YEKATIT 12 HOSPITAL MEDICAL COLLEGE,

ABEBECH GOBENA MATERNAL & CHILD

HEALTH CENTER

QUALITY IMPROVEMENT PROJECT TO DECREASE

NEONATAL DEATH IN YEKATIT 12 HOSPITAL
MEDICAL COLLEGE, ABEBECH GOBENA MCH
CENTER NEONATAL INTENSIVE CARE UNIT,2022/23

DECEMBER, 2022
ADDIS ABABA, ETHIOPIA
Team Members
S.
No
Name Department Qualification position Responsibility
1 Dr Ananya Gyni/Obs Gynaecologist & Center director QI team leader
Solomon Obstetrician
2 Dr Dureti Paediatrics & Paediatrician Medical Member
Abas child heath director
5 Dr Rome Quality General practitioner Quality director Member
Girma
5 Mr Yosef quality BSc Nurse, MPH Reform team member
Yelemfirhat fellow member
6 Mr Shegaye quality BSC Midwifery MPDSR focal member
Zele
7 Dr Amare quality General practitioner Clinical audit QI team focal
Tarekegn team member
8 Mr Melese Paediatrics & Neonatal Nurse NICU case Member
Niguse child heath team leader
9 Sr Hymanot Gyni/Obs BSC Midwifery Labor ward Member
Worku team leader
10 Mr Aselef Paediatrics & Neonatal Nurse NICU case Member
Endazenew child heath team member
11 Mr Awrajaw quality BSC Midwifery Labor ward Member
Asmare team
Contents
1. Introduction................................................................................................................................................6
2. What are we trying to accomplish?.......................................................................................................7
3. Project Description........................................................................................................................................8
4. Rationale.......................................................................................................................................................9
5. Expected Outcomes and Benefits.................................................................................................................9
6. Aim Statement..............................................................................................................................................9
7. Measurement (Outcome, Process)..............................................................................................................10
8. Initial Activities..........................................................................................................................................10
9. Fish-bone diagram......................................................................................................................................11
10. Driver Diagram.......................................................................................................................................12
11. List of change ideas................................................................................................................................13
12. Prioritization of change ideas.............................................................................................................14
The top 3 change ideas to be implemented in this project are use of perinatal asphyxia and
prematurity management bundles, transfer of neonates with flanel and strictly applying aseptic
techniques while performing procedures &transferring neonates............................................................14
13. PDSA Cycle............................................................................................................................................15
14. Work Plan...............................................................................................................................................16
15. Barriers....................................................................................................................................................17
16. Boundaries..............................................................................................................................................17
17. Testing PDSA cycle................................................................................................................................17
19. References...............................................................................................................................................21
List of Abbreviations

CPAP---Continuous positive airway pressure

GA---Gestational age
MCH----Maternal and child Health
IPC---Infection prevention and control
NICU—Neonatal intensive care unit
OR---operation room
PNA----Perinatal Asphyxia
SVD---Spontaneous vaginal delivery
List of tables

Table 1: problem identification & prioritization in Abebech Gobena MCH center, 2022/23.............................6
Table 2: outcome and process measures of the project, 2022/23........................................................................9
Table 3: prioritization of changes ideas to be implemented, 2022/23................................................................13
Table 4: work plan of the project, 2022/23........................................................................................................15
List of figures

Figure 1: phases of project intervention, 2022/23................................................................................................7

Figure 2: Fish bone diagram of illustrating a root causes of neonatal mortality, 2022/23.................................10
Figure 3: driver diagram of the project to decrease neonatal death at AG-MCH center 2022/23......................11
Figure 4: Run chart of the project, 2022/23........................................................................................................19
Project Identification

Project: Decreasing neonatal death at neonatal intensive care unit

Facility: Yekatit 12 Hospital Medical College, Abebech Gobena MCH center
Region: Addis Ababa City/Town: Addis Ababa

