072 - Impact of a Treatment Protocol, adapted from Newborn Brain Society’s Guidelines, on Outcomes among Perinatally-Asphyxiated Neonates Referred to a Public Teaching Hospital in Nigeria: a QI Project

Publication Number: 72.5474

Peter O. Ubuane, Neonatology Unit, Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria; Ekaete Olajide. Alaje, Lagos State University Teaching Hospital, Lagos, Lagos, Nigeria; Olanike Abosede. Olutekunbi, Massey Street Children's Hospital, Lagos, Lagos, Nigeria; Azeez Arisekola. Shodiya, Lagos state university teaching hospital, Lagos, Lagos, Nigeria; Ayodeji O. Akinola, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria; Blessing Adeoluwa. Owadokun, Lagos State University Teaching Hospital, Lagos, Lagos, Lagos, Nigeria; Victor O.V. Obayanju, LASUTH, Lagos, Lagos, Nigeria; Olubukola Oreoluwa. Ransome-Kuti, Lagos State university Teaching hospital, Ikeja ,Lagos, Lagos, Nigeria; Adewole Philip. Sijuade, Lagos State University Teaching Hospital, Ikeja, Lagos state, Lagos, Lagos, Nigeria; Bertha Odawai. Okoro, Lagos State University Teaching Hospital Ikeja Lagos, Lagos, Lagos, Nigeria; MARTINA LYDIA. Ofulue, LAGOS STATE UNIVERSITY TEACHING HOSPITAL, IKEJA LAGOS, IKEJA, Lagos, Nigeria; Alaba Oladimeji, LAGOS State University Teaching Hospital, Lagos, Lagos, Nigeria; Bukola Victoria. Jeje, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria; Bharati Sinha, Boston University School of Medicine, Boston, MA, United States; Tetyana H. Nesterenko, University of Texas Southwestern Medical School, Dallas, TX, United States

Background: Nigeria contributes hugely to global burden of hypoxic-ischemic encephalopathy (HIE) from perinatal asphyxia, with high mortality. Lack of blood gases, therapeutic hypothermia and advanced supportive care, combined with worsening poverty and practice variations impedes effective HIE diagnosis, assessment and management. In such low-resource context, quality improvement (QI) efforts, although currently unexplored for neonatal HIE, could improve patient care and safety, harmonize care practices and reduce mortality. A preliminary review showed that HIE case-fatality rate (CFR) remained unchanged between two periods a decade apart (23.1%–23.8% between 2011 and 2022) among neonates in our Neonatal Unit. We hypothesized that the use of a QI approach to optimize the implementation of our Unit’s HIE clinical guidelines, updated with recent evidence-base like Newborn Brain Society (NBS)’s HIE care practice bundle (Wintermark et al., doi:10.1016/j.siny.2021.101303), could reduce HIE mortality.

Objective: To reduce case-fatality rate among infants with HIE referred to the outborn Neonatal Unit of LASUTH by 30% by April 2025.

Design/Methods: A multidisciplinary QI team, including neonatologists, pediatricians, nurses, residents and medical record officers, revised and updated the Unit’s HIE guidelines using, mainly, NBS’s HIE care practice bundle; collected baseline data (one-year retrospective and two-month prospective pre-implementation data) on neonates with HIE born at gestational age ≥ 35 wks; identified, prioritized and implemented care changes, with ongoing data collection for monitoring. We used PDSA cycles to implement consensus-driven care bundles focused on optimizing HIE diagnosis, grading and care. outcome measure (monthly CFR), process measures (refine magnesium-sulfate use [Units’ standard neuroprotective]; and minimise sodium-bicarbonate [potentially harmful] and amikacin [potentially nephrotoxic] use); and balancing measures (admitting doctors’ perception) (Driver Diagram, Fig. 1).

Results: Baseline mortality for all HIE grades and for HIE grades II and III was 32.3% (43/133) and 33.3% (43/129), respectively (April 2023–April 2024). Following care bundle revision, dissemination and implementation with PDSA cycles from July 2024, control charts show declining use of NaHCO3 and amikacin (Fig. 2) while outcome measure (monthly mortality) shows signal to improve (Fig. 3). Balancing measure: 91.7% of doctors think this QI has improved their HIE care expertise/skill.

Conclusion(s): Data-driven QI initiatives are feasible in low-resource settings, supporting improved HIE management processes and outcomes.

Figure 1. Driver Diagram for QI to reduce mortality among asphyxiated neonates


Figure 2. Control Chart on proportion of asphyxiated babies administered sodium bicarbonate and amikacin
Figure shows declining exposure to sodium bicarbonate for routine correction of metabolic acidosis (left figure), and to potentially nephrotoxic amikacin (Unit's first line antibiotics for sepsis) (right figure).

Figure 3. Control chart for mortality among asphyxiated babies
Left figure shows monthly case fatality rate among all cases of HIE, while right figure shows monthly case fatality rate for HIE 2 and 3 combined.