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CPAP) for Neonatal Care in Public Health Facilities in India: a Cross-­Sectional Cluster Survey

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CPAP) for Neonatal Care in Public Health Facilities in India: a Cross-­Sectional Cluster Survey Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-031128 on 28 February 2020. Downloaded from Availability and use of continuous positive airway pressure (CPAP) for neonatal care in public health facilities in India: a cross- sectional cluster survey Juan Emmanuel Dewez ,1 Sushma Nangia,2 Harish Chellani,3 Sarah White ,4 Matthews Mathai ,4 Nynke van den Broek4 To cite: Dewez JE, Nangia S, ABSTRACT Strengths and limitations of this study Chellani H, et al. Availability Objectives To determine the availability of continuous and use of continuous positive airway pressure (CPAP) and to provide an overview ► Nationwide assessment of the availability and use of positive airway pressure of its use in neonatal units in government hospitals across (CPAP) for neonatal care continuous positive airway pressure (CPAP) in neo- India. in public health facilities nates in a representative sample of public hospitals Setting Cross- sectional cluster survey of a nationally in India: a cross-sectional in India, through direct hospital site visits. representative sample of government hospitals from cluster survey. BMJ Open ► Our findings apply to government facilities; the avail- across India. 2020;10:e031128. doi:10.1136/ ability and use of CPAP in private hospitals, where a Primary outcomes Availability of CPAP in neonatal units. bmjopen-2019-031128 large proportion of inpatient care is provided in India, Secondary outcomes Proportion of hospitals where Prepublication history and may be different. ► infrastructure and processes to provide CPAP are available. additional material for this ► The standards used to assess the availability of Case fatality rates and complication rates of neonates paper are available online. To essential infrastructures and processes to provide treated with CPAP. view these files, please visit CPAP were decided by consensus among the re- Results Among 661 of 694 government hospitals with the journal online (http:// dx. doi. search team, and this carries a degree of subjectivity. org/ 10. 1136/ bmjopen- 2019- neonatal units that provided information on availability of ► Data about infrastructures and processes were 031128). CPAP for neonatal care, 68.3% of medical college hospitals based on participants’ reports, and there might have (MCH) and 36.6% of district hospitals (DH) used CPAP in been reporting bias. Received 17 April 2019 neonates. Assessment of a representative sample of 142 Revised 16 December 2019 ► Data on some important determinants of neonatal hospitals (79 MCH and 63 DH) showed that air- oxygen http://bmjopen.bmj.com/ Accepted 04 February 2020 mortality and morbidity were not collected, which blenders were available in 50.7% (95% CI 41.4% to 60.9%) precludes firm conclusions on the impact of lack of and staff trained in the use of CPAP were present in 56.0% infrastructures and processes on the clinical out- (45.8% to 65.8%) of hospitals. The nurse to patient ratio comes reported. was 7.3 (6.4 to 8.5) in MCH and 6.6 (5.5 to 8.3) in DH. Clinical guidelines were available in 31.0% of hospitals (22.2% to 41.4%). Upper oxygen saturation limits of above 94% were used in 72% (59.8% to 81.6%) of MCH and low- income and middle- income countries 59.3% (44.6% to 72.5%) of DH. Respiratory circuits were (LMIC) and result from prematurity, intra- 1 reused in 53.8% (42.3% to 63.9%) of hospitals. Case fatality partum- related conditions and infections. on September 26, 2021 by guest. Protected copyright. rate for neonates treated with CPAP was 21.4% (16.6% to Acute respiratory distress, common to these 26.2%); complication rates were 0.7% (0.2% to 1.2%) for causes of death, is associated with case fatality pneumothorax, 7.4% (0.9% to 13.9%) for retinopathy and rates as high as 20% in LMIC.2 The most basic 1.4% (0.7% to 2.1%) for bronchopulmonary dysplasia. respiratory support for neonates with acute Conclusions CPAP is used in neonatal units across respiratory distress is oxygen, followed by government hospitals in India. Neonates may be non- invasive support such as continuous posi- overexposed to oxygen as the means to detect and treat tive airway pressure (CPAP), and by mechan- consequences of oxygen toxicity are insufficient. Neonates © Author(s) (or their ical ventilation. Mechanical ventilation may also be exposed to nosocomial infections by reuse of employer(s)) 2020. Re- use involves endotracheal intubation, an invasive permitted under CC BY-NC. No disposables. Case fatality rates for neonates receiving CPAP commercial re- use. See rights are high. Complications might be under- reported. Support procedure requiring high technical skills. In and permissions. Published by to infrastructure, training, guidelines implementation and contrast, CPAP can in principle