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   Table of Contents      
Year : 2020  |  Volume : 68  |  Issue : 13  |  Page : 115-120

Development of a quality improvement package for reducing sight-threatening retinopathy of prematurity

1 Neonatal Unit, Department of Pediatrics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
2 Department of Neonatology, Government Medical College Hospital, Chandigarh, India
3 Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
4 Indian Institute of Public Health, Public Health Foundation of India, Hyderabad, Telangana, India
5 International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK

Date of Submission12-Nov-2019
Date of Acceptance06-Dec-2019
Date of Web Publication17-Jan-2020

Correspondence Address:
Dr. Deepak Chawla
Department of Neonatology, Government Medical College Hospital, Chandigarh - 160 047
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2087_19

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Purpose: With improving survival of preterm neonates, retinopathy of prematurity (ROP) is emerging as a major cause of childhood blindness. Incidence of sight-threatening ROP can be reduced by improving the quality of care provided to preterm neonates. Methods: This before-and-after study was designed to develop a need-based intervention package to improve knowledge, skills, and practices of those providing care for preterm neonates, and to evaluate the effectiveness of this package when combined with point-of-care quality improvement (POCQI) in improving survival of preterm neonates without sight-threatening ROP. The study had a formative component to assess baseline knowledge, skills, practices and attitudes, and to assess the needs of the healthcare staff to improve the care of preterm neonates. It was conducted in four special care neonatal units (SCNU) in the state of Madhya Pradesh in India. Results: A theory of change was developed to guide the development of study tools including needs assessment and educational package development. The educational package thus developed has been tested at the study sites in combination with POCQI projects driven by local teams of healthcare providers. The effectiveness of the interventions has been evaluated by collection of individual-level data on neonates admitted at the study sites. Conclusion: A multidimensional educational package integrated with system changes in the form of quality improvement (QI) endeavours driven by local context and needs were developed and evaluated in the project.

Keywords: Quality improvement, retinopathy of prematurity, theory of change

How to cite this article:
Kumar P, Chawla D, Thukral A, Deorari A, Shukla R, Gilbert C. Development of a quality improvement package for reducing sight-threatening retinopathy of prematurity. Indian J Ophthalmol 2020;68, Suppl S1:115-20

How to cite this URL:
Kumar P, Chawla D, Thukral A, Deorari A, Shukla R, Gilbert C. Development of a quality improvement package for reducing sight-threatening retinopathy of prematurity. Indian J Ophthalmol [serial online] 2020 [cited 2020 Feb 28];68, Suppl S1:115-20. Available from: http://www.ijo.in/text.asp?2020/68/13/115/275740

With improving access to facility-based neonatal care (FBNC), an increasing number of preterm neonates are surviving in India and new challenges are emerging about their ongoing care.[1] Such a major challenge is ensuring the survival of preterm neonates with intact and optimal neurosensory abilities. Retinopathy of prematurity (ROP) is one of the important conditions which endangers intact survival, and which needs to be detected in a timely manner and treated promptly, if severe. ROP is also amenable to primary prevention by improving adherence to evidence-based clinical care practices in hospitalized sick preterm neonates.[2],[3] Improved access to FBNC does not, however, ensure adherence to best practices, and thus a quality-improvement and assurance system needs to be put in place to prevent the consequences of suboptimal clinical care. The recent expansion of neonatal care services in many low- and middle-income countries, coupled with suboptimal care is leading to an increasing number of infants with stage 4 and 5 ROP being seen by ophthalmologists, including India.[4],[5]

ROP is not only among the commonest causes of acquired blindness in children but is also an excellent indicator of the quality of care provided to preterm neonates in a healthcare facility. Risk factors for ROP include unmonitored and unnecessary oxygen administration, sepsis, poor nutrition, and exposure to blood products.[3] Therefore, interventions aimed at reducing ROP are likely to impact many aspects of neonatal healthcare resulting in improved rates of intact survival without abnormal neurological outcomes. The hypothesis of the Madhya Pradesh-quality improvement (MP-QI) project is that among preterm neonates admitted in SCNUs (population), implementation of a need-based intervention package comprising evidence-informed practices targeting healthcare providers (nurses, doctors, coordinators) to improve their capacity and skills for providing clinical care as well as undertaking QI activities (intervention), would improve neonatal survival without severe ROP (outcome) compared with current quality of care and competencies (control). To test this hypothesis, we developed a theory of change [Figure 1] which formed the basis of the package of interventions. The current article presents the development of the theory of change and the study protocol to test this theory of change.
Figure 1: Theory of change

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  Methods Top

This before-and-after study is being undertaken in three district hospitals and a medical college in the state of Madhya Pradesh, India. Madhya Pradesh was one of the four states selected for the ROP project supported by Queen Elizabeth Diamond Jubilee Trust (2013–1019) following a situational analysis.

