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Table 1 Summary of included studies

From: Quality improvement initiatives for hospitalised small and sick newborns in low- and middle-income countries: a systematic review

Author Study type Location Population Sample size QI measure Outcomes
Agarwal et al. 2007 [36] Controlled before and after study India Neonates born within the obstetric teaching hospital 15,249 Package of interventions including rational practice, protocol usage, training and empowerment of nurses Mortality: 30% decline in NMR
Length of admission: reduction from 8.6 days to 7.1.
Sepsis: reduction in deaths due to sepsis from 37.9 to 15.5%
Appropriate antibiotic use: antibiotics use decreased to 23.2%.
Bastani et al. 2015 [48] Randomised controlled trial Iran Mothers with preterm infants 91 A family centred care (FCC) programme Hospital admission/readmission: FCC group were significantly less likely to be rehospitalised, p = 0.04.
Length of admission: 6.96 in FCC group, 12.96 in control group, p < 0.001.
Maternal satisfaction: FCC group were significantly more satisfied.
Bhutta et al. 2004 [49] Controlled before and after study Pakistan Very low birth weight infants 509 A step-down unit for mothers and babies Mortality: rates of survival increased, from 65 to 84% (p < 0.05).
Length of admission: length of stay fell from mean of 34 to 16.
Patient weight gain: there was a reduction in mean weight at discharge from 1.6 to 1.289 kg (p < 0.001).
Patient infection rates: rates of overall nosocomial infections dropped significantly.
Sepsis: increased relative risk of culture proved neonatal sepsis (95% CI 0.92–1.26).
Severe illness: non-significant changes in rates of intraventricular haemorrhage, apnoeic spells, respiratory distress, and necrotising enterocolitis; significant decrease in patent ductus arteriosus rates.
Presence of hyperbilirubinaemia: rates fell from 28.8% to 17.9%.
Cavicchiolo et al. 2016 [58] Controlled before and after study Mozambique NICU residents—inborn and outborn patients of all gestational ages up to the postnatal age of 7 days 4276 A continuous multi-level quality improvement intervention focused on infrastructure, equipment and protocol refinement Mortality: reduction in death rate from 26 to 18%, significant.
Hospital admission/readmission rate: admissions for prematurity, sepsis and asphyxia increased significantly.
Sepsis: admissions for sepsis increased significantly, deaths decreased non-significantly.
Severe illness: deaths for asphyxia increased significantly, admissions increased significantly.
Clark et al. 2012 [50] Controlled before and after study Sierra Leone Children presenting for emergency care 500 Training course based on ETAT WHO course, ward combined to form ICU and ER, triage area created, improved equipment, experienced nurses in triage, structured clerking pack introduced Mortality: decreased from 12.38 to 5.85%.
Length of admission: no change.
Crouse et al. 2016 [38] Controlled before and after study Guatemala Random sample of all patients presenting to the PED and all patients admitted to the PICU 1027 Emergency Triage Assessment and Treatment (ETAT)-based emergency triage process Mortality: decreased from 12 to 6% amongst critically ill, not significant.
Hospital admission/readmission: admission from the Paediatric Emergency Department fell significantly from 8 to 4%, and also fell significantly in critically ill group.
Length of admission: decreased, not significant.
Darmstadt et al. 2005 [51] Controlled before and after study Bangladesh Preterm infants in Special Care Nursery Infection control programme Mortality: decline in deaths of certain causes, significance not mentioned.
Patient infection rates: decrease in nosocomial infection reports, and K. pneumoniae.
Infection detection rates: decline in cases of culture-proven sepsis and suspected sepsis.
Sepsis: significant decline in patients with clinical diagnosis of sepsis (79%).
Appropriate antibiotic use: antibiotic use guidelines were reviewed, no data.
Adherence to national guidelines of care: staff trained in standard guidelines, antibiotic guidelines were adhered to.
dos Santos et al. 2015. [47] Intervention study (non-random) Brazil NICU newborns 24 NIPS scale; non-pharmacological actions in pain control in newborns Adherence to national guidelines of care: significantly lower NIPS (pain scale) score with intervention.
Erdeve et al. 2008 [52] Intervention study (non-random) Turkey All mother−preterm infant dyads that were consecutively admitted to the NICU 60 Use of individual rooms Hospital admission/readmission: rehospitalisation rate was higher in non-intervention group p < 0.05.
Length of admission: no significant difference regarding duration of intensive care hospitalisation.
Patient weight gain: no significant change on discharge in body weight.
