STRENGTHENING THE USE OF MAGNESIUM SULPHATE FOR MANAGEMENT...

STRENGTHENING THE USE OF MAGNESIUM SULPHATE

FOR MANAGEMENT OF SEVERE PRE-ECLAMPSIA

AND ECLAMPSIA

This publication is made possible through support provided by USAID Nepal, Office of Health and Family Planning. The ACCESS program is supported by the Maternal and Child Health Division, Office of Health, Infectious Disease and Nutrition, Bureau for Global Health, U.S. Agency for International Development, under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-04-00002-00. The opinion expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.

Access to clinical and communitymaternal, neonatal and women’s health services

Strengthening the Use of Magnesium Sulphate for Management of SPE/E 1

TABLE OF CONTENTS

LIST OF ABBREVIATIONS AND ACRONYMS

EXECUTIVE SUMMARY .........................................................................................................1

I. INTRODUCTION Purpose ...............................................................................................................................3 Background ........................................................................................................................3

II. PROJECT DESIGN Goal and Objectives ............................................................................................................5 Key Activities ......................................................................................................................5 Approaches .........................................................................................................................5 Selected Health Facilities for Strengthened Quality of Care .................................................6

III. KEY ACTIVITIES ................................................................................................................8

IV. KEY FINDINGS AND RESULTS......................................................................................12

V. LESSONS LEARNED, CHALLENGES AND OPPORTUNITIES FOR SCALING UP AND SUSTAINIBILITY Overall Project Lessons Learned ........................................................................................18 Challenges ........................................................................................................................18 Opportunities for Scaling Up and Sustainability ...............................................................19

Appendix 1: Quality Improvement Tool 3-Standards 13, 14, 15Appendix 2: Ten Health Facilities that Received Further SupportAppendix 3: Focal Person and Dates for AssessmentAppendix 4: In-service Orientation PackageAppendix 5: Action Plan Developed for Janakpur Hospital, August 2009

Strengthening the Use of Magnesium Sulphate for Management of SPE/E2


LIST OF ABBREVIATIONS AND ACRONYMS

ACCESS The ACCESS program, USAID global maternal and newborn health programAMDA Association of Medical Doctors in Asia ANM Auxiliary Nurse MidwifeBPKIHS BP Koirala Institute of Health SciencesBZH Bheri Zonal HospitalE EclampsiaEOC Essential Obstetric CareFHD Family Health DivisionGoN Government of NepalIDH Inaruwa District HospitalJH Janakpur HospitalIM IntramuscularIV IntravenousKZH Koshi Zonal HospitalLZH Lumbini Zonal HospitalMDG Millennium Development GoalMNC Maternal and Newborn CareMWRH Mid Western Regional HospitalNESOG Nepal Society for Obstetricians and GynecologistsNHTC National Health Training CenterNMC Nepal Medical CollegeNMMMS Nepal Maternal Mortality and Morbidity StudyNMS National Medical StandardPE Pre-eclampsiaPHCC Primary Health Care CenterQI Tools Quality Improvement ToolsSBA Skilled Birth AttendantsSBM-R Standard Based Management and RecognitionSPE Severe Pre-eclampsiaSZH Seti Zonal HospitalUCMS Universal College of Medical SciencesUSAID United States Agency for International DevelopmentWHO World Health OrganizationWRH Western Regional Hospital


EXECUTIVE SUMMARY Pre-eclampsia/eclampsia is now the second leading cause of maternal mortality in Nepal—accounting for 21% of all maternal deaths according to the Nepal Maternal Mortality and Morbidity Study (2009). For treatment of severe pre-eclampsia and eclampsia (SPE/E), WHO has identified magnesium sulphate as the most effective and low cost medication. This global evidence-based practice is also the national medical standard in Nepal.

To help move this national policy into clinical action, the ACCESS Program in collaboration with Nepal Society for Obstetricians and Gynecologists (NESOG) and Family Health Division (FHD) worked to strengthen the use of magnesium sulphate for the treatment of SPE/E in 22 health facilities across Nepal. Funded by the United States Agency for International Development (USAID), ACCESS mobilized NESOG members as local clinical champions to disseminate national clinical guidelines on SPE/E management and improve the quality of care.

From June to December 2009, ACCESS and NESOG conducted three rounds of assessments, using the relevant standards from the Maternal and Newborn Care (MNC) Quality Improvement (QI) Tools developed by National Health Training Center (NHTC). Baseline and first assessment was done in 22 health facilities, with additional monitoring visits to 10 sites. At each site visit, staff identified gaps and created an action plan to address them. NESOG members conducted clinical updates, disseminated job aids and supported staff with on-site coaching.

At each visit, health care providers were assessed. Each provider’s performance was scored 0–3 (0–100%), and then these were averaged to create the facility score. It is intended to reflect the health facility’s readiness and ability to manage SPE/E appropriately. A total of 52 site visits were conducted, and 250 providers were assessed.

In the baseline assessments, only three out of 22 sites scored 80% or higher—meaning the majority of the facilities were not ready or able to effectively diagnose, manage and monitor SPE/E using magnesium sulphate. The average baseline score was 26%. After on-site support and staff-led improvements, the average site score increased to 60%. Eight out of 22 sites scored 80% or higher and another 12 sites had made significant improvements. By the end, 11 of the 22 facilities were performing at 80% or higher. SBA training sites and medical colleges were the strongest performing sites. Other key findings include:

l SBA-trained providers performed better than those without SBA training.l Providers improved their knowledge of SPE/E but found changes in practices— particularly managing severe pre-eclampsia and monitoring for toxicity—more difficult.l Magnesium sulphate was available but the supply not always sufficient for full SPE/E treatment. For example, calcium gluconate and complete resuscitation kits including ambu bag and mask were not available in some sites.

To address the Nepal Maternal Mortality and Morbidity Study (2009) findings that 41% of all maternal deaths occurred at health facilities and PE/E was the leading cause of facility-based deaths, this SPE/E management initiative can be expanded to all hospitals and other Aama Suraksha facilities. The job aids and tools used in this intervention can be used and integrated into other national efforts to strengthen quality of maternal and newborn care services.


I. INTRODUCTION

PURPOSEThis report summarizes the activities and results from a focused intervention to strengthen the use of evidence-based practice for management of severe pre-eclampsia and eclampsia (SPE/E) with magnesium sulphate in 22 health facilities across Nepal.