The study has three main objectives. Firstly, to assess baseline levels of knowledge, skills, attitudes, and practices of SCNU healthcare personnel, state SCNU coordinators, and child health consultants about clinical care pathways which are likely to reduce the risk of severe ROP, to assess their problem solving and QI skills, and the awareness of parents regarding the need for ROP screening and potential therapy. Secondly, to formulate pilot test and finalize a package of interventions (consisting of educational materials [webinars and videos], protocols/guidelines, simulation-based training, standard operating procedures, advocacy tools for policy change, collaborative quality-improvement network) to improve knowledge, skills, attitudes and practices of SCNU coordinators, child health consultants, and SCNU healthcare workers in abovementioned domains. Lastly, to evaluate the effectiveness of this package of interventions in improving knowledge, skills, attitudes and practices of the health care professionals identified above; increasing awareness of parents regarding the need for ROP screening and potential therapy; improving clinical practices related to risk of ROP and ultimately, increasing the survival of preterm infants without severe ROP.

For objective 1, the needs assessment was undertaken by the coordinating centers (PGIMER, Chandigarh, GMCH Chandigarh, and AIIMS New Delhi) in the four facilities outlined above. For objective 2, a learning package was developed by the coordinating centers which was tested in the SCNUs used for objective 1. (website for free access to the learning package: https://www.pretermcare-eliminatingrop.com.) For the development of QI collaborative, network data were collected from the participating SCNUs and coordinating centers through an app developed specifically for this purpose. POCQI tool developed in collaboration with World Health Organization South-East Asia Reginal Office (WHO-SEARO) was used for imparting training for QI projects (www.pocqi.org and http://workbook.pocqi.org/) For objective 3, the study unit consisted of a teaching institution as the hub and three SCNUs as the spokes, with the intention that the teaching institution would mentor the SCNUs and help implement the educational and QI packages.

For objectives 1 and 2, participants included medical officers or consultants employed in the state child health program with responsibilities pertaining to SCNU; pediatricians, medical officers, and nurses working in SCNUs. For objective 3, data were collected from neonates who fulfilled criteria for ROP screening as per guidelines of the Government of India.

[Table 1] presents the methods of data collection for the formative component of the study. [Table 2] presents the outcomes relevant to each specific objective of the study.
Table 1: Method of information collection for the formative phase (objective 1)

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Table 2: Study outcomes

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Approval was obtained from the ethics committees of the respective institutions and written informed consent was obtained from healthcare providers (for objective 1 and 2) and either parent of preterm neonates (for objective 3).

  Results Top

Five main target clinical areas were identified in the theory of change for improvement which could impact preterm survival without severe ROP. These areas included good control of oxygen, less exposure to blood products, good nutritional status, less systemic infections, and good developmentally supportive care. Good control of oxygen included steps to improve methods of oxygen administration and monitoring and optimizing the use of continuous airway pressure (CPAP) and surfactant. Strategies to reduce exposure to blood products included less blood sampling, policy to restrict the use of blood products and effective use of phototherapy. Strategies to improve nutritional status included early initiation and rapid advancement of enteral feeding with breastmilk. Various strategies were planned to improve aseptic techniques at the time of birth and during hospital admission to reduce systemic infections. Prevention of hypothermia, kangaroo mother care, pain control and less noise, and light exposure were strategies to improve developmental care, with greater involvement of parents in the care of their preterm baby during the hospital stay.

[Table 3] enlists the QI projects conducted in the SNCUs during the study. [Figure 2] presents an example of a successful QI project. At present, data collected during the project are being analyzed to evaluate the effectiveness of the intervention package on the study outcomes.
Table 3: Quality improvement projects conducted during the project

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Figure 2: Example of a quality improvement project

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  Discussion Top

This study was planned to improve the survival of preterm neonates without sight-threatening ROP. The interventions used in the study are based on two important evidence-based approaches. Firstly, it has been recognized that although healthcare workers in resource-limited settings have suboptimal knowledge and skills about preterm care, the latter cannot be improved by continuing medical education or skill training alone.[6] System barriers which preclude the application of evidence-based practices need to be overcome along with improvement in knowledge and skills.[7] Therefore, the interventions in this study have components of improving the capacity of healthcare workers and their teams in both clinical and QI domains. Secondly, it has been recognized that risk factors for ROP in preterm neonates cared for resource-limited settings are different from those in reported from well-resourced countries.[3],[8],[9],[10] Unmonitored and unnecessary use of oxygen therapy and a high incidence of infection are two important risk factors identified in low- and middle-income countries. As a result, ROP is often observed in heavier and relatively mature preterm neonates.[11] Therefore, improvement strategies to decrease the incidence of ROP need to focus on improving context-specific risk factors and health systems.