Project scope: Department level

Sponsor: Yekatit 12 Hospital Medical College

Project start date: December 23, 2023

Project end date: June 23, 2023

Last Revised:

Initial Activities

Establishment of Project team

Select team Coordinator
Brainstorm health problems
Organize and categorization of listed ideas
Prioritization of the problem
 1. Introduction

Yekatit 12 Hospital Medical College was established in 1915 E.C. The hospital is currently equipped
with over 1,200 Personnel and is giving different kinds of services. Currently, our hospital medical
college has a catchment population of two million people and above 190, 000 Clients visit our
hospital each year. Besides giving General Medical services, our hospital is renowned for its service
in plastic surgery, neonatology and speech therapy services.

Abebech Gobena Maternal and child health center is an afflation of Yekatit 12 Hospital medical
college which was established in 2013E.C. The major service units are emergency, labor &delivery,
neonatal intensive care unit, neonatal ward/septic ward, Outpatient service unit, Youth &adolescent
service unit, Gender based violence (GBV) service unit, High risk ward, maternity ward,
gynaecology ward, and Pharmacy & laboratory service units.

Neonatal mortality remains a prominent public health problem in developing countries. Particularly,
Ethiopia has a higher neonatal mortality rate than the average sub-Saharan African countries(1)

The first month of life is the most vulnerable period of child survival. Nearly half (47 percent) of all
under-five deaths in 2020 occurred during the neonatal period. This is an increase from 1990 (40 per
cent), as the global level of under-five mortality declines faster than neonatal mortality. Likewise,
divergent chances at survival start from the earliest ages – sub-Saharan Africa has the highest
neonatal mortality rate in the world, at 27 (25–32) deaths per 1,000 live births, followed by Southern
Asia at 23 (21–26) deaths (2)

Globally, three fourth of neonatal deaths occur during the early neonatal period, this makes it a
critical time to reduce the burden of neonatal death. The survival status of a newborn is determined
by the individual (neonatal and maternal), and facility-level factors. Several studies were conducted
in Ethiopia to assess early neonatal death; however, most of the studies had limited participants(3)

The survival of a newborn during the early neonatal period is determined by both individual
(gestational age, cause of death, and delay one) and facility (residence, type of health facility and
delay three) level factors. Thus, to have a positive early neonatal outcome, a tailored intervention is
needed for the three major causes of death (i.e infection, birth injury, and complications of the
intrapartum period)(3)
 2. What are we trying to accomplish?

Problem
In Abebech Gobena MCH center the major problems being identified are surgical site
infections, low immediate postpartum family planning coverage and increase in neonatal
death. From the listed problems neonatal mortality is the top priority.

Table 1 problem identification & prioritization in Abebech Gobena MCH center, 2022/23

Criterion
Problems (causes of
Importance Affordable Easy to Under control Total Rank
neonatal death)
(1-5) (1-5) measure of team
(1-5 members (1-5

Surgical site infection 4 5 4 4 17 2nd

Low immediate 3 4 4 3 14 3rd
postpartum family
planning coverage
Neonatal Mortality 5 4 5 4 18 1st

Neonatal mortality
Definition: Neonatal mortality is the probability of dying within the first month of life(4). In a total
of 22 studies, pooled results indicate that about 62% of the total neonatal deaths occurred during the
first 3 days of life; the first day alone accounted for two-thirds. Almost all asphyxia-related and the
majority of prematurity- and malformation-related deaths occurred in the first week of life (98%,
83% and 78%, respectively). Only one-half of sepsis-related deaths occurred in the first week while
one-quarter occurred in each of the second and third to fourth weeks of life. The distribution of both
overall and cause-specific mortality did not differ greatly between Asia and Africa. The first 3 days
after birth account for about 30% of under-five child deaths. The first week of life accounts for most
of asphyxia, prematurity and malformation-related mortality and one-half of sepsis-related deaths(5)

