Evaluating the Effectiveness of a Training Intervention in Neonatal Resuscitation: Establishing Grounds for Further Rollout Faith Kayembe (MA, BSc, PGCert.Ed, RM, Krankenschwester Germany) Senior Midwifery Lecturer/Project Lead Canterbury Christ Church university, Kent, UK
Aim To share findings from a training project evaluation OBJECTIVES Background Methods Findings Implications for practice What this presentation will not do
Background
Zambia Neonatal mortality rate: 24:1000 (Central Statistics 0ffice (CSO) 2015) 4
Scoping (2015) Intervention (2016) Immediate evaluation (2016) 7 month evaluation (2017)
Scoping: Benefactors, Sponsors & Partners Mr & Mrs Chowen Project Benefactors Prof. Newport Chair BLHL Prof. Hatzidimitriadou - CCCU Ms Jean Musonda - UTH Mr Wisdom Chelu Zambia MoH
Scoping Key suggestions: Staff knowledge/skills in neonatal care including assessment, initial management at birth and resuscitation Standardisation of approach to neonatal resuscitation Leadership Clarify communication systems Equipment including fetal & neonatal monitoring Transportation between wards Thermoregulation Discharge examination of the newborn Health care support role
Intervention Multidisciplinary Team Teaching material Senior Neonatal Nurse Neonatologist Senior Resuscitation Officer Midwife/ Lecturer
Intervention: Preparation and set up
Teaching: theory, skills, simulation, TTT
Scores 35 Immediate evaluation 30 25 20 15 10 5 0 Candidates Pre-test score Post-test score
Author Defining effectiveness Dempsey et al (2015) Opiyo et al (2008) Disu et al (2015) Measure of effectiveness Neonatal mortality rate Trevisanuto et al (2015) Dempsey et al (2015) Opiyo et al (2008) Hoban et al (2013) Dempsey et al (2015) Fuchs et al (2015) Bookman et al (2010) Carlo et al (2009) Enweronu-Loryea et al (2009) Clinical practice/ Change in team work and resuscitation behaviour Knowledge (immediate and long-term)
Defining effectiveness for the Zambia project: Further training More staff Quality and integrity of training Positive impact on trainee knowledge Goals Clinical practice
Methods
Methodology Single Case study approach (Yin 2009; Taylor & Thomas-Gregory 2015) Selection/recruitment of participants o Process/arrangements o different levels o informed consent
Methods - Triangulation Interviews Questionnaire Documents Observation 1-1/focus groups/telephone; Range of settings: Health/shopping centres Review of goals Training records; Pre/post-test results; Training programme Lectures; Team interaction/ Meetings; Feedback; Skills and Simulation Stations
Findings
Thematic map Successes Challenges Further Training Activity Quality of training Challenges Clinical Impact Positive accounts from practice Review of goals Moving forward Efforts & work in progress Suggestions/Support required Implications for future practice
Clinical impact
Individual accounts from practice (I) from August up to February this year, we have not recorded any mortality the referrals can even be counted it has greatly improved our skills (Midwife) Since I received that neonatal resuscitation we refer them at the point the babies are stable now we know how to manage (Nurse)
Individual accounts from practice (II) we managed to resuscitate the baby until the baby was out of danger. And then we referred for further management (Midwife from lower level hospital) the training we have got has really impacted on our services in a positive way, in that our babies and mothers are being saved. We no longer lose lives (Midwife)
Clinical guidelines Clearer view of algorithm on the wall Interviewee by a resucitaire in a local neonatal unit notice algorithm on the wall
Internalising Clinical knowledge (I) you don t even go through those complicated stages, where you need to intubate and the rest (Paediatrician) I ve seen it as a good thing, this course. It has really changed the way we used to look at some of the things, as in where we resuscitate now, where the priority is not centred in oxygen.. (Midwife) I really did apply, you know, stage by stage the inflation, yes. inflation breaths was not something that was emphasised, yes, we would go into the ventilation breath immediately (Paediatrician)
Internalising Clinical knowledge(ii) apart from the resuscitation itself there are other things We are now delivering the babies onto the mother s abdomen because we have learnt about the skin to skin contact. We are delaying cord clamping. All those majors are helpful in making the baby alive. Yes, so there is change like that (Midwife)
