Fidelity of Health Care Providers on Adhering to Guidelines for Managing Neonates With Respiratory Distress Using Silverman Anderson Severity (Sas) Score Tool in Limited Resource Settings: A Case Study at Amana Regional Referral Hospital

doi:10.21203/rs.3.rs-4291006/v1

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Fidelity of Health Care Providers on Adhering to Guidelines for Managing Neonates With Respiratory Distress Using Silverman Anderson Severity (Sas) Score Tool in Limited Resource Settings: A Case Study at Amana Regional Referral Hospital

https://doi.org/10.21203/rs.3.rs-4291006/v1

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Background: This case study was conducted at Amana Regional Referral Hospital, a referral hospital of Ilala District in Dar es Salaam Region Tanzania. The aim is to assess the adherence of healthcare providers to guidelines when providing health services to neonates with respiratory distress and how supportive the health system is in limited resource settings.

Methods: It was a case study that used a qualitative approach to data collection and analysis. A total of 16 participants did participate in this study of which the sample size was reached by the principle of information saturation. The study population was healthcare providers (pediatricians, general medical doctors, and nurses) working in the neonatal ward who were selected purposively depending on their experience in the neonatal ward. In-depth interviews (IDI) and an observation checklist were used for data collection from key informants and content analysis was used to analyze the data.

Results: The findings revealed that healthcare providers did not fully adhere to the guidelines when managing neonates with respiratory distress. The Silverman-Anderson Severity (SAS) score tool is of use to asses the neonate’s respiratory distress status. It is used for decision-making in prioritizing neonates to Continuous Positive Airway Pressure (CPAP) and monitoring them. They did know the use of the SAS score tool, which was even posted in the ward they are working in for them to follow but yet they showed partial adherence to use it. While healthcare providers displayed partial adherence, various challenges within the health system negatively impacted their consistent adherence. Factors such as understaffing, inadequate training, a shortage of CPAP machines, heavy workloads, and lack of motivation emerged as significant deterrents to adherence. These challenges hindered proper monitoring, documentation, and decision-making processes for CPAP initiation and monitoring.

Conclusion: The conclusion of the study highlights that healthcare providers at Amana Regional Referral Hospital demonstrated partial adherence to guidelines for managing neonates with respiratory distress, particularly in the consistent use of the Silverman Anderson Severity (SAS) score tool. Despite awareness of the tool and its importance, challenges such as understaffing, inadequate training, and a shortage of CPAP machines hindered full adherence. Addressing these challenges, including improving staffing, offering comprehensive training, and ensuring equipment availability, is crucial for enhancing adherence and improving neonatal care in resource-limited settings.

Silverman Anderson Severity (SAS) score

respiratory distress syndrome (RDS)

Continuous Positive Airway Pressure (CPAP)

standard treatment guideline

Tanzania still has a high neonatal mortality rate despite efforts made to reduce it. Respiratory Distress Syndrome (RDS) which is the collection of respiratory insufficiency symptoms is among the causes of such mortality whereby treatment of it requires CPAP as respiratory support. Decisions are made to prioritize these neonates to those limited CPAP machines using SAS score mostly and peripheral blood gas is not done due to its unavailability in most hospitals. Despite it being used as a standard to assess neonates' respiratory distress in settings where laboratory tests are not accessible, still healthcare workers do not adhere to using it consistently.

Each year, the neonatal period, encompassing the first 28 days of life, is responsible for approximately 2.9 million infant deaths worldwide, contributing to more than half of under-five child fatalities globally (Lawn et al., 2014). This accounts for 44% of all child fatalities, with the under-five mortality rate estimated at 36 per 1000 live births (Prospects, 2022). The first month of life is the most vulnerable period for child survival, with 2.4 million newborns dying in 2020 and Tanzania being among the top ten countries in Africa. Tanzania has a high newborn mortality with a neonatal mortality rate of 20.1 per 1,000 live births in 2020 which slightly increased from the 2015 neonatal mortality rate of 19 per 1,000 live births (World Data Atlas, 2022) (Alkema et al., 2014).

