Sepsis Audit Report

THE UNIVERSTY OF WARWICK

WARWICKMEDICALSCHOOL

INSTITUTE OF CLINICAL EDUCATION

BACHELOR OF SCIENCE (INTERNATIONAL OBSTETRICS & LEADERSHIP)

SUBJECT: Re Audit Report

TOPIC: Neonatal Sepsis Audit Report Interventions Outcome;Possible Additional Interventions for Achievement of further Neonatal Sepsis Reduction at Bwaila Maternity Hospital, Lilongwe, Malawi.

STUDENT NAME: Enos Lloyd KAUDZA

REGISTRATION NUMBER: 1135925

TABLE OF CONTAINTS:

Background information………………………………………….…...…1

Statement of the problem……………………………………………..…..1

Purpose of there-audit………………………………………………...…..2

Specific objectivesof there-audit.……………………………………...... 3

Significance of the re-audit…………………………………………..…….3

Data collection…………………..………………………………………..….3

Data analysis………………………………………………………………….4

Interpretation of results……………………………………………………...5

Discussion……………………………………………………………………..6

Conclusion…………………………………………………………………….7

Recommendations……………………………………………………………8

References…………………………………………………………………….8

BACKGROUND:

It is estimated that more than half a million newbornsdie each year from serious neonatal infections.

The estimated figure accounts for about 15% of all neonatal deaths globally (BMC public Health, 2011; 11 (suppl 3): S11, S13). The most vulnerable time for both the mother and newborn is during birth and in the hours and days immediately after childbirth. About 75% of all neonatal deaths occur during the first weak of life, with the majority in the first 48 hours, which is also the period of the highest risk for the mothers. In populations with very high neonatal mortality, up to half of neonatal deaths may have an infectious cause. It is estimated that 30% to 40% of infections resulting in neonatal sepsis deaths are transmitted at the time of childbirth and have early onset of symptoms (developing during the first 72 hours after birth). In low income countries, about 60%of births occur without skilled attendants, and most of these at home. Worldwide, 60 million births happen outside facilities and even for facilities birth hygienic practices may be sub-optimal. In addition many neonatal deaths due to tetanus and other infections are acquired in postnatal period. The unhealed umbilical cordis an important entry point for local and invasive infections during this period and is rapidly colonised by bacteria from the environment.Neonatal sepsis may be categorised as early or late onset. Of newborns with early onset infections, 85% presents within 24 hours, 5% present at 24 – 48 hours, and a small percentage presents within 48 – 72 hours. The onset is rapid in premature babies. Early onset sepsis syndrome is associated with acquisition of micro organisms from the mother, transplacental infection or an ascending infection from the cervix may be caused by organisms that colonise in the mother’s genitourinary tract; with acquisition of microbes by passage through colonised birth canal at delivery. Late onset sepsis usually occurs from 4 – 90 days of life and is acquired from the care giving environment. Infant’s skin, respiratory tract, conjunctiva, genitourinary tract and umbilicus may become colonised from the environment, leading to the possibility of late onset sepsis from invasive micro organisms. Vectors for such colonisation may include vascular tissues or contact with caregivers who have bacterial colonisation. Some of the notable risk factors associated with neonatal sepsis are maternal in nature such as: Intrapartum maternal infection, premature rupture of the membranes, prolonged rupture of membranesof more than 12 hours, premature onset of labour of less than 37 weeks gestation and maternal urinary tract infection. Neonatal risk factors include low birth weight and prenatal asphyxia.

STATEMENT OF THE PROBLEM:

Bwaila Maternity Unit remains the major health facility that provides quality care maternity services in the district. It is manned by well qualified and experienced service providers of all cadres such as: Nurses and support staff, Clinical Officers, Medical Officers and Consultants. Since the insertion of this maternity unit in the early 1940s, it has encountered and still continues to encounter some challenges with case management one of which being neonatal sepsis. The prevalence rate of neonatal sepsis at this facility has been constant despite precautions taken by service providers to prevent neonatal sepsis. For this reason, thisre-audit report has been designed to compare the findings of the February 2012 audit report in relation to same parameters such as; sources, causes, clinical presentations and management, possible prevention interventions in order to see if a desired goal has been achievedto a lesser percentage.