BACKGROUNDPre-eclampsia is a condition that pregnant women can get generally in the second half of their pregnancies. Pre-eclampsia is marked by high blood pressure accompanied with a high level of protein in the urine. It may progress rapidly to severe pre-eclampsia with increased blood pressure and protein. When severe pre-eclampsia (SPE) is left untreated it can progress into the more serious and life threatening condition of eclampsia. Eclampsia can occur before, during or after childbirth. While the exact cause is unknown, pre-eclampsia and eclampsia (PE/E) is one of the leading causes of maternal deaths in the world—contributing between 8–25% of maternal mortality worldwide1 . It also causes an increased risk of perinatal mortality. Among pregnant women worldwide, 7–15% develops pre-eclampsia (high blood pressure with proteinuria). Among them, approximately 1–2% will develop eclampsia. According to Nepal Maternal Mortality and Morbidity Study conducted in 2008–2009 showed that PE/E is the second leading cause of maternal mortality in Nepal accounting for 21% of all maternal deaths and was the leading cause of all facility based maternal deaths (30%)2. For most cases of severe pre-eclampsia, eclampsia can be prevented by introducing magnesium sulphate (also known as Epsom salt) and immediately initiating labor. In women with severe pre-eclampsia, magnesium sulphate was found to reduce the occurrence of eclampsia by more than 50% and maternal deaths by 46%3 . WHO has identified magnesium sulphate as the most effective and low cost medication for treatment of eclampsia. Nepal revised its National Medical Standard for Reproductive Health (Volume III) in 2007 to list magnesium sulphate as the choice of drug for treatment of SPE/E. SPE/E management using magnesium sulphate is one of the core skills taught in skilled birth attendants (SBA) trainings. Magnesium sulphate is a part of the national essential drugs list since 2008.

To reduce SPE/E related mortality and morbidity in Nepal the ACCESS Program in collaboration with Nepal Society for Obstetricians and Gynecologists (NESOG) worked to strengthen the use of global evidence-based practice using magnesium sulphate for the management of SPE/E. In partnership with Family Health Division (FHD), the use of magnesium sulphate to treat SPE/E was promoted in 22 health facilities across 12 districts from June through December 2009. NESOG and ACCESS facilitated changes in clinical practices using existing materials, Maternal and Newborn Care (MNC) Quality Improvement (QI) Tools. Activities included: ensuring the availability of

1 World Health Organization (WHO). 1994. Mother-baby package: Implementing safe motherhood in countries. Geneva2 Nepal Maternal Mortality and Morbidity Study (NMMMS). 2009. Family Health Division.3 Magpie Trial Collaborative Group. Lancet 2002.Duley L, Gulmezoglu AM, Henderson-Smart DJ.: The Cochrane Library, 2006.

When severe pre-eclampsia (SPE) is left untreated it can progress into the more serious and life threatening condition of eclampsia. Pre-eclampsia and eclampsia cause 21% of maternal deaths in Nepal.


magnesium sulphate in facilities; orienting health care providers on SPE/E treatment protocols using magnesium sulphate; and advocating for the use of magnesium sulphate for SPE/E.

This project was funded by United States Agency for International Development (USAID) under ACCESS. The ACCESS Program worked in partnership with the government from 2005–2009 to provide technical leadership and innovation for improved maternal and newborn health. ACCESS is the USAID’s global program to expand coverage, access and use of key maternal and newborn health services across a continuum of care from the household to the hospital with the aim of making quality health services accessible as close to home as possible. Jhpiego implements the program globally in partnership with Save the Children, Constella Futures Group, the Academy for Educational Development, the American College of Nurse-Midwives and Interchurch Medical Assistance.

Gaining Confidence to Diagnose and Treat Severe Pre-eclampsia

A warm and energetic woman, Bhagawati Badal (pictured on right) is senior Auxiliary Nurse Midwife (ANM) working at Seti Zonal Hospital for the last 20 years. Over the years, she has seen a number of complicated maternity cases and has learned from a number of in-service trainings how to handle these difficult situations. Almost 10 years ago she learned in the Midwifery Refresher Training (MRT) that she could use magnesium sulphate to treat eclampsia. Hesitant, she gradually used this drug and gained confidence in it. During SBA training in 2007, she learned that it can also be used for pregnant women with severe pre-eclampsia, but she was not confident. She felt that eclampsia is easy to diagnose because the women were fitting. But without seizures, Bhagawati and other nurses find it is very difficult to diagnose severe pre-eclampsia. Often after waiting for lab results on the patient’s urine, the combination of clinical information isn’t always definitive so they often re-test or monitor her—delaying potentially life-saving care.

During a clinical update at her hospital by NESOG, Bhagawati said the staff at the maternity unit realized these mothers are at increased risk of developing eclampsia without immediate and appropriate intervention. Nursing staff now understood how to diagnose severe pre-eclampsia cases and can start treatment independently with magnesium sulphate and then inform the doctor.

Photo credit: Gita Dhakal


II. PROJECT DESIGN

GOAL AND OBJECTIVES The goal was to strengthen the use of magnesium sulphate for the management of SPE/E at the 22 selected facilities, improving the quality of care and ultimatly reducing maternal and newborn morbidity and mortality. The objectives were to:1. Strengthen capacity of NESOG to advocate for and institutionalize/standardize the use of magnesium sulphate for management of SPE/E.2. Assess the staff knowledge and skills in managing SPE/E with magnesium sulphate. 3. Assess the availability of magnesium sulphate in these facilities.4. Support facilities to strengthen SPE/E management using magnesium sulphate.

KEY ACTIVITIESTo fulfill these objectives, ACCESS with NESOG conducted the following activities over the six-month project period, June through December 2009.1. Development of resources and resource personnel (June–July 2009) l Standards development l Orientation and planning workshop l Development of orientation package l Development of job aids2. Baseline assessment (August 2009) l Site selection l Assessment of 22 sites3. First monitoring of 22 sites (September–October 2009)4. Additional monitoring visits of 10 sites (November–December 2009)

APPROACHESOverall project design was guided by the following three strategies/approaches:1. Disseminating evidence based practices and operationalizing existing national guidelines, standards and tools

Evidence based practices for the management of SPE/E using magnesium sulphate are incorporated in the key national policies and guidelines but are not consitently in use by health care providers and facilities throughout Nepal. Standards were disseminated through trainings and job aids to help operationalize them.

2. Mobilizing technical and clinical leadersACCESS worked with NESOG, a professional organization with strong network of about 250 members. As specialists in health facilities, obstetrician/gynecologists take the lead in managing SPE/E cases along with maternity unit and other colleagues. For this reason, NESOG has championed evidence based practices such as the use of magnesium sulphate for SPE/E to address major causes of maternal morbidity and mortality.


3. Improving quality of careACCESS addressed quality of care by using simple job aids and Standards Based Management and Recognition (SBM-R) approach. SBM-R is a four-step process using standards for quality improvement. The steps are: setting performance standards (such as Quality Improvement Tools); using the standards to assess performance and identify gaps; measuring progress; and recognizing and rewarding achievements through combination of feedback and social recognition. SBM-R emphasizes empowering service providers to make changes and measuring progress.

