Audit on the Use of Continuous Positive Airway Pressure at Kenyatta National Hospital Newborn Unit

Abstract

Background : CPAP is a form of positive airway pressure ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract and is mostly used in preterm neonates. Along with the increased survival of extremely premature newborns, better knowledge on the different kinds of respiratory diseases and advances in technology have led to new evidence in this field. The Ministry of Health Kenya has published guidelines on the use of CPAP in Basic Paediatrics Protocol (revised in 2016). This study aims to assess CPAP use in the newborn unit at Kenyatta National Hospital (KNH). This study will assess the adherence of medical staff to the guidelines and protocols of using CPAP, since adhering to guidelines brings about good outcome. Ever since the publication of these guidelines, audit on CPAP use in KNH newborn unit (NBU) has not been formally conducted. Therefore, audit on CPAP use will improve our knowledge, inform our ways of practice and, help correct errors. It will also inform development of CPAP user training that addresses the gaps in care of the preterm neonates with respiratory problems. Objective: To audit the use of CPAP at Kenyatta National Hospital newborn unit. Methods: This was a prospective audit study carried out over a period of three months in NBU at KNH on neonates who were put on CPAP. Neonates admitted at the NBU and were put on CPAP were enrolled into the study at admission and an audit on the use of CPAP was carried out to determine the newborns who received CPAP treatment consistent with Ministry of Health (MOH) Basic Paediatrics Protocol 2016 guidelines which is adopted by KNH NBU. Results: The commonly documented indication for CPAP was based on the Apgar score of the neonates (100%) and Silverman-Anderson Score (SAS) score (54.2%). Complete documentation of examination findings was not done in all the 72 neonates who were put on CPAP. The examination findings not documented by clinician on admission were apnea at 21 (29.2%) and, upper chest wall retraction at 38 (52.8%). Blood culture was done in 5 (6.9%) of neonates on admission, chest Xray done on 7 (9.7%) while full hemogram and C reactive protein were done in 71 (98.6%) and 56 (77.8%) respectively. Overall documentation of CPAP use was very poor. Documentation of FiO2 was at 56 (77.8%), PEEP 48 (66.7%), PIP 17 (23.6%). There was no documentation on nasal prong size/position, head position, pressure level in all the neonates. Overall monitoring of CPAP equipment over 4 days following initiation of CPAP was poor. Pulse oximetry was done in 71 (98.6%) neonates, chest Xray was done in 24 (33.3%) neonates and BGA was least done in 18 (25%) of neonates. Documentation on weaning was done in 33 (45.8%) and it was gradual and successful in 17 (23.6%) and it xii failed in 16 (22.2%). Appropriate CPAP use as per the Kenyan guidelines (Basic Paediatrics protocol 2016) in this study was at 75.2%. Conclusion: There was poor documentation on indication of CPAP use such as SAS score which was documented in only 54.2% of the neonates who were put on CPAP. Appropriate CPAP use as per the Kenyan guidelines (Basic Paediatrics protocol 2016) in this study was at 75.2%. No recording was done on the parameters on neonate connection to the CPAP machine. There was suboptimal documentation on investigations required before CPAP connection and follow up of the neonate. Weaning was not recorded in most neonates at 54.2% and it was gradual and successful in only 23.6%. Recommendations: There is need to have strategies to help improve documentation on indications, contraindications, investigations of the use of CPAP as well as improvement of documentation of data on CPAP set up and monitoring. There is need to provide CPAP user training on initiation, monitoring and weaning of CPAP.