Newborn Clinical and Mortality Audit Tool

Name of health facility: BUNGOMA COUNTY REFERRAL HOSPITAL

Type of health facility: Sub-County Hospital □ County Referral Hospital ✔

□

National Teaching and Referral Hospital □

Date of audit 6/9/23

Section 1: Newborn Details

I.P. number newborn 0076841/24 Age at review/death 2 days Birth weight 3200 grams

Date of birth 09-Mar-24 Weight at review/death 2750 grams

Date of admission 11-Mar-24 weeks

Gestation at birth 38
Referral Y✔
□ N □ F Indeterminate
Sex M ✔

Referring facility NABUALA MEDICAL CENTRE

Apgar Score: 1 min 4 5 mins 5 10 mins 6 20 mins
Reason for referral
Not documented
FOR NBU CARE AND FURTHER MANAGEMENT
HC 37 cm Not done Length 49 cm Not done

Section 2: Mother’s Details

Antenatal History
ANC attendance Y □
✔ N □ Blood Group A +ve VDRL status pos □ neg □
✔ unkn. □

PMTCT status pos □ neg ✔

□ unkn. □ If positive, on HAART? Y □ N □ unkn. □
HTN in pregnancy Y □ N □
✔ unkn. □ Diabetes in pregnancy Y □ N □
✔ unkn. □

Any other conditions in pregnancy

Labour and Delivery
Delivery SVD ✔
□ CS □ Breech □ Vacuum □ If CS, type? Elective □ Emergency □
ROM < 18h ✔
□ ≥ 18h □ unkn. □ Any other complications NONE

BVM resuscitation at birth? Y✔

□ N □ Not documented
Chest compressions at birth? Y □ N Not documented ✔
Medication used during resuscitation? If yes, Not documented

Oxygen administered post resuscitation Y N □✔ If yes, method of delivery and flow rate
flow rate ?? Nasopharyngeal catheter □ flow rate
Nasal prongs/short nasal catheter □
Face mask with reservoir bag □ flow rate Other

Section 3: Review of Care Provided

Time of birth 7:50 PM Time of admission by clinician 9:00 PM

Time of admission by nurse 8:10 PM Date of admission by clinician 11-Mar-24

Date of admission by nurse Time to referral (if applies)

11-Mar-24
 1. Danger signs & symptoms at admission: 2. Management provided at referring facility (if applies)
FULL HAEMOGRAM, RENNAL FUNCTION TESTS, CALCIUM LEVELS
Temp 39.4 0C Not done □ Sp02 94 % Not done
OXYGEN THERAPY INITIATED 2L/MIN, VIT K ADMINISTERED,[Link], A
RR 42 /min Not done ✔
□ Jaundice +++

HR 169 /min Not done □ Pallor NONE

RBS 10.3 mmol/l Not done □ Cap refill time <2 secs

a. Difficulty in breathing Y □ ✔ Not documented

N □ if yes,
• Chest indrawing Y □ N □✔ Not documented
• Grunting Y □ N ✔ Not documented
• Central cyanosis Y □ N □✔ Not documented
b. Inability to breastfeed Y □ N □✔ Not documented 3. Initial diagnosis
c. Convulsions Y ✔ N Not documented
Primary diagnosis BIRTH ASPHYXIA
d. Apnoea Y N ✔ Not documented
d. Reduced/absent
e. Reduced/absent
Y N ✔ Not documented Secondary diagnoses
movement
movement
NEONATAL JAUNDICE

f. Bilious vomiting Y N ✔ Not documented

4. Describe how the child’sYillnessN progressed

Not documented
since admission (document new or worsening clinical signs or diagnoses and day of life
identified)

NEXT DAY: (12/03/2024) AT 10:20 AM, THE BABY WAS CONFIRME DEAD.

AT 9:10 AM, BABY D.N STARTED GASPING WITH SATURATION OF 67% ON CPAP.

RESUSCITATION STARTED, 15 CHEST COMPRESSION AND 2 AMPU BAGING WITH OXYGEN 10L/MIN.

I.V ADRENALINE 3 DOSES INITIATED WITH NO IMPROVEMENT. PUPILS WERE NOT RESPONDING TO LIGHT, WITH ABSENT PULSE
5. Describe the daily vital signs monitoring of the newborn (Nursing section)
Day of life Frequency of Temperature Respiratory Rate Heart Rate Oxygen saturations
monitoring
Highest temp 0c Highest RR /min Highest HR 167 Highest Spo2
38 54 /min 96
12/03/24 Lowest temp 0c Lowest RR /min Lowest HR 143 /min Lowest Spo2 94

