THE ROLE OF A NEONATAL NURSING SPECIALIST IN THE PHC RE-ENGINEERING PROCESS vv Vanessa Booysen Neonatal Nursing Specialist. Free State Province UFS
MDG 4: neonatal death rates From: 4 million neonatal deaths: When? Where? Why? Lawn J et al, The Lancet, Vol 365, March 2005
Final Neonatal Causes of Death (All 1000g+)
The top causes of perinatal deaths are: a. Labour related complications (namely intrapartum asphyxia and birth trauma) 17% BIG BABY b. Spontaneous preterm birth 23%. Small baby (NEEDS SPECIALIZED CARE) c. Placental disease (namely pre-eclampsia and placental abruption) 23%.
The majority of births (59%) occur in CHCs or district hospitals, as do the majority of perinatal deaths.
Place of stillbirth, 2008 StatsSA, N=14 626 Place of early neonatal death, 2008 StatsSA, N=9 572 Unknown 13% Home/Oth 8% Unknown 11% Home/Oth 10% Hosp 79% Hosp 79% Place of late neonatal death, 2008 StatsSA, N=3 621 Place of post neonatal death, 2008 StatsSA, N=32 123 Unknown 14% Unknown 16% Home/Oth 25% Hosp 61% Home/Oth 41% Hosp 43%
Proportions of Deliveries by Level of Care
PPIP Avoidable Factors: Administrator related Immaturity 1. Inadequate facilities/ equipment 2. No NICU bed with ventilator 3. Lack of transport from home 4. Personnel not sufficiently trained 5. No syphilis screening Hypoxia 1. Inadequate facilities/ Equipment 2. Insufficient nurses 3. No accessible NICU bed 4. Anaesthetic delay 5. Lack of transport
PPIP Avoidable Factors: Healthcare Provider Related Immaturity 1. Management plan inadequate 2. Delays in referring patient 3. No antenatal steroids 4. Inadequate monitoring 5. Resuscitation inadequate Hypoxia 1. Fetal distress not detected but monitored 2. Prolonged 2 nd stage with no intervention 3. Fetal distress not detected and not monitored 4. Delays in referring patient 5. Poor progress, partogram not used properly
Cross-cutting recommendations: National Perinatal Morbidity and Mortality Committee (NaPeMMCo)
Guiding principles to improve neonatal care (1) Neonatal services should be structured in such a way that every neonate has access to the necessary level of care and the full range of services if needed. Neonatal facilities should be specifically designed, equipped and staffed according to the needs of each level of care. Avoidable factors responsible for the major contributors to PNMR and NMR (asphyxia, LBW, infections) should be addressed and where not preventable / avoidable, to offer best available care for these conditions. 11
Neonatal beds per level of care in the Free State ICU HCU LC/SC Current 14 73 83 Need 51-77 155-206 206-310 Shortfall 37-63 82-133 123-227 ICU s, HCU s and LC / SC units should be compliant with the norms / standards set for these facilities in terms of care to be provided, staffing, equipment and other resources. 12
Guiding principles to improve neonatal care (2) More focus on low technology high impact interventions / modalities of care at district (L1) and regional (L2) hospitals. - - Baby Friendly Hospital Initiative environment. MBFHI - Neonatal Resuscitation HBB - Basic and essential newborn care, eg. neonatal emergencies, feeding, nasogastric feeds, oxygen administration and monitoring, IV fluid therapy, temperature regulation, glucose monitoring, jaundice, infections and identifying early markers of medical / surgical neonatal conditions. - Adhere to disease / disorder specific referral criteria to ensure timeou STABILISATION and referral of ill neonates to the correct level of care. 13
Guiding principles to improve neonatal care (3) The neonatal and obstetric services cannot function in isolation. Good communication, interaction and co-ordination of these services are pivotal. An efficient and safe neonatal and maternal transport service is essential at provincial, regional and district level. Issues to address include: referral criteria, referral routes, modes of transport (road + air), escorts, vehicles, equipment, staff, training, procedure to arrange for transport and response times. KMC during transport In utero transport of a fetus at risk to ensure that the mother deliver in a facility where the newborn has access to the appropriate level of care. Improve communication, co-operation and co-ordination between the levels of care. The outreach programme should address level specific neonatal care issues. MSSN???? 14
Guiding principles to improve neonatal care (3) Use of level of care specific newborn care treatment protocols MSSN??? Breastfeeding Breastmilk banks. Kangaroo mother care. Neurodevelopmental sensitive newborn care. Motherhood empowerment programmes. Pulse oximetry and vital signs monitoring. Non invasive respiratory support e.g. CPAP, IN/OUT surfactant, emergency ventilation, TPN and head / whole body cooling (under supervision of a paediatrician) should be considered for HCU in regional hospitals identified as future developing tertiary hospitals. 15