SELECTED HEALTH FACILITIES FOR STRENGTHENED QUALITY OF CARE In consultation with FHD and external development partners, 22 health facilities were selected for on-site technical support. These sites represent all five regions of the country. Different levels of health facilities were included: referral hospitals; medical colleges; zonal and district hospitals; primary health care centers (PHCCs); and private nursing homes. More sites were selected in the Terai where SPE/E is more common. Sites also included tertiary center with high numbers of referral/complicated maternity cases. Table 1 lists the sites which includes seven that offer skilled birth attendant (SBA) in-service training4 and/or 12 that provide free maternity care services through the national Aama Suraksha program5 .

4 There are currently 15 working SBA in-service training sites in Nepal as of December 2009.5 This national Aama Suraksha (meaning Safer Mother) program was launched by the Ministry of Health and Population in January 2009 to offer free maternity care at home or health facility under Government of Nepal (GoN) or in the private and NGO run health facilities and teaching hospitals permitted by GoN. It also provides specified travel expense for women who come to a health facility for the institutional delivery.


Table 1. Participating Health Facilities

REGION SN FACILITY FACILITY

TYPE

SBA TRAINING

SITE

AAMA SURAKSHA

SITE

Eastern 1 Koshi Zonal Hospital (KZH) Zonal hospital

etavirP)HN(emoH gnisruN ihsokatpaS 2

3 BP Koirala Institute of Health Sciences (BPKIHS)

Medical college

4 Inaruwa District Hospital (IDH) District hospital

Central 5 Janakpur Zonal Hospital (JZH) Zonal hospital √

6 Bharatpur Hospital District hospital √ √

7 A etavirP latipsoH ahs

8 Nepal Medical College (NMC) Medical college

etavirPemoH ytinretaM yellaV 9

10 Dhulikhel hospital Medical college √

Western 11 Western Regional Hospital (WRH) Regional hospital √ √

etavirPlatipsoH ytiC aweF 21

13 Abhiyan Hospital Community

14 Lumbini Zonal Hospital (LZH) Zonal hospital √ √

15 A etavirPlatipsoH ADM

16 Universal College of Medical Sciences (UCMS) Medical college

17 Dumkauli PHCC √

Mid Western 18 Mid Western Regional Hospital(MWRH)

Regional hospital √ √

19 Bheri Zonal Hospital (BZH) Zonal hospital √ √

Far Western 20 Seti Zonal Hospital (SZH) Zonal hospital √ √

21 Chaumala PHCC √

22 Malakheti PHCC √

PHCC

PHCC

PHCC

√ √

√


III. KEY ACTIVITIESACCESS in partnership with FHD and NESOG worked to promote the use of magnesium sulphate to treat SPE/E in selected health facilities. Activities focused on ensuring the availability of magnesium sulphate in facilities, supporting health care providers to use magnesium sulphate appropriately according to treatment protocols and providing on-site technical support to improve the quality of care. ACCESS and NESOG jointly developed, implemented and monitored these activities together.

1. Development of Resources and Resource PersonnelFrom June 2009, ACCESS and NESOG focused on reviewing existing clinical guidelines to develop provider-oriented job aids and update a core group of NESOG members who would provide on-site coaching. It was important that NESOG mobilized its members across Nepal and standardize there SPE/E practices to be clinical champions.

Standards development. Existing materials were collected and reviewed. NESOG first reviewed the National Medical Standard for Reproductive Health Volume III (NMS III) and Maternal and Newborn Care (MNC) Quality Improvement (QI) Tools. Both promoted evidence based practices on SPE/E management consistent with international guidelines.

A few standards from the MNC QI Tools were selected because they defined the minimum standards for services and training at SBA in-service training sites, developed by the National Health Training Center (NHTC) on complications during pregnancy was used for this activity. Specifically ACCESS and NESOG used standards 13, 14 and 15 related to the management of SPE/E from Tool 3 (See Appendix 1). Consistent use of the same tools and standards helped reinforce existing quality improvement efforts underway at some sites.

Orientation and planning workshop. Following the guidelines review, NESOG selected 30 of its members and several nurses to participate in a two-day workshop. NESOG first technically updated the group on SPE/E related evidence based practices. The group then developed a workplan and planned for the assessment visits (see Appendix 3). Each NESOG members selected one or more sites in their region to support over the coming months.

Development of orientation package. To orient health facility staff and standardize their skills on the use of magnesium sulphate to manage SPE/E in 22 sites, a brief orientation was developed from the national standards (see Appendix 4). All NESOG members used these materials to orient and update service providers at the sites so that the consistent information was shared.


Development of job aids. ACCESS and NESOG developed three job aids to bring the key information on management of SPE/E using magnesium sulphate into maternity wards and providers’ hands:l A small pocket diary for providers;l A large pictorial flex to be posted on the facilities wall; andl A laminated pictorial piece for providers.

Based on provider feedback, the standard wall chart job aid was updated to simplify give steps and add illustrations. ACCESS printed 650 posters, 650 diaries and 200 flyers that were disseminated by NESOG during the provider orientation at the sites.

Lessons Learned

l The orientation for NESOG members to the SBM-R process and national standards on SPE/E management was important because it strengthened their capacity to assess performance using standards, analyze gaps and develop action plans.

l The orientation workshop also built consensus on clinical protocols—as not all participants were providing SPE/E management consistent with the national medical standards. The job aids also helped with standardization.

l Mobilization of NESOG members from the five regions of Nepal was a good decision as it enabled them to provide more frequent on-site support, reduced time and travel costs and establised them as a locally available technical resource.

2. Baseline Assessment In July and August 2009, teams of NESOG members in each of the five regions of Nepal visited the health facilities to conduct a baseline assessment using the short list of standards from the QI Tools (see Appendix 3 for assessement dates). Two NESOG members spent a day at each facility to understand the current practices around SPE/E management including availability of magnesium sulphate and staff skills. At each facility, five staffs working in the maternity ward (ANMs, doctors, staff nurses) were randomly selected and assessed using the QI Tools. Each health care provider’s performance was scored 0–3 (0–100%), and then these were averaged to create the facility score. The exercise was intended to assess the facility’s ability and readiness to manage SPE/E appropriately, not individual provider performance. The facility score was shared and then used to discuss and identify gaps. Some of the gaps were then addressed during the visit by:

l Knowledge and skill updates. Providers in the maternity ward were oriented on the standards. Providers and facilities were also supplied with job aids.

l Development of action plan. NESOG members and the facility staff together developed an action plan for each site and monitored progress over the coming months (see Appendix 5 for a sample action plan). The action plan is a problem-solving and planning process that uses a simple “Why? Why?” exercise to determine the cause of poor performance. It helps identify ways for the facility staff themselves to address gaps in knowledge, skills, motivation and the enabling environment. The action plan was shared with the facility administrative staff and management to ensure their support.

