AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 9, NUMBER 5/6
Sept/Nov 1992
CREATION OF A NEONATOLOGY FACILITY IN A DEVELOPING COUNTRY: EXPERIENCE FROM A 5-YEAR PROJECT IN CHINA John W. Peabody, M.D.* Therese Hesketh, M.B., Ch.BJ and John Kattwinkel, M.D.
ABSTRACT
In 1983, Project HOPE, an American-based, nongovernmental, organization that supports efforts to improve health around the world, was invited by Zhejiang Medical University (ZMU) to establish collaborative programs in health in the People's Republic of China. Fourteen projects involving various medical disciplines were initiated with ZMU and three other universities. Children's Hospital in Hangzhou is one of ZMU's four affiliated hospitals and serves as the tertiary care facility for pediatrics in Zhejiang Province, which has a population of over 40 million. It was here that the University requested development of a neonatal and pediatric intensive care (NICU) facility as one of the 14 projects. This report will examine the 5-year course of development of this facility and its implications for improving the
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In 1983, Project HOPE was invited by Zhejiang Medical University to collaborate in developing a neonatal intensive care unit (NICU) at the Children's Hospital in Hangzhou, China. The initial approach involved renovating facilities, purchasing equipment and supplies, placing short-term consultants in the unit as teachers, and bringing selected leaders to the United States for brief fellowships. An evaluation at 18 months disclosed poor organization and leadership, inconsistent clinical care, and unsatisfactory utilization and maintenance of facilities and equipment. Therefore the strategy was revised to include long-term physician and nursing consultants, establishment of ties with HOPE Biomedical Engineering projects, and development of formal education programs. The unit was transferred to the Chinese after 4 years and an evaluation 1 year after transfer revealed an actively functioning independent NICU with evolving effective leadership, established purchasing and preventive maintenance programs, and continuing formal education activities. Unsatisfactory progress was found with the development of a transport system, some laboratory capabilities, adherence to admission and discharge policies, and various other administrative issues. Although the goal of establishing an independent NICU was realized, perhaps the most lasting accomplishment was the establishment of a facility and a format for development of a transportable education program aimed at improving neonatal care practices throughout a larger region of China.
quality of neonatal care in Eastern China. We hope that our experience will be helpful to others contemplating similar projects in other regions in China and elsewhere in the developing world. INITIAL PLANNING VISIT; STATUS OF CHINESE NEONATOLOGY IN 1983 In August 1983, a site visit was made by a team of HOPE consultants to determine the advisability of this proposal. Five areas were evaluated: physical state of the hospital and equipment; laboratory and clinical support services; physician and nurse knowledge; quality of clinical care and the need for an intensive care facility; current
Project HOPE, Millwood, Virginia, and Department of Pediatrics, University of Virginia, Charlottesville, Virginia •Present address: World Health Organization, Western Pacific Regional Office, P.O. Box 2932,1099 Manila, Philippines t
Present address: Project HOPE Collaborative Program, Zhejiang Medical University, Hangzhou, Peoples Republic of China Reprint requests: Dr. Kattwinkel, Department of Pediatrics, Box 386, University of Virginia Health Sciences Center, Charlottesville, VA 22908 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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status and feasibility of the hospital serving as a referral center. The findings can be summarized as follows. The hospital had 460 beds and was very much in need of general physical improvement. There was inadequate heating in the winter and no air-conditioning in the summer. Housekeeping and general maintenance, such as electricity and plumbing, needed upgrading. There was no central oxygen, compressed air, or physiologic monitors, and only primitive infant incubators. Laboratory facilities were inadequate: serum chemistry and hematology testing were not consistently available nor adequate for acute clinical care; microbiology was limited or absent; quality control was not practiced; only basic, non-bedside, radiology was available. Basic principles of clinical care were taught in the university, but content was often outdated and translation of knowledge into care practice was weak. Traditional independent physician and passive nursing roles prevailed and there was little concept of the team approach to patient care. Frequently, delivery of inappropriate care resulted from individual physician bias, insufficient nurse or physician staffing during evening hours, or a predetermined parental or staff attitude about the viability of a particular patient. The quality of clinical care at the University Hospital was inconsistent and highly dependent on the personal interest and expertise of individuals. Admission policies had not been established nor were standards for procedures and interventions described. There was little concept of levels of care, with all neonatal inpatients managed in a single 60-bed ward. During winter months when hypothermia was a common problem requiring admission, up to 140 infants would be cared for in four 15 by 20 foot rooms; many infants shared cots and incubators. Although there was some evidence of teaching, the concepts of preventive care for outpatients, or anticipatory care and disease prevention for inpatients, were seldom practiced. Inpatient pediatric care provided at the Children's Hospital exceeded the care available in other hospitals in the province. Effective referral or transport systems, however, were not available, nor were education and outreach programs provided to referring hospitals and clinics. The specialty of neonatology was only beginning to be recognized as a separate discipline in China and no specialized training was available. It should be noted that many of the findings were similar to those revealed during the early stages of perinatal regionalization in the United States.12 In 1983 there were only two other NICUs in a country with over one billion inhabitants and an annual birth rate of over 18,000,000. In view of these findings, the team initially recommended that plans for a critical care unit be abandoned in favor of upgrading basic clinical care in the Children's Hospital, improving the patient referral system, and establishing an outreach education program. University and Hospital officials, however, pressed for the development of an NICU. They emphasized that, with so many pressing needs, overall care could be enhanced by selectively emphasizing neonatal and pediatric care in a specialized unit.
METHODS Initial Strategy Emphasis during the first year was on establishing a functional neonatal unit in which active teaching could 402 take place. Initially, space was allocated for a four-bed
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NICU and a four-bed intermediate care nursery. During the first winter, heating, plumbing and electricity were upgraded and some general maintenance was initiated. Selected equipment and supplies were purchased and teams of consultants from the United States were sent to spend 1 to 2 months each in Hangzhou. Three of the teams were composed of a physician and a nurse and three with the addition of a respiratory therapist. Teaching was directed at appropriate clinical use of the newly acquired equipment and supplies. Consultants also addressed general concepts of patient care and emphasized repeated patient assessment, differential diagnosis, a multisystem approach, anticipatory care, and team management. Short-term (1 to 3 month) fellowship training in the United States was offered to the administrative director of the unit and one potential clinical leader. This was designed to provide a modicum of clinical training and the opportunity to observe a critical care model and the organizational interdependence of critical care staff. This would in turn provide a context for understanding the objectives and recommendations of the foreign consultants.
Preliminary Evaluation and Revised Strategy During the first year of the program, serial evaluations by the consultants had identified several problems. A comprehensive review at 18 months revealed the following. Organization and leadership:
Effective administrative leadership was absent. Clinical responsibilities were poorly defined. Resident doctors were not consistently available for training or patient care. The professional status of the nurses was low and participation of the nurses in patient care was limited. Nurses were not involved in decision-making. Clinical care:
Daily ward rounds occurred sporadically. Patient management was inconsistent. Physicians and nurses did not discuss patient management. Formal didactic knowledge correlated poorly with patient management. Concepts of physiology and pathology were not applied at the bedside. Care practices initiated by short-term consultants were often abandoned after the brief visit. New procedures and equipment were often implemented inappropriately. Utilization of services:
Admission criteria were not written nor was the concept understood clinically; critically ill newborns were frequently managed on the general ward despite there being open beds in the NICU. Discharge criteria centered on ability to pay, parental acceptance of critical care, and other nonclinical issues. Direct referrals from other university and provincial hospitals were extremely rare. Despite linkages with the affiliated Women's Hospital, for example, referrals to the NICU and utilization of the NICU were restricted for nonclinical reasons. All triage took place in the outpatient department of Children's Hospital, where poor clinical evaluation frequently led to critically ill patients being referred to the general ward. Lack of parental ability to pay was frequently cited as a primary reason for not admitting to the unit.
