title: Managing Neonatal and Early Childhood Syndromic Sepsis in Sub-District Hospitals in Resource Poor Settings: Improvement in Quality of Care through Introduction of a Package of Interventions in Rural Bangladesh.
abstract: BACKGROUND
  Sepsis is dysregulated systemic inflammatory response which can lead to tissue damage, organ failure, and death. With an estimated 30 million cases per year, it is a global public health concern. Severe infections leading to sepsis account for more than half of all under five deaths and around one quarter of all neonatal deaths annually. Most of these deaths occur in low and middle income countries and could be averted by rapid assessment and appropriate treatment. Evidence suggests that service provision and quality of care pertaining to sepsis management in resource poor settings can be improved significantly with minimum resource allocation and investments. Cognizant of the stark realities, a project titled 'Interrupting Pathways to Sepsis Initiative' (IPSI) introduced a package of interventions for improving quality of care pertaining to sepsis management at 2 sub-district level public hospitals in rural Bangladesh. We present here the quality improvement process and achievements regarding some fundamental steps of sepsis management which include rapid identification and admission, followed by assessment for hypoxemia, hypoglycaemia and hypothermia, immediate resuscitation when required and early administration of parenteral broad spectrum antibiotics.
  
  
  METHODS
  Key components of the intervention package include identification of structural and functional gaps through a baseline environmental scan, capacity development on protocolized management through training and supportive supervision by onsite 'Program Coaches', facilitating triage and rapid transfer of patients through 'Welcoming Persons' and enabling rapid treatment through 'Task Shifting' from on-call physicians to on-duty paramedics in the emergency department and on-call physicians to on-duty nurses in the inpatient department.
  
  
  RESULTS
  From August, 2013 to March, 2015, 1,262 under-5 children were identified as syndromic sepsis in the emergency departments; of which 82% were admitted. More neonates (30%) were referred to higher level facilities than post-neonates (6%) (p<0.05). Immediately after admission, around 99% were assessed for hypoxemia, hypoglycaemia and hypothermia. Around 21% were hypoxemic (neonate-37%, post-neonate-18%, p<0.05), among which 94% received immediate oxygenation. Vascular access was established in 78% cases and 85% received recommended broad spectrum antibiotics parenterally within 1 hour of admission. There was significant improvement in the rate of establishing vascular access and choice of recommended first line parenteral antibiotic over time. After arrival in the emergency department, the median time taken for identification of syndromic sepsis and completion of admission procedure was 6 minutes. The median time taken for completion of assessment for complications was 15 minutes and administration of first dose of broad spectrum antibiotics was 35 minutes. There were only 3 inpatient deaths during the reporting period.
  
  
  CONCLUSIONS
  Needs based health systems strengthening, supportive-supervision and task shifting can improve the quality and timeliness of in-patient management of syndromic sepsis in resource limited settings.
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Ahmed Ehsanur
authors.identifier: http://orcid.org/0000-0001-9216-1079
authors.initials: AE
authors.lastname: Rahman
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Afrin
authors.initials: A
authors.lastname: Iqbal
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: D M Emdadul
authors.initials: DM
authors.lastname: Hoque
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Md
authors.initials: M
authors.lastname: Moinuddin
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Sojib Bin
authors.initials: SB
authors.lastname: Zaman
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Qazi Sadeq-Ur
authors.initials: QS
authors.lastname: Rahman
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Tahmina
authors.initials: T
authors.lastname: Begum
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Atique Iqbal
authors.initials: AI
authors.lastname: Chowdhury
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Rafiqul
authors.initials: R
authors.lastname: Haider
authors.affiliation: Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Shams El
authors.initials: SE
authors.lastname: Arifeen
authors.affiliation: The Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Niranjan
authors.initials: N
authors.lastname: Kissoon
authors.affiliation: The Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Charles P
authors.initials: CP
authors.lastname: Larson
mesh_terms: D002675:Child, Preschool; D015276:Health Care Rationing; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D011787:Quality of Health Care; D019035:Rural Health Services / Q000458:organization & administration* / Q000592:standards; D018805:Sepsis / Q000628:therapy*