THE UNIVERSTY OF WARWICK
WARWICK MEDICAL SCHOOL
INSTITUTE OF CLINICAL EDUCATION
BACHELOR OF SCIENCE (INTERNATIONAL OBSTETRICS &
LEADERSHIP)
SUBJECT: Re Audit Report
TOPIC: Neonatal Sepsis Audit Report Interventions Outcome; Possible
Additional Interventions for Achievement of further Neonatal Sepsis Reduction
at Bwaila Maternity Hospital, Lilongwe, Malawi.
STUDENT NAME: Enos Lloyd KAUDZA
REGISTRATION NUMBER: 1135925
TABLE OF CONTAINTS:
1. Background information………………………………………….…...…1
2. Statement of the problem……………………………………………..…..1
3. Purpose of the re-audit………………………………………………...…..2
4. Specific objectives of the re-audit.……………………………………......3
5. Significance of the re-audit…………………………………………..…….3
6.
Data collection…………………..………………………………………..….3
7. Data analysis………………………………………………………………….4
8. Interpretation of results……………………………………………………...5
9. Discussion……………………………………………………………………..6
10. Conclusion…………………………………………………………………….7
11. Recommendations……………………………………………………………8
12. References…………………………………………………………………….8
BACKGROUND:
It is estimated that more than half a million newborns die each year from serious neonatal infections.
The estimated figure accounts for about 15% of all neonatal deaths globally (BMC public Health,
2011; 11 (suppl 3): S11, S13). The most vulnerable time for both the mother and newborn is during
birth and in the hours and days immediately after childbirth. About 75% of all neonatal deaths occur
during the first weak of life, with the majority in the first 48 hours, which is also the period of the
highest risk for the mothers. In populations with very high neonatal mortality, up to half of neonatal
deaths may have an infectious cause. It is estimated that 30% to 40% of infections resulting in neonatal
sepsis deaths are transmitted at the time of childbirth and have early onset of symptoms (developing
during the first 72 hours after birth). In low income countries, about 60% of births occur without
skilled attendants, and most of these at home. Worldwide, 60 million births happen outside facilities
and even for facilities birth hygienic practices may be sub-optimal. In addition many neonatal deaths
due to tetanus and other infections are acquired in postnatal period. The unhealed umbilical cord is an
important entry point for local and invasive infections during this period and is rapidly colonised by
bacteria from the environment. Neonatal sepsis may be categorised as early or late onset. Of newborns
with early onset infections, 85% presents within 24 hours, 5% present at 24 – 48 hours, and a small
percentage presents within 48 – 72 hours. The onset is rapid in premature babies. Early onset sepsis
syndrome is associated with acquisition of micro organisms from the mother, transplacental infection
or an ascending infection from the cervix may be caused by organisms that colonise in the mother’s
genitourinary tract; with acquisition of microbes by passage through colonised birth canal at delivery.
Late onset sepsis usually occurs from 4 – 90 days of life and is acquired from the care giving
environment. Infant’s skin, respiratory tract, conjunctiva, genitourinary tract and umbilicus may
become colonised from the environment, leading to the possibility of late onset sepsis from invasive
micro organisms. Vectors for such colonisation may include vascular tissues or contact with caregivers
who have bacterial colonisation. Some of the notable risk factors associated with neonatal sepsis are
maternal in nature such as: Intrapartum maternal infection, premature rupture of the membranes,
prolonged rupture of membranes of more than 12 hours, premature onset of labour of less than 37
weeks gestation and maternal urinary tract infection. Neonatal risk factors include low birth weight and
prenatal asphyxia.
STATEMENT OF THE PROBLEM:
Bwaila Maternity Unit remains the major health facility that provides quality care maternity services in
the district. It is manned by well qualified and experienced service providers of all cadres such as:
Nurses and support staff, Clinical Officers, Medical Officers and Consultants. Since the insertion of
this maternity unit in the early 1940s, it has encountered and still continues to encounter some
challenges with case management one of which being neonatal sepsis. The prevalence rate of neonatal
sepsis at this facility has been constant despite precautions taken by service providers to prevent
neonatal sepsis. For this reason, this re-audit report has been designed to compare the findings of the
February 2012 audit report in relation to same parameters such as; sources, causes, clinical
presentations and management, possible prevention interventions in order to see if a desired goal has
been achieved to a lesser percentage.