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AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 9, NUMBER 5/6
NEONATAL FACILITY IN CHINA/Peabody, Hesketh, Kattwinkel
Disposable supplies were inadequate. Disposable supplies were routinely reused. Routine maintenance of equipment was not performed. Repair of equipment was entirely dependent on equipment and technical support from outside China. As a result of this severe evaluation, several major strategic changes were introduced. First a full-time on-site physician consultant was employed for a 2-year period in an effort to coordinate efforts of short-term instructors and to facilitate a more permanent translation of new concepts into care practices. Second, a full-time on-site nurse consultant was employed for a 1-year period for the purposes of developing nursing staffing and care plans and to encourage better nurse-physician communication. Third, University and Hospital officials met regularly with the HOPE field director to discuss the evolution of the program and development of leadership in the NICU. Fourth, collaboration was recruited from HOPE consultants, working with the ZMU Biomedical Engineering program, to develop a system for maintenance and repair of equipment and to develop and implement an inventory and purchasing system. Finally, a particularly important change in strategy was the institution of formal education programs by the long-term consultants. Three complementary programs were implemented: one 6-month program for physicians and two 1-month programs for nurses (basic and advanced). Traditional roles of each discipline were considered to be too polarized to permit optimum development of a multidisciplinary program.13 The format consisted of self-instructional modules that were supplemented by seminar discussions conducted within the confines of the NICU and that used current patients as subjects whenever possible. The self-instructional modules were newly developed or adapted from existing materials4"6 to meet the needs of the local situation and the level of knowledge of
the staff. NICU staff members led the seminar discussions, and personnel from other units in the hospital and from surrounding hospitals were encouraged to attend. Throughout evolution of the courses, transfer of teaching responsibility from the consultants to the unit leadership was emphasized. Complete transfer of course leadership had been accomplished after the course had been taught three times for the physician course and two times for the nursing courses. The long-term consultants also assisted the developing NICU leadership in devising systems for record keeping and statistical evaluation and in creating written admission and discharge policies. They also coordinated and defined goals for the short-term consultant visits, which continued throughout the remainder of the project. Over the 5 years, 12 physicians, 9 nurses, 4 respiratory therapists, and 1 medical technologist made a total of 35 trips to serve as on-site, short-term consultants (Table 1). RESULTS
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Equipment and supplies:
The original planning trip occurred in August, 1983, the first short-term consultants were sent in May, 1984, and the first patient was admitted in July, 1984. Over the first 4 clinical years of the program, a total of 1162 patients were admitted to the new NICU. Sixteen physicians and 28 nurses completed the educational programs. A summary of these activities is shown in Table 1. Responsibility for the program was transferred entirely to the University and Hospital in August, 1988. The program has continued in the absence of outside support. The following results were determined from on-site observations by the long-term physician consultant, through regular evaluation and quarterly review by the field director, and by site visits conducted 3 months prior to transfer of the Program and again in July, 1989.
Table 1. Activity of Intensive Care Unit, Children's Hospital, Zhejiang Medical University, August, 1984 through July, 1988 NICU*
Patients Admissions Discharges Deaths* Staff trained Physician 6-month course Basic nursing 1-month course Advanced nursing 1-month course Fellowships (overseas training) Physicians Nurse Consulting staff Medical coordinator (long term) Nursing coordinator (long term) Short-term consultants Program coordinators Physicians Nurses Respiratory therapists Laboratory technologist
784 564 220
PICU* (Medical)
PICU (Surgical)
100 75 25
278 268 10
*NICU: neonatal intensive care unit; PICU: pediatric intensive care unit. lncluding patients discharged against medical advice (see text).
+
Total 1162 907 255 16 25 12 4 1 2 years 1 year 35 total trips 4 13 11 6 1
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By the end of the 5 years, the physical plant had been improved significantly: maintenance was regularly performed, air-conditioning was provided and heating was consistently available in the winter months. A generator had been installed to protect against power failures. The total number of NICU beds had been increased to five and the intermediate nursery had been enlarged to 12 bassinets. The number of PICU beds had also been increased to four (two postoperative cardiac and two medical beds).
Equipment and Supplies Interdigitation with the hospital biomedical engineering department and establishment of an effective inventory and purchasing system were completed by the end of the fourth year. Preventive maintenance was being routinely performed and many repairs were effected in the hospital. Prepurchasing evaluation of new equipment was done by both the engineering and the clinical staff. By June 1988, 75% of the disposable supplies and 100% of the equipment were being purchased by the hospital using local funds. A problem with acquiring foreign-made materials remained largely unsolved. Although substantial Chinese funds had become available for equipment and supplies, purchasing foreign-made replacement parts and supplies (often valued at less than $1000) was bureaucratically cumbersome and often not possible. Occasionally, the problem of acquiring foreign-made consumables was addressed by manufacturing the material locally. For example, at the start of the project, cow's milk was the only formula available. Utilization of breast milk was prohibitive due to a lack of transport and preservation equipment and by Chinese tradition, which mandated that mothers remain in bed at home for 1 month postpartum. By the end of the third year, a local formula was being produced that proved on chemical analysis to be remarkably similar in composition to commercial Western formulas.
Laboratory and Clinical Services Basic laboratory services were available in a small facility established adjacent to the unit. Simple chemistry and hematology tests were performed by trained laboratory staff; several of the tests had been established in response to advice from consultants. Quality control and standardization of many laboratory tests had been introduced by the hospital biomedical engineering staff. However, establishing a reliable microbiologic service remained elusive and did not materialize and some biologic standards such as gram stains and urine sediments were rarely performed. Portable x-ray diagnosis had become routine and the films were of good quality, both at the time of transfer and at the 1-year post-transfer follow-up.
Staffing
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The number of nurses staffing the NICU and intermediate nursery improved while the number of physicians per bed declined (see Table 2). Night staffing remained unchanged for the two groups despite an increase in the number of beds.
Table 2. Staffing of the Intensive Care Unit, Children's Hospital, Zhejiang Medical University Physician Day 1984 1988 1989
6 6 6
Nurse
Night Total/Bed* 1 1 1
7/9 7/20 7/21
Day
Night
Total/Bed*
12 17 21
3 3 3
15/9 20/20 24/21
Including pediatric intensive care unit.
