Posted by Duncan Maru, MD, PHD
Nyaya Health is undertaking an innovative experiment in operations management by reviewing all deaths that occur at the Bayalpata hospital and identifying systems-level changes to prevent future deaths. Programs aimed at assessing the root causes of deaths can help to assess effectiveness and can identify programmatic weaknesses. Implementing such programs in rural, resoure-poor settings, however, is challenged by a lack of training programs, financial resources, and successful models. Nyaya Health is working to change that, building off our organizational strengths of rigorous data collection and analysis, telemedicine collaboration, and open-source programming.
Nyaya’s mortality review program aims to answer the following questions for each death. Why did the death happen? What was the immediate cause? What role, if any, did or could have been played by community health workers? By clinic staff? What are the underlying comorbid conditions suffered by the patient? What are the underlying public health and socioeconomic conditions that coalesced to lead to the death? What concrete steps can be taken to immediately help the families affected by the death? What are some long-term solutions that we need to think about? The main domains involve:
- operations– issues in patient flow, intake, processing or review of lab or pharmaceutical requests;
- supply chain– issues in obtaining a reliable supply of medicines, supplies, or equipment;
- equipment — issues in the functioning or quality of equipment, medical devices, and machines;
- personnel– issues pertaining to staff training, professionalism, management, or collaboration;
- outreach– issues in recruiting and engaging patients into timely and appropriate medical treatment;
- societal– issues in gender, caste, economic, or other forms of discrimination;
- structural– issues in roads, communications, educational facilities, and healthcare infrastructure
Consistent with Nyaya’s overall approach to transparent operations and open-source data management, we post the results of our mortality review program on our blog and on our wiki. After starting the program this September, our first two mortality reviews are summarized below; links are provided to the full discussions on our wiki’s mortality program page.
Case 1: Collapse and Demise in a Village 24 Hours from the Hospital
A 60 year old man died in the field five days after presenting to the hospital after a snake bite and being ruled out by our clinical team for serious medical conditions. He had presented to the hospital with a snake bite on his leg a day prior but otherwise doing well, and had walked 24 hours to reach the hospital. At the time, there had been a shortage of snake anti-venom from the central government supply, and the clinical suspicion for snake envenomation was low given his well and stable appearance. It was noted at the time that he had a serious problem with alcohol abuse. He was discharged from the hospital, walked home, and resumed work as an ironsmith. He subsequently had a cardiac arrest five day after his hospital admission and was brought dead on arrival to the hospital. The main question: what are the likely causes of death, and were there modifiable risk factors that we could have intervened upon to have prevented this outcome?
Summary Evaluation and Response:
It is possible that this sad and devastating death could have been prevented by a more effective community-based medical response system that is not yet available in the district. There were no obvious gaps in the care delivered at the hospital other than possibly a lack of capacity in addressing alcohol misuse and the dangers of alcohol withdrawal. A key logistics problem emerged in the supply chain of non-expired snake anti-venom from the government, although this is likely incidental to the case since it is highly unlikely that snake envenomation was the cause of this man’s demise.
Case 2: Death of a Four-month Old
A 4 month old girl, discharged from the Bayalpata hospital seven days previously on amoxicillin for presumed pneumonia, returned to the hospital from her village two hours away with severe breathing difficulty. The child had been well until seven days prior, when she developed cough and fever and was brought to the hospital. There she was diagnosed with pneumonia and prescribed amoxicillin by Nyaya staff. In the interim period, the child did not get better, and her parents brought her to a local lay practitioner and a faith healer. On arrival back to the Bayalpata hospital, the baby was irritable, respiratory rate was 70 with severe retractions. The Nyaya team started oxygen by face mask, ceftriaxone, and IV hydrocortisone. Within ten minutes of initiating therapy, however, the child stopped breathing and was pulseless. Resuscitation with bag mask ventilation was unsuccessful.
The fundamental issue with this case was not the acute management of septic shock, which was handled appropriately given the current lack of intensive care unit level care. Rather, the main preventable systems issue was the lack of follow-up of a child with pneumonia who presented originally to the Bayalpata hospital and died seven days later.
Summary Evaluation and Response:
The primary systems issue that likely contributed to this tragedy was the lack of follow-up for a child originally hospitalized and treated for pneumonia. To prevent similar deaths from occurring in the future, Nyaya Health will undertake the following systems-level changes:
1] All children under the age of six months or under the age of five years with any signs/symptoms of malnutrition and treated for pneumonia will remain in the hospital for a 24-hour observation period to assess clinical response. This is of course in addition to clinician assessment of acutely sick children, which may warrant extended hospitalization.
This is not a trivial measure, owing to the risks of infectious disease transmission in hospital settings. However, the risks of outpatient treatment of the under-six-month old with pneumonia in a setting where patients typically travel several hours to reach the hospital, and use non-licensed practitioners extensively, outweigh the risks of inpatient treatment.
2] Nyaya will continue to work with our existing community health workers to follow-up all children under the age of five years old who are diagnosed with pneumonia, to identify signs and symptoms of clinical failure to antibiotics.
3] Nyaya will work on improving our outcomes monitoring of pneumonia, to better assess programmatic effectiveness.
4] Nyaya will identify strategies to improve adherence to medicines for patients discharged from the hospital.