Important insights from Clinical log of experience delivered as an emergency caesarean section due to cord presentation and fetal distress resuscitaire warmed baby wiped, stimulated and wrapped in dry clean clothing assessed not breathing floppy blue low heart rate five(5) inflation breath given chest expansion observed baby reassessed breathing normal, heart rate fast, tone good and colour pink cried wrapped in warm clothing and given to mother I did not start the clock
Challenges to clinical application Equipment Poor Staffing levels Clinical and professional guidelines limitations Competing guidelines Lack of Leadership/mentorship
Further training
Successes Support Candidate receiving certificate of attendance from Medical superintendent LGH
Formal activity Summary of training Date Venue Numbers Staff groups trained 6-8.4.17 Livingstone 50 Doctors, nurses, midwives, anaesthetists (From one hospital) 9-10.3.17 LUSON 40 Paediatric nurses (Qualified nurses) 20-21.2.17 Lusaka 50 Midwives, nurses, doctors, anaesthetists 2016 LUSON 39 Paediatric nurses (Qualified nurses)
Informal activity Our unit, we always get new doctors, new nurses, as part of, probably you could call it an orientation, when they come to the unit we do take them through resuscitation of the babies (Senior Neonatal Nurse)
uality of training: evolving content Initial launch content One day Immediate care at birth Newborn physiology Resuscitation at birth Prematurity /Meconium Post launch content Two days Immediate care at birth Newborn physiology Resuscitation at birth Prematurity /Meconium Teamwork/communication/documentation Post resuscitation care Teamwork/communication/documentation Post resuscitation care Neonatal Intubation Umbilical Vein Cannulation Day 2 KMC/Nutrition & growth monitoring/infection prevention/hand hygiene
Teamwork and constitution Team member consulting with team leader during a session note manual in use for reference Team members discussing approach prior to a session Trainers working in pairs to support each other facilitating a skills station
Lectures Observation of training Set (includes environment) Please tick below or mark as N/A if not applicable Needs further development Effective and competent Comments Checks and adjusts layout and equipment Introductions Establishes usefulness and clearly states learning outcomes Uses visual aids appropriately Could be emphasised further Uses voice appropriately Uses eye contact appropriately Demonstrated enthusiasm resus.org.uk
Team leader offering support to refine the rate of ventilation breaths a little more accurately More Observations Learning to perform cardiac compressions Candidate being taught how to administer ventilation breaths using a BVM Teaching UVC insertion
PRE TEST AND POST TEST - FIRST GROUP Test Type Lowest Score Highest Score Mean Score Pre test 33% 80%. 61.9% For Post test 57% 97%. 84.7% PRE TEST AND POST TEST - FIRST GROUP Test Type Lowest Score Highest Score Mean Score Pre test 53% 90% 84.7% For Post test 67% 100% 88.12%
Challenges to further training Funding for rollout Recognition Equipment Previous learning/approaches
Review of goals
Goal Achieved Not achieved No response Target Lusaka Province health centres/staff Create list of potential participants 8 1 6 3 Quarterly training 5 3 1 Identify and approach funders Formulate action plan Trainers split into two groups Support from MoH 9 3 5 1 7 2 9 Create minimum requirements for Health Centres equipment Database for trained personnel First training Sept./Oct. 2016 Train in-service nursing students 5 4 9 8 1
Suggestions moving forward
Moving forward Recognition Train more trainers Evaluation in the clinical area Mentorship ---------------- Further forward o CPD strategies Government and professional body recognition, funding and support are vital to ensure successful rollout of neonatal resuscitation training o Neonatal mortality outcomes
Moving Forward Standardisation of neonatal resuscitation guidelines to facilitate application of knowledge and skills to practice
Implications for future practice we have come up with a profile... all the members having input I think actually it will give us a good direction because we will be guided with what we have documented ourselves Inform further training activity - quantity & quality Adjust post evaluation/ audit of relevant issues Focused Pilot site/ Clinical area Measure impact Neonatal morbidity & mortality /clinical practice outcome measures
Sufficient grounds for further rollout?