Use of the Neonatal Intensive Care Unit as a Referral Center Establishment of admission and discharge criteria for the NICU appeared to help improve consistency of decisionmaking in the hospital. However, although the concept was appreciated, the criteria were seldom adhered to in practice, even by the end of the 5 years. This failure appeared to be the result of several factors: The reluctance of affiliated or outside hospital physicians and administrators to refer to the NICU. A lack of information and understanding of NICU concepts by referring physicians. The preference for referring males versus females to the NICU. The high cost of care in the NICU. For example, full NICU care with ventilation and monitoring exceeded 120 yuan/day (compared with an average wage of 150 yuan/month; exchange rate on 10/88: $1.00 U.S. = 3.7 yuan). This charge was passed on to the parents, who frequently decided not to admit their child because of the high cost. Organization and Leadership By completion of the project and continuing 1 year following transfer, a director of the unit had been permanently assigned and invested with the authority to make most clinical and some administrative decisions. Work rounds were being held twice daily and were consistently being supplemented by teaching rounds. The latter were conducted initially by consultants and then were maintained by the clinical director. Record keeping steadily improved: daily notes, nursing notes, and summary statistics were regularly obtained and progressively more detailed information was provided. Close coordination between the physician and nursing services remained tentative, although formulation of job descriptions and skills training had afforded a measurable change. Clinical Care Neither the admissions rate nor the mortality rate changed significantly over the 5 years (Table 3). There was a trend toward admission of increasing numbers of low birth weight newborns. With the exception of the follow-up year (1989), this corresponded to an associated younger gestational age and an increased use of mechanical ventilation (Fig. 1). There was a consistent predominance of males admitted through the 5-year period. Previously nonexistent procedures that were being used routinely in July, 1989, are listed in Table 4. A system for outpatient followup was established, albeit late in the program. In June 1988
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Clinical Facilities
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NEONATAL FACILITY IN CHINA/Peabody, Hesketh, Kattwinkel Table 3. Immediate Mortality* of Intensive Care Unit Patients, Children's Hospital, Zhejiang Medical University, August, 1984 through July, 1989
Admissions Year
Total
Avg./Mo.
Improved
D/C AMA+
Died
Estimated Mortality* (%)
10/84-12/85 1986 1987 1988 01/89-07/89
238 212 216 208 128
15.8 17.6 18.0 17.3 18.2
175 150 151 152 93
28 35 36 30 20
35 27 24 26 15
27 29 28 27 27
*At time of discharge from the hospital. Patients were considered discharged against medical advice (D/C AMA) when parents withdrew their child from the ICU contrary to the advice of the medical staff. These patients were almost exclusively critically ill children, who generally had a poor prognosis or were deteriorating clinically. ^Estimated mortality is calculated as died plus D/C AMA. +
Formal Educational Programs
In addition to maintenance of routine daily teaching rounds and frequent in-service sessions, the formal physician and nurse educational programs that had been initi-
ated by the consultants were still active at the 1-year followup evaluation. Several courses had been conducted for visiting physicians and nurses from as far away as Beijing. Several outreach education strategies had also been implemented. One of the host physicians was certified as a trainer for The Neonatal Resuscitation Program sponsored by the American Heart Association and American Academy of Pediatrics7 and had conducted the course in several surrounding hospitals. The self-instructional modules that had been written for the physician and nurse
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this system was in place, but by July 1989 only 10% of patients who had been discharged from the NICU had been evaluated as outpatients.
Patient Characteristics Gestational Age on Admission < 32 wk«
>37 wk«
32-37 wk«
Weight on Admission (Gms) < 1000
1500-2500
1000-1500
> 2500
100 90 80 70 60 60
o
40
s
30
Q.
20 10 0 10/84-1985
1986
1988
1/89-6/89
10/84-1988
1/89-6/89
1986
Mechanical Ventilation
Gender
8fx>ntan*ou«
10/84-1986
Figure 1.
1986
1/89-6/89
Patient characteristics, 1984-1989.
10/84-1986
1986
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Table 4. Previously Nonexistent Procedures Now Performed Routinely at Z M U Children's Hospital as of July, 1989
Monitoring Oxygen saturation Transcutaneous oxygen tension Inspired oxygen concentration Continuous temperature (servocontrol) Impedence apnea monitoring Continuous noninvasive and invasive blood pressure Central venous pressure Left atrial pressure for postoperative cardiac patients Assisted ventilation Mechanical ventilation Continuous positive airway pressure Miscellaneous Intravenous or arterial infusions by pump Umbilical arterial or venous catheterization Radial artery catheterization Exchange transfusion
intensive care unit program, had been adapted and considerably expanded for outreach use. A pilot outreach education project was successfully completed in September, 1988, and a full-scale project is currently underway.
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of more sophisticated equipment and supplies, instruction from established experts, and participation in an international scholar-exchange program. The consultants' longterm goal was to establish a neonatal referral and educational center that would serve as a model for improving neonatal care locally, within the province, and eventually in other parts of China. Although a technologically capable unit is well established, it may be several years before it will be possible to determine if it can serve as such a model. Still, the ongoing activity of inservice and outreach education programs at the 5-year evaluation is encouraging. In spite of the tangible accomplishments, improvements in the quality of care are more difficult to assess. There are clearly too many confounding variables to use changes in mortality at this single facility as a measure of success or failure. Changing factors such as the gestational age, chronological age, and clinical status of patients at the time of admission and changing attitudes about neonatal intensive care expressed by parents and referring physicians will all affect mortality figures. Nevertheless, the 27% estimated death rate is at least double that for comparable units in the United States and the fact that this rate did not change significantly over the 5 years is somewhat discouraging. During the course of this project, we encountered several impediments that should be brought to the attention of others contemplating similar endeavors in a developing country.
DISCUSSION
Leadership and Dependence on Consultant Expertise
The 5-year goal of establishing an effective NICU in China and transferring operational ownership to local practitioners was clearly accomplished. This goal had been shared by both the University and Hospital and the HOPE staff and consultants. In addition, the host institutions realized most of their objectives: acquisition and utilization
It became clear by the end of the first year that, although the host professionals were very receptive to learning new concepts and skills, no one was available and qualified to provide the leadership for maintaining these new care practices in the consultants' absence. We chose to
Table 5. Establishment of an Neonatal Intensive Care Unit (NICU) in China: Original and Ongoing Impediments and 5-year Accomplishments Objective
Improved facilities Increase of appropriate equipment, supplies, and laboratory and clinical support services Improved physician and nurse knowledge
Improved level of clinical care Improved referral center image and function
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Impediments
Accomplishments
Lack of building maintenance programs Absence of other NICU models in China Lack of capital Lack of capital to obtain foreign goods Lack of local manufacturing resources Insufficient disposables Inappropriate equipment selection Nonexistence of many support disciplines Lack of adequately trained staff Weak basic science background training No appropriate textbooks in Chinese Low status of nurses Low salaries Poor coordination of hospital staff Inadequate training Lack of multidisciplinary concept Inadequate clinical background Lack of administrative structure Inadequate vehicles and roads High cost to parents Poor understanding of ICU concept Prevailing concept of isolated physician practice
Development of NICU Administrative commitment to further upgrade facilities in the future Acquisition of appropriate equipment Integration with other collaborative programs Development of an inventory, purchasing, maintenance and repair system Local production of equipment, supplies, and infant formula Development of inservice and extramural training course Introduction of modern Western concepts Improved bedside teaching by permanent staff Multidisciplinary care in NICU Daily ward rounds Improved consistency of permanent staff Improved care in surrounding hospitals Stable NICU census Increasing clinical acuity Developing national reputation of NICU
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NEONATAL FACILITY IN CHINA/Peabody, Hesketh, Kattwinkel
Relative Status of Professional Subgroups
Modern neonatology in the United States has become extremely dependent on a multidisciplinary team approach, with minute-to-minute communication between physicians and nurses established as an essential component. The current relative status of physicians and nurses in China is similar to that which was prevalent in the United States several decades ago, with the physician serving as the diagnostician and order-giver and the nurse's primary responsibilities consisting of serving the physician by carrying out orders and collecting data. Although initially we had hoped to develop multidisciplinary training strategies, it soon became clear that educational programs and care plans were more effective when introduced along traditional lines. Encouraging a more active role by the nurse has taken many years in the United States and will likely require many years in China. Equipment/Supplies
In many developing countries there is frequently a preconceived conception that if Western equipment and supplies can be obtained, there will be a tremendous improvement in the status of health care. Issues such as appropriateness of use, preventive maintenance, and inventory management are often insufficiently considered. Although acquisition of materials from the United States was essential to establishing the facility and developing a training program, it soon became apparent that this would be an inappropriate long-term source. We were fortunate that, coincident with this project, Project HOPE was developing a parallel program in Biomedical Engineering at ZMU. The existence of this collaborative resource facilitated development of an effective preventive maintenance program and purchasing system for the NICU. Nevertheless, the most effective solutions occurred when local resources could be identified or developed.