The bulk of these deaths occur in the first week of life, with the highest risk of mortality concentrated in the first days of life. 99% of newborn deaths take place in low- and middle-income nations; the absolute number of neonatal deaths is highest in south-central Asian nations, while neonatal mortality rates are often highest in sub-Saharan African nations,(Lawn, Cousens and Zupan, 2005). Despite substantial global progress in child survival since 1990, neonatal fatalities have decreased from 5 million in 1990 to 2.4 million in 2020, yet the reduction in neonatal deaths has been slower compared to post-neonatal under-five mortality. In 2020, nearly half (47%) of under-five deaths occurred during the neonatal period, in contrast to 1990, when 40% of under-five mortality was attributed to neonatal mortality (WHO). The United Nations General Assembly adopted the 2030 Agenda for Sustainable Development in September 2015, which encompasses 17 Sustainable Development Goals (SDGs). The third SDG aims to "ensure healthy lives and promote well-being for all ages," including the elimination of preventable infant and child deaths. The goal is to achieve neonatal mortality rates of at least as low as 12 per 1,000 live births and under-five mortality rates of at least as low as 25 per 1,000 live births by 2030 (Johnston, 2016) (Horbar et al., 2002).

Efforts to reduce global neonatal mortality require immediate newborn care and special attention to small or sick babies, as they significantly impact under-five child mortality. Over 50% of neonates born before 31 weeks of gestation develop respiratory distress syndrome (RDS), which can result from factors such as a deficiency of pulmonary surfactant, infections, meconium aspiration, birth asphyxia, or fluid-filled lungs. Continuous Positive Airway Pressure (CPAP) is the primary respiratory support for neonates with RDS in both global and Tanzanian healthcare settings. Intubation and mechanical ventilation are considered only in advanced Neonatal Intensive Care Unit (NICU) facilities, like Muhimbili National Hospital in Tanzania. CPAP which refers to the application of continuous distending pressure in a spontaneously breathing neonate increases the functional residual capacity of the lung resulting in better gaseous exchange. The availability of sufficient CPAP machines for all RDS-affected neonates in low-resource settings remains a challenge. Medical practitioners often face dilemmas in determining which neonate should be prioritized for CPAP intervention. To address these limitations, the SAS Score tool is recommended to assess the severity of RDS in neonates, as it covers essential indicators of the condition (Roberts et al., no date).

Silverman Anderson Severity score, introduced in 1956, is commonly used as a diagnostic tool in healthcare facilities with limited respiratory support to assess and manage neonates with respiratory distress. In other developing countries, alternative guidelines, like the TRY CPAP Algorithm in Malawi (T for Tone, R for Respiratory, and Y for Yes), are employed to identify neonates who would benefit from CPAP (Hundalani et al., no date). The SAS score assists in grading and diagnosing RDS based on physical examination, which is particularly valuable when comprehensive laboratory investigations are unavailable. It is essential to ensure healthcare workers consistently adhere to using the SAS score tool to assess RDS severity in all neonates, thereby making informed decisions on CPAP treatment and enhancing effective management and monitoring of neonates with RDS. This practice contributes to increased recovery rates and a reduction in avoidable neonatal deaths.

Aim: The study aimed to assess healthcare providers' adherence to using the SAS score tool for decision-making in prioritizing neonates with respiratory distress syndrome (RDS) for continuous positive airway pressure (CPAP) treatment in resource-limited settings. Specific objectives included exploring adherence levels, examining healthcare workers' experiences with the tool, and identifying factors influencing adherence.

Study Design: This study employed a process evaluation qualitative case study design. The case study design was chosen for its ability to provide in-depth knowledge of the intervention evaluated, allowing the use of multiple data collection techniques. The intervention under evaluation was the decision-making process by healthcare providers using the SAS score tool to initiate CPAP treatments for neonates with respiratory distress syndrome (RDS) and monitor their progress on CPAP treatment until they are weaned off from CPAP.

Study Population: The study population included doctors, who are the decision-makers, and nurses, who are the implementers of those decisions, working in the neonatal ward of Amana Regional Referral Hospital. These healthcare providers included pediatricians, registered general medical doctors, and registered nurses with experience in providing neonatal care.

