Mortality Audit Research Articles

Surgical interhospital transfer mortality: national analysis.

Interhospital transfers of surgical patients are an independent risk factor for mortality. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) aims to improve surgical care through assessment of all cases of surgical mortality. This study aimed to describe common clinical management issues that contributed to interhospital transfer patient mortality. Data for all surgical patient mortality in Australia (except New South Wales) that underwent interhospital transfer between 1 January 2010 and 31 December 2019 were extracted from ANZASM. The surgeons' reports and assessors' evaluations were examined to identify clinical management issues. Thematic analysis was performed to develop pertinent themes and subthemes. Some 8679 patients were identified over the 10-year period. Of these, 2171 (25.0 per cent) had 3259 clinical management issues identified. Prominent themes were operative design (n = 466, 14.3 per cent), decision to operate (n = 425, 13.0 per cent), medical conditions (n = 344, 10.6 per cent), diagnosis (n = 326, 10 per cent), transfer (n = 293, 10.0 per cent), intraoperative issues (n = 278, 8.5 per cent), inadequate assessment (n = 238, 7.3 per cent), communication (n = 224, 6.9 per cent), delay in recognizing complications (n = 180, 5.5 per cent), coagulopathy (n = 151, 4.6 per cent), insufficient monitoring (n = 127, 3.9 per cent), infection (n = 107, 3.3 per cent), and hospital resources (n = 100, 3.1 per cent). Assessors considered 58.4 per cent of clinical management issues (n = 1903) probably or definitely preventable. This study identified 13 themes of potentially avoidable management issues present in surgical mortality following interhospital transfers. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes.

Deaths among tuberculosis patients of the western state of India: A secondary record based analytical study on its determinants

IntroductionIndia has a significant TB burden, and ongoing attempts are being made to eradicate the disease. Globally, the number of TB deaths is declining, but not quickly enough to meet the End TB Goals. The National Strategic Plan (NSP) 2017–2025 in India set in motion an ambitious effort to expand the scope and efficacy of the National Tuberculosis Elimination Program (NTEP). MethodsA descriptive retrospective study based on secondary data was conducted on information obtained from the electronic TB notification register for 2019, abstracted from Ni-kshay. Further, descriptive analysis was undertaken to identify the factors associated with deaths and successful treatment outcomes. The binomial logistic regression model estimates the crude relative risk and a 95% confidence interval to describe the association between predictor variables and TB treatment outcomes. ResultsAfter applying the eligibility criteria for the study population, a total of 1,44,643 (88%) TB patients were included in the study. 1,35,934 (94%) TB patients had completed the treatment and survived, while 8709 (6%) TB patients died. A significant association of treatment outcomes was observed in age, gender, key population, site of diseases, type of case, type of health facilities, HIV and Diabetes. When a logistic regression was applied, the model showed the association of the independent variables with the risk of death in TB patients. ConclusionThe epidemiological factors associated with treatment outcomes among TB patients should be audited systematically. A structure of TB death surveillance and response system should be established with a mortality audit, including a community-based death review (CBDR) and a facility-based medical audit (FBMA) in case the patient is hospitalized or discharged from a hospital.

44-year temporal trends and causes of maternal mortality at the Lagos University Teaching Hospital, LUTH, Lagos, Nigeria (1976-2019).