Sociocultural Barriers
Some health care advances will not be realized until major changes occur within the society. For example, sophisticated neonatal transport systems and follow-up programs will likely not evolve until roads improve and motorized vehicles become more accessible. Common problems, such as nutrition for the low birthweight infant, required unique solutions that could not be dependent on maternal-
infant interaction for the first month after birth. We were surprised to find that, in a purportedly socialized system, personal economics frequently were responsible for patients being denied admission or being inappropriately discharged. It was likely this high cost, as well as the society's lack of familiarity with and confidence in the intensive care process, was responsible for the unit's persistently high mortality rate (see Table 3). Although we were told that gender no longer was a major concern in the new one-child-per family era, the admissions statistics showing a 70% preponderance of males suggest otherwise. Since Chinese law dictates that land can only be inherited by males, it is quite likely that gender continues to be a major selection variable in the rural areas. One frustration expressed by several short-term consultants was that new knowledge and equipment frequently were not transferred effectively into new care practices. This is a problem that has also been noted in Western programs.9 In time, this may improve as technology becomes more widely distributed and the concepts of critical care are introduced earlier in the medical curriculum. This disparity, as observed during the first 4 years of the project, may also in part have been due to language barriers.10 At times, it was not possible for consultants to offer an adequate conceptual explanation of clinical events to result in a permanent change in a particular care practice. It is hoped that the evolution of more local leaders will facilitate the process of implementing new knowledge. One of the most encouraging results of the project was the apparent continuation of educational programs initiated by the consultants. One year after transfer of the program, the inservice neonatology programs were continuing without any consultant involvement. Although the outreach program was being developed by the consultants, it is hoped that the host leaders will assume responsibility for this as well. Such programs aimed at the hospital, rather than the university, level are new for China, but are consistent with recently expressed intentions to pursue innovative medical education strategies that are aimed at practical issues.1011 Establishment of a reputation for the ZMU NICU as a center of excellence has helped to allow this facility to serve as a home base for the various educational activities. Success for a project such as this is difficult to measure. Establishment of this small NICU has offered, and will continue to offer, direct benefit to a limited number of admitted patients. However, the greatest successes may be unmeasurable. The introduction of appropriate technologies, new procedures, and modern concepts for diagnosis and treatment; the establishment of a management system for staffing, procurement, and equipment maintenance; and discussions of economic and ethical dilemmas in critical care, will all have ramifications beyond the walls of the unit. Most importantly, a sustainable independent teaching facility now exists. It is hoped that those who have been taught in this program and will be taught in the future will propagate what they have learned. Could these resources have been better spent? The wisdom of establishing critical care facilities in the developing world could be legitimately questioned. When we were initially asked to advise our hosts, it was readily apparent that improvements in basic neonatal care were required far more urgently than were high-technology intensive care facilities. However, the latter was identified by our host as a priority interest. We believe that acceptance of compromise objectives and strategies, which could be altered during the course of the project as described in this report, resulted in far more host enthusiasm and participa-
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address this problem by establishing long-term on-site consultants who could help the hosts develop the leadership expertise and educational programs required for establishment of a truly ongoing and evolving self-sufficient system. Although we were concerned that this strategy might make the hosts even more dependent on outside leadership, the 1-year post-transfer evaluation showed that local leaders had evolved and suggested that independence will continue. An alternative strategy might have been to bring several physicians and nurses to the United States for several years of leadership training before attempting to develop a facility. However, this alternative would likely have resulted in a significant delay of tangible results and would not have been acceptable to the host organizers.
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tion than might have occurred otherwise. However, ideally, this question should be addressed again in another 5 years by examining the status and local reputation of the unit, the educational programs that have evolved from the unit, the quality of neonatal care practices in effect, and the clinical competence of the individuals being trained at that time.
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8. Grenvik A: Pursuit of critical care medicine in China. Crit Care Med 14:992, 1986 9. KattwinkelJ, Nowacek G, Cook L, Hurt H, Short J: Perinatal outreach education: A continuation strategy for a basic program. Am J Perinatol 1:335, 1984 10. Ongley P: Asian medical education. Acad Med 64:S22,1989 11. Kaufman A, Hamilton J, Peabody J: Medical education in China for the 21st century: The context for change. Med Educ 22:253, 1988
We wish to thank the doctors and nurses at Children's Hospital and the Zhejiang Medical University for their continued support and to Dr. William Walsh and Project National Foundation-March of Dimes, Committee on PeriHOPE for making the project possible. Special thanks to natal Health: Toward improving the outcome of preghost directors President Zheng Shu, Director Hong Wen nancy: Recommendations for the regional development of maternal and perinatal health services. White Plains, Lan and Doctor Sun Mei Yu; U.S. co-organizer David N.Y., National Foundation-March of Dimes, 1977 Todres; and Project HOPE coordinators William Walsh, KattwinkelJ, Cook L, Nowacek G, Ivey H, Short J: Improved Jr., Don Weaver, Dorothy Aeschliman, Dan Baranowski, perinatal knowledge and care in the community hospital and Shelley Baranowski. The Hospital-based neonatal edthrough a program of self-instruction. Pediatrics 64:451, ucation programs were largely the products of Dr. Ronald 1979 Bloom and long-term nursing consultant, Sue Kinnen. A Gray J: Continuing education: What techniques are effecspecial note of appreciation to all of the following voluntive? Lancet 2:447, 1986 teer consultants from Project HOPE; many of the strateKattwinkelJ, Cook L, Ivey H, Nowacek G, Short J: Perinatal gies were developed as a result of their reports: Thomas Continuing Education Program: A Self Instructional Program, Massaro, M.D., Allison Massaro, R.N., Barbara Cobb, 4 vol. Charlottesville: University of Virginia, 1978-90 Bloom R, Cropley C: Textbook of Neonatal Resuscitation. R.N., Morris Cohen, M.D., Albertina Hicks, R.N., Althea Cervantes, R.N., Robert Boyle, M.D., Ann Ziehm, R.N., Dallas: American Heart Association and American Academy of Pediatrics, 1987 Pearl O'Roarke, M.D., Alistair Phillip, M.D., Lynn Cook, Bloom R, Cropley C: Neonatal Education Program, NHLBIR.N., Hallam Hurt, M.D., Patricia Koff, R.R.T., Larry Roy, NIH contract #N01-HR-5-2958, Charles R. Drew PostR.R.T., Warren Nicholson, RRT, Evelyn Nicholson, R.N., graduate Medical School, Los Angeles, 1978 Martha McDermott, R.N., Ivan Frantz, M.D., Albert Brann, American Heart Association and American Academy of M.D., Martha Mullett, M.D., Pat English, RRT, Richard Pediatrics: Neonatal Resuscitation Program, Dallas and Molteni, M.D., Dana Waggoner, R.N. Evanston, IL, 1987
1.
