Missed Opportunity for Nasal Continuous Positive Airway Pressure (Ncpap) in Preterm Neonates With Respiratory Distress Syndrome Admitted at Kenyatta National Hospital, New Born Unit - a Mixed Method Study.

Abstract

Background: Respiratory distress syndrome (RDS) is the commonest complication of preterm infants and remains one of the major public health issues that contribute to neonatal mortality and morbidity, especially in Africa where 80% of neonatal mortality is estimated to be caused by preterm complications. Due to aggressive mechanical ventilation complications, a lot of strategies have been put in place to manage RDS and reduce its mortality including surfactant and less invasive modalities like continuous positive pressure (CPAP) ventilation. Nowadays, CPAP is the preferred mode of RDS treatment. However, CPAP is not easily accessible to every preterm infant in the low and middle-income countries (LMICs) and may be the case in Kenya. Objectives: The objectives were to determine the proportion of preterm infants with RDS admitted to the newborn unit (NBU) at Kenyatta National Hospital (KNH) with a missed opportunity (within 48 hours of life) for CPAP, and to determine the barriers and facilitators of CPAP utilization. Methodology: This was a hospital-based cross-sectional study that employed interactive explanatory concurrent mixed methods at the NBU in KNH. The study population was mainly preterm neonates (<37 weeks) within forty-eight hours of life who had signs of moderate respiratory distress (Silverman Anderson Score 4-6) or met the criteria for prophylactic CPAP (GA28-30 weeks or BW 1000g -1300g) from 28th July to 29th November 2021 (Quantitative arm). Participants who met the inclusion criteria were recruited consecutively until the desired sample size was reached. The qualitative arm was to determine the barriers and facilitators of CPAP utilization. The key informants were mainly; neonatologists, neonatal fellows, pediatric registrars, medical officers, nurses, and equipment nurse who utilize CPAP daily in their work from the newborn unit, procurement officer, and a biomedical engineer. These interviews happened from September to October 2021. Data was integrated by merging two data sets for analysis and a joint display was used whereby the quantitative and qualitative data were listed in different sections with an integrative statement. Results: A total of one hundred and sixty-seven term neonates were reviewed and analyzed. Fifty six of these children (33.5% [95% CI 59.0% - 73.2%]) missed the opportunity to receive NCPAP. Missed opportunity for prophylactic group and Silverman Anderson Score group was 44.7 (34.1% - 55.9%) and 24.2 (16.5% - 33.9%) respectively. Twenty key informants were interviewed and the facilitators of NCPAP use reported were: i) the training and mentorship of health workers, ii) availability of NCPAP machines, iii) KNH being a referral hospital and conditions of referrals, iv) global evidence that NCPAP use is beneficial, v) development of xii

technology, and vi) there was a need for NCPAP use. Barriers to NCPAP use were mainly: i) the inadequate number of NCPAP machines, ii) inadequate training and mentorship, iii) inadequate and inappropriate size of NCPAP consumables, iii) staff shortage, iv) faulty CPAP and v) long servicing turnaround time, vi) long cleaning turnaround time, vi) infrastructure challenges e.g. limited space in the unit, and vii) insufficient utilities like oxygen outlet points. Conclusion: The proportion of the missed opportunity for NCPAP at the NBU in KNH was found to be high (33.5%). Barriers to NCPAP use were mainly related to medical products and technologies, health workforce related challenges, and service delivery. We recommend the provision of more NCPAP machines, human resource support, frequent training/CMEs/mentorship, infrastructure improvement, the adequate and appropriate size of consumables, and promotion of family-centered care to support more preterm neonates in need and also for the quality of care improvement.