Nigeria has committed to global initiatives aimed at improving maternal and child health. Institutional audit of maternal mortality over a long period can provide useful information on the trends in maternal death and the impact of interventions. To evaluate the trends in annual deliveries, maternal mortality ratio and causes of maternal death at a tertiary institution in Nigeria over a period of 44 years (1976-2019). We conducted a temporal trend analysis of annual births, maternal deaths, maternal mortality ratio (MMR), and ranking of causes of maternal deaths at a Teaching Hospital, in Southwest Nigeria using available data from 1976 to 2019. Overall and segmental annual percent change (APC) of the observed trends were conducted using Joinpoint version 4.5.0.1 software. Over the 44-year study period, 1323 maternal deaths occurred at approximately 30 maternal deaths per annum. There was a four-fold increase in MMR from 881/100,000 total births in 1976 to 3389.8/100,000 total births in 2019, at an average increase of 3.1% per annum. (APC: 3.1%; P value < 0.001). The leading causes of maternal mortality were hypertension, sepsis, haemorrhage, and abortion, which together contributed to more than 70% of maternal deaths. All the leading causes of maternal deaths except abortion had constant ranking during the study period. The four-fold increase in MMR at our hospital from 1976-2019 is worrying and may suggest that previous efforts at reducing maternal mortality in our institution did not lead to significant improvement toward the attainment of Sustainable Development Goal 3 (SDG3). The hospital increasingly managed complex cases especially the unbooked patients who were referred to the hospital as a last resort.

Retrospective Analysis of Mortality in a Tertiary Care Teaching Hospital in South India

Introduction: Mortality data reveals much about the health of the population. Traditionally and universally,most epidemiological studies begin with mortality data. Mortality characteristics and the audit give a myriad ofinformation. This helps to identify trends of mortality. Mortality audit of mortality data is essential to improvehospital services and helps in proper allocation of resources. Hence this study was conducted to identify themortality characteristics of the patients admitted in the year 2021 in the Tertiary care hospital in South India.Material and Methods: This retrospective study was conducted after Institutional ethical clearance with mortalityrecords pertaining to the patients admitted to Hangal Sri Kumareshwar Hospital and Medical Research Center,Bagalkot, Karnataka during the year 2021. The data retrieved included demographic characteristics like ageand sex, place of residence, ward of admission and causes of death classified according to ICD 10th revision andanalysed using percentages and chi-square test and a p value of less than 0.05 was considered as significant in allthe tests.Results: Out of 592 deaths in 2021, 64.19% were males and 35.81% were females. Majority of the deaths (34.46%)occurred between the ages of 41 to 60 years followed by 61 to 80 years (27.20%). Communicable diseases contributedto 54.56% of the total deaths (p= 0.0022).Conclusion: Statistical analysis of causes of death from mortality statistics is the backbone of National healthpolicy and planning of health programs. It monitors the trend in public health issues like infant mortality, maternalmortality, infectious diseases, accidents and suicides.

Current approach and attitudes toward neonatal near-miss and perinatal audits: An exploratory international survey.

Combined with perinatal mortality review, neonatal near-miss (NNM) audit has the potential to inform strategies to better prevent adverse perinatal outcomes. Nonetheless, there is lack of standardised definitions of NNM and limited evidence of implementation of NNM audits. To describe definitions of NNM and assess current approaches and attitudes toward perinatal mortality and morbidity audit. Online survey from December 2021 to February 2022, with a mix of Likert scales, polar, pool, multi-choice, and open-ended questions, disseminated through national and international organisations to perinatal healthcare workers from high-income countries. One hundred and twenty participants came from Australia (n=86), New Zealand (n=18), Canada (n=7), USA (n=4), Netherlands (n=2), other countries (n=3). Neonatologists (35%), midwives (21.7%), obstetricians (12.5%), neonatal nurse practitioners (11.7%) and others (23.3%) responded. Most respondents thought the main characteristics to define NNM were birth asphyxia needing therapeutic hypothermia (68.3%), unexpected resuscitation at birth (67.5%), need for intubation/chest compression/adrenaline (65.0%) and metabolic acidosis at birth (60.0%). There were 97.5% of participants who considered NNM important for identifying cases for perinatal morbidity audits. However, only 10.0% of their institutions used a NNM definition. Overall, 98.4% of participants considered perinatal mortality and morbidity audits important to prevent adverse outcomes. Neonatal near-miss audit is viewed as a valuable tool to reduce adverse neonatal outcomes. There was reasonable consensus that NNM encompassed evidence of birth asphyxia and/or advanced neonatal resuscitation. Data from this international survey identifies a starting point for a consensus definition of NNM, which can be used for perinatal audits to identify opportunities for improvement.