Intervention
I.V PCM 27MG ADMINISTERED

Highest temp Highest RR Highest HR Highest Spo2

0c
/min /min

Lowest temp 0c Lowest RR /min Lowest HR /min Lowest Spo2

Intervention

Highest temp 0c Highest RR Highest HR /min Highest Spo2

/min

Lowest temp 0c Lowest RR /min Lowest HR Lowest Spo2

/min

Intervention

Highest temp 0c Highest RR /min Highest HR /min Highest Spo2

0c /min Lowest HR
Lowest temp Lowest RR /min Lowest Spo2

Intervention

Highest temp 0c Highest RR /min Highest HR /min Highest Spo2

Lowest temp 0c Lowest RR /min Lowest HR /min Lowest Spo2

Intervention

Highest temp 0c Highest RR /min Highest HR Highest Spo2

/min

Lowest temp 0c Lowest RR /min Lowest HR /min Lowest Spo2

Intervention

Highest temp 0c Highest RR /min Highest HR Highest Spo2

/min

Lowest temp Lowest RR Lowest HR /min Lowest Spo2

0c /min

Intervention
6. What critical basic laboratory and radiological investigations were done since admission considering the progression of illness and what were the key results.

Investigations Date ordered Date results Action taken Date action taken Highest and lowest daily Action taken
received RBS
Highest Hb 10.3mmol/L BOLUSED WITH D10,
16.2
2.9mmol/l REPEAT RBS
3.6mmol/l.
Lowest Hb

Highest T. bilirubin
9.52

Lowest T. bilirubin PHOTOTHERAPY

Highest Lowest
Na+ 1140.5

K+ 5.40

Ca2+ 10.9 11-Mar-24 11-Mar-24

Mg2+ NOT DONE

Urea 66.57

Creat 0.93

Others
FHG- NEU-11.50, WBC 16.51, RBC-11-Mar-24
5.97, HB- 16.2,,MCV-82.5,PLTS-297.
11-Mar-24
Supportive Management
Airway and Breathing, Circulation, Disability and Others
7. Respiratory support Oxygen therapy ✔ CPAP □ Mechanical ventilation
11-Mar-24
Y✔
□ N □ Start date Start date Start date
Stop date 12-Mar-24 Stop date Stop date

8. Management of
dehydration

Y □ N ✔
□

9. Transfusion of blood PRBC transfusion □ Whole blood transfusion □ Other blood products □
and blood products No. of transfusions No. of transfusions FFP □ Platelets □
Y □ N✔□ Volumes Volumes No. of transfusions

Volumes
10. Management of IV 10% dextrose ✔ Buccal 50% dextrose □ Others
hypoglycaemia
Volumes NOT DOCUMENTED Volumes Volumes
Y □ N ✔
□

11. Management of Standard phototherapy Intensive phototherapy □ Exchange transfusion □

jaundice
Start date 11-Mar-24 Start date Date
Y✔
□ N □
Stop date 12-Mar-24 Stop date
 Enteral Feed and Fluid Management
12. How was the progressive maintenance fluid and enteral feed management since admission? (Document day of life, type of fluid prescribed, volume of feed and fluid prescribed and total
volume)

Day of life IV fluid type & vol. IV fluid vol. given Enteral feed type, vol., freq. Enteral feed vol. Total daily volume Documented weights
prescribed & route prescribed given
D10, NS NONE Prescribed 320MLS
3 256 MLS, 64MLS NONE
Given YES

Prescribed

Given

Prescribed

Given

Prescribed

Given

Prescribed

Given

Prescribed

Given

Prescribed

Given

Prescribed

Given

Prescribed

Given

Prescribed

Given
Definitive Management
13. What medication was progressively prescribed since admission and at what dosages and routes?

Medication Route Dose & frequency Days

Xpen □ IV 5
✔ 160,000

Gentamicin □

Ceftazidime ✔
□ IV 160MG 5

Ceftriaxone □

Amikacin □

Phenobarbitone □

• Loading dose
• Maintenance dose

Aminophylline □

• Loading dose
• Maintenance dose

Caffeine citrate □

• Loading dose
• Maintenance dose

Others
KEPPRA LOADING DOSE I.V INFUSION 96mg Stat
MANTAINANCE DOSE I.V INFUSION 48mg
Section B – To be filled during audit meeting
Care at Admission
1. Was the mother appropriately monitored during labour 2. Was the baby appropriately resuscitated if required, and was the baby
and delivery? If given another opportunity, what can be appropriately put on oxygen post resuscitation? If no, why?
done differently?

Was the mode of delivery appropriate? Yes 3. Was there a delay in transfer of baby to NBU based on guidelines set by the
hospital? If yes, what factors could have contributed to this?
If CS, were there any delays? If yes, why?

4. Was there a delay in initial clinician review based on hospital guidelines?

If yes, what factors could have contributed to this?

5. If baby was referred in, comment on the quality of care provided at the referring facility. What could be done differently?

6. Was the response to danger signs at admission timely and as recommended in 7. Comment on diagnoses
the newborn care guidelines? If not, what may have contributed to this?

