Reducing hypothermia in newborns admitted to a neonatal care unit in a large academic hospital in New Delhi, India

Abstract

Neonatal hypothermia is a common and dangerous condition around the world. 70% of neonates born in Kalawati Saran Children’s Hospital in New Delhi, India, and subsequently admitted to the neonatal intensive care unit (NICU) had a temperature below 36.5°C on admission. In July 2016, we formed a team of staff from the labour room, NICU and auxiliary staff to reduce hypothermia in babies transported to our NICU using quality improvement methods. We identified problems related to staff awareness of hypothermia and its dangers, environmental factors and supply issues in the labour room, and challenges with rapidly and safely transferring sick newborns to the NICU. We used the Plan-Do-Study-Act cycles to test and adapt solutions to these problems. Because infection is a common complication of hypothermia, we also instituted a training programme to improve handwashing skills among parents and health workers. Within 9 months of starting our quality improvement project, the proportion of neonates who were normothermic on admission increased from 27% to 75%, the number of cases of late-onset neonatal sepsis decreased from 15.2 to 5 cases/1000 patient days, and all-cause mortality fell from 4.2 to 2.6 neonatal deaths per week. Multiple factors can lead to neonatal hypothermia, and the most important factors will differ from facility to facility. Quality improvement methods provide health workers with the skills to identify the key factors contributing to hypothermia in their facility and to develop strategies to address them. Addressing processes of care can lead to improved thermal care and save lives.

Modifiable and Nonmodifiable Factors Contributing to Hypothermia Among High Risk Neonates at Admission to NICU—A Prospective Observational Study

“…In another study done in North India, Datta et al 19 found that of all the NICU admissions, only 30% of neonates had body temperature in normal range at time of admission to NICU. Other investigators, both from developed world and developing countries, also have reported high incidence of admission hypothermia.…”

“…Use of polyethylene cling wraps, use of caps at delivery, increasing labor room temperature, use of radiant warmer to receive the infant, and education of the staff are the common interventions attempted to improve admission temperature. [14][15][16][18][19][20] However, considering the need for delayed cord clamping and inability to use heat loss barriers for all infants at birth, the need of higher DR temperature to prevent subsequent hypothermia should be emphasized. The fear among the obstetricians, of excessive sweating and increased infections rates, when DR temperature is in the recommended ranges needs to be tested to improve compliance on DR temperatures.…”

Combining bottleneck analysis and quality improvement as a novel methodology to improve the quality of neonatal care in a northeastern state of India: a feasibility study

“…These methods have also been found to be effective in India. 28 , 29 Based on our experience of using the F-BNA tool to identify problems and QI methods to address these problems, we propose that this methodology can help in the identification of health system bottlenecks at the facility level, their prioritisation, and improvement in these key areas. This methodology is of prime importance in low- and middle-income countries (LMICs) where resource constraints are a constant problem.…”

Disposable low-cost cardboard incubator for thermoregulation of stable preterm infant – a randomized controlled non-inferiority trial

“…Maintaining normothermia (36.5 to 37.5 °C) in neonates from delivery room till discharge, and ensuring thermoregulation at discharge is recommended by the World Health Organization (WHO) and other organizations [2] , [21] , [22] . Hypothermia increases the risk of respiratory distress, hypoglycemia, sepsis and pulmonary hemorrhage in preterm infants [23] , [24] , [25] , [26] , [27] . Despite providing respiratory support and surfactant, prolonged hypothermia in preterm infants increases the mortality for respiratory distress syndrome [26] .…”

“…Although observational studies show admission-hypothermia as risk factor for mortality in preterm infants [28] , [29] , [30] , meta-analyses of interventions to decrease admission-hypothermia did not show improved survival [23] . Preventing admission-hypothermia is a key-driver to improve survival of preterm infants in quality improvement studies [27] , [31] , [32] .…”