In addition to the staff assessment, sites were also requested to maintain a separate register for SPE/E cases and outcomes.

Job aid to be posted on the wall


Lessons Learned

l Providers were not using magnesium sulphate to manage severe pre-eclampsia.

l While it was expected that magnesium sulphate would not be available, most sites had some stock, enough for initial case management (loading doses). Calcium gluconate which is required for treating respiratory arrest due to magnesium sulphate toxicity however was lacking in most of the sites.

l SBA training sites were performing well at baseline. Other service sites with lack of trained staffs (SBA, MRT) or site strengthening needed substantially more on-site support to make changes in SPE/E management.

l In the future, the baseline assessment should be immediately followed with a facility- wide clinical update and other on-site coaching activities to build interest and momentum for change.

3. First Monitoring Visits to Measure Progress In September and October 2009, teams of NESOG members again visited all 22 health facilities to conduct the first followup visit to assess the progress since the baseline. At each facility, five staff working in the maternity ward were selected and assessed using QI Tools. Often these providers were different than those assessed at baseline.

Again the provider scores were aggregated and averaged to create a facility score, which then could be compared to the baseline to quantify progress. Almost all sites had improved their performance (the detailed results on page 12), but still faced challenges to achieve 100% of the three standards.

Together the action plan was reviewed and updated to address the remaining gaps identified from this assessment. Because there were often a number of new staff on the maternity ward, the NESOG members updated them on SPE/E management using magnesium sulphate—focusing on the key knowledge or skills areas that still remained difficult for providers to routinely perform appropriate SPE/E management. For example, in a number of sites providers had difficulty in checking patellar reflex, an important step in monitoring magnesium toxicity. To address this gap, the team simulated the monitoring of patellar reflex and administration of magnesium sulphate. Other sites were not prepared or equipped for rapid patient assessment and management. Some did not have a proper supply of magnesium sulphate or calcium gluconate, or necessary equipment for monitoring and resuscitation. In all sites, the team also helped set up magnesium sulphate tray and asked the care providers to keep this tray in the maternity ward. NESOG members also encouraged staff to conduct regular emergency drills on management of SPE/E—as these cases are rare but often arrive in critical condition.

At many sites, NESOG members found that the providers were so busy providing care with increasing numbers of deliveries that it was difficult to get all staff together for clinical updates and for them to impliment the action plan.

During a September 2009 site visit, staff at Mid-Western Regional Hospital in Surkhet district participated in a demonstration on how to check the patellar reflex—an important part of monitoring during SPE/E management.

Photo credit: C P Dhakal


Lessons Learned

lProviders were very enthusiastic to learn and participate in the updates. They also wanted to practice skills related to SPE/E management and monitoring.

l On-site coaching and support from NESOG members helped make changes at the facilities and implement the action plans. For example, staff recognized that they were not ready to prompt management of SPE/E and liked setting up the magnesium sulphate tray in the ward.

l Action plans may have been better implemented if they were more detailed and had more ownership from the maternity unit staff and facility administration.

4. Additional Monitoring Visits of 10 Sites to Provide More On-site Support and Measure Progress

By the end of October, NESOG members with ACCESS staff reviewed overall progress and performance of the 22 sites. While most of the sites had made improvements in SPE/E management using magnesium sulphate, there were a number of sites the team felt needed some additional on-site support and additional time to implement their action plan. NESOG members identified 10 sites they wanted to continue to work with to improve the quality of care (shown in Appendix 2).

In November and December 2009, NESOG members visited these sites for two-three days to provide on–site coaching, focused on addressing the remaining gaps in the site action plans. One of the common challenges across facilities was the frequent rotation and/or transfer of staff, particularly in hospitals and medical colleges where staff rotate to different wards every 6–12 months. To address this, NESOG members conducted a larger clinical update to all service providers in the facility—beyond the maternity ward staff. They were updated on SPE/E management using magnesium sulphate including simulation on administration of magnesium sulphate and toxicity monitoring.

Another challenge was addressed during these visits, as raised by the sites themselves. Frequently women arrive at facilities in critical condition suffering from eclampsia—referred from other facilities that did not diagnose SPE/E or start treatment. For the clinical update, few staff from such private health facilities were invited and provided with job aids. This should improve the referral system and overall care for women if they at least receive the loading dose of magnesium sulphate before transfer to a higher facility.

At this last site visit, all providers in the maternity ward were assessed using the QI Tools—where in the first two visits only five staff participated. Additional facility scores therefore reflect all providers’ performance which may have affected the facility scores. Of the 10 sites, five had made improvements and achieved 80% or higher. The other five still scored low and need to continue to address their gaps to ensure quality of care for SPE/E management meets the national standards.

Lessons Learnedl A number of sites that were not able to make substantial improvements were challenged by larger issues that need to be addressed before the quality of care will improve, such as caseload, clinical leadership and staffing.

l During this visit a large clinical update was conducted for all facility staff because they frequently rotate between wards within hospitals. This was affecting the quality of care in the maternity ward as many nurses were not updated on SPE/E management.

l All sites would benefit from regularly conducting SPE/E emergency drills to simulate rapid patient assessment, treatment and monitoring.


Scores of 22 Facilities on SPE/E Management

0%

20%

40%

60%

80%

100%

KZ

H

Sapt

akos

hi

BP

KIH

S

IDH

JZH

Bha

ratp

ur

Ash

a

NM

C

Val

ley

Dhu

likhe

l

WR

H

Few

a

Abh

iyan

LZH

AM

DA

UC

MS

Dum

kaul

i

MW

RH

BZ

H

SZH

Cha

umal

a

Mal

akhe

ti

Baseline % First % Second %

IV. KEY FINDINGS AND RESULTSFACILITIES ARE NOW MORE CAPABLE TO MANAGE AND MONITOR SPE/E APPROPRIATELYIn the baseline assessments, only three out of 22 sites scored 80% or higher—meaning the majority of the facilities were not ready or able to effectively diagnose, manage and monitor SPE/E using magnesium sulphate. The average baseline score for the 22 facilities was 26%.

After on-site support, clinical updates, job aids and staff-led improvements, eight out of 22 sites scored 80% or higher and another 12 sites made improvements. The average site score increased to 60%. By the end of the intervention, 11 of the 22 facilities were performing at 80% or higher.