Study Area: The study was conducted at Amana Regional Referral Hospital, which is the Regional Referral Hospital of the Ilala District in Dar es Salaam, Tanzania. The hospital receives referred patients with various diagnoses, including neonates in need of respiratory support and intensive care. The hospital has an authorized bed capacity of 362, with the pediatric ward, including the neonatal ward, having a bed capacity of 72. The neonatal ward is equipped with five CPAP machines, and the High Dependency Unit (HDU) where RDS neonates are admitted is equipped with five CPAP machines, 15 neonatal beds, 3 warmers, 1 emergency trolley, 3 monitors, 2 phototherapy machines, and 2 oxygen cylinders.

Sampling Technique: Purposive sampling was used for this study to select healthcare workers (registered doctors and nurses) assigned to practice in the neonatal ward and trained in using the SAS score for managing RDS and CPAP.

Sample Size: A total of 16 participants were involved in this study out of 22 healthcare workers working in the neonatal ward of Amana Regional Referral Hospital. This included doctors (Pediatricians and registered general practitioners) and nurses practicing in the neonatal ward. The final sample size was determined in the field by the principle of information saturation, whereby no new information emerged from informants.

Data Collection Tools: Data were collected using an observation checklist and in-depth interviews. The observation checklist was formulated from The Silverman-Anderson Severity score tool, Tanzania’s standard treatment guidelines, literature, and study objectives. The in-depth interview guide was developed with open-ended questions to gather information about healthcare providers' adherence to using the SAS score tool, their experience, and factors influencing adherence.

Data Collection Methods: Data collection was conducted in June 2023 through in-depth interviews and participant observation. In-depth interviews were conducted with healthcare workers in the neonatal ward of Amana Regional Referral Hospital. The interviews were audio-recorded, transcribed, and translated into English. Participant observation was conducted by the researcher in the neonatal ward over one week, observing healthcare providers' adherence to using the SAS score tool for neonates with RDS.

Data Management and Analysis: Data analysis was done using content analysis. Transcripts and observation notes were coded inductively to generate codes from reading transcripts. Recurring patterns and concerns from the data were found through the coding of respondents. Data organization, administration, and analysis were performed using NVivo software version 12.

Ethical Issues: Ethical clearance was obtained from the Muhimbili University of Health and Allied Sciences (MUHAS) Institutional Review Board (IRB). Informed consent was obtained from all participants, and they were informed of their right to withdraw from the study at any time. Participant anonymity and confidentiality were ensured throughout the study.

Social demographic characteristics of the study population.

The study population involved 16 healthcare providers, among which are 10 doctors and 6 nurses. Among the doctors, there are 4 pediatric specialists and 6 general medical practitioners. Among the nurses, 3 are registered nurses (with a diploma in nursing) and 3 are nursing officers (with a degree in nursing). The age range was between 26 to 57 years old with mean age of 36 and the majority being between 29 to 49 years. Years of experience range was between 1 to 16 years with a mean of approximately 5.6 years working in the neonatal ward at Amana Regional Referral Hospital.

Utilization of the SAS score tool by healthcare workers

Issues emerged with the adherence of healthcare workers to implement the SAS score tool in both observational findings and interview findings. Results suggest that healthcare workers do partially adhere to the use of the SAS score tool for neonates presenting with respiratory distress due to some issues with decision-making and documentation of the SAS score. These issues are presented below.

