study sites (Jinja, Iganga, Kamuli public, Kamuli Mission hospital, and Buluba).. This is an opportunity to disseminate the use of the form but also capture data on newborn disease burden and quality of care in other hospitals. This data from the PTBi study sites will be shared with UPA

Supporting school-centered asthma care in boarding schools (SCAPE Project)

In July 2016, the Uganda Paediatric Association, started a 3-year asthma care in Gayaza High School.. The overall project goal is to establish a self-sustaining school-centered quality asthma care service that will ensure appropriate asthma care for the boarding school students through enhanced community engagement and partnerships.

It was noted that there was poor access to quality asthma care in the boarding school because the school nurses have limited current information coupled with lack of regular physician support. These nurses were usually left out of in-service training or continuous medical education programs. As a result, the students have poor asthma control leading to poor quality of life while in school and frequent absenteeism due referrals back home for treatment. Whereas there is a health facility with a physician in the vicinity of the school, there is limited or no linkage with this facility. This program intends to reduce asthma exacerbations, maintain good asthma control and reduce absenteeism of children with asthma while at school through training, adequate asthma management and making linkages with parents and the physicians who care for these students.

The key stakeholders in this project include students with asthma and their peers, , the school nurses, the school administration, primary care physician, parent doctors and the parents of affected children

The program activities;

At Community level:

• We engage the school community in dialogues for continued support for the asthma care project
• Establishing an innovative asthma care consultative forum
• We conduct public asthma care awareness activities

At School Nurses Level:

• Mentorships of nurses in standard asthma care
• Train nurses in use of an asthma application for education, assessing and monitoring asthma control.

At Students Level:

• Equip asthmatic students with self-care and coping skills.
• Strengthen and/or establish the peer health club to support children with asthma.
• Train peer health club members in communication and advocacy skills

UPA 12th Annual Scientific Conference 2016

Uganda Paediatric Association (UPA) recognizes the significant morbidity and mortality in children attributed to communicable diseases, malnutrition and neonatal conditions, and the emergence and rapid increase of non-communicable diseases. During the MDG (Millennium Development Goals) era, significant strides were made in key child health indicators like the reduction of malaria prevalence rate and the universal access to treatment of HIV/AIDS. The under-5 mortality rate dropped by 42% from 156 per 1000 live births in 1995 to 90 per 1000 live births in 2011(1) Despite this progress, many children still die from preventable diseases, especially the newborn babies in whom the mortality rate is unacceptably high and little progress was realized during the MDG era. The Sustainable Development Goal 3 which aims to ensure healthy lives and promote wellbeing for all at all ages, is an ambitious one and largely focuses on those areas where there was no significant gains/progress during the MDG era. For example, the goal states that by 2030, all countries should have reduced the neonatal mortality rate (NNMR) to 12 per 1000 live births and the under- 5 mortality rate (UMR) to 25 per 1000 live births. The same goal recognizes that communicable diseases are still a challenge. In addition, unlike the MDG era, the SDGs will also address the challenge of premature deaths from non-communicable diseases. To achieve the above mentioned goals/targets, strategic, innovative and evidence- based approaches to improvements in child health must be designed, with a commitment to translate them into practice.

To enable the sharing of new information and exchange of knowledge between the different promoters of child health-related issues, UPA organized its 12th Annual Scientific conference on the 20th – 21st October 2016 at Hotel Africana.

The theme of the conference was “Sustainable Development Goals and Child Health: Opportunities and Challenges”, which provided an opportunity for health workers, health professional educators, policy makers, child advocates and other key child health stakeholders to reflect on the achievements and gaps of the MDG era. It also offered a platform to explore opportunities and anticipate challenges during the SDG era, which will be helpful in designing strategic interventions that will ensure achievement of the SDG 3.

The objectives of the conference were:

• To identify strategies that will aim to end preventable deaths of mothers, newborns and children less than 5 years of age.
• To discuss the burden of emerging communicable diseases that continue to threaten the existence of children and other non-communicable diseases.
• To emphasize the importance of child advocacy and community health strategies in combating the high burden of child morbidity and mortality.
• To highlight the need to support the research and development of vaccines and medicines for communicable and non-communicable diseases that primarily affect developing countries.

Conference Attendance

The 2 day conference drew over 250 participants from; UPA and sister professional associations in the region, the East Africa Paediatric Association, officials from the Uganda Ministry of Health, representatives from WHO and other important child health stakeholders, academicians, and members of the general public. Regional experts in different fields presented, and discussed a range of pertinent issues in line with the conference theme.

Health Camp

On the 11th of November 2016, Uganda Paediatric Association offered technical support to SOS Children’s Village Kakiri during their (SOS) medical camp. A total of 1736 clients received a variety of health services that ranged from immunization, health education, diagnosis and treatment, blood donation, HIV counseling and testing, cervical cancer screening, safe male circumcision, family planning, blood pressure measurement and dental.

The health camp was a great successful with support from other partners that included; Wakiso District Health Office (Kakiri Health Centre III), Makerere University Department of Pediatrics, Uganda Pediatric Association, Uganda Non Communicable Diseases Alliance (NCDA), Nakasero Blood Bank, Alfa Dental Services, Century bottling ltd(Coca-Cola), KAFCO, First Division Military Hospital- Kakiri, Kawempe Community Based Healthcare, JESA Farm, Uganda Health Marketing Group, Hermann Gmeiner Medical Centre Entebbe, Kakiri Town Council, Kakiri Police Station, Childcare Academic Centre and St. Charles international school– Kakiri.

• Increasing awareness on Paediatric asthma among healthcare providers
1. Recognizing the huge problem of under-diagnosis of childhood asthma, and poor management of the few that get to be diagnosed correctly, UPA in partnership with the Pharmaceutical companies has embarked on activities to increase awareness about childhood asthma in Uganda, with special focus on diagnosis and management. In this respect, UPA conducted two CME sessions on asthma;
2. A one-day training workshop on diagnosis and management of asthma was conducted in collaboration with the Chest Research Foundation (CRF) of India and Cipla Uganda. The participants were drawn from the public and private health facilities in Kampala and Wakiso district, and a few from regional referral hospitals. The sessions were delivered by international experts on pediatric asthma and also involved practical sessions. Participants were very appreciative of the knowledge they acquired and requested for regular updates on the asthma. A scientific meeting on updates in pediatric asthma was conducted by UPA in collaboration with GSK Pharmaceutical Company. This meeting specifically focused on selected health care professionals who were directly involved in the care of children with asthma. The main aim was to provide updates on pediatric asthma regarding prevalence, diagnosis and management, specifically highlighting the changes in the GINA ( Global Network for Asthma) guidelines.
• Integration of Early Childhood Development (ECD) into the IMCI guidelines

Early childhood development is a major contributor of adult life. A lot of what happens in adulthood has a strong and direct link to the early childhood period. As such, early childhood development is globally recognized as a key contributor to the global growth and development. One of the key components of ECD is Care for Child Development (CCD) which is directly linked to recognition and management of developmental problems in childhood, as well as prevention strategies. In Uganda, CCD has been incorporated into IMCI strategy. The process of integration of ECD/CCD into IMCI was spearheaded by UNICEF and UPA provided technical support through its members. The members also participated in training regional teams on CCD as a new component of IMCI.