A study conducted in Baghdad showed that the neonatal mortality rate increased with the time
sequence for the last 10 years (2008–2017) in Al-Elwaya maternity hospital in Baghdad city. The
majority of the neonatal deaths are concentrated in the first day and within a week, Neonatal
mortality accounts for a large proportion of child deaths in many countries, especially in low-income
settings like Iraq. Mortality during neonatal period is considered as an indicator of both maternal and
newborn health and care. Most of the pregnant woman does not receive the primary health care
during pregnancy related to several causes, such as the emigration, country’s social, educational and
healthcare systems and strategies. Other factors such as duration of hospitalization, birth weight, and
gestational age have effect on newborns mortality and gestational blood pressure has direct effect on
newborns mortality(6)
At national level neonatal mortality declined from 39 deaths per 1,000 live births in 2005 to 29
deaths per 1,000 live births in 2016 before increasing to 33 deaths per 1,000 births in 2019(4)

A study conducted in southwest Ethiopia showed that care during pregnancy, knowledge of key
danger signs, skilled care at birth, parity, twin pregnancy, previous history of perinatal mortality, and
occurrence of complications during labor were identified as determinants of perinatal mortality(7)

3. Project Description
This project will seek to reduce neonatal death at Yekatit12 hospital Medical College, Abebech
Gobena MCH center via using different change ideas.

Figure 1: phases of project intervention, 2022/23

 4. Rationale

Document review of 3 months (Hamle1, 2014ec to meskerem 30, 2015ec) in Abebech Gobena MCH
center intensive care unit showed that from 480 admissions there was 73(15.2%) neonatal deaths at
NICU and the most common causes were sepsis, prematurity and perinatal asphyxia which accounts
5.4%, 4.8% & 1.7% from all admissions respectively.
So the aim of this project is to decrease neonatal death at NICU through practicing standardized
treatment protocols & follow up charts of the main causes of neonatal death.

5. Expected Outcomes and Benefits

With possible maximum effort, this project is expected to decrease neonatal death. This will in turn,
increase customer satisfaction & national productivity in near future.

6. Aim Statement

We, Abebech Gobena MCH center teams aim to decrease neonatal death from 15.2% to 11.4% (25%
of the baseline) from December 23, 2022 to June 23, 2023.
 7. Measurement (Outcome, Process)

The outcome measure of this project is the percentage of neonatal death while the process measure is
the percentage of neonates who are fully managed with perinatal asphyxia & prematurity
management bundles.

Table 2 outcome and process measures of the project, 2022/23

Neonatal Change idea Outcome measures Process measures(indicator)

death (indicators)

Percentage of neonatal death % of neonates who fully managed

Use of perinatal = Total neonatal death x100 with perinatal asphyxia & prematurity
asphyxia & prematurity Total number of neonatal management bundles
management bundles admission

8. Initial Activities

The project team members are formed initially by the center director. The team tried to explore the
current situation/practices regarding to neonatal mortality through interview, direct observation,
cause and effect diagram (root cause analysis) and driver diagram (change ideas)
 9. Fish-bone diagram

The main root causes that contribute to neonatal death are grouped in to 7 categories as staff related,
supply &equipment related, referring health center relate, IPC related, data related, community
related and infrastructure related factors.

Figure 2: Fish bone diagram of illustrating a root causes of neonatal mortality, 2022/23
 10.Driver Diagram

Figure 3: driver diagram of the project to decrease neonatal death at AG-MCH center 2022/23
 11.List of change ideas

1. Shift of neonatal nurses from septic ward to NICU

2. Use of PNA &Prematurity management bundles
3. Provide on-site training for Nurses & Interns
4. strengthen regular catchment meetings & provide the necessary supplies to strengthen NICU setup
at referring primary Hospital (e.g Sandafa Hospital)
5. Availing equipment such as surfactants, CPAP, mechanical ventilators, Pulse-oximetry, flanel &
Purfuser
6. transfer neonate from triage room to NICU ward with flanel
7. Using aseptic techniques while performing procedures & transferring neonates
8. Strengthening health education for pregnant mother
 12.Prioritization of change ideas

