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NCH and Georgetown Public Hospital: A Joint Venture to Improve Infant Mortality in Guyana

Gail A. Bagwell RN, MSN, CNS

Caitlin Beggs RN, MSN, RNC-NIC, AHN-BC

Leif Nelin MD

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Co-Operative Republic of Guyana

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Kaieteur Falls

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Guyana Infant Mortality

• Historically Infant

Mortality Rate –

35.9/1000 Live Births

• Ranks 2nd for the 15

Caribbean Community

nations

• Ranks 67th worldwide

out of 220

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Guyana Help the Kids

• Founded by Guyana born physician NarendaSingh to help improve the lives of the children of Guyana

• Partnering with the Government of Guyana, the University of Guyana and Georgetown Public Hospital (GPHC)

• Funding a Pediatric Residency Program at GPHC

• Assisting in equipping and opening a 10 bed Neonatal Unit at GPHC

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Improving Neonatal Care

• In order to provide the highest level of care to the ill neonate, there was a need for specially trained Neonatal staff

• In 2012, physicians, nurses, and respiratory therapists from Nationwide Children’s Hospital developed a neonatal nurse education program.

• Inaugural class – 11 nurses

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Inaugural Class of Neonatal Nurses at GPHC

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Maternity Hospital at GPHC

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Curriculum

• Needs Assessment– Child mortality results from

• Respiratory distress

• Neonatal bacterial infection

– Guyana’s IMR rates similar to rates seen in US & Canada prior to regionalized NICUs in the1970’s

– Guyana Births in 2010• 14,527 births

• 91% in hospitals

• 54% in Georgetown

• 6,000 occurred at GPHC

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Curriculum

• Learner Assessment– 11 RN’s recruited

• Average RN experience - 3.5 years

• Range of prior Neonatal experience -5-24 months

• Primary Work Site– 8 work at GPHC

– 3 in Linden

• BKAT Assessment

• Resource Analysis– Funding from:

• Pan American Health Organization (PAHO)

• Guyana Help the Kids,

• Ministry of Health

• GPHC

• Nationwide Children’s Hospital

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Program Goal

• Utilize an innovative educational

and mentoring program to

implement NICU methods at

GPHC to allow for the successful

use of evidence-based family-

centered strategies to save lives,

particularly for those neonates

suffering from respiratory distress

and infection, to positively impact

child mortality in Guyana

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Program Expected Outcomes

• All enrolled nurses will:– Primary

• Complete training program

– Secondary

• Take an active role in decreasing infant mortality through the use of advanced equipment, quality improvement initiatives, and communication with physicians

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Program Development

• Phase 1

– 2 month live didactic curriculum

• Phase 2

– 1 month preceptorship at GPHC

• Phase 3

– 8 month nurse-to-nurse preceptorship (2 weeks at NCH)

• Phase 4

– 2 week final preparation and evaluation period at GPHC

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Phase 1

• Assessment of Nurses Knowledge

– BKAT Examination prior to beginning classes

• Didactic Curriculum

– June 1, 2012 to July 31, 2012

– Classes

• Twice a week

• 3rd day for Q&A

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Phase 1

• Didactic Curriculum

– Developed from

• PAHO Curriculum

• Core Curriculum for Neonatal Nursing

• Test Results

– Long distance learning done through:

• SharePoint

– Lectures stored on site

– Question and answers posted

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Phase 1

• Didactic Curriculum• WebEx

– Used for live lectures

– Office time to answer questions

– Pro’s

– Con’s

Phase 2Week Skills/Topics Taught

1 • EKG monitor use and alarm settings

• neonatal vital sign norms

• Isolette use and trouble shooting

• breast pump set up and use

• CPAP use and set up

• nasopharyngeal suctioning

• physical assessment

• infant code (compression, hand bagging) and assisting with intubation

2 • CPAP circuit set up and trouble shooting

• thermoregulation-isolette use

• patient care schedules (Q3 or Q4 hrs to promote consistent care)