Status of patient safety in selected Ghanaian hospitals: a national cross-sectional study

BackgroundSafety is one of the dimensions of healthcare quality and is core to achieving universal health coverage and healthcare delivery worldwide. In Ghana, the status of patient safety in the...

Mortality audit of COVID-19 infection among children.

As severe COVID-19 and mortality are not common in children, there is a scarcity of data regarding the cause of mortality in children infected with SARS-CoV-2. This study was aimed to describe the all-cause mortality and COVID-19 death (disease-specific mortality) in children with SARS-CoV-2 infection admitted to a paediatric COVID facility in a tertiary care centre. Data with respect to clinical, epidemiological profile and causes of death in non-survivors (0-12 yr old) of SARS-CoV-2 infection admitted to a dedicated tertiary care COVID hospital in north India between April 2020 and June 2021 were retrieved and analyzed retrospectively. A total of 475 SARS-CoV-2-positive children were admitted during the study period, of whom 47 died [18 neonates, 14 post-neonatal infants and 15 children (1-12 yr of age)]. The all-cause mortality and COVID-19 death (disease-specific mortality) were 9.9 per cent (47 of 475) and 1.9 per cent (9 of 475), respectively. Underlying comorbidities were present in 35 (74.5%) children, the most common being prematurity and perinatal complications (n=11, 24%) followed by congenital heart disease (n=6, 13%). The common causes of death included septic shock in 10 (21%), COVID pneumonia/severe acute respiratory distress syndrome in nine (19%), neonatal illnesses in eight (17%), primary central nervous system disease in seven (15%) and congenital heart disease with complication in six (13%) children. Our results showed a high prevalence of underlying comorbidities and a low COVID-19 death (disease-specific mortality). Our findings highlight that mortality due to COVID-19 can be overestimated if COVID-19 death and all-cause mortality in children infected with SARS-CoV-2 are not separated. Standardized recording of cause of death in children with SARS-CoV-2 infection is important.

The Hazard of Dying Before Five Years among Children Born To HIV-Positive and HIV-Negative Mothers in Botswana: A Five-Year Retrospective Study

Background: Our previous study suggested that factors affecting the hazard of dying among under-five children (UFC) born to HIV-positive mothers in Botswana depended on many factors such as maternal and child biomedical and sociodemographic characteristics. Identification of such characteristics and those that enhance/reduce the hazard of UFC-death and the strength of their association with the event is critical for an effective response. We aim herein at addressing these issues. Methods: This was a 5-years retrospective cohort study of mortality among UFC in Botswana. Data were extracted from the National Under-Five Mortality Audit Committee (NUFMAC) and analyzed using UFC-death as event and time in months. UFC feeding methods and immunization were treated as time dependent factors, age at death as a continuous-time variable; UFC-HIV status was treated as time fixe variable as all HIV-positive UFC in the study were positive at birth, none of them became positive through breastfeeding. Adjusted hazard ratios (AHRs) and their 95% CIs were computed. The Hazard functions for UFC born to HIV-positive and HIV-negative mothers were plotted and compared. Results: UFC born to HIV-positive mothers were more likely to die than UFC born to HIV-negative mothers. While UFC’s HIV-positive status, prematurity/gestational age &lt;28 weeks, pneumonia, septicaemia, birth asphyxia and malnutrition independently enhanced the hazard of UFC-death, mixed feeding and immunizations reduced UFC’s hazard of dying. Conclusion: Although the country has commendable prevention of mother-to-child transmission programs, the fact that UFC born to HIV-positive mothers still have almost twice the hazard of dying than their counterpart calls for urgent public health action. New strategies focussing on UFC born to HIV-positive mothers are imperative to improve the survival of UFC in general, given the high proportion of UFC born to HIV-positive mothers in this setting.

