Improving Child Health in Nicaragua

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Improving Child Health in Nicaragua

• Oscar Nuñez
• USAID Health Care Improvement Project University
  Research Co., LLC

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Context

• Since 2003, we have implemented a Paediatric
  Hospital Improvement (PHI) Collaborative with the
  Ministry of Health of Nicaragua and UNICEF
• Collaborative began with 6 (out of 22)
  maternal-child referral hospitals in Nicaragua
  hospitals were selected based on high case
  fatality rates and hospital interest in improving
  care processes
• Today, the collaborative includes 16 maternal
  infant hospitals (73 of such hospitals in
  Nicaragua) and 28 (58) health centres

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Problem Analysis

• Prior to 2003, no national guidelines for the
  management of critically ill or severely
  malnourished children under five
• 2003 assessment by national evaluators found
• No emergency triage assessment and treatment
  (ETAT) systems in place and little training of
  staff in paediatric emergency procedures
• 35 of cases incorrectly diagnosed
• Lack of assessment of danger signs and poor
  patient monitoring (including during rehydration
  for severe diarrhea)
• Weak counselling of parents/guardians and local
  of follow-up planning at discharge

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Strategies for Change 1) National Guidelines

• WHO Referral Care manual was adapted for
  Nicaragua by our team working with Ministry of
  Health pediatricians
• Pre-tested with hospitals and reviewed by
  national paediatrics faculty
• Created pocket version for health personnel

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Strategies for Change 2) Team Work

• Team formed in each hospital to lead
• PHI work
• Teams conducted self-assessments
• of their compliance with standards
• Learning sessions held with groups of
• hospitals to discuss common problem
• areas, new guidelines, how to measure
  improvement, and results
• Teams tested changes to improve compliance with
  guidelines, including
• introducing formal pediatric triage process
• ensuring availability of critical lab tests and
  essential drugs
• improving staff competency for clinical
  management of common pediatric complications

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Strategy for Change 3) Training /monitoring

• Training centers were created in hospitals to
  provide in-depth clinical training in management
  of acute paediatric illnesses
• Paediatric emergency care job aid used in US was
  adapted to Nicaragua
• Prize for knowledge Contests on knowledge of
  case management
• Monthly audits of clinical records to assess
  compliance with the guidelines

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Effects of Changes

• Compliance with case management standards for
  key pediatric conditions has risen steadily since
  the start of the collaborative and has now has
  reached high, stable levels across hospitals

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Effects of Changes

• Trend towards reduction in number of deaths from
  key paediatric conditions seen in the same
  hospitals.
• The most significant declines seen in pneumonia
  (55) and respiratory distress syndrome (32)

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Lessons Learnt

• Linking PHI with the Ministry of Healths
  Mother-Baby Friendly Hospital Accreditation
  Program (supported by UNICEF) has facilitated
  sustainability of improvement work
• More institutional incentives are needed to
  reward and encourage quality champions
• Key message Large-scale clinical quality
  improvement is possible in developing countries
  but greater use of incentives and motivators for
  quality improvement may be needed, especially to
  induce more
• patient-centered care.

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Acknowledgements

• This work was supported by the U.S. Agency for
  International Development (USAID) through the
  Quality Assurance Project (2002-2007) and the
  USAID Health Care Improvement Project
  (2007-2012), both managed by University Research
  Co., LLC (URC).
• For more information on the paediatric care
  improvement work in Nicaragua, contact Dr. Oscar
  Nuñez at onunez_at_ibw.com.ni

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