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TRACKING NEW BORN DISCHARGED FROM SCNU Dr. Gagan Gupta Health Specialist , UNICEF
Background……..
2002- 2006 : IMR reduced by 11 points with out a single point drop in Neonatal Mortality
Highest IMR in the Country at 67 per 1000 (SRS 2009)
Government Sector: Special Care was Non Existent
Key Strategy : Guna ModelKey Strategy : Guna ModelContinuum of Care from Community to FacilityContinuum of Care from Community to Facility
Community:-IMNCI
-Immunization.
-ORS & Zinc in Diarrhea.
-ASHA for Social Mobilization
-Maternal Death Audit
Facility:-SCNU
-NRC
-Model Labour Rooms
-24 x 7 Safe Delivery Centers at Sub - Block level
-Staff trained in Skilled Birth attendance and Essential Newborn Care
24 x 7 Referral Transport
Piloted in Guna in 2007,Replicated in Shivpuri being Scaled up State Wide
Strengthening Facility Based New Born Care
To ensure Continuum of Care with IMNCI in community and SCNU at the Facility.
First 2 Units established by UNICEF at Guna and Shivpuri.
Establishment cost of each unit Rs. 45 Lakhs.( Civil work 25 lakh, Equipments 20 lakh)
Running cost of pilot units and scale up entirely through NRHM. SCNU Shivpuri
Scale Up Under NRHM : SCNU Vidisha District Hospital
New-Born being treated at SCNU
Backed Up By….
Model Maternity wing at District Hospital …..
Model Labor Room : Shivpuri
Maternity Ward : Shivpuri District Hospital
Free 24 x 7 Referral transport with Call Centre
Saving Life on Wheels : 24 x 7
BTL
SVP
SNI
SDH
SA
CDWBLG
CTP
KRG
RSN
MDL
STN
VDS
DHRJBA
PAN
SJP
KND
DMH
SHE
SOP
UJN
RJGSDL
DWS
JBP
HSB
GUNRWATKM
NSP
MDS
KTN
DDR
AKN
BHD
IDR
GLR
MRN
RTM
ANP
BRW
UMR
NMC
HRD
BHP
BPL
DTA
31 Functional
09 to start by 31st January
Status of Special Care New Born Units : M.P
10 under construction
What Happens After Discharge ??
Objective….
Determine survival at One year in babies discharged from SCNU
To follow this cohort for Neurological Development
Learn and put in place system for prospective follow up of
discharged new born with Community – Facility linkages.
Generate evidence for justifying continued investments of large
funds on SCNU amongst other competing priorities
Methodology….
Study Area : SCNU Guna and Shivpuri
- First 2 units in the State were established in these districts.
- Presence of Call Centre, Block Coordinators for support
Study Sample : All New Born discharged from SCNU since
inception till 31st December 2008.
Guna : 1617 (14th Dec. 2007 – 31st Dec.2008 )
Shivpuri : 557 (1st July 2008- 31st December 2008)
Methodology….
Type of Study : Retrospective in 3 phases.
- Phase 1 : Desk review, Data entry, Telephonic Tracking.
- Phase 2 : Visit to community for verification
- Phase 3 : Clinical evaluation for developmental assessment.
Follow up Stages..…..
Phase 1 : Screening of Records
Phase 2 : Verification by Home visit
Phase 3 : Developmental Assessment
ADMISSIONS – FOR WHAT ??
Respiratory Distress
681
Septicemia
603
Birth Asphyxia
748
258 10467 20 30
67 620
423
INDICATIONS OF ADMISSION
Respiratory Distress (HMD,TTNB,MSL,PNEUMONIA) Septicemia Birth Asphyxia
Hyperbilirubinemia Low Birth Wt. Congenital Anomaly
Hypothermia Feeding difficulties Pre term
Tetanus Convulsion Polycythemia
IUGR
N= 2681
FOLLOW UP FINDINGSDISTRICT SHIVPURI
ISO : 9001 Certified Unit
TRACKING OUTCOME
466
5833
433(92.9%)
55 (94.8%)29(87.9%)
SUCESSFULLY DISCHARGED LAMA/DOR TERTIARY REFERRAL
TOTAL TRACKED
SURVIVAL OUTCOME433
55
29
392(90.5%)
39 (70.9%)16 (55.2%)
SUCESSFULLY DISCHARGED LAMA/DOR TERTIARY REFERRAL
TRACKED SURVIVED
TIME DISTRIBUTIONTotal deaths = 70
URBAN RURAL DISTRIBUTION
Total deaths = 70
CASTE WISE DISTRIBUTION
Total deaths = 70
WEIGHT ON ADMISSION
46
84
175
212
17(37%) 19(23%) 18(10%) 16(7.5%)
0
50
100
150
200
250
< 1500 GM 1500-2000 GM 2000 -2500 GM > 2500 GM
DISCHARGE PLUS LAMA PLUS TERTIARY REFERRAL
DEATHS
Total deaths = 70
FOLLOW UP OUTCOME DISTRICT
: GUNA
ISO : 9001 Certified Unit
SURVIVAL OUTCOME1169
194
31
1048 (89.6 %)
148(76..3%)
15(48.4%)
SUCESSFULLY DISCHARGED LAMA/DOR TERTIARY REFERRAL
TRACKED SURVIVED
TIME DISTRIBUTION114
23
125 2 5 4 5 2 0 0 1
10
0
20
40
60
80
100
120
1 Month
2 Month
3 Month
4 Month
5 Month
6 Month
7 Month
8 Month
9 Month
10 Month
11 Month
12 Month
>12 Month
Total deaths = 183
WEIGHT ON ADMISSION
115
287358
634
45 (39.1%) 54 (18.8%) 36 (10.1%) 48 (7.6%)
0
100
200
300
400
500
600
700
< 1500 GM 1500-2000 GM 2000 -2500 GM > 2500 GM
DISCHARGE PLUS LAMA PLUS TERTIARY REFERRAL DEATHS
Total deaths = 183
Phase 3 :Developmental Screening
District Shivpuri (M.P.)
