etinopathy of prematurity (ROP) is a leading
cause of childhood blindness [1,2], and parental sensitization and
counselling play a vital role in its prevention. Literature shows that
education and counselling of parents regarding ROP has resulted in
improved screening and follow-up rates [3]. Similarly, training and
education of neonatal nurses can play a major role in prevention and
treatment of ROP [1]. However, in the existing public health care
delivery system, these two measures have not been effectively
implemented.
The Point of care quality improvement model (POCQI)
has been designed to build capacity for quality improvement in
healthcare facilities [4,5]. In this study, the quality initiative
method was used to improve existing screening of ROP by educating
neonatal nurses and parents regarding ROP. Using point of care quality
improvement methods (POCQI) [5], the existing flow of outborn NICU
(neonatal intensive care units) graduates for ROP screening was also
modified to increase and sustain the screening rate of ROP.
Methods
This was a quality improvement study [6] that was
done in outborn neonatal intensive care unit (NICU) of a tertiary care
centre from May 2017 to March 2018. Ethical clearance was obtained from
Institutional Ethics Committee-Human Research (IEC-HR). The study was
conducted in three phases, baseline/pre-intervention (two months),
intervention phase (two months) and post-intervention phase/sustenance
phase (seven months). A QI team consisting of lead investigator (team
leader), co-investigator, nursing in charge NICU, doctor in charge NICU,
two neonatal nurses, one senior resident (post MD), one postgraduate
student, and one parent of a neonate was constituted. A total of 89
parents (42 in the pre-intervention and 47 in post-intervention phase)
and 40 nurses (same group in both phases) were included in the study
after taking informed consent. All the nursing staff of the outborn NICU
and Step-down area were included in the study (universal sampling).
Similarly, all the parents of the high risk neonates who were admitted
to outborn NICU and met the inclusion criteria as per the Government of
India guidelines for ROP screening [7] were included consecutively in
the study after taking informed consent. Data of 345 neonates was
analyzed to assess the ROP screening rate.
In the baseline phase, QI team met once a week. This
phase dealt with process mapping and collection of baseline data.
Process mapping was to understand and document the existing protocol for
identification, counselling about ROP and discharge of high risk NICU
graduates (Web Fig. 1). The baseline data
included existing ROP screening rate, knowledge of neonatal nurses
regarding ROP using a self-designed questionnaire, awareness regarding
ROP among parents of LBW/preterm infants using a self-designed
questionnaire. The QI team discussed the bottlenecks in the existing
protocol and barriers in implementing the suggested improvement
strategies. A fish bone analysis for various factors determining ROP
screening rate was analyzed (Web Fig. 2)
The questionnaire for testing the knowledge of
nursing staff was a self-administered questionnaire. It had eight
factual, closed-ended questions covering various aspects of ROP, like
eligibility criteria for screening, risk factors for ROP, age of first
screening, etc. Each correct answer was given a score of +1 while wrong
answer got 0 (maximum score +8 and minimum 0). It was pretested on four
nurses and modified based on their feedback. Likewise, the questionnaire
for assessing the awareness of parents was also a self-administered
questionnaire. It had four dichotomous (Yes/No) questions and one
semi-open ended question. Each Yes was given +1 while No was given 0
(Maximum positive response +5 and minimum 0). It was pre-tested on ten
parents and modified accordingly.
ROP screening rate (expressed as %) was defined as
number of neonates coming for first ROP screening (at four weeks
post-natal age) out of total neonates requiring ROP screening [7]. For
the baseline ROP screening rate, retrospective data of 6 months was used
(January 2017 to June 2017). In the intervention phase, change ideas
that came out of fish bone analysis were introduced into the system.
Each change idea was tested using small PDSA (Plan-do-study-act) cycles.
Adaptations were made in the change ideas and then they were
implemented.
After baseline phase, we concluded that training of
nurses and counselling of parents was required. For training of nurses,
PDSA cycle was done involving four nurses over a period one week.
Training material was prepared by the QI team. Each one of them was
trained shift-wise at their place of duty (outborn NICU and step-down
area). They were individually explained and written material was given.
Posters were displayed at appropriate points. Based on PDSA learnings,
changes in the training process and training material were made and
implemented on rest of the nursing staff.
Similarly, for counselling of parents, we conducted
PDSA cycle. The method of counselling was demonstrated to the nursing
staff. Initially, it was decided that counselling will be done in
outborn NICU. This was tested for one week. Feedback was taken and we
learned that nursing staff was not able to counsel the parents in the
NICU due to the workload. So, place of counselling was shifted to step
down area. It was also decided to conduct counselling twice to reinforce
the importance of ROP screening (first at the time of transfer to step
down and second at the time of discharge).