In general, teaching institutions—SBA training centers and medical colleges—performed better. Six of the seven SBA training centers achieved the score of 80% or higher.

Looking at Aama Suraksha facilities, 12 of the 22 facilities offer free maternity care services. Excluding the seven SBA in-service training sites that have been strengthened over several years, four of remaining five facilities never met these quality of care standards (scored >80%). For example, Janakpur Hospital has a high case load with increasing numbers of women coming for deliveries.It also has a large number of SPE/E cases: 75 SPE/E were reported in the past year. Providers, infrastructure and resources there are stretched. This highlights the need to ensure that the quality of free maternity care services is high—otherwise poor care can undermine efforts to promote institutional deliveries.

Scores by Type of Health Facilities

37%

2%

37%

7%

52%45%

80%

66% 67%

30%

54%

86%

64%

15%

0%

20%

40%

60%

80%

100%

SBA TrainingSites (7)

PHCCs (3) Hospitals (2) MedicalColleges (5)

PrivateHospital (5)

Baseline % First % Second %


PROVIDERS WITH SBA TRAINING ARE BETTER AT MANAGING SPE/EBecause management of SPE/E using magnesium sulphate is a part of the SBA curriculum, it is not surprising that providers who completed the SBA in-service training performed better. Of the 250 providers who participated in various rounds of assessment, 70 SBA trained providers scored an average of 89%—versus 61% among the 180 non-SBA trained providers. The on-site updates and coaching provided by the NESOG members improved non-SBA trained providers performance.

PROVIDERS IMPROVED THEIR KNOWLEDGE OF SPE/E BUT FOUND CHANGES IN PRACTICES MORE DIFFICULTOver time, providers increased their knowledge of SPE/E (standard 13) and by the final assessment over 80% understood how to clinically diagnose severe pre-eclampsia and eclampsia. Providers at these 22 sites however made less substantial improvements in their performance managing SPE/E (standard 14) and monitoring for toxicity (standard 15)—due mainly to the need to change clinical decision-making practices among the maternity unit staff, ensure supplies and equipment and address other enabling environment factors.

Average Provider Score by SBA Training Experience (n=250)

61%

89%

0%

20%

40%

60%

80%

100%

Completed SBA Training No SBA Training

Performance by SPE/E-Related Standards (QI Tools)

32%

55% 59%72%

24% 26%

59%

91%

65%

0%20%40%60%80%

100%

Standard 13: Knowledge Standard 14:Management

Standard 15: Monitoring

Baseline First Second


GOOD AVAILABILITY OF MAGNESIUM SULPHATE IN SELECTED FACILITIES FOR LOADING DOSE—BUT OTHER DRUGS, SUPPLIES AND EQUIPMENT LACKINGAt the baseline assessment, 19 out of 22 health facilities had magnesium sulphate available for SPE/E management but often only enough for the loading dose. Most of the sites didn’t have adequate supply on a regular basis to support maintenance dose. Stock was not regularly being checked and expired drugs replaced with new ones. By September 2009, all 22 facilities had sufficient magnesium sulphate available: specifically PHCCs and private hospitals had adequate loading doses stock for referring cases, and SBA training centers and medical colleges had enough for full case management.

While it was originally thought availability of magnesium sulphate would be a problem, other key drugs and equipment for monitoring and resuscitation were found missing. Calcium gluconate, hammers for checking patellar reflex and complete resuscitation including ambu bag and mask were not available in a number of sites.

Photo credit: Gita Dhakal

Eclamptic Patients No Longer Wait for Magnesium Sulphate at Seti Zonal Hospital

Although magnesium sulphate has been the recommended drug for the management of severe pre-eclampsia and eclampsia, it hasn’t always been available to providers in Nepal. Six or seven years ago, when an eclamptic women came for care to Seti Zonal Hospital, only then the search for magnesium sulphate began. Staff would look at the local Sajha medicine shop near the hospital, but it was frequently out of stock. Or they would ask the patient’s family to buy it across the border in India—3–4 hours away and often too late to save the patient’s life. After Manju KC, a sister in charge, learned in trainings how to manage severe pre-eclampsia and eclampsia using magnesium sulphate, she and other maternity unit staff helped ensure the medicine is regularly available and continuously used at the hospital. They have also set up the magnesium sulphate tray in labor ward which is replenished from time to time.

Manju said,“Before the NESOG work we used magnesium sulphate for eclampsia cases only, but now we use the drug to treat severe pre-eclampsia as well. From NESOG, we also learned the importance of and how to monitor patients after giving them magnesium sulphate and how to manage its complications.”

Across Nepal, magnesium sulphate has been included on the national essential drug list since 2008. From July 2009, it has been distributed through the government logistics system to health facilities.


CONTINUED COMMITMENT NEEDED TO ENSURE QUALITY OF CARETable 2 summarizes the main gaps found during the site baseline assessments from all sites. Future work to improve quality of maternal and newborn care at facilities can focus on these main challenges to SPE/E diagnosis, treatment and monitoring. Further, ongoing preservice and in-service training programs can strengthen teaching to address the knowledge and skills gaps. The table also details next steps that are still required to continue to improve quality of care, which can inform both site-specific support as well as national efforts to improve SPE/E management in all health facilities.

Table 2. Summary of Baseline Gaps, Actions, Results and Further Needs

GAPS IDENTIFIED STEPS TAKEN RESULTS ACCOMPLISHED

NEXT STEPS

Knowledge Sign and symptoms of SPE/E

Repeat dose if further fits occur after 15 minutes

Time of delivery to SPE/E cases

Management of low urine output

Monitoring: ― Sign and

symptoms of pulmonary edema

― Patellar reflex

Updating the facility staffs by focal person

Onsite coaching to the staffs

Demonstration/Simulation of checking patellar reflex

Increased knowledge over time

Regular updates assigned to a local facility staff as focal person from NESOG

Transfer of knowledge to the students

Advocating for staff to be sent to SBA training

Skill Loading and maintenance dose of magnesium sulphate

Repeating the dose of magnesium sulphate if further fits occur after 15 minutes

Time of delivery to SPE/E cases

Checking patellar reflex

Management of low urine output

Demonstration on management of SPE/E using magnesium sulphate

Simulation on monitoring of magnesium sulphate toxicity

Updating the facility staffs

Demonstration of requirements for magnesium sulphate tray set up

Increased skills over time

Continue to perform emergency drills over time



NEXT STEPS

Human Resources Internal rotation of service providers every six months to one year

Transfer of trained service providers

Hesitancy among nurses to diagnose and treat SPE

In some sites, only doctors administer magnesium sulphate for SPE cases and decide when to deliver