SPECIFIC OBJECTIVES OF THE RE AUDIT REPORT:
This re-audit report is specifically aimed at comparing the outcome of the interventions that were put
in place against the indicators of the initial audit report. The comparison will be based on interventions
as follows; after tracing the sources of neonatal sepsis and after finding out the causes of neonatal
sepsis. Management in practice based on clinical presentations of neonatal sepsis and after practicing
preventive measures of neonatal sepsis. Finally, outcome based on the established local protocols
being used in the nursery ward, and after training service providers in sepsis prevention/infection
prevention.
SIGNIFICANCE OF THE RE AUDIT:
Following the interventions put in place to improve the situation after the initial audit report, this reaudit report will better assist service providers to recognise and deal with the sources and causes of
neonatal infections at this hospital. This being the case, infections will be prevented before spreading.
In cases where infection is already there, clinical presentations will be recognised and management
will be instituted in time. With the ongoing interventions, such as trainings, and beliefings on care of
neonates, service providers will be able to manage neonatal sepsis. As such the prevalence rate of
neonatal infection will probably reduce.
Other obvious benefits, after reducing the rate of sepsis in babies, will be a reduced bed occupancy rate.
All service providers will be equipped with adequate knowledge on how to prevent neonatal sepsis.
The hospital and other agencies will have the information with which to use to formulate protocols.
DATA COLLECTION:
For re-audit purposes, the data was collected for three months, May, June and July, 2012. Just like the
initial audit, data was collected from the nursery ward register and in-patients files retrieved from the
ward clerk’s office. The sample sizes were 22, 18 and 7 in each month respectively. The sample sizes
were derived from a total of cases, with desired clinical indicators, of clinical neonatal sepsis admitted
in each of the three months. In May, 2012, total number of neonatal sepsis cases was 22. Out of the 22
cases, 20 had clinical marker of temperatures above 38 degrees Celsius despite being on antibiotics for
two days. The remaining 2 cases presented with temperatures below 35 degrees Celsius.
In June, 2012, total number of neonatal sepsis cases reduced to 18 out of which, 13 had temperatures
above 38 degrees Celsius and the remaining 4 had temperatures below 35 degrees Celsius
In July, 2012, total number was 7, of which 3 cases had temperatures above 38 degrees Celsius and 4
cases with temperatures below 35 degrees Celsius.
DATA ANALYSIS:
The three months data captured was imported into relevant tables for comparison purposes inoder to
carry out meaningful analysis that can draw a conclusion which is linked to the objective of the reaudit report. From the data so far collected, it seems the number of cases of neonatal sepsis is gradually
reducing. However, even before interventions initiated soon after the February audit, sepsis is not an
outstanding problem at this hospital as it represents less than 10% of all admissions at the Nursery
Ward and a death rate of less than 2% annually. This re-audit report will focus on comparing the cases
for the month of February 2012. Out of 365 babies admitted for various reasons in February, 2012, 47
babies were admitted due to high fevers >38 degrees Celsius (clinical sepsis) and other clinical
presentations of sepsis, representing 12.9% of all admissions in the said month.
Total Sepsis cases admitted / % of total admission per month in the initial audit and re-audit periods
Month (2012)
Feb
May
June
July
Total Admitted
365
318
311
302
Sepsis
47
22
18
7
%
12.9
7.9
5.7
2.3
Period
Initial audit
Re audit
Re audit
Re audit
The table above shows that incidence of clinical neonatal sepsis is gradually decreasing, as evidenced
by the rate of monthly admissions. The assumption may be attributed to the interventions that were put
in practice following the initial audit results.