Guiding principles to improve neonatal care (7) ALL LEVELS of hospitals and CHC s should have a KMC ward and a LC / SC neonatal service, Basic laboratory and imaging services should be available at the hospital. Regional hospitals, Donor Breastmilk bank, Well equiped HCU and a LC ward Some regional hospitals may qualify to have a HCU with selected down scaled ICU functions ( developing tertiary hospital ) A paediatrician with an interest in and experience of neonatal care, should be head of the neonatal service. A laboratory, imaging, and a general surgery service should be available. 16
Guiding principles to improve neonatal care (4) Audits, statistics and quality control / assurance should be an integral part of the neonatal service. Each of the guiding principles to improve neonatal care should be further refined and transformed into a well structured and workable programme of action and then integrated into a detailed level specific neonatal care and outreach programs The community paediatrician, obstetrician and Neonatal Nursing Specialist and midwife have a pivotal role to play in the implementation of the neonatal care and outreach programme. 17
The community paediatrician, obstetrician and Neonatal Nursing Specialist and midwife have a pivotal role to play Obst Midw Baby Neon Nurse Paed
Cross-cutting recommendations: National Perinatal Morbidity and Mortality Committee (NPMMC) 1. REGIONAL CLINICIANS TO BE APPOINTED to establish, run and monitor and evaluate outreach programmes for maternal and neonatal health. THE MORE SENIOR THE OVERSEEING IS THE BETTER THE CARE More Deaths in District Hospital
Ten worst performing districts all child health indicators 2011 O Tambo DM J T Gaetsewe DM Ehlanzeni DM T Mofutsanyane DM A Nzo DM Zululand DM Waterberg DM umgungundlovu DM Sisonke DM Umkhanyakude DM
FREE STATE PROVINCE
Number\1000 births or livebirths FREE STATE: Thabo Mofutsanyane Population 750 000 40 35 30 36.3 32.6 37 30.5 27.5 31.7 25 20 15 10 10.3 9.6 10.5 2007 2008 2009 5 0 PNMR SBR ENDR
Assisting Poorly performing districts Solutions to be developed with full participation of the provinces and districts. Ownership by the province and district & avoiding a top-down approach. Specific solutions for specific districts & health facility. Working smarter and being more efficient instead of asking for more resources. How? Process mapping in order to identify and pin-point bottlenecks and come up with solutions. Quality Improvement methodology can be expanded to child health programs.
Manapo implements saving of mothers and babies Mofumahadi Manapo Mopeli Regional Hospital in Qwa-Qwa takes pride in saving babies and mothers by starting to implement Primary Health Care Re-engineering programs HEALTH WISE Issue 21. 22 November 2011
Bought Equipment: Cozy Cots
Bubble CPAPS
Brand new Neonatal HC Unit
Brand new Neonatal HC Unit
Public Private Partnership Thanks to Private Paediatric specialists,drs Wessels, Van Lill and Van der Merwe who agreed to enter into Public Private Partnership with Manapo so as to improve, empower and capacitate the staff in rendering quality service to the community of Thabo Mofutsanyana district. Their practice is in BETHLEHEM, a daily 60MIN DRIVE TO Manapo Dr van Lill and Mediclinic agreement to transfer tertiary babies to Hoogland Medi Clinic for ventilation
First baby in the unit kicking; with the dedicated Public Private Partnership Team Paediatrician, Dr Elsa van der Merwe; baby sucking expressed breast milk, breathing room air, off CPAP! WOW!
Very first baby saved in Manapo
The setting up of this Neonatal HC Unit, now prevents delay in giving IN/OUT Surfactant. Saves unnecessary travelling costs and referral time of up to 7 hrs and about 400 km transfers to the already overcrowded hospital, Pelonomi,in Bloemfontein. Thus overall we are preventing neonatal complications, IVH, BPD Hypothermia and death.
HEALTH CARE WORKERS TRAINED ON: Neonatal Resuscitation, Kangaroo Mother Care, Neuro Developmental Care of the Pre Term Infant, Transporting the Pre Term Infant and Breastfeeding and the Pre term Infant...
Training done in Thabo Mofutsanyane
Private Paediatrician Dr Riaan v Lill.
Brand new KMC Unit at Manapo Hospital
Training of EMS Staff on Resus and KMC Transport
The proof is in the...
Pudding...
stats and graphs
Mofumahadi Manapo Mopeli Regional Hospital: Neonatal deaths: August 2011 - January 2012 14 13 12 11 10 10 9 8 8 Inpatient death - early neonatal 6 Inpatient death - late neonatal 4 3 3 2 1 1 1 0 0 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 0 Early neonates - 8, Late neonates - 43
The first premature baby who benefitted from the project, was born on 7 November 2011 with Hyaline Membrane disease
Neonatal High Care hubs of excellence Xhariep Diamant Hospital Jagersfontein Fezile Dabe Fezi Ngunbentombi, Sasolburg Lejweluputswa Khatleho Virginia Motheo Botsabello Hospital
MIDWIFE VS PEADIATRIC NURSE VS NEONATAL NURSING SPECIALIST
Early Neonatal Mortality Rates (All 1000g+)
MIDWIFE supporting the WELL BABY
But what about the SICK NEONATE????