Staff rotation (internal): orient all staffs from each ward

Capacity building of nursing staffs by updating them

Realizing the staffs that they can self diagnose the SPE/E cases and administer magnesium sulphate to them using QI Tools and job aids

Staff transfers (external): identify and promote the locally haired staff from development board

Staff rotation (internal): all staff oriented in all sites in second assessment visits

Staff transfers (external): promoted locally hired staff

Advocated the use of magnesium sulphate by nursing staffs as essential drug

Advocate with FHD for proper deployment and relocation of trained staff

Coordinate with NHTC for nomination of staff for SBA training

Coordinate with NHTC to involve the staff from private hospitals for SBA training

Logistics Magnesium sulphate was not available in three sites in baseline assessment

Unavailability of calcium gluconate

Unavailability of reflex hammer in most of the sites

Unavailability of resuscitation kit including ambu bag

Set up magnesium sulphate tray for emergency and quick management of SPE/E cases

Advocated to keep the magnesium sulphate as emergency drug as it was listed in the essential drug list

Advocated to keep the calcium gluconate compulsorily with magnesium sulphate

All sites have magnesium sulphate available in first assessment but the dose was incomplete in few sites

Need to keep all requirements in magnesium sulphate tray

Advocate with the facility chief to procure reflex hammer and calcium gluconate

Client Case Load High case loads in some sites: ― Service providers

too busy; limited time for update and training

― Infrastructure limited to cope with client load

Low case loads in some sites–staff tend to forget what they learned

Updated the staff according to standards

Advocated the importance of regular updates and drills for enhancing the skills

Conducted simulation

Regular update and emergency drill by site staff



NEXT STEPS

Infrastructure and Management

Infrastructure limited to cope with client case load

Need to advocate with FHD to upgrade the maternity unit of some facilities (such as Janakpur hospital)

Referrals Come in Serious Condition

Increased mortality as women arrive without any previous treatment (loading dose) with eclampsia.

Providers are hesitant to treat due to fear for personal safety if poor outcome

Strengthen sites that refer cases

For Seti Zonal Hospital, Bheri Zonal Hospital, Mid Western Regional Hospital, Asha Hospital staff from sites that refer cases were trained and oriented on providing loading dose of SPE/E

Need to train sites that refer cases to these larger facilities

Need to prepare all hospitals for SPE/E management


V. LESSONS LEARNED, CHALLENGES AND OPPORTUNITIES FOR SCALING UP AND

SUSTAINIBILITY

OVERALL PROJECT LESSONS LEARNEDl Ensuring evidence-based practice for SPE/E management is more complex than simply ensuring magnesium sulphate is available and providers are knowledgeable about dosing. Changes in clinical practice require motivated staff and on-going support within an enabling clinical environment.

l Continued focus on SPE/E management can be specific to the level of care expected: a focus on sites that should diagnose SPE/E, give loading dose and refer (such as PHCCs and private nursing homes); and a more intensive effort at referral sites (such as larger zonal hospitals) on rapid assessment, case management and toxicity monitoring.

l SBA training is effective at improving provider management of SPE/E and should be expanded to include participants from private hospitals, locally-hired providers and medical colleges. Providers at Aama Suraksha facilities should be given priority for SBA training.

l Because there is are little data available at facilities, recording systems that identify the SPE/E incidence, management, maternal and neonatal outcomes are needed.

l Regular emergency drills on management of SPE/E would help both facilities with overstretched maternity units as well as PHCCs where SPE/E cases are infrequent.

l Greater involvement of the hospital administration in the assessments may help accelerate improvements particularly in staffing, protocols and procurement.

CHALLENGES l High case load and few staff were seen in busy hospitals, so it was difficult to update providers together as a team on SPE/E management.

l Keeping health care providers clinical updated on appropriate SPE/E management required continuous updates and on-site coaching. Frequent turnover of staff was encountered in many sites.

l In some sites only obstetricians were permitted to start magnesium sulphate for SPE/E patients, so nurses were hesitant to start treatment—resulting in delays in urgently need care.

l Staff at PHCCs needed repeated orientation because case load is low and they tend to forget.

l Four-five months was a short of a time period to see facility-wide changes in SPE/E management.


OPPORTUNITIES FOR SCALING UP AND SUSTAINABILITY l To address the recent study findings that PE/E is the second leading cause of maternal deaths and 41% of all maternal deaths are occurring at health facilities, this SPE/E management initiative can be expanded to all hospitals and all other Aama Suraksha facilities. The job aids and tools used in this intervention can be used and integrated into other national efforts to strengthen quality of maternal and newborn care services. It is also essential that sites that referred need to be able to diagnose SPE/E, begin tretment and quickly referral.

l NESOG has a team of regional and national champions and a set of user-friendly job aids to promote SPE/E management. These members are familiar now with how to facilitate baseline assessments, analyze gaps, prepare action plans, and conduct follow-up assessments.

l NESOG is maintaining an eclampsia register in these 22 sites, collecting data and making a central database in NESOG for SPE/E. These datas over time will be useful to inform the national program and could be further expanded.

l SBA training needs to emphasize knowledge and skills in SPE/E management and monitoring for magnesium sulphate toxicity so providers post-training are more skilled and confident.

l As medical colleges performed well, SPE/E management can easily updated in medical preservice education, resulting in more skilled providers and less need for future refresher training.


Appendix 1: Quality Improvement Tool 3-Standards 13, 14, 15PERFORMANCE

STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

Severe pre-eclampsia or eclampsia7: Interview a provider who is likely to manage severe pre-eclampsia or eclampsia.

13. �e provider correctly describes the signs and symptoms of severe pre-eclampsia and eclampsia.

Ask the provider “What are the signs and symptoms of severe pre-eclampsia and eclampsia?”

Severe pre-eclampsia:

— Diastolic BP equal to or more than 110 mm Hg

— noitatseg erom ro skeew 02

— Proteinuria 3+

Eclampsia:

— snoisluvnoC

— Diastolic BP equal to or more than 90 mm Hg

— noitatseg erom ro skeew 02

— retaerg ro +2 airunietorP

14. �e provider describes the correct management of severe pre-eclampsia and eclampsia.

Ask the provider “How would you manage severe pre-eclampsia and eclampsia?”

Administer initial (loading) dose of magnesium sulphate:

— Administer 4 grams of 20% magnesium sulphate in solution (20 mL) IV over a 5-minute period.

— Administer 5 grams of 50% magnesium sulphate solution (10 mL) with 1 mL of 2% lidocaine IM deep in each buttock (total 10 grams).

In the event of a second convulsion after 15 minutes, administer 2 grams of 50% magnesium sulphate IV over a 5-minute period.