be applied by 3 BMJ. staffing are needed to improve CPAP use. non- specialist healthcare providers. It is esti- For numbered affiliations see mated that the use of oxygen in combination end of article. with CPAP for the treatment of respiratory INTRODUCTION distress contributed to a 70% increase in the Correspondence to An estimated 2.9 million neonates die every survival of preterm babies in high-income Professor Matthews Mathai; year worldwide. Most of these deaths are in Matthews. Mathai@ lstmed. ac. uk countries.4 Several studies reported that Dewez JE, et al. BMJ Open 2020;10:e031128. doi:10.1136/bmjopen-2019-031128 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-031128 on 28 February 2020. Downloaded from CPAP is safe and effective in LMIC and its use in these 1. District performance ranking based on a composite settings is increasing.5–12 health index developed by the Government of India However, CPAP use can lead to serious complications to identify districts needing priority investments in such as pneumothorax, or nasal trauma.13 14 Moreover, healthcare.21 High priority districts were defined as the when CPAP is used with supplemental oxygen, the bottom 25% of districts for health index scores; non- unregulated use of oxygen may lead to retinopathy of high priority districts were those in the top 75%. prematurity (ROP),15 a major cause of blindness, or bron- 2. Type of neonatal unit—NICU or SNCU. NICU are chopulmonary dysplasia (BPD).16 funded and monitored by state governments. SNCU CPAP is easy to initiate, but to be effective, CPAP needs are funded and monitored by the central government. to be used continuously for hours or days. This implies Because of these differences, we initially considered continuous supplies of electricity and medical gases, three types of neonatal units: NICU in MCH, SNCU in continuous clinical monitoring for timely detection of MCH and SNCU in DH. acute complications and long- term follow-up for chronic Prior to sample selection, facilities within the two strata complications. Consequently, the WHO recommends determined by district performance were assigned to considering the wider context of care prior to intro- 62 clusters, typically either as a state or a subset of the ducing and scaling- up CPAP use in LMIC.17 districts within a state. Within each of the clusters there India accounts for an estimated 779 000 neonatal deaths were between 3 and 10 facilities providing CPAP. These every year.1 The Government of India has launched several clusters were then stratified by type of neonatal unit. initiatives to reduce neonatal mortality. These include the Random sampling (among the 62 clusters) was strat- establishment of Special Newborn Care Units (SNCU) ified to ensure that the margin of error in each of the which provide level II care including treatment for sepsis, three facility- type strata did not exceed 10%, assuming jaundice and respiratory distress. SNCU have been imple- the ICC did not exceed 0.1. A list of 42 randomly selected mented in district hospitals (DH), that is, secondary care clusters was generated using the Runiform function in hospitals, and in medical college hospitals (MCH), that is, Stata with a sequence for inclusion of hospitals within the tertiary care hospitals.18 The current national recommen- clusters until the planned sample size (see below) in each dations in terms of respiratory support are to use oxygen of the three strata was achieved. in DH, and CPAP and mechanical ventilation in MCH.19 20 However, CPAP seems to be used in DH. The extent of Sample size CPAP use in neonates at the different levels of care, the We initially estimated that the sample sizes of neonatal availability of structures and processes to enable its use, units required to estimate the outcomes of interest with and the clinical outcomes of this intervention in India are 95% CI and a margin of error not exceeding 10% would unclear. be: The aims of this study were to determine the availability ► 36 NICU in MCH. http://bmjopen.bmj.com/ of CPAP and to provide an overview of its use in neonatal ► 51 SNCU in MCH. units in government hospitals across India. ► 76 SNCU in DH. However, during data collection, it became evident that NICU and SNCU in MCH were not substantially different in organisation (eg, staff deployment, purchasing and METHODS maintenance of equipment) or provision of neonatal Study design healthcare (eg, the same clinical guidelines where avail- A cross- sectional cluster survey was conducted among on September 26, 2021 by guest. Protected copyright. able were used). Therefore, it was decided to combine neonatal units using CPAP in government hospitals in NICU and SNCU into a single stratum (called neonatal India. units in MCH). Treating them as one stratum for sampling, the sample size was revised to: Identification of hospitals using CPAP in neonates ► 62 neonatal units in MCH. Programme officers responsible for neonatal health in ► 76 neonatal units in DH.
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