the evidence Further training activity undertaken More staff strained Knowledge improvement Goals achieved/progress Clinical impact Lives are Being Saved
Questions?
Reference list Bookman L.; Engmann, C.; Srofenyoh, E.; Enweronu-Laryea, C.; Owen, M. ; Randolph, G.; Price, W.; Barker, P. (2010) Educational impact of a hospital-based neonatal resuscitation program in Ghana Resuscitation, Vol.81(9), pp.1180-1182 Carlo WA, Wright LL, Chomba E, Mcclure EM Carlo ME, Bann CM, Collins Harris, H. (2009)Educational Impact of the Neonatal Resuscitation Program in Low-Risk Delivery Centres in a Developing Country. The Journal of Paediatrics, Vol.154 (4), pp.504-508 Central Statistical Office (CSO) (2015) Zambia Demographic and Health Survey 2013-14. Rockville, Maryland, USA: Central Statistical Office, Ministry of Health, and ICF International. 2015 Dempsey E., Pammi M., Ryan A.C., Barrington K.J. (2015) Standardised formal resuscitation training programmes for reducing mortality and morbidity in newborn infants (Review) Cochrane Database of Systematic Reviews Disu E.A., Fergusson I.C., Njokanma O.F., Anga L.A., Solarin A.U., Olutekunbi A.O., Ekure E.N., Ezeaka V.C., Esangbedo D.O., Ogunlesi T.A. (2015) National neonatal resuscitation training program in Nigeria (2008-2012): A preliminary report Nigerian Journal of Clinical Practice Jan-Feb Vol. 18 Issue 1 p.102-109 Enweronu-Laryea, C.; Engmann, C.; Osafo, A.; Bose, C. (2009) Evaluating the effectiveness of a strategy for teaching neonatal resuscitation in West Africa Resuscitation, Vol.80 (11), pp.1308-1311 Fuchs, T. ; Nibbe, Y. ; Mahmoud, E. (2015) Impact of on-site training of neonatal resuscitation techniques in Shirati district hospitals: Does on-site training improve knowledge, attitude, and practices? Annals of Global Health, January-February Vol.81(1), pp.26-27 Hoban R, Bucher S, Neuman I, Chen M, Tesfaye N, Spector JM (2013) Helping babies breathe training in sub- Saharan Africa: Educational Impact and learner impressions Journal of tropical Paediatrics Jun;59(3):180-6 Opiyo N, Were F, Govedi F, Fegan G, Wasunna A, English M, Belizan JM. (2008) Effect of Newborn Resuscitation Training on Health Worker Practices in Pumwani Hospital, Kenya (Newborn Resuscitation Training) PLoS ONE, Vol.3(2), pp.1599 Resus.org.uk - Neonatal resuscitation guidelines (2015) Taylor R & Thomas-Gregory A (2015) Case study research Nursing standard Vol.29(41), pp.36-40 Trevisanuto, D ; Bertuola, F ; Lanzoni, P ; Cavallin, F ; Matediana, E ; Manzungu, Ow ; Gomez, E ; Da Dalt, L ; Putoto, G (2015) Effect of a Neonatal Resuscitation Course on Healthcare Providers' Performances Assessed by Video Recording in a Low-Resource Setting Plos One, Dec 11, Vol.10(12) Yin RK (2009) Case Study Research: Design and Methods. 4 th ed. Sage Publications, London.