Unexpected deaths after endocrine surgery: learning from rare events using a national audit of surgical mortality.

The mortality rate is low in endocrine surgery, making it a difficult outcome to use for quality improvement in individual units. Lessons from population data sets are of value in improving outcomes. Data from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) were used here to understand and elucidate potential systems issues that may contribute to preventable deaths. ANZASM data relating to 30-day mortality after thyroidectomy, parathyroidectomy, and adrenalectomy from 2009 to 2020 were reviewed. Mortality rates were calculated using billing data. Thematic analysis of independent assessor reports was conducted to produce a coding framework. A total of 67 deaths were reported, with an estimated mortality rate of 0.03-0.07 per cent (38 for thyroidectomy (0.03-0.06 per cent), 16 for parathyroidectomy (0.03-0.06 per cent), 13 for adrenalectomy (0.15-0.33 per cent)). Twenty-seven deaths (40 per cent) were precipitated by clinically significant adverse events, and 18 (27 per cent) were judged to be preventable by independent ANZASM assessors. Recurrent themes included inadequate preoperative assessment, lack of anticipation of intraoperative pitfalls, and failure to recognize and effectively address postoperative complications. Several novel themes were reiterated, such as occult ischaemic heart disease associated with death after parathyroid surgery, unexpected intraoperative difficulties from adrenal metastasis, and complications due to anticoagulation therapy after thyroid surgery. This study represents a large-scale national report of deaths after endocrine surgery and provides insights into these rare events. Although the overall mortality rate is low, 27 per cent of deaths involved systems issues that were preventable following independent peer review.

Health System- and Patient-Related Factors Associated with COVID-19 Mortality among Hospitalized Patients in Limpopo Province of South Africa's Public Hospitals.

South Africa has recorded the highest COVID-19 morbidity and mortality compared to other African regions. Several authors have linked the least amount of death in African countries with under-reporting due to poor health systems and patients’ health-seeking behaviors, making the use of clinical audits more relevant for establishing the root causes of health problems, and improving quality patient care outcomes. Clinical audits, such as mortality audits, have a significant role in improving quality health care services, but very little is documented about the outcomes of the audits. Therefore, the study sought to determine the health care system and patient-related factors associated with COVID-19 mortality by reviewing the COVID-19 inpatient mortality audit narration reports. This was a retrospective qualitative research approach of all hospitalized COVID-19 patients, resulting in death between the first and second COVID-19 pandemic waves. Thematic analysis employed inductive coding to identify themes from mortality audits from all 41 public hospitals in Limpopo Province, South Africa. Four themes with seventeen sub-themes emerged: sub-standard emergency medical care provided, referral system inefficiencies contributed to delays in access to health care services, the advanced age of patients with known and unknown comorbidities, and poor management of medical supplies and equipment, as a health system and patient-related factors that contributed to the high mortality of COVID-19 patients. There is a need to routinely conduct clinical audits to identify clinical challenges and make recommendations for health promotion, risk communication, and community engagement. We recommend reviewing and expanding the scope of practice for health-care providers during epidemics and pandemics that include aspects such as task-shifting.

Audit of in-hospital mortality by age and time-of-day among patients presenting to a low-resource Ugandan hospital

Introduction: Admission to hospital outside of normal working hours is consistently associated with poorer patient outcomes. Our aim was to determine the association of patients’ age and time of presentation to a low-resource Ugandan hospital with admission rate and in-hospital mortality.Method: Prospective observational non-interventional audit in the emergency and outpatient departments of Kitovu Hospital in Uganda, a low-resource sub-Saharan hospital. Data on age, sex, time of admission was collected from all non-pregnant patients during 2020 and 2021, and outcomes analysed.Results: Out of 17,133 patients who presented to the hospital 189 died in hospital (1.1% of all presentations and 7.9% of all admissions); 46 (24.3%) patients died within 24 hours of arrival (0.3% of all presentations and 1.9% of all admissions). Deaths within 24 hours of arrival in hospital were more likely in the very young and the old, and in those who presented at night and on the weekend.Conclusion: As many in-hospital deaths occur shortly after arrival, resuscitation skills are needed even in low-resource settings for as much of the 24-hour day as possible.

