Integrated care pathways: a tool to improve infant monitoring in a neonatal unit

Improved management of stillbirth using a care pathway

Purpose

Each year approximately 3,200 women have a stillbirth in the UK. Although national evidence-based guidance has existed since 2010, case reviews continue to identify suboptimal clinical care and communication with parents. Inconsistencies in management include induction and management of labour and the frequency of investigation after stillbirth. The paper aims to discuss these issues.

Design/methodology/approach

An audit of stillbirths was performed in 2014 in 13 maternity units in the North West of England, this confirmed variation in practice described nationally. An integrated care pathway (ICP) was developed from national guidelines to enable optimal care for the management of stillbirth, reduce variation, standardise investigations and coordinate patient-focussed care. This was launched in 2015 and updated in 2016 to resolve the issues that were apparent after implementation.

Findings

Each participating unit had commenced using the ICP by May 2015. Following implementation there were changes in care, most notably from diverse methods for the induction of labour to guideline-directed induction of labour. There were trends towards better care in terms of information given, choices offered, more appropriate analgesia in labour and improved post-delivery investigation for cause. Staff feedback about the ICP was positive.

Practical implications

The use of this ICP improved care for women who had a stillbirth and their families. Issues with implementing a changed care pathway meant that further iterations were required, ongoing improvement is expected following the refinement of the ICP.

Originality/value

ICPs have been used for various clinical conditions. However, this is the first example of their use in women who had a stillbirth.

Setting up and running a paediatric emergency department in a hospital in Malawi: 15 years on

Paediatric emergency care is not recognised as a specialty in many countries in Africa but is being practised increasingly. Setting up a paediatric emergency care unit takes time and often involves trial and error. Here we describe the start of the paediatric emergency department in Blantyre, Malawi, a low-income country and how it has continued to evolve over 15 years, in the hope that our experience will inform and assist others who are already developing their own emergency unit or wishing to do so.

Integrated Care Pathway to Promote the Health of Looked after Children

Background:

There are currently major national drivers set out in the Children Act 2004 and the National Service Framework for Children, Young People and Maternity Services that require closer working between statutory agencies, the voluntary sector and young people. Integrated care pathway methodology was used to improve the coordination of health assessments for looked after children.

Methods:

A working group of looked after children, health, education and social-care professionals, and a care pathway facilitator was established. Meetings were held with all interested parties. National guidance, ‘Promoting the Health of Looked After Children’, was incorporated into a process map for this service in Birmingham.

Results:

The outcomes include the process itself and a set of operational products. The process enabled young people and different professionals to better understand each other's roles and perspectives. The operational products included a process map and detailed care pathway, new health assessment documentation, an audit tool and a variance reporting strategy.

Conclusions:

An integrated care pathway process is a useful tool in facilitating closer working between agencies and young people. It can establish inter-agency governance procedures fundamental to delivering a Children's Trust model of working.

INFANT MONITORING SYSTEM BASED ON ARM EMBEDDED PLATFORM

Since both the parents need to work and look after their babies/infants simultaneously, the families bear more workload. Thus, this paper presents an innovative infant monitoring system consisting of an embedded system platform with a Linux kernel embedded operation system using the TCP/IP protocol, a CMOS image sensor, and peripheral control systems. The key feature of the system is that it can be used to monitor the living environment and the activities of the babies and/or infants through a web browser at any time from any place in the world. In order to increase the accuracy of the temperature sensor, the measured values from the digital temperature sensor were calibrated using regression analysis methods, resulting in an accuracy of ± 0.1°C, a correlation coefficient of 0.996, and a standard deviation of 0.124. The experimental results show that the proposed concept and the resulting system are feasible.

Implementation of a structured paediatric admission record for district hospitals in Kenya--results of a pilot study

BACKGROUND

The structured admission form is an apparently simple measure to improve data quality. Poor motivation, lack of supervision, lack of resources and other factors are conceivably major barriers to their successful use in a Kenyan public hospital setting. Here we have examined the feasibility and acceptability of a structured paediatric admission record (PAR) for district hospitals as a means of improving documentation of illness.

METHODS

The PAR was primarily based on symptoms and signs included in the Integrated Management of Childhood Illness (IMCI) diagnostic algorithms. It was introduced with a three-hour training session, repeated subsequently for those absent, aiming for complete coverage of admitting clinical staff. Data from consecutive records before (n = 163) and from a 60% random sample of dates after intervention (n = 705) were then collected to evaluate record quality. The post-intervention period was further divided into four 2-month blocks by open, feedback meetings for hospital staff on the uptake and completeness of the PAR.

RESULTS

The frequency of use of the PAR increased from 50% in the first 2 months to 84% in the final 2 months, although there was significant variation in use among clinicians. The quality of documentation also improved considerably over time. For example documentation of skin turgor in cases of diarrhoea improved from 2% pre-intervention to 83% in the final 2 months of observation. Even in the area of preventive care documentation of immunization status improved from 1% of children before intervention to 21% in the final 2 months.

CONCLUSION

The PAR was well accepted by most clinicians and greatly improved documentation of features recommended by IMCI for identifying and classifying severity of common diseases. The PAR could provide a useful platform for implementing standard referral care treatment guidelines.

Aetiology of neonatal sepsis in Blantyre, Malawi: 1996-2001

AIM

The aim of this retrospective study was to report causes, antibiotic resistance and outcome of neonatal sepsis (often fatal in developing countries) in Malawi.

METHODS

All blood and cerebrospinal fluid isolates collected between January 1996 and December 2001 from inpatients aged 0-30 days with suspected sepsis at Queen Elizabeth Central Hospital, Blantyre, Malawi were reviewed. In vitro resistance to antibiotics commonly used in Malawi was assessed. Case fatality rate was analysed with respect to age, bacterial pathogen and infection site.

RESULTS

A total of 801 bacteria were isolated from 784 neonates over 6 years-599 isolates from blood and 202 from cerebrospinal fluid. Overall, 54% of bacteria were gram-positive and 46% gram-negative. The commonest causes of neonatal sepsis were group B Streptococcus (17%) and non-typhoidal Salmonella (14%). In vitro antibiotic susceptibility to the first-line antibiotic combination of penicillin and gentamicin was 78% for all isolates, but in vitro sensitivities to gentamicin for Klebsiella spp and non-typhoidal Salmonella were only 33% and 53%, respectively. In-hospital case fatality rate was known for only 301 cases and was high at 48%. Group B Streptococcus was associated with the best outcome. Mortality was significantly higher if presentation was in the 1st week of life or if sepsis was caused by gram-negative bacteria. The causes of neonatal sepsis in this population show a different pattern from other studies in developing countries.