2.
3. 4. 5. 6. 7.
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REFERENCES
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CREATION OF A NEONATOLOGY FACILITY IN A DEVELOPING COUNTRY: EXPERIENCE FROM A 5-YEAR PROJECT IN CHINA John W. Peabody, M.D.* Therese Hesketh, M.B., Ch.BJ and John Kattwinkel, M.D.
ABSTRACT
In 1983, Project HOPE, an American-based, nongovernmental, organization that supports efforts to improve health around the world, was invited by Zhejiang Medical University (ZMU) to establish collaborative programs in health in the People's Republic of China. Fourteen projects involving various medical disciplines were initiated with ZMU and three other universities. Children's Hospital in Hangzhou is one of ZMU's four affiliated hospitals and serves as the tertiary care facility for pediatrics in Zhejiang Province, which has a population of over 40 million. It was here that the University requested development of a neonatal and pediatric intensive care (NICU) facility as one of the 14 projects. This report will examine the 5-year course of development of this facility and its implications for improving the
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In 1983, Project HOPE was invited by Zhejiang Medical University to collaborate in developing a neonatal intensive care unit (NICU) at the Children's Hospital in Hangzhou, China. The initial approach involved renovating facilities, purchasing equipment and supplies, placing short-term consultants in the unit as teachers, and bringing selected leaders to the United States for brief fellowships. An evaluation at 18 months disclosed poor organization and leadership, inconsistent clinical care, and unsatisfactory utilization and maintenance of facilities and equipment. Therefore the strategy was revised to include long-term physician and nursing consultants, establishment of ties with HOPE Biomedical Engineering projects, and development of formal education programs. The unit was transferred to the Chinese after 4 years and an evaluation 1 year after transfer revealed an actively functioning independent NICU with evolving effective leadership, established purchasing and preventive maintenance programs, and continuing formal education activities. Unsatisfactory progress was found with the development of a transport system, some laboratory capabilities, adherence to admission and discharge policies, and various other administrative issues. Although the goal of establishing an independent NICU was realized, perhaps the most lasting accomplishment was the establishment of a facility and a format for development of a transportable education program aimed at improving neonatal care practices throughout a larger region of China.
quality of neonatal care in Eastern China. We hope that our experience will be helpful to others contemplating similar projects in other regions in China and elsewhere in the developing world. INITIAL PLANNING VISIT; STATUS OF CHINESE NEONATOLOGY IN 1983 In August 1983, a site visit was made by a team of HOPE consultants to determine the advisability of this proposal. Five areas were evaluated: physical state of the hospital and equipment; laboratory and clinical support services; physician and nurse knowledge; quality of clinical care and the need for an intensive care facility; current
Project HOPE, Millwood, Virginia, and Department of Pediatrics, University of Virginia, Charlottesville, Virginia •Present address: World Health Organization, Western Pacific Regional Office, P.O. Box 2932,1099 Manila, Philippines t
Present address: Project HOPE Collaborative Program, Zhejiang Medical University, Hangzhou, Peoples Republic of China Reprint requests: Dr. Kattwinkel, Department of Pediatrics, Box 386, University of Virginia Health Sciences Center, Charlottesville, VA 22908 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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status and feasibility of the hospital serving as a referral center. The findings can be summarized as follows. The hospital had 460 beds and was very much in need of general physical improvement. There was inadequate heating in the winter and no air-conditioning in the summer. Housekeeping and general maintenance, such as electricity and plumbing, needed upgrading. There was no central oxygen, compressed air, or physiologic monitors, and only primitive infant incubators. Laboratory facilities were inadequate: serum chemistry and hematology testing were not consistently available nor adequate for acute clinical care; microbiology was limited or absent; quality control was not practiced; only basic, non-bedside, radiology was available. Basic principles of clinical care were taught in the university, but content was often outdated and translation of knowledge into care practice was weak. Traditional independent physician and passive nursing roles prevailed and there was little concept of the team approach to patient care. Frequently, delivery of inappropriate care resulted from individual physician bias, insufficient nurse or physician staffing during evening hours, or a predetermined parental or staff attitude about the viability of a particular patient. The quality of clinical care at the University Hospital was inconsistent and highly dependent on the personal interest and expertise of individuals. Admission policies had not been established nor were standards for procedures and interventions described. There was little concept of levels of care, with all neonatal inpatients managed in a single 60-bed ward. During winter months when hypothermia was a common problem requiring admission, up to 140 infants would be cared for in four 15 by 20 foot rooms; many infants shared cots and incubators. Although there was some evidence of teaching, the concepts of preventive care for outpatients, or anticipatory care and disease prevention for inpatients, were seldom practiced. Inpatient pediatric care provided at the Children's Hospital exceeded the care available in other hospitals in the province. Effective referral or transport systems, however, were not available, nor were education and outreach programs provided to referring hospitals and clinics. The specialty of neonatology was only beginning to be recognized as a separate discipline in China and no specialized training was available. It should be noted that many of the findings were similar to those revealed during the early stages of perinatal regionalization in the United States.12 In 1983 there were only two other NICUs in a country with over one billion inhabitants and an annual birth rate of over 18,000,000. In view of these findings, the team initially recommended that plans for a critical care unit be abandoned in favor of upgrading basic clinical care in the Children's Hospital, improving the patient referral system, and establishing an outreach education program. University and Hospital officials, however, pressed for the development of an NICU. They emphasized that, with so many pressing needs, overall care could be enhanced by selectively emphasizing neonatal and pediatric care in a specialized unit.
METHODS Initial Strategy Emphasis during the first year was on establishing a functional neonatal unit in which active teaching could 402 take place. Initially, space was allocated for a four-bed
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NICU and a four-bed intermediate care nursery. During the first winter, heating, plumbing and electricity were upgraded and some general maintenance was initiated. Selected equipment and supplies were purchased and teams of consultants from the United States were sent to spend 1 to 2 months each in Hangzhou. Three of the teams were composed of a physician and a nurse and three with the addition of a respiratory therapist. Teaching was directed at appropriate clinical use of the newly acquired equipment and supplies. Consultants also addressed general concepts of patient care and emphasized repeated patient assessment, differential diagnosis, a multisystem approach, anticipatory care, and team management. Short-term (1 to 3 month) fellowship training in the United States was offered to the administrative director of the unit and one potential clinical leader. This was designed to provide a modicum of clinical training and the opportunity to observe a critical care model and the organizational interdependence of critical care staff. This would in turn provide a context for understanding the objectives and recommendations of the foreign consultants.
Preliminary Evaluation and Revised Strategy During the first year of the program, serial evaluations by the consultants had identified several problems. A comprehensive review at 18 months revealed the following. Organization and leadership:
Effective administrative leadership was absent. Clinical responsibilities were poorly defined. Resident doctors were not consistently available for training or patient care. The professional status of the nurses was low and participation of the nurses in patient care was limited. Nurses were not involved in decision-making. Clinical care:
Daily ward rounds occurred sporadically. Patient management was inconsistent. Physicians and nurses did not discuss patient management. Formal didactic knowledge correlated poorly with patient management. Concepts of physiology and pathology were not applied at the bedside. Care practices initiated by short-term consultants were often abandoned after the brief visit. New procedures and equipment were often implemented inappropriately. Utilization of services:
Admission criteria were not written nor was the concept understood clinically; critically ill newborns were frequently managed on the general ward despite there being open beds in the NICU. Discharge criteria centered on ability to pay, parental acceptance of critical care, and other nonclinical issues. Direct referrals from other university and provincial hospitals were extremely rare. Despite linkages with the affiliated Women's Hospital, for example, referrals to the NICU and utilization of the NICU were restricted for nonclinical reasons. All triage took place in the outpatient department of Children's Hospital, where poor clinical evaluation frequently led to critically ill patients being referred to the general ward. Lack of parental ability to pay was frequently cited as a primary reason for not admitting to the unit.
