Implementation of the resuscitation bundle
To improve the quality of neonatal resuscitation, the SUSTAIN project provided each hospital with the HBB guidelines and the following new equipment: upright bag-masks, NeoBeat newborn heart rate monitors, and NeoNatalie live training manikin. In each hospital, before introduction of neonatal resuscitation package, external facilitators together with hospital team conducted context analysis of the maternity care and planned for introduction of resuscitation training, quality improvement package, equipment and continuous measurement of resuscitation. Following which training on HBB was conducted to all health care providers working in the maternity ward. To measure the performance of resuscitation, observation of the resuscitation care was done independently and recorded in progress board on a daily basis. The measure of resuscitation included ventilation within golden minute and ventilation at rate of 40 to 60 bpm. A bi-weekly quality improvement meeting using Plan-Do-Study-Act (PDSA) was established by the external facilitator and hospital leadership to review the progress in neonatal resuscitation and review the data based on progress board measure. The skill-drills in the high fidelity neonatalie were conducted on daily basis to maintain the resuscitation skills in the maternity ward. The project staff facilitated the implementation and was involved in the daily practice, data collection, and management.
SUSTAIN project adapted the HBB protocol with use of NeoBeat, where in all newborns who do not cry at birth, stimulation was to be done. The newborn was then assessed for breathing, if there was no or difficulty in breathing, secretion to be assessed. If there was any secretion, suction was to be done to remove the secretion. The newborn was further assessed for breathing, if there was no/difficulty in breathing, ventilation was to be initiated. After first ventilation, the breathing was assessed together with HR, the HR was measured using NeoBeat. Both breathing and HR was used to guide further ventilation procedure.
Practice change – move to a more systematic resuscitation
According to the health care providers, the HBB implementation clearly changed the resuscitation practices in each of the four participating hospitals. The health care providers described that, before the SUSTAIN project, there was no regular training on neonatal resuscitation. Tube suctioning was done to all newborns, and when necessary, ventilation was provided through a horizontal bag-mask with an oxygen fitting system. The initiation of resuscitation was often delayed due to the lack of a clear resuscitation protocol and a determination of the newborn’s heart rate. To determine whether a newborn had a pulse, the health care providers used manual palpation and a stethoscope. These procedures required at least two staff members, and they interrupted ventilation as one health care provider described: “I mean, in the past, when we did bag-and-mask we had to put the stethoscope in the ear and listen to the heart rate … we had to look at the time … we had to stop working for a while and listen to the heart rate’’ (ID06).
After the SUSTAIN project, all four sites performed neonatal resuscitation mainly in line with the new protocol. The nurses described that resuscitation had become more systematic and that it was initiated earlier and performed longer. NeoBeat helped the nurses to identify the newborns requiring resuscitation and distinguished them from fresh stillbirths. Among the non-breathing newborns after stimulation, health care providers often successfully initiated ventilation within 60 seconds of birth (golden minute). The NeoBeat displayed the heart rate during ventilation and help guide ventilation, while previously after the first ventilation, health care provider had stopped the ventilation procedure to check for heart rate either by cord pulsation or stethoscope. NeoBeat enabled continuous heart rate monitoring and continue ventilation until the newborn was stabilized: “Now when we resuscitate, we don’t even have to listen with the stethoscope … once we put it on (NeoBeat), it instantly shows the heart rate … we can also determine if effective ventilation has been done or not and how long shall we continue’’ (ID10). The health care providers performed ventilation by using the upright bag-mask, although some of the hospitals still used the old horizontal bag.
Innovation – neonatal heart rate monitoring driving the change
There was a high demand for the new equipment. According to the health care providers, all new devices were in continuous use. The provided equipment made work easier, which encouraged the nurses to use it: “The equipment provided by SUSTAIN has made it very comfortable and easier to work’’ (ID08). Theory and knowledge behind each equipment was also seen as a motivating factor to use them. The health care providers considered penguin suction to be good, helpful, and less risky than the old suctioning device. The upright bag-mask was easier to use and more ergonomic than the old horizontal bag-mask. Improved ventilation was provided with the new bag-mask, and the health care providers experienced it was safer for the newborns because there was not much leakage.
The health care providers explained that NeoBeat had contributed to the biggest change in their practice, as it guided resuscitation by instructing whether ventilation should be initiated, how long it should be provided, and if a doctor should be called. NeoBeat saved time, required fewer staff resources, and therefore, helped the nurses to reach the golden minute. The health care providers considered the NeoBeat reliable and effective. They also explained that the doctors trusted NeoBeat, which led to better communication between the professions: “Using NeoBeat has made resuscitation much easier, it has made heart rate monitoring very convenient, and the reading provided by it is better than that obtained from listening to the stethoscope” (ID14).