Administer maintenance dose:

— Administer 5 grams of 50% magnesium sulphate solution with 1 mL of 2% lidocaine deep IM alternately in each buttock every 4 hours, providing there are no complications.

— Continue with magnesium sulphate for 24 hours following birth or the most recent convulsion (which ever occurs last).

.reddalb eziretehtaC

.tuptuo dna ekatnI rotinoM

.nemow fo sngis lativ rotinoM

.)RHF( etar traeh latef rotinoM

Instructions to the assessors: Remember that severe pre-eclampsia and eclampsia are managed similarly except that birth

must take place within 12 hours following a convulsive episode and within 24 hours in the absence of a convulsion.


Scoring Method:1. All Providers were assessed using each tool. A provider received 100% if all answers were correct, 33% if only one was correct, and zero if none of the answers were correct.2. To get a perfect score for a standard, the provider has to answer all sections of the standard correctly. If even one section is incorrect, the provider scores zero for the entire standard.

The score of the site is based upon the average score of the providers.

PERFORMANCE STANDARDS DEFINITION (VERIFICATION CRITERIA) Y/N NA

�e provider describes the correct management of severe pre-eclampsia and eclampsia. (Continued)

If there were convulsions, birth must take place within 12 hours following the convulsion or, in the absence of convulsions, within 24 hours.

Provide antihypertensive treatment (if diastolic BP is 110 mm Hg or more if no convulsion; 90 mm Hg if convulsion):

— Plan 1: Hydralazine 5 mg IV slowly every 5 minutes or 12.5 mg IM every 2 hours, until diastolic BP stabilizes between 90 and 100 mm Hg OR

— Plan 2: Nifedipine 5 mg sublingual, repeating the dose if the diastolic BP is still >110 after 10 minutes

15. �e provider correctly describes followup.

Ask the provider “What is the correct follow up for woman with severe pre-eclampsia or eclampsia?”

Monitor hourly:

— PB

— esluP

— erutarepmeT

— etar yrotaripseR

— Patellar reflex

— RHF

— tuptuo eniru dna ekatnI

— Signs and symptoms of pulmonary edema

Suspend or postpone use of magnesium sulphate if respiration <16/minute, patellar reflexes absent or output <30 mL/hour.

If urine output less than 30/hour, magnesium sulphate withheld and patient infused with ringer’s lactate 1 L IV over 8 hours, with monitoring for pulmonary edema.

In the event of respiratory arrest:

— .noitalitnev detsissa mrofreP

— Administer calcium gluconate 1 g (10 mL of a 10% solution) IV slowly (over 10 mins) until calcium gluconate begins to antagonize the effects of magnesium sulphate and respiration begins.


S.N. HEALTH FACILITIES TYPE

1 Seti Zonal Hospital SBA training center2 Malakheti PHC PHCC3 Asha Hospital Private hospital4 Dumkauli PHC PHCC5 Mid Western Regional Hospital SBA training center6 Bheri Zonal Hospital SBA training center7 Fewa City Hospital Private hospital8 Abhiyan Hospital Private hospital9 Janakpur Zonal Hospital Aama suraksha site10 Saptakoshi Nursing Home Private hospital

Appendix 2: Ten Health Facilities that Received Further Support


App

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x 3:

Foc

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Appendix 4: In-service Orientation Package

What is Severe Pre-eclampsia and Eclampsia?It is a condition that pregnant women can get, generally in the latter part of their pregnancies, the second or in the third trimesters, although it can occur earlier.

Sign and Symptoms of Severe Pre-eclampsia l Diastolic BP equal to or more than 110 mm Hg l 20 weeks or more gestation l Proteinuria 3+

Sign and Symptoms of Eclampsia l Convulsion l Diastolic BP equal to or more than 90 mm Hg l 20 weeks or more gestation l Proteinuria

Management of Severe Pre-eclampsia and Eclampsia l Administer initial (loading) dose of magnesium sulphate: l Administer 4 grams of 20% magnesium sulphate in solution (20 mL) IV over a 5-minute period. l Administer 5 grams of 50% magnesium sulphate solution (10 mL) with 1 mL of 2% lidocaine IM deep in each buttock (total 10 grams). l In the event of a second convulsion after 15 minutes, administer 2 grams of 50% magnesium sulphate IV over a 5-minute period. l Administer maintenance dose: l Administer 5 grams of 50% magnesium sulphate solution with 1 mL of 2% lidocaine deep IM alternately in each buttock every 4 hours, providing there are no complications. l Continue with magnesium sulphate for 24 hours following birth or the most recent convulsion (which ever occurs last). l Catheterize bladder. l Monitor intake and output. l Monitor vital signs of women. l Monitor fetal heart rate (FHR). l If there were convulsions, birth must take place within 12 hours following the convulsion or, in the absence of convulsions, within 24 hours. l Provide antihypertensive treatment (if diastolic BP is 110 mm Hg or more if no convulsion; 90 mm Hg if convulsion): l Plan 1: Hydralazine 5 mg IV slowly every 5 minutes or 12.5 mg IM every 2 hours, until diastolic BP stabilizes between 90 and 100 mm Hg OR l Plan 2: Nifedipine 5 mg sublingual, repeating the dose if the diastolic BP is still >110 after 10 minutes


Monitoring of Severe Pre-eclampsia and Eclampsia l Monitor hourly: l BP l Pulse l Temperature l Respiratory rate l Patellar reflex l FHR l Intake and urine output l Signs and symptoms of pulmonary edema—shortness of breath, wheezing etc. l Suspend or postpone use of magnesium sulphate if respiration <16/minute, patellar reflexes absent or output <30 mL/hour. l If urine output less than 30/hour, magnesium sulphate withheld and patient infused with ringer’s lactate 1 L IV over 8 hours, with monitoring for pulmonary edema. l In the event of respiratory arrest: l Perform assisted ventilation. l Administer calcium gluconate 1 g (10 mL of a 10% solution) IV slowly (over 10 minutes) until calcium gluconate begins to antagonize the effects of magnesium sulphate and respiration begins.)