SPECIFIC OBJECTIVES OF THE RE AUDIT REPORT:

This re-audit report is specifically aimed at comparing the outcome of the interventions that were put in place against the indicators of the initial audit report.The comparison will be based on interventions as follows; after tracing the sources of neonatal sepsis and after finding out the causes of neonatal sepsis. Management in practice based on clinical presentations of neonatal sepsis and after practicing preventive measures of neonatal sepsis. Finally, outcome based on the established local protocols being used in the nursery ward, and after trainingservice providers in sepsis prevention/infection prevention.

SIGNIFICANCE OF THE RE AUDIT:

Following the interventions put in place to improve the situation after the initial audit report, this re-audit report will better assist service providers to recognise and deal with the sources and causes of neonatal infections at this hospital. This being the case, infections will be prevented before spreading. In cases where infection is already there, clinical presentations will be recognised and management will be instituted in time. With the ongoing interventions, such as trainings, and beliefings on care of neonates, service providers will be able to manage neonatalsepsis.As such the prevalence rate of neonatal infection will probably reduce.

Other obvious benefits, after reducing the rate of sepsis in babies, will bea reducedbed occupancy rate.All service providers will be equipped with adequate knowledge on how to prevent neonatal sepsis. The hospital and other agencies will have the information with which to use to formulate protocols.

DATA COLLECTION:

For re-audit purposes, the data was collected for three months, May, June and July, 2012. Just like the initial audit, data was collected from the nursery ward register and in-patients files retrieved from the ward clerk’s office. The sample sizeswere 22, 18 and 7 in each month respectively. The sample sizes werederived from a total of cases, with desired clinical indicators, of clinical neonatal sepsis admitted in each of the three months. In May, 2012, total number of neonatal sepsis cases was 22. Out of the 22 cases, 20 had clinical marker of temperatures above 38 degrees Celsius despite being on antibiotics for two days. The remaining 2 cases presented with temperatures below 35 degrees Celsius.

In June, 2012, total number of neonatal sepsis cases reduced to 18 out of which, 13 had temperatures above 38 degrees Celsius and the remaining 4 had temperatures below 35 degrees Celsius

In July, 2012, total number was 7,of which 3 cases had temperatures above 38 degrees Celsius and 4 cases with temperatures below 35 degrees Celsius.

DATA ANALYSIS:

The three months data captured was imported into relevant tables for comparison purposes inoder to carry out meaningful analysis that can draw a conclusion which is linked to the objective of the re-audit report. From the data so far collected,it seems the number of cases of neonatal sepsis is gradually reducing.However, even before interventions initiated soon after the February audit, sepsis is not an outstanding problem at this hospital as it representsless than 10% of all admissions at the Nursery Ward and a death rate of less than 2% annually. Thisre-audit reportwill focus on comparing the cases for the month of February 2012. Out of 365 babies admitted for various reasons in February, 2012, 47 babies were admitted due to high fevers >38 degrees Celsius (clinical sepsis) and other clinical presentations of sepsis, representing 12.9% of all admissions in the said month.

Total Sepsis cases admitted / % of total admission per month in the initial audit and re-audit periods

Month (2012) / Total Admitted / Sepsis / % / Period
Feb / 365 / 47 / 12.9 / Initial audit
May / 318 / 22 / 7.9 / Re audit
June / 311 / 18 / 5.7 / Re audit
July / 302 / 7 / 2.3 / Re audit

The table above shows that incidenceof clinical neonatal sepsis is gradually decreasing, as evidenced by the rate of monthly admissions. The assumption may be attributed to the interventions that were put in practice following the initial audit results.