Analysis of surgical mortality in rural South Australia: a review of four major rural hospital in South Australia.

BackgroundOne‐third of Australia's population reside in rural and remote areas. This audit aims to describe all‐causes of mortality in rural general surgical patients, and identify areas of improvement.MethodsThis is a retrospective multi‐centre study involving four South Australian hospitals (Mt Gambier, Whyalla, Port Augusta, and Port Lincoln). All general surgical inpatients admitted from June 2014 to September 2019 were analysed to identify all‐cause of mortality.ResultsA total of 80 mortalities were recorded out of 26 996 admissions. The overall mortality rate of 0.3% was the same as the 2020 Victorian state‐wide Audit of Surgical Mortality. No mortality was secondary to trauma. Mean age was 79 ± 11 years and ASA was 3.9 ± 1. Malignancy was associated in over a third of cases (41.2%), mostly colorectal and pancreatic. Most cases were related to general surgical subspecialties: colorectal (51.3%), upper gastrointestinal (21.3%), hepatopancreaticobiliary (13.8%); however, there were also vascular (6.3%) and urology (3.8%) cases. The most common causes of mortality were large bowel obstruction (13.4%), ischemic bowel (10.4%), and small bowel obstruction (7.5%). Majority of mortality were beyond the surgeon's control (73.8%). Of the 21 potentially preventable mortalities, 42.9% were attributed to aspiration pneumonia and decompensated heart failure. Only one (1.3%) mortality case was due to pulmonary embolism.ConclusionRural general surgical mortalities occur in older, comorbid patients. Rural surgeons should be equipped to manage basic subspeciality conditions. To further reduce mortalities, clear protocols to prevent aspiration pneumonia and resuscitation associated fluid overload are needed.

Surgical inter‐hospital transfers: life saver or resource drainer?