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Disposable supplies were inadequate. Disposable supplies were routinely reused. Routine maintenance of equipment was not performed. Repair of equipment was entirely dependent on equipment and technical support from outside China. As a result of this severe evaluation, several major strategic changes were introduced. First a full-time on-site physician consultant was employed for a 2-year period in an effort to coordinate efforts of short-term instructors and to facilitate a more permanent translation of new concepts into care practices. Second, a full-time on-site nurse consultant was employed for a 1-year period for the purposes of developing nursing staffing and care plans and to encourage better nurse-physician communication. Third, University and Hospital officials met regularly with the HOPE field director to discuss the evolution of the program and development of leadership in the NICU. Fourth, collaboration was recruited from HOPE consultants, working with the ZMU Biomedical Engineering program, to develop a system for maintenance and repair of equipment and to develop and implement an inventory and purchasing system. Finally, a particularly important change in strategy was the institution of formal education programs by the long-term consultants. Three complementary programs were implemented: one 6-month program for physicians and two 1-month programs for nurses (basic and advanced). Traditional roles of each discipline were considered to be too polarized to permit optimum development of a multidisciplinary program.13 The format consisted of self-instructional modules that were supplemented by seminar discussions conducted within the confines of the NICU and that used current patients as subjects whenever possible. The self-instructional modules were newly developed or adapted from existing materials4"6 to meet the needs of the local situation and the level of knowledge of
the staff. NICU staff members led the seminar discussions, and personnel from other units in the hospital and from surrounding hospitals were encouraged to attend. Throughout evolution of the courses, transfer of teaching responsibility from the consultants to the unit leadership was emphasized. Complete transfer of course leadership had been accomplished after the course had been taught three times for the physician course and two times for the nursing courses. The long-term consultants also assisted the developing NICU leadership in devising systems for record keeping and statistical evaluation and in creating written admission and discharge policies. They also coordinated and defined goals for the short-term consultant visits, which continued throughout the remainder of the project. Over the 5 years, 12 physicians, 9 nurses, 4 respiratory therapists, and 1 medical technologist made a total of 35 trips to serve as on-site, short-term consultants (Table 1). RESULTS
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Equipment and supplies:
The original planning trip occurred in August, 1983, the first short-term consultants were sent in May, 1984, and the first patient was admitted in July, 1984. Over the first 4 clinical years of the program, a total of 1162 patients were admitted to the new NICU. Sixteen physicians and 28 nurses completed the educational programs. A summary of these activities is shown in Table 1. Responsibility for the program was transferred entirely to the University and Hospital in August, 1988. The program has continued in the absence of outside support. The following results were determined from on-site observations by the long-term physician consultant, through regular evaluation and quarterly review by the field director, and by site visits conducted 3 months prior to transfer of the Program and again in July, 1989.
Table 1. Activity of Intensive Care Unit, Children's Hospital, Zhejiang Medical University, August, 1984 through July, 1988 NICU*
Patients Admissions Discharges Deaths* Staff trained Physician 6-month course Basic nursing 1-month course Advanced nursing 1-month course Fellowships (overseas training) Physicians Nurse Consulting staff Medical coordinator (long term) Nursing coordinator (long term) Short-term consultants Program coordinators Physicians Nurses Respiratory therapists Laboratory technologist
784 564 220
PICU* (Medical)
PICU (Surgical)
100 75 25
278 268 10
*NICU: neonatal intensive care unit; PICU: pediatric intensive care unit. lncluding patients discharged against medical advice (see text).
+
Total 1162 907 255 16 25 12 4 1 2 years 1 year 35 total trips 4 13 11 6 1
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By the end of the 5 years, the physical plant had been improved significantly: maintenance was regularly performed, air-conditioning was provided and heating was consistently available in the winter months. A generator had been installed to protect against power failures. The total number of NICU beds had been increased to five and the intermediate nursery had been enlarged to 12 bassinets. The number of PICU beds had also been increased to four (two postoperative cardiac and two medical beds).
Equipment and Supplies Interdigitation with the hospital biomedical engineering department and establishment of an effective inventory and purchasing system were completed by the end of the fourth year. Preventive maintenance was being routinely performed and many repairs were effected in the hospital. Prepurchasing evaluation of new equipment was done by both the engineering and the clinical staff. By June 1988, 75% of the disposable supplies and 100% of the equipment were being purchased by the hospital using local funds. A problem with acquiring foreign-made materials remained largely unsolved. Although substantial Chinese funds had become available for equipment and supplies, purchasing foreign-made replacement parts and supplies (often valued at less than $1000) was bureaucratically cumbersome and often not possible. Occasionally, the problem of acquiring foreign-made consumables was addressed by manufacturing the material locally. For example, at the start of the project, cow's milk was the only formula available. Utilization of breast milk was prohibitive due to a lack of transport and preservation equipment and by Chinese tradition, which mandated that mothers remain in bed at home for 1 month postpartum. By the end of the third year, a local formula was being produced that proved on chemical analysis to be remarkably similar in composition to commercial Western formulas.
Laboratory and Clinical Services Basic laboratory services were available in a small facility established adjacent to the unit. Simple chemistry and hematology tests were performed by trained laboratory staff; several of the tests had been established in response to advice from consultants. Quality control and standardization of many laboratory tests had been introduced by the hospital biomedical engineering staff. However, establishing a reliable microbiologic service remained elusive and did not materialize and some biologic standards such as gram stains and urine sediments were rarely performed. Portable x-ray diagnosis had become routine and the films were of good quality, both at the time of transfer and at the 1-year post-transfer follow-up.
Staffing
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The number of nurses staffing the NICU and intermediate nursery improved while the number of physicians per bed declined (see Table 2). Night staffing remained unchanged for the two groups despite an increase in the number of beds.
Table 2. Staffing of the Intensive Care Unit, Children's Hospital, Zhejiang Medical University Physician Day 1984 1988 1989
6 6 6
Nurse
Night Total/Bed* 1 1 1
7/9 7/20 7/21
Day
Night
Total/Bed*
12 17 21
3 3 3
15/9 20/20 24/21
Including pediatric intensive care unit.