Breastfeeding practice: no significant change in groups regarding breastfeeding rates.
Gathara et al. [39] Controlled before and after study Kenya Sick newborns aged 0–7 days and malnourished children aged 6–59 months 798 Package of interventions including clinical guidance booklets, admission record form, a training course on emergency and admission care, external support supervision, local facilitation, performance assessment, and feedback Mortality: mortality was reduced by 3% post intervention in intervention group, control group was static.
Appropriate antibiotic use: overdoses of penicillin were reduced in intervention vs control group, but overdoses of gentamicin were increased.
Adherence to national guidelines of care: documentation of gestation in weeks were increased in intervention group, and mean documentation score was higher. More vitamin K was prescribed in intervention groups.
Gilbert et al. 2014 [53] Controlled before and after study Brazil Neonates admitted to NICU 1242 A 5-phase POINTS of Care package Mortality: crude survival rates did not change over time significantly except in one NICU where it decreased.
Patient weight gain: days to regain birth weight were significantly higher in post-intervention period.
Retinopathy of prematurity: no significant change.
Sepsis: rates did not change—11.3/12.3 cases per 1000 infant days.
Lower respiratory tract disease: non-significant increase in bronchopulmonary dysplasia.
Severe illness: non-significant increase in bronchopulmonary dysplasia, no change in necrotising enterocolitis.
Leng et al. 2016 [40] Controlled before and after study China Very low birth weight neonates 172 Use of radiant warmers, warmer delivery room, STABLE programme, consulting services, standardised transportation, education of staff, review and feedback Mortality: mortality rates decreased from 12 to 7%, p = 0.03.
Length of admission: reduced from 60 to 45 days, p = 0.01
Sepsis: sepsis rates did not change significantly.
Hypothermia rates: significant decrease in patients with temperatures < 36 degrees Celsius.
Lower respiratory tract disease: percentage with chronic lung disease did not change significantly.
Severe illness: rates of intraventricular haemorrhage and necrotising enterocolitis did not change significantly, but SNAPPE-II score increased significantly.
Mais et al. 2015 [41] Controlled before and after study Lebanon Neonates with central lines in NICU 213 Theoretical and practical teaching sessions, dressing change guidelines, sterile technique, auditing adherence to guidelines Length of admission: there was no significant change.
Patient infection rates: CLABSI rates declined significantly, p < 0.05.
Mechanical ventilation: no significant change.
Central line duration: no significant decline in usage.
Namazzi et al. 2015 [42] Controlled before and after study Uganda All pregnant and newly delivered mothers residing within the villages of the Iganga/Mayuge Health and Demographic Surveillance Site District led training, support supervision, mentoring, supply of essential medicine and equipment Mortality: hospitalised NMR declined from 17 to 9%, not significant.
Kangaroo Mother Care: by the end of the study, 547 preterm babies had been cared for in a KMC unit.
Premature delivery rate: rate was 8% in deliveries in health units.
Pinto et al. 2013 [43] Controlled before and after study Brazil Newborns with very low birth weight 136 Dissemination of a new protocol proposed by the Brazilian National Health Surveillance Agency for antibiotic usage in LBW infants Mortality: overall mortality decreased from 20.9 to 4.4%, significant.
Patient infection rates: no significant change in multi-resistant infection rates.
Sepsis: no difference in relation to confirmed sepsis, but a significant reduction in diagnoses of probable sepsis.
Severe illness: no change in diagnoses of severe illnesses, e.g., PDA, PBD, necrotising enterocolitis.
Appropriate antibiotic use: decrease in number of antimicrobial regimens used and days of antibiotic use.
Rahman et al. 2017 [44] Controlled before and after study Bangladesh Children identified as having systemic sepsis 1036 Triage, fast assessment, immediate results, immediate antibiotics, training package, slow charts, checklist, records system, infection control measures, equipment stocking Mortality: mortality decreased, significance not reported.
Length of admission: increase in % with syndromic sepsis staying for over 48 h, significance not reported.
Appropriate oxygen use: post intervention 94% were given oxygen with hypoxaemia.
Appropriate antibiotic use: first-line recommended antibiotic usage increased from 49 to 75%, p < 0.005.
Ramaswamy et al. 2015 [59] Controlled before and after study Ghana Obstetric and neonatal cases in regional referral facilities Ridge-Kybele model for obstetric and neonatal care—an integrated approach to systems change Adherence to national guidelines of care: 37% improvement in NICU hand hygiene rates.
Waiting times: 74% reduction in mothers with unacceptable waiting times.