Developmental Screening : Protocols
Neurodevelopmental , Visual and Hearing screening done
Neurodevelopmental : Pathaks modification of Baroda Scale.
Hearing : American Academy of Pediatrics criteria
Visual : American Academy of Pediatrics guidelines
Developmental Screening…
Head Circumference
Screening for Visual Deficits
SUMMARY : FOLLOW UP OUTCOME
Survival in New Born discharged after successful completion of treatment was 90% at 1 year of age
Deaths were higher in new born who were discharged against medical advise and tertiary referrals.
More than 60 % Deaths occurred in 1st month after discharge.
Deaths were higher in excluded and rural population .
SUMMARY : FOLLOW UP OUTCOME
Survival in < 1500 gram birth wt. was 61 % against 93% in
> 2500gm.
Deficits were seen in 11 % of Children who survived with Neurological deficit being commonest.
SAM prevalence was unusually low on follow up.
LESSONS LEARNED….
Strong tracking system should be in place.
Vital information on admission should be recorded (Postal Address ,Mobile numbers)
Need to develop follow up protocols with community and facility linkages. (Extending continuum of care)
Local resources are best suited for follow up and tracking. (AWW, ASHA)
First month after discharge is most critical with need to focus on very low birth wt babies < 2000 grams
Action Initiated :Tracking System….
SCNU Software developed and all vital information on admission / discharge recorded in it by data operator.
On discharge Parents are counseled & provided contact of IMNCI worker along with a community follow up card.
Data operator sends SMS to IMNCI trained worker to enroll the discharged child.
SMS reminders are sent to Parents as well as worker on day of Follow up.
Community Follow up card
Actions Initiated : Tracking System
IMNCI trained AWW to make Six home visits as per IMNCI schedule in first month.
At least one home visit to be done by ANM
SCNU follow up at 15 days, 1,3,6 & 12 months or in case of complications
Status upgraded at the end of the day of visit.
Admission Entry Form
Entry after Treatment Outcome
Daily Follow - up List
SCNU Software Generated Graphs : 2010
DISTRICT SHIVPURI
District Hospital Delivery Vs Inborn Admission SNCU Shivpuri (M.P.)
8276
6734
8292
891 (10.8%)607 ( 9%) 725 ( 8.7%)
0
13000
2008-09 2009-10 2010-11
Adm
issi
ons
in N
umbe
rs
DH DeliveryInborn Admission
SNCU functioning since June 2008
SCNU Case Record Sheets & Monitoring Formats
Case Record File
Neonatal Admission Sheet
Discharge Card
SCNU Follow-up Statistics 2011
District Shivpuri (M.P.)
Facility Follow-up Statistics: 2010- 2011, SCNU Shivpuri
Total Facility Follow-up done since start : 2184
Community Follow-up Statistics , Shivpuri : 2011( Till Oct.)
Mainstreaming and Scaling Up….
Mainstreamed under NRHM for State wide use.
Data operators sanctioned and on board in all units
SCNU Software installed in all SCNUs across the State.
Case Record sheets and SCNU stationary compatible with software developed and put in use Statewide
Both Software and Case record sheets in line with GOI guidelines on FBNC
Support to Other States : Orissa / Haryana / Uttaranchal / Andhra Pradesh / Maharashtra
Work Under Progress…… Mentoring visits to New Born corners & Stabilization units
by SCNU / Maternity team
Work Under Progress……
Linkage of Software and Neonatal case sheets with
Maternity records
Setting up online monitoring system for centralized
monitoring
Neonatal transport system
Early intervention clinic for limiting disability
Sharing Across States…..
States being Supported :
• Haryana• Andhra Pradesh• Uttaranchal• Tamilnadu• Orissa• Maharashtra
Justified Investment For Tomorrow…
BABY 2
New Born Discharged from SCNU….
N = 42
TREATMENT OUTCOME
STATUS UNCLEAR =2
N = 53
New Born Corners till Sub Block level ….
24 x 7 Sub Centre at Shivpuri