App

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nal

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ard

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the

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s wer

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t se

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In

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14. T

he p

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desc

ribe

s the

cor

rect

ma n

agem

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f SPE

/ E

Inad

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and

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ance

dos

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m

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petit

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ose

in

the

case

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nvul

sion

Inad

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te k

now

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e an

d sk

ills i

n co

ntin

uatio

n of

mag

nesiu

m su

lpha

te

Inad

equa

te k

now

ledg

e an

d sk

ills i

n tim

ing

of d

eliv

ery

Sta

ff do

not

ha

ve a

dequ

ate

know

ledg

e an

d sk

ills i

n m

agne

sium

su

lpha

te

adm

inist

ratio

n-lo

adin

g an

d m

aint

enan

ce

dose

T

ill n

ow, n

o ca

ses w

ere

requ

ired

to

repe

at th

e do

se

due

to

recu

rren

ce o

f fit

s. So

that

they

th

ough

t it i

s not

ne

cess

ary

Mos

t of t

he

staffs

follo

w th

e do

ctor

s ord

er

whe

n to

star

t

Reg

ular

upd

ate

and

on si

te

coac

hing

to a

ll sta

ffs in

the

mat

erni

ty w

ard

acco

rdin

g to

na

tiona

l pro

toco

l U

pdat

e th

em

abou

t the

im

port

ance

of

repe

atin

g th

e do

se

in th

e ca

se o

f re

curr

ence

of fi

ts

Upd

ate

them

ab

out e

xact

tim

ing

of d

eliv

ery

for S

PE c

ases

and

E

case

s and

also

on

mag

nesiu

m

sulp

hate

di

scon

tinua

tion.

Upd

ate

them

im

med

iate

ly a

nd

dem

onstr

ate

the

requ

ired

dose

s of m

agne

sium

su

lpha

te fo

r loa

ding

and

m

aint

enan

ce d

ose.

R

egul

ar u

pdat

e an

d dr

ills

on S

PE/E

man

agem

ent

by m

agne

sium

sulp

hate

R

egul

ar u

pdat

e an

d on

sit

e co

achi

ng to

the

staffs

on

tim

ing

of d

eliv

ery

Dr R

ani J

ha

and

Siste

r In

char

ge

29 A

ug

Upd

ated

onc

e D

rills

not d

one


CO

LUM

N 1

: ST

AN

DA

RD

AN

D C

RIT

ERIO

N O

R

STEP

NO

T P

ERFO

RM

ED W

ELL

CO

L UM

N 2

:C

AU

SE O

F D

EFI C

I EN

CY

CO

L UM

N 3

:SO

LUT

ION

S C

OLU

MN

4:

AC

TIO

NS/

NEX

T S

TEP

S C

OLU

MN

5:

B Y W

HO

M

CO

LUM

N 6

:BY

WH

E N

CO

LUM

N 7

:ST

AT

US

and

stop

the

mag

nesiu

m

sulp

hate

�

ey d

eliv

ered

th

ese

case

s as

soon

as p

ossib

le

so th

at d

oesn

't kn

ow a

bout

the

exac

t tim

ing

of

deliv

ery

15. T

he p

r ovi

der

corr

ectly

de s

cri b

e s fo

ll ow

up

Do

not h

ave

skill

s in

chec

king

pat

ella

r re

flex

Do

not k

now

the

sign

and

sym

ptom

s of

pulm

onar

y ed

ema

Do

not h

ave

the

know

ledg

e an

d sk

ills i

n m

anag

emen

t of l

ow u

rine

outp

ut p

ost

adm

inist

ratio

n Fe

w st

affs d

o no

t kno

w th

e m

anag

emen

t of r

espi

rato

ry a

rres

t pos

t ad

min

istra

tion

�ey

onl

y he

ard

abou

t thi

s but

do

n't h

ave

the

skill

s. H

ospi

tal

does

n't h

ave

refle

x ha

mm

er

and

mat

erna

l am

bu b

ag.

Till

now

nur

ses

are

not a

war

e on

che

ckin

g th

e pu

lmon

ary

edem

a an

d th

ey

don'

t kno

w th

e sig

n an

d sy

mpt

oms o

f pu

lmon

ary

edem

a.

Sim

ulat

ion

on

chec

king

pat

ella

r re

flex

Purc

hase

refle

x ha

mm

er a

nd

ambu

bag

. U

pdat

e an

d or

ient

sta

ffs in

che

ckin

g pu

lmon

ary

edem

a

Perfo

rm si

mul

atio

n to

de

mon

strat

e ch

ecki

ng

pate

llar r

eflex

R

eque

st ho

spita

l ad

min

istra

tor t

o pu

rcha

se re

flex

ham

mer

an

d am

bu b

ag.

Orie

nt a

nd u

pdat

e sta

ffs

on c

heck

ing

pulm

onar

y ed

ema,

man

agem

ent o

f lo

w u

rine

outp

ut a

nd

man

agem

ent o

f re

spira

tory

arr

est.

Dr R

ani

D

r Ran

i, Si

ster i

n ch

arge

and

sto

reke

eper

D

r Ran

i

29 A

ug Se

ptem

ber 1

0

Sim

ulat

ion

done

but

no

t for

all

staffs

R

eque

sted

hosp

ital

adm

istra

tor b

ut n

ot

purc

hase

d U

pdat

ed fe

w st

affs


CO

LUM

N 1

: ST

AN

DA

RD

AN

D C

RIT

ERIO

N O

R

STE P

NO

T P

ERFO

RM

ED W

E LL

CO

L UM

N 2

:C

AU

SE O

F D

EFIC

IEN

CY

CO

LUM

N 3

:SO

LUT

ION

S C

OLU

MN

4:

AC

TIO

NS/

NE X

T S

TEP

S C

OL U

MN

5:

BY W

HO

M

CO

LUM

N 6

:BY

WH

EN

CO

LUM

N 7

:ST

AT

US

Whe

n th

ey

foun

d de

crea

sed

urin

ary

outp

ut,

they

stop

m

agne

sium

su

lpha

te a

nd

give

RL

fast

but

not a

ccor

ding

to

pro

toco

l; so

me

of th

em

told

to g

ive

calc

ium

gl

ucon

ate

for

this.

�ey

thin

k ca

lciu

m

gluc

onat

e al

so

trea

t low

urin

e ou

tput

. M

ost o

f the

sta

ff to

ld to

giv

e ca

lciu

m

gluc

onat

e fir

st ra

ther

than

ot

her s

uppo

rtiv

e m

easu

res.

O

rient

and

upd

ate

staffs

on

man

agem

ent o

f lo

w u

rine

outp

ut.

Orie

nt th

em o

n m

anag

emen

t of

resp

irato

ry

depr

essio

n an

d ar

rest.

Aug

29

STRENGTHENING THE USE OF MAGNESIUM SULPHATE

FOR MANAGEMENT OF SEVERE PRE-ECLAMPSIA

AND ECLAMPSIA

This publication is made possible through support provided by USAID Nepal, Office of Health and Family Planning. The ACCESS program is supported by the Maternal and Child Health Division, Office of Health, Infectious Disease and Nutrition, Bureau for Global Health, U.S. Agency for International Development, under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-04-00002-00. The opinion expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.

Access to clinical and communitymaternal, neonatal and women’s health services

STRENGTHENING THE USE OF MAGNESIUM SULPHATE FOR MANAGEMENT...

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