Progression of Illness
8. Comment on the monitoring of the newborn to enable early recognition of danger signs including frequency of monitoring of vital signs.
 Laboratory and Radiological Investigations
9. Comment on any critical investigations that were not done and what 10. Was timely and appropriate action taken on the key results?
factors may have contributed to this?
If no, what was not appropriately acted on? What may have
contributed to this?

Management
Supportive care
Fluid and Enteral Feed Management
11. Comment on the fluid and enteral feed prescription and management b. Were enteral feeds and fluids given as prescribed? Is this
since admission. Was it consistent with the accepted guidelines? Were clearly documented in the feed and fluid chart? If no, what
fluids and feeds given as prescribed? may have contributed to this?

a. Was the selection of enteral feed and IV fluid types, volumes and
frequencies appropriate? If no, what may have contributed to this?

c. Comment on weight monitoring and progressive weight gain (Check the % weight loss/day in the 1st 5-7 days & weight gain in g/kg/d if > 7
days)
 Other Supportive Management After Admission

12. Comment on the modes of supportive management selected. What was done well? What could be done differently?

Definitive Management
13. Was the selection of medication, dosage and route of administration appropriate as per the management guidelines? If no, what factors may
have contributed to this?

14. Was the medication given as prescribed and clearly documented? If no, what factors may have contributed to this?

Section 4: Details of death (mortality audit) or cause of near miss (clinical audit)

Mortality audit Clinical audit

Date of death 3/9/23 Diagnoses in case audited

Time of death 10.02am SBA and HIE

Primary diagnosis that led to death

AKI, metabolic acidosis

Underlying conditions or associated diagnoses

SBA
Section 5: Action Plan Summary Form

Name of hospital BCRH Review action at follow-up

Date of mortality audit meeting 6/9/23

Practice to be improved Action to be taken Level at which Person responsible Action taken and outcome
for making change Deadline
action is required
Members of Newborn Audit Committee Present

1. Paediatrician (Chair of audit committee)

2. Nursing officer in-charge of newborn unit

3. Nursing officer in-charge of labour ward

4. Obstetrician/ Medical officer from labour ward

5. Representative from records department

6. Nutritionist

7. Hospital administration (medical superintendent/hospital

administrator/matron in-charge of facility)

8. Representative from pharmacy

9. Others
Modifiable Factors
Administrative factors Health worker related factors
• Medical practice • Medical practice • Tests/investigations
• Absence of guidelines to guide on • Investigation not ordered.
• Absence of guidelines to guide on diagnosis. • Increased turn around time for
diagnosis • Poor use of guidelines to guide on investigations.
• Absence of guidelines to guide on diagnosis. • Delayed review of investigation
management plan. • Absence of guidelines to guide on results.
management plan. • Incorrect interpretation of
• Equipment and materials
• Poor use of guidelines to guide on investigation results.
• Absence of guidelines on use. management plan. • Poor documentation of
• Equipment and materials available • Substandard monitoring to enable examination findings.
but not functioning as intended. early recognition of danger signs. • Poor documentation of
• Investigation not ordered. observations (insufficient use of
• Equipment and materials available • Incorrect interpretation of results. monitoring charts).
but not used as intended. • Poor documentation of the • Poor documentation of the
• Lack of capacity to conduct considerations leading to patient considerations leading to patient
investigations. management. management.
• Delay in execution of management • Documentation
• Medication
plan. • Delayed review of investigation
• Lack of medication. • Management executed is not as results.
• Communication prescribed. • Poor documentation of
• Delay in transportation/referral from examination findings.
• Insufficient communication among labour ward or theater to newborn • Transportation
members of the same cadre and unit. • Delay in transportation/referral
equal level. • Equipment and materials from labour ward or theatre to
• Insufficient communication among • Absence of guidelines to guide on newborn unit.
members of the same cadre and use. • Delay in decision for referral to
different levels. • Equipment and materials available higher level facility.
• Insufficient communication among but not functioning as intended.
members of different cadres. • Lack of capacity to conduct
investigations.
• Delay in transportation from other Patient oriented factors
health facility. • Medication
• Poor use of available guidelines to
• Human resources for health/ • Health seeking behaviour/health
guide on diagnosis.
health systems • Incorrect choice of medication
financing
prescribed. • Delay in seeking treatment for child.
• Staff shortage. • Ignorance/beliefs/myths/
• Incorrect dosage and/or route
• Transport misconceptions
prescribed.
• Delay in transportation/referral from • Incorrect medication administered. • Refusal of treatment for child.
other health facility. • Incorrect dosage administered and/
• Lack of means for transportation/ or incorrect route of administration
referral used.
• Communication
• Insufficient communication among
members of the same cadre and
equal level.
• Insufficient communication among
members of the same cadre and
different level.
• Insufficient communication among
members of different cadres.
• Refusal of treatment for child.
• Health seeking behaviour/health
financing
• Delay in seeking treatment for child.