Quality in practice: preventing and managing neonatal sepsis in Nicaragua.

QUALITY PROBLEM OR ISSUE: Incorrect and excessive diagnosis of newborn infections in Nicaragua caused overcrowding in the neonatal intensive care units and unnecessary hospitalization. INITIAL ASSESSMENT: A baseline study in nine hospitals found that none correctly utilized disinfectants, sterilization or hand hygiene and that diagnosis of neonatal sepsis was based primarily on clinical manifestations. CHOICE OF SOLUTION: In 2007, the Ministry of Health (MINSA), with Unites States Agency for the International Development technical assistance, began developing guidelines and implementing quality improvement in infection prevention and control to reduce neonatal infections. In a second intervention phase, the MINSA introduced an algorithm for correct identification of maternal risk factors and standardized laboratory tests for neonatal sepsis. IMPLEMENTATION: Interventions included developing national guidelines on correct use of disinfectants and hand hygiene; training medical staff on the guidelines; revising the basic medical supply list to support appropriate antisepsis; defining a package of diagnostic tests for neonatal sepsis and systematically measuring compliance with the new procedures. EVALUATION: The 18 hospitals achieved appropriate use of disinfectants in a 12-month period. In seven hospitals that introduced improvements in diagnosis and management of neonatal sepsis, application of the standardized laboratory package in suspected sepsis cases increased from 0% in April 2009 to 93% in July 2011, and the median incidence of neonatal sepsis was reduced by 67%. LESSONS LEARNED: The organizational changes implemented for the diagnosis and verification of neonatal sepsis led to a reduction in the newborn sepsis admissions and expenditures for antibiotics, allowing resources to be redirected to treating other critically ill newborns.