As to diseases, make a habit of two things – to help, or at least to do no harm. The Hippocratic Corpus1 IHTs may be necessary for multiple reasons. These include lack of appropriate resources at the index hospital, higher acuity of care requirement, or need for complex multidisciplinary specialist care to ensure adequate patient management.4, 9 The process of IHT is complicated, requiring effective dialogue between the referring and receiving teams to ensure pertinent clinical information is communicated and patient-specific needs relayed.8, 10 Each transfer requires individualized shared decision making with patient safety and medical stability foremost in mind, taking into consideration the indication for transfer, capabilities of the health-care settings, distance and mode of transportation.10 The inherent intricate nature of the transfer process highlights the importance of having a robust, repeatable and dependable system to ensure optimal patient outcomes. This need has become increasingly apparent in recent years due to the trend of increasing preoperative IHT of surgical patients.11 This is likely due to increasing specialization of urban hospitals and the increased resource demands associated with sophisticated preoperative and intraoperative care.4, 12 However, there is limited evidence on the widespread benefits of surgical IHTs. Many groups of transferred surgical patients have poorer outcomes compared to their non-transferred counterparts, including increased hospital admission length, healthcare costs and in-hospital mortality.9, 13 Transferred patients have twice the associated health-care costs and three times the in-hospital mortality compared with their non-transferred counterparts.9, 13 These poorer outcomes have been demonstrated in a range of surgical pathologies and specialties.5-9 Proposed contributing factors relate to patients (e.g. older age, lower SES), disease (e.g. life-threatening illness) and transportation (e.g. mode of transport, distance travelled).9 Postponement of surgery due to delay in transfer or increased preoperative transfer time due to remoteness of the referring hospital is a major contributor to poorer surgical outcomes.5-7 There are several proposals to address and overcome the barriers associated with effective IHTs. Utilizing an appropriate mode of transportation concordant with the distance needing to be traversed, the geography of the region, the equipment and expertise of available transfer crew, and the medical stability of the patient have been shown to improve survival.10 Developing a systematic and rigorous health information exchange and handover system between facilities improve patient outcomes by ensuring accurate and up-to-date patient clinical data and diagnosis is available.10 The presence of specialized and experienced staff during transfer has also been shown to reduce transport morbidity.4 Patients with myocardial infarction or stroke experience improved outcomes following IHTs, likely due to standardized transfer protocols and expedited interventions.9 These success stories demonstrate the potential positive consequences of effective IHTs. Particularly in the dynamic climate of COVID-19, an evidence-based approach must be utilized to improve IHTs in Australia.14 There remains a need for further investigation into factors affecting the negative trajectory of surgical patients that undergo IHTs. It is imperative that factors resulting in futile transfers are identified to ensure best patient care and that scarce regional resources are not squandered. A national surgical audit database, such as the Australian and New Zealand Audit of Surgical Mortality, captures data from all surgical mortality in Australia and may play a key role in discovering relevant avoidable factors contributing to patient mortality during IHT.15 Recent reviews of this data identified that IHTs were involved in up to 30% of cases of surgical mortality11. IHTs to provide necessary patient care is inevitable due to the unique challenges of the Australian geography, population density and health-care system. Current evidence demonstrates that IHTs are an independent risk factor for mortality in surgical presentations. Avoidable transport-associated factors have been identified, however the current rate of mortality in IHT suggest further research into attributable factors should be performed to minimize patient harm and reduce surgical mortality. IHTs have the potential to be a lifeline for the unwell surgical patient, and careful planning is imperative to ensure it is not an unintended resource drainer. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. Ishraq Murshed: Conceptualization; investigation; writing – original draft; writing – review and editing. Aashray K. Gupta: Conceptualization; investigation; writing – review and editing. Joshua G. Kovoor: Conceptualization; investigation; writing – review and editing. Guy J. Maddern: Conceptualization; investigation; supervision; writing – review and editing.

Predictors of interhospital transfer delays in acute surgical patient deaths in Australia: a retrospective study.

Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay. Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05. After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P=0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P <0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P <0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P=0.0035). In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.

Audit of In-Hospital Mortality from a Medical Oncology and Hemato-Oncology Center with the Emphasis on Best Supportive Care.

Deepak SundriyalBackground and Objectives The newly established medical oncology and hemato-oncology center at the All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India, provided us an opportunity to audit in-hospital mortalities with a vision that the audit will serve as a standard for ceaseless improvement. Aim of the study was to initiate a vigorous process for the evaluation of all-cause mortality in patients suffering from cancer. Methods An audit of all in-hospital deaths that occurred during the year 2019 was performed, and comprehensive scrutiny of various parameters (demographic, clinico-pathological, therapeutic, causes of death) was done. Reviews from two independent observers sharpened the infallibility of the audit. The lacunae in the existing practices and the scope for further improvement were noted. Results Forty-five in-hospital deaths were registered during the study period (January-December 2019). The majority of the deaths occurred in patients with advanced stage of malignancy ([ n = 31] 68.8%). Most common causes of death were progressive disease, neutropenic, and non-neutropenic sepsis. Chemotherapeutic agents, growth factors, blood components, and antibiotics were found to be used judiciously as per institutional policy. The reviewers emphasized on the use of comorbidity indexes in the treatment planning and avoiding intensive care unit referrals for patients receiving best supportive care (BSC). Emphasis was put on providing only BSC to the patients with a very limited life expectancy. Emphasis was also laid down on record of out of the hospital deaths. Interpretation and Conclusion The audit disclosed areas of care which require further improvement. The mortality audit exercise should become a regular part of evaluation and training for the ongoing and future quality commitment. This should impact the clinical decision making in an oncology center providing quality care to the terminally ill patients.