Use of the Neonatal Intensive Care Unit as a Referral Center Establishment of admission and discharge criteria for the NICU appeared to help improve consistency of decisionmaking in the hospital. However, although the concept was appreciated, the criteria were seldom adhered to in practice, even by the end of the 5 years. This failure appeared to be the result of several factors: The reluctance of affiliated or outside hospital physicians and administrators to refer to the NICU. A lack of information and understanding of NICU concepts by referring physicians. The preference for referring males versus females to the NICU. The high cost of care in the NICU. For example, full NICU care with ventilation and monitoring exceeded 120 yuan/day (compared with an average wage of 150 yuan/month; exchange rate on 10/88: $1.00 U.S. = 3.7 yuan). This charge was passed on to the parents, who frequently decided not to admit their child because of the high cost. Organization and Leadership By completion of the project and continuing 1 year following transfer, a director of the unit had been permanently assigned and invested with the authority to make most clinical and some administrative decisions. Work rounds were being held twice daily and were consistently being supplemented by teaching rounds. The latter were conducted initially by consultants and then were maintained by the clinical director. Record keeping steadily improved: daily notes, nursing notes, and summary statistics were regularly obtained and progressively more detailed information was provided. Close coordination between the physician and nursing services remained tentative, although formulation of job descriptions and skills training had afforded a measurable change. Clinical Care Neither the admissions rate nor the mortality rate changed significantly over the 5 years (Table 3). There was a trend toward admission of increasing numbers of low birth weight newborns. With the exception of the follow-up year (1989), this corresponded to an associated younger gestational age and an increased use of mechanical ventilation (Fig. 1). There was a consistent predominance of males admitted through the 5-year period. Previously nonexistent procedures that were being used routinely in July, 1989, are listed in Table 4. A system for outpatient followup was established, albeit late in the program. In June 1988
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Clinical Facilities
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NEONATAL FACILITY IN CHINA/Peabody, Hesketh, Kattwinkel Table 3. Immediate Mortality* of Intensive Care Unit Patients, Children's Hospital, Zhejiang Medical University, August, 1984 through July, 1989
Admissions Year
Total
Avg./Mo.
Improved
D/C AMA+
Died
Estimated Mortality* (%)
10/84-12/85 1986 1987 1988 01/89-07/89
238 212 216 208 128
15.8 17.6 18.0 17.3 18.2
175 150 151 152 93
28 35 36 30 20
35 27 24 26 15
27 29 28 27 27
*At time of discharge from the hospital. Patients were considered discharged against medical advice (D/C AMA) when parents withdrew their child from the ICU contrary to the advice of the medical staff. These patients were almost exclusively critically ill children, who generally had a poor prognosis or were deteriorating clinically. ^Estimated mortality is calculated as died plus D/C AMA. +
Formal Educational Programs
In addition to maintenance of routine daily teaching rounds and frequent in-service sessions, the formal physician and nurse educational programs that had been initi-
ated by the consultants were still active at the 1-year followup evaluation. Several courses had been conducted for visiting physicians and nurses from as far away as Beijing. Several outreach education strategies had also been implemented. One of the host physicians was certified as a trainer for The Neonatal Resuscitation Program sponsored by the American Heart Association and American Academy of Pediatrics7 and had conducted the course in several surrounding hospitals. The self-instructional modules that had been written for the physician and nurse
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this system was in place, but by July 1989 only 10% of patients who had been discharged from the NICU had been evaluated as outpatients.
Patient Characteristics Gestational Age on Admission < 32 wk«
>37 wk«
32-37 wk«
Weight on Admission (Gms) < 1000
1500-2500
1000-1500
> 2500
100 90 80 70 60 60
o
40
s
30
Q.
20 10 0 10/84-1985
1986
1988
1/89-6/89
10/84-1988
1/89-6/89
1986
Mechanical Ventilation
Gender
8fx>ntan*ou«
10/84-1986
Figure 1.
1986
1/89-6/89
Patient characteristics, 1984-1989.
10/84-1986
1986
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Table 4. Previously Nonexistent Procedures Now Performed Routinely at Z M U Children's Hospital as of July, 1989
Monitoring Oxygen saturation Transcutaneous oxygen tension Inspired oxygen concentration Continuous temperature (servocontrol) Impedence apnea monitoring Continuous noninvasive and invasive blood pressure Central venous pressure Left atrial pressure for postoperative cardiac patients Assisted ventilation Mechanical ventilation Continuous positive airway pressure Miscellaneous Intravenous or arterial infusions by pump Umbilical arterial or venous catheterization Radial artery catheterization Exchange transfusion
intensive care unit program, had been adapted and considerably expanded for outreach use. A pilot outreach education project was successfully completed in September, 1988, and a full-scale project is currently underway.
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of more sophisticated equipment and supplies, instruction from established experts, and participation in an international scholar-exchange program. The consultants' longterm goal was to establish a neonatal referral and educational center that would serve as a model for improving neonatal care locally, within the province, and eventually in other parts of China. Although a technologically capable unit is well established, it may be several years before it will be possible to determine if it can serve as such a model. Still, the ongoing activity of inservice and outreach education programs at the 5-year evaluation is encouraging. In spite of the tangible accomplishments, improvements in the quality of care are more difficult to assess. There are clearly too many confounding variables to use changes in mortality at this single facility as a measure of success or failure. Changing factors such as the gestational age, chronological age, and clinical status of patients at the time of admission and changing attitudes about neonatal intensive care expressed by parents and referring physicians will all affect mortality figures. Nevertheless, the 27% estimated death rate is at least double that for comparable units in the United States and the fact that this rate did not change significantly over the 5 years is somewhat discouraging. During the course of this project, we encountered several impediments that should be brought to the attention of others contemplating similar endeavors in a developing country.
DISCUSSION
Leadership and Dependence on Consultant Expertise
The 5-year goal of establishing an effective NICU in China and transferring operational ownership to local practitioners was clearly accomplished. This goal had been shared by both the University and Hospital and the HOPE staff and consultants. In addition, the host institutions realized most of their objectives: acquisition and utilization
It became clear by the end of the first year that, although the host professionals were very receptive to learning new concepts and skills, no one was available and qualified to provide the leadership for maintaining these new care practices in the consultants' absence. We chose to
Table 5. Establishment of an Neonatal Intensive Care Unit (NICU) in China: Original and Ongoing Impediments and 5-year Accomplishments Objective
Improved facilities Increase of appropriate equipment, supplies, and laboratory and clinical support services Improved physician and nurse knowledge
Improved level of clinical care Improved referral center image and function
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Impediments
Accomplishments
Lack of building maintenance programs Absence of other NICU models in China Lack of capital Lack of capital to obtain foreign goods Lack of local manufacturing resources Insufficient disposables Inappropriate equipment selection Nonexistence of many support disciplines Lack of adequately trained staff Weak basic science background training No appropriate textbooks in Chinese Low status of nurses Low salaries Poor coordination of hospital staff Inadequate training Lack of multidisciplinary concept Inadequate clinical background Lack of administrative structure Inadequate vehicles and roads High cost to parents Poor understanding of ICU concept Prevailing concept of isolated physician practice
Development of NICU Administrative commitment to further upgrade facilities in the future Acquisition of appropriate equipment Integration with other collaborative programs Development of an inventory, purchasing, maintenance and repair system Local production of equipment, supplies, and infant formula Development of inservice and extramural training course Introduction of modern Western concepts Improved bedside teaching by permanent staff Multidisciplinary care in NICU Daily ward rounds Improved consistency of permanent staff Improved care in surrounding hospitals Stable NICU census Increasing clinical acuity Developing national reputation of NICU
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Relative Status of Professional Subgroups
Modern neonatology in the United States has become extremely dependent on a multidisciplinary team approach, with minute-to-minute communication between physicians and nurses established as an essential component. The current relative status of physicians and nurses in China is similar to that which was prevalent in the United States several decades ago, with the physician serving as the diagnostician and order-giver and the nurse's primary responsibilities consisting of serving the physician by carrying out orders and collecting data. Although initially we had hoped to develop multidisciplinary training strategies, it soon became clear that educational programs and care plans were more effective when introduced along traditional lines. Encouraging a more active role by the nurse has taken many years in the United States and will likely require many years in China. Equipment/Supplies
In many developing countries there is frequently a preconceived conception that if Western equipment and supplies can be obtained, there will be a tremendous improvement in the status of health care. Issues such as appropriateness of use, preventive maintenance, and inventory management are often insufficiently considered. Although acquisition of materials from the United States was essential to establishing the facility and developing a training program, it soon became apparent that this would be an inappropriate long-term source. We were fortunate that, coincident with this project, Project HOPE was developing a parallel program in Biomedical Engineering at ZMU. The existence of this collaborative resource facilitated development of an effective preventive maintenance program and purchasing system for the NICU. Nevertheless, the most effective solutions occurred when local resources could be identified or developed.
