Strengthening sepsis care at a tertiary care teaching hospital in New Delhi, India.

INTRODUCTION: Failure of early identification of sepsis in the emergency department (ED) leads to significant delays in antibiotic administration which adversely affects patient outcomes. AIM: The primary objective of our Quality Improvement (QI) project was to reduce the door-to-antibiotic time (DTAT) by 30% from the preintervention in patients with suspected sepsis. Secondary objectives were to increase the blood culture collection rate by 30% from preintervention, investigate the predictors of improving DTAT and study the effect of these interventions on 24-hour in-hospital mortality. METHODS: This QI project was conducted in the ED of a tertiary care teaching hospital of North India; the ED receives approximately 400 patients per day. Adult patients with suspected sepsis presenting to our ED were included in the study, between January 2019 and December 2020. The study was divided into three phases; preintervention phase (100 patients), intervention phase (100 patients) and postintervention phase (93 patients). DTAT and blood cultures prior to antibiotic administration was recorded for all patients. Blood culture yield and 24-hour in-hospital mortality were also recorded using standard data templates. Change ideas planned by the Sepsis QI Team were implemented after conducting plan-do-study-act cycles. RESULTS: The median DTAT reduced from 155 min in preintervention phase to 78 min in postintervention phase. Drawing of blood cultures prior to antibiotic administration improved by 67%. Application of novel screening tool at triage was found to be an independent predictor of reduced DTAT. CONCLUSION: Our QI project identified the existing lacunae in implementation of the sepsis bundle which were dealt with in a stepwise manner. The sepsis screening tool and on-site training improved care of patients with sepsis. A similar approach can be used to deal with complex quality issues in other high-volume low-resource settings.

Triaging the triage: reducing waiting time to triage in the emergency department at a tertiary care hospital in New Delhi, India.

BACKGROUND: Prolonged wait times prior to triage outside the emergency department (ED) were a major problem at our institution, compromising patient safety. Patients often waited for hours outside the ED in hot weather leading to exhaustion and clinical deterioration. The aim was to decrease the median waiting time to triage from 50 min outside ED for patients to <30 min over a 4-month period. METHODS: A quality improvement (QI) team was formed. Data on waiting time to triage were collected between 12 pm and 1 pm. Data were collected by hospital attendants and recorded manually. T1 was noted as a time of arrival outside the ED, and T2 was noted as the time of first medical contact. The QI team used plan-do-study-act cycles to test solutions. Change ideas to address these gaps were tested during May and June 2018. Change ideas were focused on improving the knowledge and skills of staff posted in triage and reducing turnover of triage staff. Data were analysed using run chart rules. RESULTS: Within 6 weeks, the waiting time to triage reduced to <30 min (median, 12 min; IQR, 11 min) and this improvement was sustained for the next 8 weeks despite an increase in patient load. CONCLUSION: The authors demonstrated that people new to QI could use improvement methods to address a specific problem. It was the commitment of the frontline staff, with the active support of senior leadership in the department that helped this effort succeed.

Reducing hypothermia in newborns admitted to a neonatal care unit in a large academic hospital in New Delhi, India.

Neonatal hypothermia is a common and dangerous condition around the world. 70% of neonates born in Kalawati Saran Children's Hospital in New Delhi, India, and subsequently admitted to the neonatal intensive care unit (NICU) had a temperature below 36.5°C on admission. In July 2016, we formed a team of staff from the labour room, NICU and auxiliary staff to reduce hypothermia in babies transported to our NICU using quality improvement methods. We identified problems related to staff awareness of hypothermia and its dangers, environmental factors and supply issues in the labour room, and challenges with rapidly and safely transferring sick newborns to the NICU. We used the Plan-Do-Study-Act cycles to test and adapt solutions to these problems. Because infection is a common complication of hypothermia, we also instituted a training programme to improve handwashing skills among parents and health workers. Within 9 months of starting our quality improvement project, the proportion of neonates who were normothermic on admission increased from 27% to 75%, the number of cases of late-onset neonatal sepsis decreased from 15.2 to 5 cases/1000 patient days, and all-cause mortality fell from 4.2 to 2.6 neonatal deaths per week. Multiple factors can lead to neonatal hypothermia, and the most important factors will differ from facility to facility. Quality improvement methods provide health workers with the skills to identify the key factors contributing to hypothermia in their facility and to develop strategies to address them. Addressing processes of care can lead to improved thermal care and save lives.

Improving service uptake and quality of care of integrated maternal health services: the Kenya Kwale District improvement collaborative.

BACKGROUND: Health-related millennium development goals are off track in most of the countries in the sub-Saharan African region. Lack of access to, and low utilization of essential services and high-impact interventions, together with poor quality of health services, may be partially responsible for this lack of progress. We explored whether improvement approaches can be applied to increase utilization of antenatal care (ANC), health facility deliveries, prevention of mother-to-child transmission services and adherence to ANC standards of care in a rural district in Kenya. We targeted improvement of ANC services because ANC is a vital point of entry for most high-impact interventions targeting the pregnant mother. METHODS: Healthcare workers in 21 public health facilities in Kwale District, Kenya formed improvement teams that met regularly to examine performance gaps in service delivery, identify root causes of such gaps, then develop and implement change ideas to address the gaps. Data were collected and entered into routine government registers by the teams on a daily basis. Data were abstracted from the government registers monthly to evaluate 20 indicators of care quality for improvement activities. For the purposes of this study, aggregate data for the district were collected from the District Health Management Office. RESULTS: The number of pregnant mothers starting ANC within the first trimester and those completing at least four ANC checkups increased significantly (from 41 (8%) to 118 (24%) p=0.002 and from 186 (37%) to 316 (64%) p<0.001, respectively). The proportions of ANC visits in which provision of care adhered to the required standards increased from <40% to 80-100% within three to six months (X2 for trend 4.07, p<0.001). There was also a significant increase in the number of pregnant women delivering in health facilities each month from 164 (33%) to 259 (52%) (p=0.012). CONCLUSION: Improvement approaches can be applied in rural health care facilities in low-income settings to increase utilization of services and adherence to standards of care. Using the quality improvement methodology to target integrated health services is feasible. Longer follow-up periods are needed to gather more evidence on the sustainability of quality improvement initiatives in low-income countries.

Promoting patient safety in India: situational analysis and the way forward.

Unsafe healthcare is a well-recognized issue internationally and is attracting attention in India as well. Drawing upon the various efforts that have been made to address this issue in India and abroad, we explore how we can accelerate developments and build a culture of patient safety in the Indian health sector. Using five international case studies, we describe experiences of promoting patient safety in various ways to inform future developments in India. We offer a roadmap for 2020, which contains suggestions on how India could build a culture of patient safety.