Midwife Healthy newborn Paeds Nurse Older baby/ Child SICK Newborn?
District Clinical Specialist Teams Adv Midwife Paed Nurse PHC Nurse
HOD Provincial Obstetrician Provincial Adv Midwife Maternal service Reproductive health Women s health Provincial Paediatrician Provincial Paediatric Nurse Child health Neonatal care IMCI Provincial Family Physician Provincial PHC Nurse PHC outreach Chronic/communicable disease School health Nutrition EMERGENCY CARE Specialised support Research/policy oversight HIV/TB (PMTCT, NIMART, HAART, TB) Adolescent/Youth health Maternal death notification/ Monitor & Evaluate /PPIP/ChPIP DISTRICT SPECIALIST TEAMS Dept Anesthesia
MANAGEMENT OF SICK AND SMALL NEWBORNS Assess & Classify Emergency & Priority Signs Version: Dec 2010
TOTAL OF PEP BOOKS ORDERD THROUGHOUT THE PROVINCE Newborn Care 76 Modules Primary Newborn Care 30 Modules Maternal Care 36 Modules Primary Maternal Care 8 Modules Intra partum Care 12 Modules Perinatal HIV 1 Module Adult HIV 1 Module Childhood TB 5 Modules Child Health Care 4 Modules Total 173 modules
Training of Neonatal Nursing Specialists???? SANC DOES NOT ACKNOWLEDGE THE MOST EVOLVING SPECIALITY AREA IN THE WORLD... AS A SPECIALITY AREA OSD?????...No. We are losing trained and experienced neonatal nurses that are chasing money...osd. Does this mean because we are not going to be $$$$$$$$$ we must stop training???? God forbid
Training of Neonatal Nursing Specialists???? In Adv Midw Curric Neonatal Nursing Adv Midwifery
Training of Neonatal Nursing Specialists???? In Paeds/ Child Heath Curric HOSPICENTRIC!! Neonatal Nursing PAEDS
Late neonatal mortality rate: 4 per 1000 births Almost 1/3 of neonatal deaths occur in late neonatal period ¾ of these deaths (1284) were avoidable. Why? Inadequate monitoring and poor nursing care
Recommendations 1. Strengthen data collection and quality 2. Newborns must receive the specialised care they require in hospitals (nurseries), NOT IN PAEDS WARDS postnatal care for mothers and babies 3. Ongoing strengthening of PMTCT and other HIV prevention strategies
Training of Neonatal Nursing Specialists???? In ADULT ICU HOSPICENTRIC!! Nonatal Nursing Adult ICU
But meanwhile.who will OVERSEE Neonatal Care Dis die oog van die boer wat die bees vetmaak
In Conclusion We need to remember that ALL newborns are vulnerable. Early AND late newborn deaths contribute significantly to both newborn and under-five mortality. Neonatal Nurses are the voice of the most vulnerable.
Our voice needs to be heard We believe we can make a difference in reducing the NNMR. Must we wait for 2165 to reach MDG 4???
WITS UNIVERSITY In the meantime WITS (in collaboration with the Nelson Mandela Childrens Hospital) is offering a Short Course in Neonatal Intensive Nursing Skills through to CANS.NursingEd@wits.ac.za. This course is not accredited with SANC and will probably not qualify you for the specialty stream in the public sector but will provide you with valuable skills and knowledge. In addition, there is an opportunity to cover the cost of this course through the generous bursary option available from Nelson Mandela Children s Hospital Trust Fund.
Meetings with: Min of Health together USSANA SANC Ministerial Nursing Education Task Team National NNASA Conference (4,5, August 2016, KZN, Pietermaritzburg)
NNASA is currently tasked to submit documents again to SANC to motivate for recognition of the qualification for clinical neonatal nursing specialists, as well as advanced neonatal nursing specialists.
The neonatal clinical nurse specialist qualification Will be submitted to SANC as a new qualification unrelated to legacy qualification. Thereafter it has to go through university structures After university approval the curriculum has to be submitted to SANC, CHE, SAQA, DHET and can then be presented. We might be able by 2019 The neonatal clinical nurse specialist qualification (once approved) will be presented as a postgraduate diploma, which can be followed with a master's degree as advanced clinical nurse specialist. NNASA is pushing towards a national qualification.
Presently KZN (NELS Programme) Dr N. Mc Kerrow and Ruth Davidge And Limpopo, Lolly Mashao and Dr Anne Robertson are the ONLY Provinces acknowledging the expertise and necessity of a Neonatal Nursing Specialist... With results... Should the rest of the country wait any longer????... Or FOLLOW
Thank You