Sociocultural Barriers
Some health care advances will not be realized until major changes occur within the society. For example, sophisticated neonatal transport systems and follow-up programs will likely not evolve until roads improve and motorized vehicles become more accessible. Common problems, such as nutrition for the low birthweight infant, required unique solutions that could not be dependent on maternal-
infant interaction for the first month after birth. We were surprised to find that, in a purportedly socialized system, personal economics frequently were responsible for patients being denied admission or being inappropriately discharged. It was likely this high cost, as well as the society's lack of familiarity with and confidence in the intensive care process, was responsible for the unit's persistently high mortality rate (see Table 3). Although we were told that gender no longer was a major concern in the new one-child-per family era, the admissions statistics showing a 70% preponderance of males suggest otherwise. Since Chinese law dictates that land can only be inherited by males, it is quite likely that gender continues to be a major selection variable in the rural areas. One frustration expressed by several short-term consultants was that new knowledge and equipment frequently were not transferred effectively into new care practices. This is a problem that has also been noted in Western programs.9 In time, this may improve as technology becomes more widely distributed and the concepts of critical care are introduced earlier in the medical curriculum. This disparity, as observed during the first 4 years of the project, may also in part have been due to language barriers.10 At times, it was not possible for consultants to offer an adequate conceptual explanation of clinical events to result in a permanent change in a particular care practice. It is hoped that the evolution of more local leaders will facilitate the process of implementing new knowledge. One of the most encouraging results of the project was the apparent continuation of educational programs initiated by the consultants. One year after transfer of the program, the inservice neonatology programs were continuing without any consultant involvement. Although the outreach program was being developed by the consultants, it is hoped that the host leaders will assume responsibility for this as well. Such programs aimed at the hospital, rather than the university, level are new for China, but are consistent with recently expressed intentions to pursue innovative medical education strategies that are aimed at practical issues.1011 Establishment of a reputation for the ZMU NICU as a center of excellence has helped to allow this facility to serve as a home base for the various educational activities. Success for a project such as this is difficult to measure. Establishment of this small NICU has offered, and will continue to offer, direct benefit to a limited number of admitted patients. However, the greatest successes may be unmeasurable. The introduction of appropriate technologies, new procedures, and modern concepts for diagnosis and treatment; the establishment of a management system for staffing, procurement, and equipment maintenance; and discussions of economic and ethical dilemmas in critical care, will all have ramifications beyond the walls of the unit. Most importantly, a sustainable independent teaching facility now exists. It is hoped that those who have been taught in this program and will be taught in the future will propagate what they have learned. Could these resources have been better spent? The wisdom of establishing critical care facilities in the developing world could be legitimately questioned. When we were initially asked to advise our hosts, it was readily apparent that improvements in basic neonatal care were required far more urgently than were high-technology intensive care facilities. However, the latter was identified by our host as a priority interest. We believe that acceptance of compromise objectives and strategies, which could be altered during the course of the project as described in this report, resulted in far more host enthusiasm and participa-
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address this problem by establishing long-term on-site consultants who could help the hosts develop the leadership expertise and educational programs required for establishment of a truly ongoing and evolving self-sufficient system. Although we were concerned that this strategy might make the hosts even more dependent on outside leadership, the 1-year post-transfer evaluation showed that local leaders had evolved and suggested that independence will continue. An alternative strategy might have been to bring several physicians and nurses to the United States for several years of leadership training before attempting to develop a facility. However, this alternative would likely have resulted in a significant delay of tangible results and would not have been acceptable to the host organizers.
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tion than might have occurred otherwise. However, ideally, this question should be addressed again in another 5 years by examining the status and local reputation of the unit, the educational programs that have evolved from the unit, the quality of neonatal care practices in effect, and the clinical competence of the individuals being trained at that time.
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8. Grenvik A: Pursuit of critical care medicine in China. Crit Care Med 14:992, 1986 9. KattwinkelJ, Nowacek G, Cook L, Hurt H, Short J: Perinatal outreach education: A continuation strategy for a basic program. Am J Perinatol 1:335, 1984 10. Ongley P: Asian medical education. Acad Med 64:S22,1989 11. Kaufman A, Hamilton J, Peabody J: Medical education in China for the 21st century: The context for change. Med Educ 22:253, 1988
We wish to thank the doctors and nurses at Children's Hospital and the Zhejiang Medical University for their continued support and to Dr. William Walsh and Project National Foundation-March of Dimes, Committee on PeriHOPE for making the project possible. Special thanks to natal Health: Toward improving the outcome of preghost directors President Zheng Shu, Director Hong Wen nancy: Recommendations for the regional development of maternal and perinatal health services. White Plains, Lan and Doctor Sun Mei Yu; U.S. co-organizer David N.Y., National Foundation-March of Dimes, 1977 Todres; and Project HOPE coordinators William Walsh, KattwinkelJ, Cook L, Nowacek G, Ivey H, Short J: Improved Jr., Don Weaver, Dorothy Aeschliman, Dan Baranowski, perinatal knowledge and care in the community hospital and Shelley Baranowski. The Hospital-based neonatal edthrough a program of self-instruction. Pediatrics 64:451, ucation programs were largely the products of Dr. Ronald 1979 Bloom and long-term nursing consultant, Sue Kinnen. A Gray J: Continuing education: What techniques are effecspecial note of appreciation to all of the following voluntive? Lancet 2:447, 1986 teer consultants from Project HOPE; many of the strateKattwinkelJ, Cook L, Ivey H, Nowacek G, Short J: Perinatal gies were developed as a result of their reports: Thomas Continuing Education Program: A Self Instructional Program, Massaro, M.D., Allison Massaro, R.N., Barbara Cobb, 4 vol. Charlottesville: University of Virginia, 1978-90 Bloom R, Cropley C: Textbook of Neonatal Resuscitation. R.N., Morris Cohen, M.D., Albertina Hicks, R.N., Althea Cervantes, R.N., Robert Boyle, M.D., Ann Ziehm, R.N., Dallas: American Heart Association and American Academy of Pediatrics, 1987 Pearl O'Roarke, M.D., Alistair Phillip, M.D., Lynn Cook, Bloom R, Cropley C: Neonatal Education Program, NHLBIR.N., Hallam Hurt, M.D., Patricia Koff, R.R.T., Larry Roy, NIH contract #N01-HR-5-2958, Charles R. Drew PostR.R.T., Warren Nicholson, RRT, Evelyn Nicholson, R.N., graduate Medical School, Los Angeles, 1978 Martha McDermott, R.N., Ivan Frantz, M.D., Albert Brann, American Heart Association and American Academy of M.D., Martha Mullett, M.D., Pat English, RRT, Richard Pediatrics: Neonatal Resuscitation Program, Dallas and Molteni, M.D., Dana Waggoner, R.N. Evanston, IL, 1987
1.
2.
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REFERENCES