The top 3 change ideas to be implemented in this project are use of perinatal asphyxia and prematurity management bundles, transfer of
neonates with flanel and strictly applying aseptic techniques while performing procedures &transferring neonates
Table 3: prioritization of changes ideas to be implemented, 2022/23

Change Idea Criterion

Importance Affordability Under control of team Easy to Total remark
members
measure score

Shift of neonatal nurses from septic ward to NICU 5 3 3 5 16 4

Use of PNA &Prematurity management bundles 5 5 4 5 19 1
Provide on-site training for Nurses & Interns 3 3 3 4 13 7
strengthen regular catchment meetings & provide the necessary 4 2 2 1 9 8
supplies to strengthen NICU setup at referring primary Hospital
(e.g Sandafa Hospital)
Availing equipment such as surfactants, CPAP, mechanical 5 3 2 5 15 5
ventilators, Pulseoximetry, Flanel & Purfuser
transfer neonate from triage room to NICU ward with flanel 4 5 4 5 18 2
Using aseptic techniques while performing procedures & 4 5 4 4 17 3
transferring neonates
Strengthening health education for pregnant mother 4 4 3 3 14 6

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 13.PDSA Cycle

 Plan
 What: Use of Perinatal asphyxia &Prematurity management bundles
 When: December 23, 2022 to June 23, 2023
 Where: Abebech Gobena Hospital, Neonatal intensive care unit
 Who: NICU Staff
 How: Initially we will prepare preterm neonate management bundle and perinatal asphyxia management bundle. We will then review
the management of preterm & perinatal asphyxia babies in neonatal intensive care unit by conducting chart review daily using the
bundle assessment checklist. The checklist will be prepared by Dr Dureti Abas and Dr Frezer. The chart review will be done by Dr
Amare & Mr Shegaye. The feedback will be given to nurses & residents who will manage the neonate immediately after the chart
review.

Prediction: The change idea will reduce neonatal death in neonatal intensive care unit from 15.2% to 12.92% (15% reduction from the
baseline within 3months)

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 14.Work Plan

Table 4 work plan of the project, 2022/23

November December January February March April June

Task W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4

QI Team formation
QI project Design
QI project document
preparation

Baseline data collection

project initiation
PDSA(test) -cycles
Project implementation
Data collection
Data analysis

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 15.Barriers
- shortage of neonatal nurses, absence of essential equipments for neonatal care

16.Boundaries
- This project will not require additional rooms/space or cannot renovate the rooms

17.Testing PDSA cycle

17.1 Do
i. Orientation session for residents, interns, nurses &Midwifes

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 ii. Check list preparation

 Asphyxia management bundle check list

MRN____________ APGAR score at 1st__5th __10th min__

Gestational age______________ Duration of resuscitation_________
Mode of delivery __________ Saranat stage of HIE_______

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
1 Is normal oxygenation and
ventilation maintained (90-95%)?
2 If not is respiratory support used to
maintain?
3 Is the neonate hemodynamically
stable or perfusion maintained?
4 Fluid restriction to 2/3rd of
maintenance for moderate and
severe asphyxia
5 Is maintenance calcium gluconate
provided?
6 Is blood glucose checked and
maintained between 60 mg/dl and
150mg/dl?
7 Was antibiotic initiated at admission
with Ampicillin and cefotaxime?
8 Does the neonate have seizure?
9 If yes at what age did the seizure
start?
10 If yes Was the seizure treated as
protocol?
11 Is urine output monitored and
maintained as 1ml/kg/hr?
12 Is the neonate kept 2-3 days NPO for
moderate to severe Asphyxia?
13 Were baseline investigations done
and managed accordingly?
14 Is the neonate followed with
neurosign chart?