Rosenthal et al. 2012 [33] Controlled before and after study Argentina, Colombia, El Salvador, India, Mexico, Morocco, Peru, the Philippines, Tunisia, Turkey NICU patients 6829 VAP (ventilator-associated pneumonia) bundle—11 items Patient infection rates: ventilator-associated pneumonia rates per 1000 mechanical ventilator days decreased from 17.8 to 12.0.
Lower respiratory tract disease: ventilator-associated pneumonia rates per 1000 mechanical ventilator days decreased from 17.8 to 12.0.
Adherence to National Guidelines of Care: hand hygiene compliance rates rose from 62 to 81%.
Mechanical ventilation: days of MV did not change.
Rosenthal et al. 2013 [34] Controlled before and after study El Salvador, Mexico, Philippines, and Tunisia NICU patients with central line insertion 2214 INICC multidimensional infection control approach Patient infection rates: CLABSI rate reduction from baseline of 54%, 95% CI 0.33–0.63 RR.
Adherence to National Guidelines of Care: hand hygiene and sterile gauze rates rose significantly.
Salehi et al. 2015 [45] Controlled before and after study Iran Hospitalised ‘infants’ 100 Implementation of guidelines and education Patient weight gain: patients in intervention group had a mean weight change of + 96 g compared to − 59, p = 0.001.
Sethi et al. 2017 [54] Controlled before and after study India Preterm neonates 26 neonates, 23 mothers CPNC—comprehensive post-natal counselling package, comprising education of health care providers and family members Breastfeeding practice: the proportion of mothers expressing milk on day 1 increased to 86.6% from 12.5%, after 1 year the proportion of neonates on exclusive breast milk was more than 80%.
Soni et al. 2016 [55] Controlled before and after study India Infants admitted to a rural Indian neonatal intensive care unit (NICU) 648 Presence of physician champions Length of admission: length of stay was greater with champions, at 9 days, compared to 7 without, p = 0.01.
Patient infection rates: patients who experienced infections decreased significantly as physician champions left.
Appropriate antibiotic use: no association between champions and antibiotic usage.
Breastfeeding practice: breastfeeding rates were not changed.
Usage of Kangaroo Mother Care: skin to skin care increased with champions and lasted longer hours per day.
Premature delivery rate: with KMC champions there was a higher percentage of premature deliveries, p = 0.01 for trend.
Srofenyoh et al. 2012 [35] Controlled before and after study Ghana Mothers and neonates in Ridge Regional Hospital 29,508 An interdisciplinary approach, high-level sponsorship, establishment of guidelines, measurement, feedback, leadership and teamwork coaching, training including QI training, and a multimodal focus on patients, providers, and systems Mortality: perinatal mortality was reduced, no information on significance.
Maternal satisfaction: this improved.
Maternal health: 34% decrease in maternal mortality.
Stillbirth: reduced by 36%, p < 0.05.
UNICEF 2014 [37] Controlled before and after study Bangladesh Hospitalised newborns Quality improvement initiatives delivered alongside SCANUs—Special Care Newborn Units Mortality: average case fatality rates dropped in most SCANUs.
Hospital admission/readmission: admissions at SCANUs increased.
Wrammert et al. 2017 [56] Controlled before and after study Nepal Neonates in maternity hospital, Kathmandu 299 Implementation of Helping Babies Breathe Protocol Mortality: decrease in death rate in first 24 h, p < 0.01. No significant change in 7/28 day mortality.
Yawson et al. 2016 [60] Controlled before and after study Ghana Users of Ghanaian newborn care service BNA tool to identify service gaps with group discussions, leading to national and regional operational plans and monitoring/evaluation framework Mortality: mortality reduced in the intervention regions.
Zhou et al. 2013 [57] Controlled before and after study China All neonates who received mechanical ventilation for at least 48 h and were hospitalised in the NICU for ≥ 5 days 491 A bundle of comprehensive preventive measures against VAP were gradually implemented using the evidence-based practice for improving quality method. Mortality: mortality rates decreased from 14% in phase 1 to 3% in phases 2 and 3, statistically significant.
Patient infection rates: sustained decline in VAP rates, p = 0.01.
Zhou et al. 2015 [46] Controlled before and after study China Neonates in the NICU 171 EPIQ programme—team taught for 2 days, who then identified strategies for adoption of CLABSI prevention, and trained other members Patient infection rates: CLABSI rates declined in each successive phase.
Central line duration: time in situ increased across the phases, significance not reported.