Employing a Novel Tool for Supportive Clinical Supervision Following Helping Babies Breathe Training in Selected Ethiopian Delivery Room Settings for Targeted Quality Improvement Initiatives

Purpose/Objectives: Helping Babies Breathe (HBB) is a simulation-based curriculum developed to standardize neonatal resuscitation and basic newborn care in low-to-middle income countries. Improvements in neonatal morbidity and mortality following HBB training are inconsistent without ongoing skills practice and integration into local health facilities. We aimed to develop a model of supportive clinical supervision following HBB training to assess clinical skills, identify equipment deficiencies and systems-based barriers to curriculum implementation using a novel checklist tool (Figure 1). Design/Methods: US-based HBB Master Trainers were unable to conduct in-country study activities due to the global COVID-19 pandemic. Alternatively, four graduates of Ethiopia's first Masters of Neonatal Nursing Program (NNP) were recruited to lead curriculum implementation and conduct clinical observations. Baseline knowledge of 12 Masters of NNP students was assessed, followed by a 4-day HBB simulation training course and Objective Structured Clinical Evaluation (OSCE). Master Trainers subsequently observed students implementing HBB in tertiary delivery rooms and completed the HBB Clinical Skills Checklist to characterize barriers to curriculum completion. Results: Students entered the program with wide range of previous years nursing experience (range: 3-11 years) in varied health care settings. 9/12 (75%) students had completed HBB training prior to the study period (range: 2-7 years). Mean score ± SD for pre- and postcurriculum evaluation is reported: HBB Knowledge Check 95 ± 4%, Bag-Mask Ventilation Skill Check 90% ± 8% and OSCE B 96 ± 4%. Master Trainers assessed students during a convenience sample of 6 daytime deliveries (Table 1). Equipment deficiencies were identified, including a lack of gloves, suction, cloths and preterm masks. As a result, 4/6 infants were not “dried thoroughly”. Students appropriately identified “not breathing” and initiated bag-mask ventilation within The Golden Minute®. Contrary to HBB protocol, cords were cut immediately for all infants. 4/5 infants triaged to Routine Care were not placed skinto-skin per OB request. Clinical supervisors noted open doors and windows, significant distance between the delivery and resuscitation area and no water source for hand washing or equipment decontamination. Conclusion/Discussion: Despite the range of clinical experience and prior HBB training, students performed consistently well on OSCE B. Delivery room observations revealed equipment deficiencies that hindered thorough drying. Systems-based barriers prevented delayed cord clamping, immediate skin-to-skin, timely placement in the resuscitation area, environmental thermoregulation and infection control. This model of supportive clinical supervision aids in translating HBB skills from the classroom to local health care systems by identifying barriers to curriculum implementation for targeted quality improvement initiatives. The clinical checklist tool enables tracking of program quality indicators in the domains of clinical performance and facility preparedness. Testing this model on a larger scale with alternative formats for data collection tools (i.e. smartphone Apps) is needed to enable adaptation to other countries where HBB is employed.

Mentoring Quality Improvement Teamsin Ethiopia via a Virtual Partnership Between the American Academy of Pediatrics and the Ethiopian Pediatric Society

Background: Despite a marked decline in worldwide under-five mortality over the past 30 years, the largest proportion of these deaths remain neonates. In 2018, 4 million (75% of all under-five deaths) infants died worldwide [1]. The neonatal mortality rate in Ethiopia was 28.1 per 100 live births, compared to 17.7 globally and 27.2 in Africa, ranking 23rd for highest neonatal mortality [2]. The Ethiopian Pediatric Society (EPS), entered a virtual partnership with the American Academy of Pediatrics (AAP) in 2020 to provide educational and practical support to clinicians in Ethiopia to perform quality improvement (QI) research. QI training for clinicians at eight Ethiopian sites is modeled on Project ECHO (Extension for Community Healthcare Outcomes) [3]. ECHO improves capacity for specialists to deliver care to underserved communities via collaboration with local clinicians using video teleconferencing, which has been a particularly advantageous tool to continue global health work during the COVID-19 pandemic. The goal of this project is to support local Ethiopian providers in designing, implementing, and assessing a QI intervention. Methods: We adapt the Project ECHO model to have U.S. neonatology faculty-fellow teams mentor clinicians from 8 hospitals in Ethiopia. Using video conferencing and regular contact through mobile devices, teams work to identify gaps in care, create SMART aim statements, identify key stakeholders and barriers to change, and implement interventions. Interventions are measured with a phone application, Liveborn, which allows instant transmission of data internationally. Sites provide monthly progress updates to the EPS. AAP/EPS leadership, U.S.-based faculty-fellow teams, and QI team leaders meet monthly via video conference for didactic sessions on QI methodology followed by teams presenting their progress, which promotes discussion and collaboration between the sites, AAP/EPS leadership, and U.S. mentorship teams to address any barriers. Results: Teams identified compliance with delayed cord clamping (DCC) and skin-to-skin (STS) after delivery as a gap by independently collecting local data. QI teams are currently still implementing interventions and measuring improvement. Teams have identified several barriers, the most common cited being stakeholder buy-in and logistic challenges in implementation. During monthly meetings, teams continually discuss and brainstorm ways to address barriers overall and among individual sites. Conclusion: Via the ECHO model, the AAP and EPS are supporting Ethiopian QI teams in designing and implementing QI interventions despite the limitations imposed by the COVID-19 pandemic. Challenges to this mentorship process include communication barriers (language, internet network) and perception of lack of need by Ethiopian clinicians for U.S. mentorship. Using the ECHO model, all teams have defined SMART aims, begun to implement interventions, and are now collecting compliance data.

Transmission of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) through infant feeding and early care practices: A systematic review.

BACKGROUND: Perinatal practices such as breast-feeding, kangaroo mother care, rooming-in, and delayed cord clamping have varied by institution during the COVID-19 pandemic. The goal of this systematic review was to examine the success of different practices in preventing viral transmission between SARS-CoV-2 positive mothers and their infants. METHODS: Electronic searches were performed in the Ovid MEDLINE, Ovid Embase, Cochrane Library, EBSCOhost CINAHL Plus, Web of Science, and Scopus databases. Studies involving pregnant or breastfeeding patients who tested positive for SARS-CoV-2 by RT-PCR were included. Infants tested within 48 hours of birth who had two tests before hospital discharge were included. Infants older than one week with a single test were also included. RESULTS: Twenty eight studies were included. In the aggregated data, among 190 breastfeeding infants, 22 tested positive for SARS-CoV-2 (11.5%), while 4 of 152 (2.63%) among bottle-fed (Fisher's exact test p = 0.0006). The positivity rates for roomed in infants (20/103, 19.4%) were significantly higher than those isolated (5/300, 1.67%) (P < 0.0001). There was no significant difference in positivity rate among infants who received kangaroo care (25%vs 9%, p = 0.2170), or delayed cord clamping (3.62%vs 0.9%, p = 0.1116). CONCLUSIONS: Lack of robust studies involving large patient population does not allow meaningful conclusions from this systematic review. Aggregated data showed increased positivity rates of SARS-CoV-2 among infants who were breast fed and roomed-in. There were no differences in SARS-CoV-2 positivity rates in infants received skin to skin care or delayed cord clamping.