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 Remark:- Y/N (Y=Yes, N= No)

 Premature neonate management bundle check list

Neonate with birthweight <2kg (28-35weeks)
MRN_____ Gestational Age_____Antenatal corticosteroid □ given □ not given Mode of delivery □ SVD
□ Emergency C/S □ Elective C/s
Management bundle Date of admission and NICU stay

Prevention of hypothermia yes No Yes No Yes No Yes No Yes No Yes N

o

NICU charge nurse/physician aware of pending preterm delivery

Infant warmer turned on at OR or delivery room
Plastic bag on warm blankets applied
Is the neonate in Incubator?
If yes, is the incubator Functional
Documented temperature instability (hypo or hyperthermia)
If yes were correction measures taken
Temperature probes plugged into warmer
Excess exposure avoided
Feeding
Was trophic feeding initiated?
Was feeding chart appropriately filled?
Was maintenance fluid running according to standard?
Was RBS measured every 6hr?
Any hypoglycemia? was it managed according to standard
Preventing apnea
Does the neonate has apnea?
Was tactile stimulation or CPAP used?
Was aminophylline given?
Respiratory distress syndrome
Was the neonate on O2 supplementation during transfer from OBS?
Is the patient on CPAP?
If yes, is CPAP checklist being used?
PSO2 maintained between 90-95%
Was antibiotic initiated as protocol
Necrotizing enterocolitis
Was the diagnosis of NEC made? (suspected, confirmed or advanced)
If yes Was enteral feeding discontinued?
Was nasogastric drainage tube in place?

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Was antibiotic initiated?
Was screening trans fontanelle U/S done for GA<32wks
Was kangaroo mother care according to the standard
18.

17.2 Study

After we started the QI project, there were 37 neonatal deaths at neonatal intensive care unit within 10
weeks (14/4/15 to 233/6/15ec) and the total admission to NICU were 356 which makes the percentage
of neonatal death to be 10.39%.
The prediction was to decrease neonatal death at NICU by 15% from baseline after implementing a
single change idea (from 15.2% to 12.92% )
This change idea reduces decrease neonatal death at NICU from 15.2% to 10.39%)

The overall neonatal deaths after the implementation of the first change idea for the last 10weeks are
illustrated in the run chart below.

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 Figure 4: Run chart of the project, 2022/23

17.3 Act

 Using prematurity & perinatal asphyxia management bundles, we decrease the total neonatal
deaths at neonatal intensive care unit from 15.2% to 10.39% and as stated above in the run chart there is
sign of improvement after we implement the change idea. Therefore, we decided to adopt this change
idea and continue the second PDSA cycle.

19.References

1. Girma D, Dejene H, Adugna L. Predictors of Neonatal Mortality in Ethiopia: A

Comprehensive Review of Follow-Up Studies. Int J Pediatr (United Kingdom).
2022;2022:1–4.
2. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels &
Trends in Child Mortality. Report 2020. 2021. 1-56 p.
3. Tesfay N, Tariku R, Zenebe A, Dejene Z, Woldeyohannes F. Cause and risk factors of early
neonatal death in Ethiopia. PLoS One [Internet]. 2022;17(9 September):1–22. Available
from: http://dx.doi.org/10.1371/journal.pone.0275475

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4. Demographic M, Survey H. Ethiopia. 2019.
5. Sankar MJ, Natarajan CK, Das RR, Agarwal R, Chandrasekaran A, Paul VK. When do
newborns die? A systematic review of timing of overall and cause-specific neonatal deaths
in developing countries. J Perinatol [Internet]. Nature Publishing Group; 2016;36(S1):S1–
11. Available from: http://dx.doi.org/10.1038/jp.2016.27
6. Ghafel HH. Neonatal mortality rate at Al-Elwaya maternity hospital in Baghdad city:
Retrospective study. J Contemprory Med Sci [Internet]. 2018;4(2):88–91. Available from:
http://www.jocms.org/index.php/jcms/article/view/407
7. Debelew GT. Magnitude and Determinants of Perinatal Mortality in Southwest Ethiopia. J
Pregnancy. 2020;2020.

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