The health care providers indicated that one of the biggest barriers for the effective implementation of HBB was the lack of equipment, which led to iniquity in patient treatment. Some of the equipment was damaged during sterilization, and the amount of provided equipment was limited. In some hospitals, an old oxygen system has hindered practice changes in ventilation. The old horizontal bag-masks were preferred because they had an oxygen fitting system, and the old resuscitation routine included the use of oxygen: “We have another horizontal bag-and-mask with oxygen fitting system and prefer to use it more frequently’’ (ID03). Technical difficulties with NeoBeat also caused a barrier for its use. For example, it caused confusion by showing a heartbeat on a newborn with no breathing and heartbeat confirmed by stethoscope after prolonged ventilation and was declared deceased. In addition, not all nurses were trained to maintain the NeoBeat. The lack of systematically implemented maintenance led to situations in which the health care providers did not remember to charge the device.
Recipients – Feedback supporting the change.
The nurses explained several motivating factors, such as reaching the set goals and seeing the positive outcomes that supported them, to continue practicing and developing resuscitation practices. The nurses succeeded in resuscitating the newborn and reaching the golden minute. The health care providers reported to have gained confidence in the training with NeoNatalie and saw improvement in their own skills. This motivated the health care providers to continue perfecting the skills through training. The health care providers learned that teamwork had been good during the project: “We perform all these activities in team including project staff that we have been provided’’ (ID06). Trust was established between the hospital and project staff, and everyone’s input affected the outcome as the context analysis of the maternity care in the hospital was done together as team during the introduction of the intervention package. The health care providers attitudes and trust toward the intervention package gradually improved, which led to better performance visible in the progress board during training and daily work.
At the same time, some of the health care providers explained that not all staffs were motivated to train resuscitation. Some of the health care providers felt that their colleagues were negligent toward the new routines and equipment, which they thought was irresponsible: “The main barrier is negligence from hospital staffs because although the delivery decreased by half but still, they are not performing skill drill” (ID01). In addition, the health care providers brought up the lack of staff multiple times, and they explained that teamwork was harder when there were not enough nurses on duty. They did not have time to do all their normal tasks, and the project increased workload because the new routines included more steps, skill drills, trainings, and meetings that required time. In addition, there was some confusion between the professions because only the health care providers took part in the SUSTAIN trainings, and the doctors did not share the same information.
Facilitation – An enabler for change and a barrier for sustainable change.
The health care providers described that the facilitators and SUSTAIN project staff provided by the project were effective and that the trainings were informative. The health care providers positively experienced putting theory into practice. New things were learned, and updated information was provided to refresh knowledge. The health care providers explained that regular training had led to new routines, which made daily practice easier, and continuous practice helped retain skills. Successful trainings motivated the health care providers to practice more. However, the health care providers indicated that the skill drills were done outside the working hours, which meant that they did not always have the time to practice and were exhausted: “Due to the lack of staff we had to work on night duty and attend the training in the morning hour, so the schedule was so packed that we were exhausted’’ (ID06).
The health care providers also perceived the facilitators as nice, talented, and positive. They explained that the project staff had provided human resources and equipment. The project staff worked at the wards and was involved in the daily practice, making the health care providers’ work easier. The health care providers also noted that the project staff took care of the equipment by cleaning and charging the units. In addition, they had regular follow-ups with the nurses and encouraged them to change the practice: “Yes, we are getting more support than before on our work in aspects such as human resources, equipment, management, PDSA meetings, feedback and so on” (ID05).
The health care providers explained that PDSA meetings were held biweekly. The data showed at the meeting illustrated how many times the equipment was used, how many times the golden minute was achieved, and how well the trainings went. The health care providers discussed the problems, and new solutions were introduced. The PDSA meetings improved daily practice, led to skill improvement, motivated the health care providers, and provided transparency to the implementation process: “PDSA has helped to solve common gaps and problems, change our behavior and improve our clinical practice” (ID03).
Context – The unclear role of leadership and medical doctors.
The health care providers explained that most of the feedback supporting practice change was received in the PDSA meetings. This constant feedback for the health care providers led to improvement in daily practice. The health care providers also received feedback from a tablet that recorded their performance in the trainings: “Intrapartum care has improved through constant feedback and support from mentors, their facilitation and mostly because of SUSTAIN program itself” (ID06). The leadership and management for the change was perceived good. The health care providers indicated that coordination and delegation from the leaders had worked well. They explained that the department head and chief of nursing visited the ward every day to observe the practice. However, some of the health care provider seemed to be a bit reserved when answering questions about the leaders and management. One health care provider also noted that the hospital management was poor and that the leaders could have played more active roles in supporting the project. The health care providers said that there had been dysfunctional interprofessional communication. At some hospitals, only the chief of nursing discussed the protocol with the ward staff. The project staff was available for questions, but due to the busy schedules, the support was sometimes inhibited. The health care providers found that they were trusted, although they also indicated that sometimes teamwork was ineffective: “We have to follow the doctors rather than our practical knowledge, that’s a problem we are facing” (ID09).