• importance of continuous alarm use and monitoring

• Ballard scoring

• cardiac EKG rhythm reading

3 • Thermoregulation

• communication between family members and health care team

• responding to alarms

• Q3hr feeding schedules for infants less than 1500g

• NRP certification

4 • Physical assessment and charting,

• bereavement care

• daily weight and fluid calculations

• glucose management

• temperature monitoring and regulation,

• hand bagging with correct pressure and rate

• assisting with ETT intubation

• Emergency Department management of newborn in distress (done in ED)

• developmental positioning

• surfactant administration,

• nurse to nurse handoff report

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Phase 3

• Mentoring– Online Mentorship

• RN mentors

• Focus topics

– Preceptorship in Columbus, OH• J4 NICU

• Respiratory

• Transport

• Labor & Delivery @ Riverside

• NICU skills

• Outpatient clinic

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Phase 4

• On Ground Evaluation – BKAT final administration– Assess

• Comfort with advanced equipment

• Use of nursing process

– Nursing involvement in QI initiatives

• Each student to present top 3 initiatives

– Nurses to evaluate full program

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Results- Phase 1

• BKAT Administration (out of 75 Questions)

– First attempt (June 2012)

• scored 23 - 44 (30.6 - 58.6%), average score - 36

– Second attempt (August 2012)

• scored 33 - 51 (44-68%), average score - 44

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Results- Phase 2Week Identified Learning Needs

1 • Patient assignment use/management,

• Response to alarms

• Physician-nurse communication

• family centered care (especially in infant death)

• Consistent & ordered care (routine vitals more often, follow up on

interventions, evaluation)

• infection control

2 • Skin assessment/use of skin rounding form,

• continued correct use of isolettes and monitors

3 • Thermoregulation

• Responding to alarms

• infection control measures

• communication (physician to nurse and health care team to family members)

• family centered care/kangaroo care

4 • Thermoregulation

• developmental positioning

• Nutrition

• fluid management

• relationship building between nurses in program and remaining nurses on

unit

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Mortality in the Neonatal Unit from January to December 2012

Month0 2 4 6 8 10 12

Mo

rta

lity (

%)

0

2

4

6

8

10

12

14

16

web-baseddidatics

NCH staffon-site

10.8%

5.9%

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Barriers to Implementation

• Culture– Language/tone– Comfortable with high mortality– Lack of family centered care

• Nursing/physician hierarchy – Communication style– Nurses uncomfortable with being patient

advocate

• Supply issue – Lack of hospital support for neonatal care

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Lessons Learned • Needed a truly committed team

• Do an assessment of nurses and environment before setting up the program

• Be involved in the selection of the nurses from Guyana who entered training program

• More organized for both parties with more specific details written out

• PCEP

• Buy-in – nurses, nursing management and GPHC

• Buy-in from NCH and NICU

• Nurses when visiting should have been working preceptor schedule

• More clear cut criteria for preceptors at NCH and their roles/training

• Preceptor should have been treated as new grad orientee vsa visitor

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Next Steps

• Phase 3 finished June 1st, phase 4

planned for June 17-28, 2013

• Administer last BKAT exam June

2013

• Start to establish neonatal

network: Linden, West Demerara,

New Amsterdam, & Suddie to

provide coverage for 73% of

deliveries in Guyana

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Questions?

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References

• American Academy of Pediatrics & American Heart Association (2010). Neonatal Resuscitation Program

• Bryan, C. (April 2011). Improving the health of Children in Guyana: Guyanese Diaspora Partner with the Guyanese Medical Community. http://guyaneseonline.files.wordpress.com/2011/04/april-2011-newsletter-final.pdf.

• Caribbean Community Secretariat. Members and Associate Members. http://caricom.org.

• Central Intelligence Agency (Updated Weekly). World Fact book: Country Comparison, Infant mortality rankings. https://cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html.

• Google Images. Country maps and Guyana Help the Kids logo.

• Guyana Help the Kids Organization. http://guyanahelpthekids.com/index.php.

• Nationwide Children’s Hospital. Mission statement. http://nch.org/mission-vision-values. Accessed 5 September 2012.

• Pan American Health Organization & World Health Organization (December 2010). Neonatal Nursing Standards of Care.

• Verklan, MT., Walden, M. (2010). Core Curriculum for Neonatal Intensive Care Nursing (4th ed). Saunders: St Louis, MO.