520 - “Just in Time Review “of Neonatal Morbidity and Mortality (M&M) in a Low Resource Setting - A Quality Improvement Initiative

Poster Number: 520
Publication Number: 520.318

Emily Ahn, New York-Presbyterian Komansky Children’s Hospital, New York, NY, United States; MARIA Martha M. Mayer, Nelson Mandela Academic Hospital, MTHATHA, Eastern Cape, South Africa; Namhla S. Notununu, Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, South Africa; Esethu Mntonintshi, Nelson Mandela Academic Hospital, Walter Sisulu University, Mthatha, Eastern Cape, South Africa; Nosipho N. Dhlomo, Walter Sisulu University, Mthatha, Eastern Cape, South Africa; Sandile P. Mdunge, Collage of medicine, Johannesburg, Gauteng, South Africa; Sithembiso Velaphi, Chris Hani Baragwanath Academic Hospital, Johannesburg, Gauteng, South Africa; Jeffrey Perlman, Weill Cornell Medicine, New York City, NY, United States

Background: Neonatal mortality (NM) rates ( < 28 days) remain high in the OR Tambo region of the Eastern Cape (18.4/1000 live births). Major causes of death include birth asphyxia, prematurity, and infection. Putative associated factors contributing to high NM rates remain poorly categorized. To address this knowledge gap we have instituted a weekly one-hour M&M telehealth conference to review deaths and complicated medical cases.

Objective: To review all deaths in the prior week in order to identify potential preventable factors/interventions.

Design/Methods: A one hour video call is initiated from the regional Nelson Mandela referring hospital. A case review includes birth weight, primary labor complications, mode of delivery, major clinical issues, inborn versus outborn status, presumed cause of death, and day of death. Local participants include a neonatologist, pediatric residents, a radiologist, and consultants as indicated. In addition, a neonatologist from the Chris Hani Hospital in Gauteng and one from Cornell in New York participate.

Results: During the first three weeks following inception 15 newborns died (Table). Six (43%) were < 1000g, four of whom died on the first day: two from extreme prematurity, one from respiratory failure, and one with encephalopathy following abruption. Three infants died primarily from presumed culture negative sepsis; one from Acinetobacter baumannii sepsis. Blood cultures took ~7 days to result. Two had grade 3 intraventricular hemorrhage and pulmonary hemorrhage. Two transfers resulted in deaths: one upon arrival with underlying necrotizing enterocolitis, the second presented with hypoxia, hypotension, and hypoglycemia upon arrival. Three deaths were associated with congenital diagnoses including trisomy 18, a large gastroschisis with bowel necrosis associated with closure, and trisomy 21 with death following duodenal atresia repair from presumed sepsis. One infant presented in DIC at birth following maternal warfarin use and subsequently died from presumed sepsis. One infant with Tetralogy of Fallot also died from presumed sepsis.Conclusion(s): This novel approach to understanding causes of NM has identified several opportunities for improvement. First, 50% of the neonates died from presumed sepsis; strategies targeting infection control processes needs to be urgently explored. Second, outside transfer deaths point to improved triaging prior to transfer and enhancing EMS training of sick newborns. Third, ~ 33% died from extreme prematurity likely secondary to a lack of resources. A “just in time” strategy has identified several areas for improvement that may decrease NM.
Neonatal deaths by birth weight, labor complications, and clinical events.