Perinatal mortality audit in a rural referral hospital in Tanzania to inform future interventions: A descriptive study.

BackgroundClear evidence exists that perinatal audit and feedback can lead to important improvements in practice. The death audit can lead to the identification of existing potential delays which are the decision to seek medical care, reaching an appropriate facility, and receiving timely adequate care at the facility. Such an audit potentially initiates a positive discussion, which may foster the implementation of changes that aims at saving more lives.ObjectiveTo review the perinatal deaths case notes and identify potential gaps in care provision and health-seeking behavior to foster best practice.MethodsThe stillbirths and neonatal death case notes that occurred between January 2019 and May 2020 at the hospital were reviewed using an adapted WHO checklist. The completed review case notes were entered into an electronic system and a quality control check-up was done. Data were analysed descriptively, and findings were presented in tables.ResultsThere were 4,898 births, and 1,175 neonatal admissions, out of these there were 135 recorded stillbirths (2.8%) and 201(4.1% of the total hospital births) early neonatal deaths. Out of the 1,175 neonates, 635 (54%) were born within the hospital and 540 (46%) were admitted from other facilities and home deliveries. In total 86 stillbirths and 140 early neonatal deaths case notes were retrieved and audited. Out of 86 stillbirths’ case notes audited, 30 (34.9%) seemed to have died during labor, and of these 5 had audible fetal heart rate during admission. Apgar scores less than 7 at 5 minutes, prematurity, and meconium aspiration were the top three recorded causes of neonatal deaths. Inadequate/late antenatal care visits and home delivery were the maternal factors likely to have contributed to perinatal deaths. Inadequate labor monitoring (12%) and documentation (62%) were among the providers’ factors likely to have contributed to perinatal deaths.ConclusionThis audit shows that there are high rates of preventable intrapartum stillbirths and early neonatal deaths. Both women and providers’ factors were found to have contributed to the stillbirths and neonatal deaths. There is a need to encourage women to adequately attend antenatal care, utilize health facilities during birth, and improve maternity and neonatal care at the health facilities.

Facility-based stillbirth surveillance review and response: an initiative towards reducing stillbirths in a tertiary care hospital of India.

India has the highest number of stillbirths in the world in 2019, with an estimated stillbirth rate of 13.9 per 1,000 births. Towards better identification and documentation, a stillbirth surveillance pilot was initiated with the World Health Organization Southeast Asia collaboration in Northern India in 2014. This study aimed to assess whether stillbirth surveillance is feasible and whether this approach provides sufficient information to develop strategies for prevention. This study followed the framework provided in "WHO Making Every Baby Count" in which mortality audit is conducted in six steps; (1) identifying cases; (2) collecting information; (3) analysis; (4) recommending solutions; (5)implementing solutions; and (6) evaluation. A total of 5,284 births were examined between December 2018 and November 2019; 266 stillbirths were identified, giving a stillbirth rate of 50.6 per 1,000 births in a tertiary care referral hospital of northern India. Out of 266 stillbirths, 223 cases were reviewed and recommendations were formulated to strengthen obstetric triage, implementing fetal growth charts, strengthen the existing referral system and improve the communication skills of health care providers for better compliance with clinical practice guidelines. Conducting stillbirth surveillance review and the response of cases in low-middle income countries setting is feasible. As countries progress towards ending preventable mortality, this has the potential to serve as a key process in improving evidence-based and context-specific planning and preventive strategies towards improving the quality of care.