We have used both in-person contact and e-learning approaches to reach many healthcare providers in the target hospitals. While in-person two-way interaction is an important component of adult learning, e-learning has advantages as it can reach a large number of learners in a shorter time, there are opportunities of repeated synchronous (web-meetings and chat session) and asynchronous (discussion boards and group emails) interactions and standardization of learning material. We believe that in a vast country like India with tens of thousands of healthcare providers involved in neonatal care, it is important to use e-learning platforms. We have previously demonstrated the effectiveness of the e-learning approach in improving knowledge and skills of healthcare providers.[12]

  Conclusion Top

Due to weak and fragmented health systems, even skilled and knowledgeable healthcare providers may face challenges in using evidence-based practices. Some of the health system-related challenges are due to poor infrastructure (e.g., lack of an adequate number of pulse oximeters) but many are related to lack of point-of-care policies or standard operating procedures (e.g., identifying neonates needing oxygen therapy). A QI approach managed by local teams of doctors and nurses can overcome these contextual issues. The success of such an approach in improving clinical practices has been demonstrated in both resource-rich and resource-limited settings.[6],[13] Therefore, we planned to integrate the QI approach with knowledge and skill-building.

Financial support and sponsorship

The Queen Elizabeth Diamond Jubilee Trust, London, UK and National Health Misson, Madhya Pradesh, India.

Conflicts of interest

There are no conflicts of interest.

  References Top

Care of small and sick newborns in special newborn care units (SNCUs) of India. Two year report April 2013-March 2015. National Health Mission, Ministry of Health and Family Welfare, Government of India; 2016.  Back to cited text no. 1
Blencowe H, Lawn JE, Vazquez T, Fielder A, Gilbert C. Preterm-associated visual impairment and estimates of retinopathy of prematurity at regional and global levels for 2010. Pediatr Res 2013;74(Suppl 1):35-49.  Back to cited text no. 2
Chawla D, Agarwal R, Deorari A, Paul VK, Chandra P, Azad RV. Retinopathy of prematurity. Indian J Pediatr 2012;79:501-9.  Back to cited text no. 3
Azad R, Chandra P, Gangwe A, Kumar V. Lack of screening underlies most stage-5 retinopathy of prematurity among cases presenting to a tertiary eye center in India. Indian Pediatr 2016;53(Suppl 2):S103-6.  Back to cited text no. 4
Sanghi G, Dogra MR, Katoch D, Gupta A. Demographic profile of infants with stage 5 retinopathy of prematurity in North India: Implications for screening. Ophthalmic Epidemiol 2011;18:72-4.  Back to cited text no. 5
Rowe AK, de Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet 2005;366:1026-35.  Back to cited text no. 6
Cochrane LJ, Olson CA, Murray S, Dupuis M, Tooman T, Hayes S. Gaps between knowing and doing: Understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof 2007;27:94-102.  Back to cited text no. 7
Dutta S, Narang S, Narang A, Dogra M, Gupta A. Risk factors of threshold retinopathy of prematurity. Indian Pediatr 2004;41:665-71.  Back to cited text no. 8
Kumar P, Sankar MJ, Deorari A, Azad R, Chandra P, Agarwal R, et al. Risk factors for severe retinopathy of prematurity in preterm low birth weight neonates. Indian J Pediatr 2011;78:812-6.  Back to cited text no. 9
Maheshwari R, Kumar H, Paul VK, Singh M, Deorari AK, Tiwari HK. Incidence and risk factors of retinopathy of prematurity in a tertiary care newborn unit in New Delhi. Natl Med J India 1996;9:211-4.  Back to cited text no. 10
Vinekar A, Dogra MR, Sangtam T, Narang A, Gupta A. Retinopathy of prematurity in Asian Indian babies weighing greater than 1250 grams at birth: Ten year data from a tertiary care center in a developing country. Indian J Ophthalmol 2007;55:331-6.  Back to cited text no. 11
[PUBMED]  [Full text]  
Thukral A, Sasi A, Chawla D, Datta P, Wahid S, Rao S, et al. Online neonatal training and orientation programme in India (ONTOP-IN)--the way forward for distance education in developing countries. J Trop Pediatr 2012;58:486-90.  Back to cited text no. 12
Deorari A, Livesley N. Delivering quality healthcare in India: Beginning of improvement journey. Indian Pediatr 2018;55:735-7.  Back to cited text no. 13


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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