Proven sepsis remains difficult due to lack of laboratory capacity to culture spacemen; therefore, cases are mostly diagnosed based on clinical presentations. The admission criteria for the nursery ward at Bwaila Hospital is for; premature babies, low birth weight babies, birth asphyxia, neonatal sepsis, low Apgar score, and other conditions that require observation of the neonates within 48 hours. Babies are admitted from the labour ward, in cases of low Apgar score, birth asphyxia, aspiration,prematurity and other conditions. Others come from normal (low risk) postnatal ward, high risk postnatal ward, and from home after home delivery or after being discharged from postnatal ward.In the initial audit report, out of the total 47 cases of clinical sepsis only 26 cases were randomly selected and I came up with the following findings: 14 cases reported within 24 hours, 6 cases within 48 – 72 hours, the remaining 6 cases from 72 hours to 9 days.

Due to the reduced numbers of neonatal sepsis cases in the re-audit months, all cases for the months in question well used (no random sampling). The table below reflects the comparable figures from that of February, 2012.

Table 1a: Time reported to Nursery (Feb, 2012, Audit Report)

Time in hours/days / No of cases
Within 24 hours / 14
48 – 72 hours / 6
72 hours – 9 days / 6

Table 1b: Time reported to Nursery (Audit & Re-audit Reports)

Report Time / Feb / May / June / July
Within 24 hrs / 14 / 10 / 4 / 1
48-72 hrs / 6 / 7 / 7 / 2
72-108 hrs / 6 / 5 / 7 / 5

The tables above is a reflection of reported cases in both initial audit and re-audit periods in relation to time in hours.

Table 2a: Place cases reported from (Feb, 2012, Audit Report)

Ward / Place / No of cases
Low risk (normal) postnatal ward / 12
High risk postnatal ward / 6
Home after discharge / 4
Home deliveries / 2
Labour ward / 2

Table 2b: Place cases reported from (Audit & Re audit Reports)

Ward/Place / Feb / May / June / July
Low risk postnatal ward / 12 / 6 / 3
High risk postnatal ward / 6 / 9 / 5 / 1
Home after discharge / 4 / 2 / 6 / 3
Home deliveries / 2 / 5 / 4 / 3

Initially, the table above shows more cases reporting from within the wards than other places. Then the numbers, though notequally sampled, gives the opposite trend of scenario. More cases seem to report from outside than within the hospital within the period of intervention.

Table 3a: Cases clinical presentation (Feb, 2012, Audit Report)

Clinical presentation / No of cases
High fever > 38 degrees Celsius / 19
Low birth weight with fever / 2
Impetigo / 1
Lethargic / 1
Umbilical infection / 1
Purulent eye discharges / 1
Severe prematurity with fever / 1

Table 3b: Cases Clinical Presentation (Audit & Re-audit Reports)

Clinical presentation / Feb / May / June / July
Fever >38 / 19 / 20 / 13 / 3
Fever >35 & LBW / 6 / 2 / 4 / 4
Impetigo / 1 / - / - / -
Lethargic / 1 / - / - / -
Umbilical infection / 1 / - / - / -
Purulent eye discharges / 1 / - / - / -
Severe prematurity with fever / 1 / - / 1 / -
Total / 26 / 22 / 18 / 7

Whether a surprise or an improvement, almost all the cases presented with only hyperpyrexia and hypothermia in the re-audit period. In the initial audit period, in February, there were trace cases indicating other clinical presentation of sepsis.

Table 4a: Modes of delivery (Feb, 2012, Audit Report)

Mode of delivery / No of cases
Hospital spontaneous delivery / 18
Caesarean Section / 4
Home delivery / 4

Table 4b: Modes of Delivery (Audit & Re-audit Reports)

Delivery Modes / Feb / May / June / July
Hospital SVD / 18 / 13 / 10 / 4
C/Section / 4 / 6 / 3 / 1
Home deliveries / 4 / 3 / 5 / 2
Total / 26 / 22 / 18 / 7

In relation to modes of delivery, there are still more cases of sepsis from babies born in the hospital and caesarean sections, though in the last two re-audit months there is a reduction of sepsis from caesarean section cases.