Decision Making

In this study, it is seen from in-depth interviews that decisions on prioritizing neonates to CPAP machines are made based on distress severity which is determined using the SAS score tool. This was also reported using the observation checklist that doctors do use the SAS score tool to assess neonate's distress severity and make decisions on using CPAP. However, monitoring these neonates after they have been kept on CPAP was a challenge which was both seen in the In-depth interviews and was also observed from the observation checklist. This is due to some different factors that are explained in the Factors Influencing Adherence section. One of the informants had this to say

“Decisions to put a child on CPAP are often correct, the problem is in the follow-up. For example, a patient set on CPAP should be monitored every fifteen minutes for the first hour, and after that should be monitored every four hours. It should be so until the day that CPAP is taken off where he or she has to be reassessed for SAS score.” (Informant No. 16, Pediatrician, 49 years, Amana RRH)

The decision-makers are the registered doctors but due to the high workload, decisions are also made by intern doctors together with nurses alone, and later on, the registered doctors come to review the decisions made. Most informants mentioned the importance of using the SAS score tool in decision making and they even mentioned that it is posted on the neonatal ward walls for all the practitioners to use it effectively since there is no access to peripheral blood gas laboratory investigations hence they have to abide to use the SAS score tool to know the distress severity prior CPAP initiation and monitoring.

“We rely on severity, we do use the SAS score, others will continue with oxygen therapy and other important medications and supportive management, there is nothing much you can do.”

(Informant No. 06, Registered medical doctor, Amana RRH)

SAS score is not used for decision-making alone when having premature neonates with or without distress for initiating CPAP treatment. It is reported through in-depth interviews that all neonates born prematurely with less than 1.5 kg birth weight should be kept on CPAP as prophylaxis for respiratory distress regardless of the neonate´s SAS score grade. One of the informants had this to say:

“Concerning CPAP, we assess the ability to breathe by using the Silverman Score. If the baby scores 4 and above we put him/her on CPAP. For babies with low birth weight, born before time, and those below 1.5 kg we also put them on CPAP. Even if the SAS score doesn’t support, we initiate supportive CPAP for breathing.” (Informant no. 10, Registered medical doctor, 49 years, Amana RRH

Proper documentation

It is reported in this study with both observations and in-depth interviews (IDI) that there is a challenge with proper documentation after using the SAS score tool. The biggest challenge is the documentation of all the SAS score tool parameters that the doctor has assessed in the patient’s file. This is evidenced by one of the informants who had this to say:

“Documentation is done by most of the doctors although not everyone writes everything.” (Informant no. 16, Pediatrician, 49 years, Amana RRH)

However, informants mentioned poor documentation is mostly caused by a high workload due to understaffing. Doctors are overwhelmed with lots of serious sick neonates and lots of admissions, especially during the night shifts hence they do not properly document the SAS score to all files of neonates with respiratory distress.

“I can forget or get overwhelmed but we really insist on writing them down but are mostly done.” (Informant no. 10, Registered medical doctor, 49 years, Amana RRH)

The informant's report on the interviews is supported by the observation results which show they are adhering to the use of the SAS score tool to assess distress severity in neonates with respiratory distress but there was poor documentation of all SAS score tool parameters accurately. On the observation results, most of them missed one or two parameters in the SAS score tool and one parameter in the vitals.

The study's findings indicate that medical practitioners somewhat adhere to the employment of the SAS score tool for decision-making when it comes to prioritizing neonates for CPAP treatment. This approach aligns with the established guidelines for children and adolescent’s standard treatment, mandating doctors to evaluate neonatal respiratory distress before initiating CPAP. This evaluation includes the utilization of a physical examination, as recommended in conjunction with the SAS score tool, and arterial blood gas analysis (National Medicine and Therapeutic Committee, 2018). Moreover, the guidelines necessitate continuous monitoring of neonates receiving CPAP, with assessments performed every 15 minutes during the first hour and every 4 hours after that until CPAP discontinuation. These assessments involve scoring the infant's distress using the SAS score tool along with vital signs. The SAS score comprises five parameters: upper chest movement, lower chest retraction, xiphoid retraction, nares dilatation, and expiratory grunt (Hedstrom et al., 2018). The study illustrates that doctors' adherence to the SAS score tool results in better decision-making regarding CPAP initiation and monitoring for neonates with RDS. This is particularly valuable in settings where access to peripheral blood gas testing is limited, which is vital for determining blood oxygenation levels. Study participants reported that the SAS score tool is easy and simple to use once healthcare workers grasp the knowledge of its application. These findings corroborate results from other studies advocating the use of the SAS score tool to assess the severity of respiratory distress in resource-limited settings without access to laboratory investigations (Panthee and Paudel, 2022). A study in Malawi emphasized the importance of using scoring systems, including the SAS score, to assess neonatal respiratory distress for sound decision-making regarding CPAP initiation (Hundalani et al., no date). Despite healthcare workers´ adherence to the SAS score tool, the study identifies issues related to poor documentation of these scores. This is primarily attributed to an imbalanced patient-to-doctor ratio, leading to lapses in appropriate documentation. The guidelines stipulate that neonates with respiratory distress should undergo an assessment to determine the severity of their condition before initiating CPAP. Subsequently, they should be continuously monitored, with a 15-minute interval for the first hour and subsequent four-hour intervals, encompassing the evaluation of vital signs and SAS scores (National Medicine and Therapeutic Committee, 2018) (Roberts et al., 2011). The findings from this study highlight the practicality of employing the SAS score tool for neonates with respiratory distress. It is perceived as an uncomplicated and cost-effective tool that can be used effectively even by inexperienced healthcare workers. This aligns with the outcomes of a study evaluating the SAS score tool's performance in predicting the need for respiratory support in neonates, emphasizing its suitability for application in resource-limited settings, even by relatively inexperienced staff (Hedstrom et al., 2018).