Proven sepsis remains difficult due to lack of laboratory capacity to culture spacemen; therefore, cases
are mostly diagnosed based on clinical presentations. The admission criteria for the nursery ward at
Bwaila Hospital is for; premature babies, low birth weight babies, birth asphyxia, neonatal sepsis, low
Apgar score, and other conditions that require observation of the neonates within 48 hours. Babies are
admitted from the labour ward, in cases of low Apgar score, birth asphyxia, aspiration, prematurity and
other conditions. Others come from normal (low risk) postnatal ward, high risk postnatal ward, and
from home after home delivery or after being discharged from postnatal ward. In the initial audit report,
out of the total 47 cases of clinical sepsis only 26 cases were randomly selected and I came up with the
following findings: 14 cases reported within 24 hours, 6 cases within 48 – 72 hours, the remaining 6
cases from 72 hours to 9 days.
Due to the reduced numbers of neonatal sepsis cases in the re-audit months, all cases for the months in
question well used (no random sampling). The table below reflects the comparable figures from that of
February, 2012.
Table 1a: Time reported to Nursery (Feb, 2012, Audit Report)
Time in hours/days
Within 24 hours
48 – 72 hours
72 hours – 9 days
No of cases
14
6
6
Table 1b: Time reported to Nursery (Audit & Re-audit Reports)
Report Time
Within 24 hrs
48-72 hrs
72-108 hrs
Feb
14
6
6
May
10
7
5
June
4
7
7
July
1
2
5
The tables above is a reflection of reported cases in both initial audit and re-audit periods in relation to
time in hours.
Table 2a: Place cases reported from (Feb, 2012, Audit Report)
Ward / Place
Low risk (normal) postnatal ward
High risk postnatal ward
Home after discharge
Home deliveries
Labour ward
No of cases
12
6
4
2
2
Table 2b: Place cases reported from (Audit & Re audit Reports)
Ward/Place
Low risk
postnatal
ward
High risk
postnatal
ward
Home after
discharge
Home
deliveries
Feb
12
May
6
June
3
July
6
9
5
1
4
2
6
3
2
5
4
3
Initially, the table above shows more cases reporting from within the wards than other places. Then the
numbers, though not equally sampled, gives the opposite trend of scenario. More cases seem to report
from outside than within the hospital within the period of intervention.
Table 3a: Cases clinical presentation (Feb, 2012, Audit Report)
Clinical presentation
High fever > 38 degrees Celsius
Low birth weight with fever
Impetigo
Lethargic
Umbilical infection
Purulent eye discharges
Severe prematurity with fever
No of cases
19
2
1
1
1
1
1
Table 3b: Cases Clinical Presentation (Audit & Re-audit Reports)
Clinical
presentation
Fever >38
Fever >35 &
LBW
Impetigo
Lethargic
Umbilical
infection
Purulent eye
discharges
Severe
prematurity
with fever
Total
Feb
May
June
July
19
6
20
2
13
4
3
4
1
1
1
-
-
-
1
-
-
-
1
-
1
-
26
22
18
7
Whether a surprise or an improvement, almost all the cases presented with only hyperpyrexia and
hypothermia in the re-audit period. In the initial audit period, in February, there were trace cases
indicating other clinical presentation of sepsis.
Table 4a: Modes of delivery (Feb, 2012, Audit Report)
Mode of delivery
Hospital spontaneous delivery
Caesarean Section
Home delivery
No of cases
18
4
4
Table 4b: Modes of Delivery (Audit & Re-audit Reports)
Delivery Modes
Hospital SVD
C/Section
Home deliveries
Total
Feb
18
4
4
26
May
13
6
3
22
June
10
3
5
18
July
4
1
2
7
In relation to modes of delivery, there are still more cases of sepsis from babies born
in the hospital and caesarean sections, though in the last two re-audit months there is a reduction of
sepsis from caesarean section cases.
DISCUSSION:
.
