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NICU Clinical 4th Q Audit Result 2016

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Feyissa Bacha
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26 views

NICU Clinical 4th Q Audit Result 2016

Uploaded by

Feyissa Bacha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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BELE GESGAR HOSPITAL4th Quarter AUDIT REPORT OF 2016

Title of the audit Neonatal sepsis


Date of report 12/10/2016
Department/specialty NICU
Audit lead- Name- Job title
Dr Surafel GP
Key stakeholders Names Department Sign
1. Elmu Suyum NICU Head Nurse __ _________
2. Ashenafi Legese NICU Nurse ____________
3. Beyan Tina NICU Nurse ____________
4. Abebe lema NICU Nurse ____________
5. Kebeki Hailu NICU Nurse ____________
Background & aim: Say why the audit was This audit aim at improving clinical care provided for neonates admitted with diagnosis of sepsis
done. Per- haps a problem had been (Suspected and proven)
identified? Statement of what the project is Objective - To ensure neonates with suspected or proven sepsis appropriately evaluated
trying to achieve: - To ensure neonates with suspected or proven sepsis appropriately investigated
- To ensure neonates with suspected or proven sepsis appropriately treated
- To ensure neonates with suspected or proven sepsis appropriately monitored
- To ensure neonates with suspected or proven sepsis receive appropriate discharge care
Standard- standards are nationally prepared 1. Identification information is recorded for a neonate with sepsis
standard (EMOH) 2. Appropriate history is taken
Has Nine standards 3. Appropriate physical examination is performed
4. Relevant investigations are done
5. Appropriate diagnose is made
6. Appropriate treatment is provided
7. Appropriate monitoring is done
8. Appropriate Discharge care is provided
9. Identification of provider is documented
BELE GESGAR HOSPITAL4th Quarter AUDIT REPORT OF 2016

Methodology:  Retrospective data collection method was used.


 19 chart were selected randomly from NICU registration among patient attends NICU
 Then structured questioner developed by MOH was used.
 All necessary information was evaluated thoroughly from triage formats and recorded on
structured questioner.
 Data was analyzed by excel and presented in table form
 Action plan was developed on identified gaps and discussed with all department member

Results: 19 Sample size was take based on clinical audit guideline of ministry of Ethiopia.
 19 charts were complete regarding with Patients identification information was recorded (100%)
 No complete regarding with appropriate history is recorded
 All(100%) patient physical examination were assessed accordingly
 47.4% of neonate relevant investigations were completed regarding with standard
 All charts have appropriate diagnosis
 All neonates are managed according to neonate management protocols
 All neonates monitored as per standard, except for urine output monitoring
 All neonate gets appropriate discharge care as per standard
 All provider identifications are complete
Conclusion: (List key points that  For all neonate identification information and physical examination was complete. In addition all neonates
flow from results) were managed as per guideline. This shows the adherence of staff to available protocol.
 None of neonate folders were complete regarding with taking complete history and relevant investigation.
 There is good outcome regarding appropriate dx, mgt, monitoring and discharge care.
Recommendation: (bullet point  As result shows there was good practice in recording neonate identification, PE, treatment and provider
prioritized problems and information. As well as dx, mgt, monitoring and discharge care . This practice should continue.
change ideas/interventions to be  In reverse there was poor practice in performing complete history taking. This should be improved
tested)  All investigation should be availed and neonate should investigate accordingly as much as possible
BELE GESGAR HOSPITAL4th Quarter AUDIT REPORT OF 2016

Action plan for identified gaps on neonatas sepsis at NICU Department


Identified problem Possible solution Responsible Time frame Follow up
body result
Gap in recording complete Record all pertinent history physician From July 1/2016
history
Gap in availability of neonate Availing relevant DTC, SMT From July 1/2016
relevant investigations were investigations were
completed regarding with completed regarding with
standard standard
Gap in close monitoring of Monitoring neonate closely All NICU From July 1/2016
admitted urine out put as per protocol nurses

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