Bridging the Gaps January 31, 2014

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A Case St dA Case Study: Leveraging m/eHealth to Help Improve Care

for Women with Eclampsia and Their Pre-term Newborns in Zaza District

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Kathleen Hill, M.D., M.P.H.

Deputy Director, USAID ASSIST Project

University Research Co., LLC

The Case of Mariama and Boubacar: Zaza District

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Bridging the Gaps January 31, 2014

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At the Lava Clinic

• Mariama presented to the Lava Clinic 35 weeks pregnant with her first baby complaining of severe headacheheadache.

• Her blood pressure was elevated at174/110; the health post was out of urine dipsticks.

• The nurse asked Mariama and her husband to find transportation to the nearest hospital as soon as

iblpossible.

• Mariama and her husband decided to go the next morning once they could borrow money and arrange transportation.

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At the Hospital

• The next morning on the way to the hospital Mariama suffered a seizure

• Once at the hospital they were told to wait in a long queue• Once at the hospital they were told to wait in a long queue

• 10 hours later Mariama was admitted to hospital and Magnesium Sulfate treatment was started for eclampsia

• The following morning Mariama delivered a small baby son who never started breathing; a neonatal bag and mask could not be found in the delivery room

M i d h h b d d th i d d b b• Mariama and her husband named their deceased baby son Boubacar

• A subsequent review of Mariama’s antenatal record during a death audit revealed that Mariama’s BP had been elevated on 2 prior ANC visits4

Bridging the Gaps January 31, 2014

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Critical Quality & System Gaps for Mariama and Boubacar

Clinic:• Failure to detect and act on Mariama’s elevated blood pressure at prior

ANC visits (pre-eclampisa red flag)• No urine dipstick in clinic (diagnosis pre-eclampsia)

Linkages between Clinic and Hospital: • Failure of communication and timely transport between clinic & hospital• Nurse didn’t know who to contact (although she had a cell phone)

Hospital: D l d it (3 d d l ) d l k f t i t h it l

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• Delayed wait (3rd delay) and lack of triage at hospital• Lack of timely administration Magnesium Sulfate (treatment eclampsia)

and corticosteroids (maturation lung in pre-term fetus)• Lack of timely resuscitation Boubacar (no resuscitation bag & mask)

What is the Problem?

“The reality is straightforward The power ofThe reality is straightforward. The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and at an adequate scale.”

—Margaret ChanMargaret Chan

Director General

World Health Organization

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• Effectiveness of Care (adherence with best practices)

• Safety of Care (“do no harm”)

The Issue of Quality in Health Care

Safety of Care ( do no harm )

• Client-centeredness of Care (“respectful care”)

• Coordination of Care across system levels and life-cycle phases (“fragmentation of care”)

• Timeliness of Care

C t ff ti ( l )• Cost-effectiveness (value)

• Equity of Care (same quality for everyone)

“Every system is perfectly designed to achieve exactly the results it achieves” (Bataldan)Institute of Medicine 2001

Crossing the Implementation Divide to Improve Care

Understanding health care in terms of processes and systems

Team-work (all relevant actors, all system levels)

Regular use of data for action

Focus on patient needs

(client-centered)

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Conceptualizing Quality(Source: Donabedian)

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What m/eHealth technologies might have helped Mariama and Boubacar if integrated into an improvement effort?

INPUTS PROCESSES RESULTS

Mobile phone communication between nurse and hospital

e-referral protocol and SMS messaging

i t d t i

Mariama’s elevated BP detected early

Prompt transfer to hospital with loading dose MgS04 & ACS in clinic

EMR w/automatic alert for elevated BP

EMR Integrated eClinical decision support tool to guide clinic nurse

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e-assisted triage process at hospital Resuscitation and

survival of Boubacar

MgSO4, ACS & Bag&Mask available bedside

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Every Newborn Action Plan: Delivering integrated MNH packages at critical leverage points along the MNH continuum (Bernadette Daelmans, WHO)

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One year later in Zaza District:District Management Team Takes Action

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Key District Team Actions

• Improvement team created & actively supported in every facility including: – Competency based training/supervision coupled with on-siteCompetency based training/supervision coupled with on site

e-clinical decision support

– Team support to test changes to improve care processes (e.g., e-automated triage in hospital)

– Mobile phones with emergency contact #s

• Supply chain e-tools adopted all levels to ensure essential commodities at the bedside (MgSO4 ACS bag & mask)commodities at the bedside (MgSO4, ACS, bag & mask)

• Facility teams supported to document and analyze common monthly quality and outcome measures using automated run charts generated by EMR

• Quarterly district meetings to assess progress & share learning

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Competency Based Newborn Resuscitation Training and Peer to Peer Observation

(could use an e-checklist…)

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Percentage of pre-eclampsia and eclampsia case management standards achieved

Jan-Dec 2008, average of 120 cases analyzed per monthBased on detection in 120,000 patient contacts at 31 MOH facilities

Measuring Adherence withPre-eclampsia/eclampsia Best Practices to Improve

PE/E Care in Niger 31 facilities

40%

50%

60%

70%

80%

90%

Changes implemented:•Systematic screening at every contact•Organization daily tasks to prevent

0%

10%

20%

30%

40%

J08 F08 M08 A08 M08 J08 J08 A08 S08 O08 N08 D0815

•Organization daily tasks to prevent stock outs•Standardized emergency case management eclampsia•Standardized referral protocols

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Hospital Improvement Team

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Accelerating Progress through Shared Learning…..Tracking Automated Results Across Facilities for Collective Action

What changes are robust and effective Learningrobust and effective across teams?

Collaborative coachor manager

Site-level summaryQI team

LearningSession

representative

Which changes really yield improvements?

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Moving beyond building blocks to grow dynamic systems that strategically integrate

m/eHealth technologies

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Thank You

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