Two days per week were fixed as days of ROP screening
because it helped the QI team keep a track of neonates who required
screening and it was more convenient for ophthalmology department, as
per their feedback. Guidelines were displayed in the Neonatal high-risk
clinic. A neonatal nurse was assigned as ROP nurse so as to supervise
the new system, collect feedback from nurses and parents, motivate the
staff and monitor the screening rate fortnightly. A separate register
for ROP was made in the step- down area. All details of infants that
required ROP screening were entered in that register including number of
counselling sessions, date of screening and phone number.
Finally, following changes were made in the system:
(1) training of neonatal nurses; (2) counselling of parents; (3) fixing
the place and time of counselling; (4) fixing the day of ROP screening;
(5) pupillary dilation for ROP screening within the same premises; (6)
displaying the guidelines for ROP screening in neonatal high risk clinic
(NHRC) and on follow-up sheet of neonates; (7) assigning a ROP nurse;
and (8) pre-registration of neonates for ROP screening.
Post-intervention/sustenance phase dealt with
reinforcement, monitoring, feedback, training of new staff by the ROP
nurse. Data for ROP screening rate, knowledge of nurses, and awareness
of parents about ROP after the intervention was also collected. QI team
meets once in two months to collect feedback from all stakeholders and
to make any further changes in the system, if required.
Results
In the pre-intervention phase, there was no uniform
counselling, screening and discharge protocol for ROP (Web
Fig. 1). Knowledge of nurses regarding ROP was deficient
(median score of 5 on an 8 point questionnaire). They were not aware
about identifying which neonates required ROP screening (Web
Table I). Parents had poor awareness regarding ROP and
hence did not understand the need for screening (median positive
response of 1 out of 5 on the questionnaire). Only 2.4% (1/42) parents
knew about ROP (Web Table II) while 81% (34/42) parents
knew about breastfeeding and 64.3% (27/42) knew about Kangaroo mother
care. This was because of a pre-existing counselling protocol for
breastfeeding and Kangaroo mother care. Baseline ROP screening rate was
10.7% (16/149).
After the intervention, a new protocol for
counselling and screening was formed (Web Fig. 1).
Nursing staff were now aware about ROP (median score of 8 on a 8- point
questionnaire); 97.5% nurses correctly answered about the screening
criteria of ROP (Web Table I). Also, the median positive
response of parents on the questionnaire increased to 5 out of 5 and
78.7% (37/47) parents knew about ROP after the intervention (Web
Table II). ROP screening rate during the period of
intervention was 45.5% (21/46) .
Web Fig. 3 shows the time-run chart for ROP
screening rate in the intervention phase. After training of nursing
staff and effective counselling of parents, ROP screening rate started
to rise. The two dips in sceening rate were handled by change in place
of counselling and assigning an ROP nurse (Web Fig. 3).
ROP screening rate in the post intervention phase was 87.3% (131/150).
Screening rate increased from 36% at the start of intervention to 94.7%
at the end of post-intervention phase.
Discussion
Parental awareness regarding ROP is crucial to
successful ROP screening and follow-up. Vinekar, et al. [3]
showed that improving awareness of parents can result in improved ROP
follow-up rate.
All this could be achieved as the learning points for
the nursing staff and counselling points for parents prepared by QI team
were made objective and easy to understand and recall. Simplification of
the material was possible because of small PDSA (Plan-do-study-act)
cycles which were tested in a smaller group of 2-3 nursing staff and
parents before implementation.
The limitations of the study include lack of
pre-study data, only outborn NICU graduates, unvalidated questionnaires,
and a short duration sustenance phase of only seven months.
The existing process flow was re-engineered to form a
new process flow. The revised process flow also helped substantially in
ensuring effective counselling and prevented any additional workload to
the existing nursing work-schedule. The nursing staff also had a sense
of empowerment and satisfaction in being able to effectively communicate
with the parents about ROP, which may have played a major role in
sustaining the changes.
The most important barrier we faced while
implementation of a new system was that certain staff members were rigid
to change. This was tackled by motivating them, explaining them the
importance of ROP screening and sharing with them the success stories of
other QI projects. Inter-departmental coordination was another
challenge. This was overcome by including ophthalmology resident and
nurse in the team. There active participation improved the coordination.
QI method helped us in significantly improving
parental awareness, knowledge of nurses and ROP screening rate in a
short interval of time without additional resources and manpower. This
shows that small PDSA (Plan-do-study-act) cycles can yield good results
within the existing system. Our study proves that point of care quality
improvement methods can be successfully used to improve the health care
delivery system in a resource-limited setting.