Audit identified modifiable factors in Hospital Care of Newborns in low-middle income countries: a scoping review

BackgroundAudit of facility-based care provided to small and sick newborns is a quality improvement initiative that helps to identify the modifiable gaps in newborn care (BMC Pregnancy Childbirth 14: 280, 2014). The aim of this work was to identify literature on modifiable factors in the care of newborns in the newborn units in health facilities in low-middle-income countries (LMICs). We also set out to design a measure of the quality of the perinatal and newborn audit process.MethodsThe scoping review was conducted using the methodology outlined by Arksey and O’Malley and refined by Levac et al, (Implement Sci 5:1-9, 2010). We reported our results using the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We identified seven factors to ensure a successful audit process based on World Health Organisation (WHO) recommendations which we subsequently used to develop a quality of audit process score.Data sourcesWe conducted a structured search using PubMed, CINAHL, EMBASE, LILACS, POPLINE and African Index Medicus.Study selectionStudies published in English between 1965 and December 2019 focusing on the identification of modifiable factors through clinical or mortality audits in newborn care in health facilities from LMICs.Data extractionWe extracted data on the study characteristics, modifiable factors and quality of audit process indicators.ResultsA total of six articles met the inclusion criteria. Of these, four were mortality audit studies and two were clinical audit studies that we used to assess the quality of the audit process. None of the studies were well conducted, two were moderately well conducted, and four were poorly conducted. The modifiable factors were divided into three time periods along the continuum of newborn care. The period of newborn unit care had the highest number of modifiable factors, and in each period, the health worker related modifiable factors were the most dominant.ConclusionBased on the significant number of modifiable factors in the newborn unit, a neonatal audit tool is essential to act as a structured guide for auditing newborn unit care in LMICs. The quality of audit process guide is a useful method of ensuring high quality audits in health facilities.

Exploring healthcare workers\u2019 perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals\u2019 newborn units

BackgroundIn many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits.MethodsThis was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach.ResultsPerceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors.ConclusionOur findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.

Incidence of Mortality among Under-Five-Year-Old Children Born to Women Living with HIV and Those Born to Women Not Living with HIV in Botswana: A 5-Year Retrospective Study.

Background Child mortality is a core indicator for child health and wellness. Botswana reported an under-five-year-old children (UFC) mortality rate of 48 deaths per 1000 live births in 2017 against 152 deaths per 1000 live births in 1971. This was a commendable accomplishment. However, given the current country situation whereby 23% of children are born to women living with HIV, the incidence of mortality among UFC born to women living with and not living with HIV and their survival are better health metrics to inform decision making. Nevertheless, such data are still very scarce in Botswana. The study's objective was to estimate the incidence of UFC mortality among children born to women living with and not living with HIV and to compare UFC survival between the two groups. Methods A retrospective cohort study of mortality among UFC was conducted in Botswana, including all UFC born between January 2014 and June 2018. Data were extracted from the National Under-Five Mortality Audit Committee (NUFMAC) database using a standardized data collection tool. The incidence rate of UFC death was estimated as a function of the duration from birth to death. Survival functions of UFC born to women living with and not living with HIV were plotted and compared using Kaplan–Meier survival analysis. Results The overall incidence of UFC death was 4.63/1000 child months (CM) (95% CI 4.36–4.90). The incidence of UFC death among children born to women living with HIV was 6.96/1000 CM (95% CI 6.47–7.45) and that of UFC born to women not living with HIV was 4.34/1000 CM (95% CI 4.03–4.65). The overall average and standard error (SE) time to event/death for UFC born to women living with and not living with HIV was 54.80 (0.18) months. The mean (SE) time to death for UFC born to women living with HIV was 52.79 (0.41) months and that of UFC born to women not living with HIV was 55.44 (0.19) months (log-rank X2 = 37.59, p < 0.001). Prematurity or low birth weight was the leading cause of UFC death in both groups; but, it was higher in UFC born to women not living with HIV subgroup than their counterparts. Four cases only or 0.5% of the 806 death cases reported by reporting physicians were attributable to HIV-related complications. Conclusion Despite the commendable efforts made in reducing UFC death, the incidence of UFC death among UFC born to women living with HIV in Botswana is still higher, and their survival is shorter compared to UFC born to women not living with HIV. Child survival interventions should prioritize UFC born to women living with HIV to improve their survival.