DISCUSSION:

From the tables above, much of what have been reflected are gradual improvements and desirable outcomes. The results above may be conclusive to show that sepsis can be reduced with proper interventions. Proper care is critical from first stage to third stage of labour and postnatal period (42 days post delivery. Currently, through observation in the wards, most midwifes and clinicians put on gloves prior to hand washing when performing vaginal examination.Antiseptic solution for perineum cleaning is found in all the rooms in the labour ward. Mothers in antenatal wardare advised to take a bath when they are in latent phase of labour. Few babies are now being admitted from postnatal wards hours or days after normal deliveries. This may be attributed to the present interventions such as infection prevention measures in the postnatal wards.The situation may improve further with correct interventions such as proper follow up and care of antenatal mothers from admission, during and after delivery, in the postnatal ward and at home after discharge. Preventive measures of sepsis such as six clean birth and good postnatal care practices in accordance with World Health Organisation, to be adhered to. The six cleans are summarised as;hand washing of birth attendant before birth, clean birth surface, clean perineum, clean cord tie and clean cloth for drying.For home deliveries, special intervention to the traditional birth attendants on hygienic standards of care during and after birth to be implemented by delivering the information to them. Basing on the above situation, Antenatal ward, Labour ward, Theatre, Postnatal and Nursery staff(nurses and clinicians)underwent two trainingsessions in Infection Prevention and Injection Safety, and Emergency Obstetrics/Neonatal Care Guidelines. The labour ward floor is now covered with tiles for easy and maximum floor cleaning. There is not much information on traditional birth attendants follow up,therefore, this re-audit will not dwell much on babies born at home.

CONCLUSION:

Despite a considerable burden of the disease, there are still strikingly few data on the precise incidence and the aetiology of early onset of neonatal bacteria sepsis in Sub-Saharan Africa, largely because of lack of reliable microbiological facilities. Simple intervention strategies are effective in other populations and evidence from a small numberof intervention studies in Sub-Saharan Africasupports the urgent need for further trials.As such, the public health measures can effectively be directed and neonatal morbidity and mortality in Sub-Saharan Africa be substantially reduced. Therefore, clinical relevance for this re-audit is to reflect on the outcome of the sepsis reductions/preventions practiced after the audit report, and to explore other possible avenuesfor improvement. To come up with a list of the causative agents of neonatal sepsis and the preventive measures, recognition of clinical presentations and management of neonatal sepsis.Upon establishingthe above factors, all implementers in the hospital and outside to be followed up and mentored on the policies. Quality assurance to be assured with biannual re-audits. Hence, re-audits will be conducted on six monthly bases to ascertain neonatal sepsis improvement rate. Finally, with the above evidence based improvement, a policy within the hospital shall be formulated. The policy, however, shall need the approval by the District Health Management Team. The policy document shall contain steps that will further bring down the morbidity and mortality rate due to neonatal sepsis at Bwaila Maternity Unit and all its surrounding health facilities.

RECOMMENDATIONS:

The District Health Office,working partners and other stakeholders such as; Centre for Disease Control(CDC), University of North Caroline (UNC) Project, Fistula Foundation, UNICEF, Light House, to continue organising trainings for service providers in Neonatal Sepsis management in the district. The District health office, through its health centres to plan sensitization campaigns during maternal health services delivery at the facilities and in their communities.The trainings, mentorship programmes being conducted at Bwaila Maternity Hospital to continue and be rolled outto all the health facilities within the District. Protocolsthat are already developed should be fully utilised by all service providers.Service provider’s knowledge gaps to be corrected by ongoing trainings within the hospital. Service providers must develop a will to improve the standards and provide quality care for patients at all times.

REFERENCES:

(a) Bwaila Maternity Unit, nursery ward register, and inpatients files: May, June and July, 2012.

(b) JA Philips, PN Kazembe, EAS Nelson, JAF Fisher, Grabosh: (2008), A Paediatric Handbook for Malawi, (3rd Edition) Limbe, Montifort Place.

(c) Baltimore RS, Neonatal sepsis: Epidemiology and Management, Yale university school of medicine, New Hawaii, Connecticut 06520-8064, USA.

(d) Ann L Anderson – Berry, MD, Chief Editor: Neonatal sepsis

(e) ETATMBA materials