From the tables above, much of what have been reflected are gradual improvements and desirable
outcomes. The results above may be conclusive to show that sepsis can be reduced with proper
interventions. Proper care is critical from first stage to third stage of labour and postnatal period (42
days post delivery. Currently, through observation in the wards, most midwifes and clinicians put on
gloves prior to hand washing when performing vaginal examination. Antiseptic solution for perineum
cleaning is found in all the rooms in the labour ward. Mothers in antenatal ward are advised to take a
bath when they are in latent phase of labour. Few babies are now being admitted from postnatal wards
hours or days after normal deliveries. This may be attributed to the present interventions such as
infection prevention measures in the postnatal wards. The situation may improve further with correct
interventions such as proper follow up and care of antenatal mothers from admission, during and after
delivery, in the postnatal ward and at home after discharge. Preventive measures of sepsis such as six
clean birth and good postnatal care practices in accordance with World Health Organisation, to be
adhered to. The six cleans are summarised as; hand washing of birth attendant before birth, clean birth
surface, clean perineum, clean cord tie and clean cloth for drying. For home deliveries, special
intervention to the traditional birth attendants on hygienic standards of care during and after birth to be
implemented by delivering the information to them. Basing on the above situation, Antenatal ward,
Labour ward, Theatre, Postnatal and Nursery staff (nurses and clinicians) underwent two training
sessions in Infection Prevention and Injection Safety, and Emergency Obstetrics/Neonatal Care
Guidelines. The labour ward floor is now covered with tiles for easy and maximum floor cleaning.
There is not much information on traditional birth attendants follow up, therefore, this re-audit will not
dwell much on babies born at home.
CONCLUSION:
Despite a considerable burden of the disease, there are still strikingly few data on the precise incidence
and the aetiology of early onset of neonatal bacteria sepsis in Sub-Saharan Africa, largely because of
lack of reliable microbiological facilities. Simple intervention strategies are effective in other
populations and evidence from a small number of intervention studies in Sub-Saharan Africa supports
the urgent need for further trials. As such, the public health measures can effectively be directed and
neonatal morbidity and mortality in Sub-Saharan Africa be substantially reduced. Therefore, clinical
relevance for this re-audit is to reflect on the outcome of the sepsis reductions/preventions practiced
after the audit report, and to explore other possible avenues for improvement. To come up with a list of
the causative agents of neonatal sepsis and the preventive measures, recognition of clinical
presentations and management of neonatal sepsis. Upon establishing the above factors, all
implementers in the hospital and outside to be followed up and mentored on the policies. Quality
assurance to be assured with biannual re-audits. Hence, re-audits will be conducted on six monthly
bases to ascertain neonatal sepsis improvement rate. Finally, with the above evidence based
improvement, a policy within the hospital shall be formulated. The policy, however, shall need the
approval by the District Health Management Team. The policy document shall contain steps that will
further bring down the morbidity and mortality rate due to neonatal sepsis at Bwaila Maternity Unit
and all its surrounding health facilities.
RECOMMENDATIONS:
The District Health Office, working partners and other stakeholders such as; Centre for Disease
Control(CDC), University of North Caroline (UNC) Project, Fistula Foundation, UNICEF, Light
House, to continue organising trainings for service providers in Neonatal Sepsis management in the
district. The District health office, through its health centres to plan sensitization campaigns during
maternal health services delivery at the facilities and in their communities. The trainings, mentorship
programmes being conducted at Bwaila Maternity Hospital to continue and be rolled out to all the
health facilities within the District. Protocols that are already developed should be fully utilised by all
service providers. Service provider’s knowledge gaps to be corrected by ongoing trainings within the
hospital. Service providers must develop a will to improve the standards and provide quality care for
patients at all times.
REFERENCES:
(a) Bwaila Maternity Unit, nursery ward register, and inpatients files: May, June and July, 2012.
(b) JA Philips, PN Kazembe, EAS Nelson, JAF Fisher, Grabosh: (2008), A Paediatric Handbook for
Malawi, (3rd Edition) Limbe, Montifort Place.
(c) Baltimore RS, Neonatal sepsis: Epidemiology and Management, Yale university school of
medicine, New Hawaii, Connecticut 06520-8064, USA.
(d) Ann L Anderson – Berry, MD, Chief Editor: Neonatal sepsis
(e) ETATMBA materials