Posted by Duncan Maru, MD, PHD
So often in our work we are confronted by our own inadequacies as a young global health organization — at fundraising, recruiting volunteers, following through on commitments, developing protocols, getting technologies out to Achham. These are felt every moment of every day when we offer less than the highest level of care to our patients. But there are times that place these inadequacies into sharp, devastating relief. The recent death of an infant girl coming back to us essentially dead on arrival, likely from overwhelming sepsis, only hours after she was discharged from the Bayalpata hospital, was one of those moments.
The mortality review below was led by Dr. Sona Shilpakar, MD, one of Nyaya Health’s volunteer physicians who was part of the team providing care for this infant. The primary concern of this mortality review is the management at the time of resuscitation and during her initial hospitalization, since that is likely where the causal pathway leading to her death started and since she was very nearly already dead by the time of her second presentation to Bayalpata Hospital. Postnatally, the baby had been listless and blue and required extensive resuscitation. There were delays in the baby receiving oxygenation, hydration, and antibiotics. We identified several critical systems-levels errors, including lack of formal neonatal resuscitation protocols, lack of appropriate equipment testing and location prior to deliveries, and lack of appropriate discharge evaluation and criteria. The clinical details of the case are provided at the link below.
The primary needs we will pursue as a result of this case:
- We will develop formal guidelines for neonatal resuscitation.
- We will develop a clear protocol on neonatal sepsis.
- Prior to discharge from Bayalpata Hospital, all infants should have a thorough physical exam including evaluation of feeding and documentation of passage of stool and urine. Strict discharge criteria should be made, and the period of observation should be liberalized.
- All deliveries should have oxygen with ambu bag-mask and suction available, and these should be tested by the individual leading the postnatal care of the infant.
- We will continue to work to identify how outreach workers can ensure follow-up of sick infants, perhaps through a roaming community health worker for those patients in whom a local CHW is not available.
- We will investigate whether the new cellular CDMA signal can be utilized for on-call staff, or whether walkie-talkies should be purchased.
We hope to update our readers as to the progress we have made in the care of the neonate over the coming months.
CLICK HERE FOR FULL TEXT OF THE MORTALITY REVIEW
Note: this report is a part of our “Comprehensive Morbidity and Mortality Review” initiative aimed at cataloguing and reflecting on the underlying causal pathways in cases of excess morbidity or mortality. This work is supported in part by a grant from the Lovejoy Foundation at Children’s Hospital Boston, Massachussetts, USA.