This study aimed to evaluate the utilization of the SAS score tool for prioritizing neonates with respiratory distress syndrome (RDS) for continuous positive airway pressure (CPAP) treatment in resource-constrained settings. The study observed that healthcare providers generally adhere to the application of the SAS score tool for decision-making when prioritizing neonates with RDS for CPAP, which is crucial for the allocation of limited CPAP resources based on the severity of the condition. However, it is essential to acknowledge that challenges related to adherence could affect the quality of decisions and the competency of healthcare workers.

In conclusion, this study highlights the challenge of moderate adherence among healthcare workers to the SAS score tool for decision-making and monitoring neonates with respiratory distress in resource-limited settings. The impact of this moderate adherence on neonatal outcomes is significant, particularly due to factors such as staff shortages and a high patient load. These challenges lead to incomplete adherence, including poor documentation and inadequate monitoring post-CPAP initiation. Addressing these challenges is crucial to improving neonatal care quality. The study also underscores the importance of supportive work environments, comprehensive training, and effective supervision in enhancing adherence to guidelines and ultimately improving outcomes for neonates with respiratory distress.

CPAP Continues Positive Airway Pressure

HDU High Dependency Unit

IDI In-depth Interview

IRB. Institutional Review Board

MUHAS Muhimbili University of Health and Allied Science

NICU Neonatal Intensive Care Unit

RDS Respiratory Distress Syndrome

RRH Regional Referral Hospital

SAS Silverman Anderson Severity

SDG Sustainable Developmental Goals

WHO World Health Organization

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Muhimbili University of Health and Allied Sciences Institutional Review Board (IRB), with reference number DA282/298/01.C/1721. All participants provided written informed consent before participating in the study.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and analyzed during this study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interest

Funding

This study was funded by the main author of this study.

Authors' contributions

FS designed and conducted the whole study, and prepared the manuscript for publication. AK conceptualized and supervised this study and manuscript development, MA contributed to the conceptualization and supervision of this study and manuscript development. All authors read and approved the final manuscript.

Acknowledgments

We gratefully acknowledge the lecturers and tutors of the School of Public Health at Muhimbili University for their invaluable insights and support, which greatly contributed to the successful completion of this study. We also extend our heartfelt appreciation to all the participants whose participation made this research possible.

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

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You are reading this latest preprint version

Fidelity of Health Care Providers on Adhering to Guidelines for Managing Neonates With Respiratory Distress Using Silverman Anderson Severity (Sas) Score Tool in Limited Resource Settings: A Case Study at Amana Regional Referral Hospital

Status:

Version 1

Abstract

BACKGROUND

METHODS AND MATERIALS

RESULTS

Social demographic characteristics of the study population.

Utilization of the SAS score tool by healthcare workers

Decision Making

Proper documentation

DISCUSSION

CONCLUSIONS

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1