Electronic application to improve management of infections in low-income neonatal units: pilot implementation of the NeoTree beta app in a public sector hospital in Zimbabwe

Abstract

There are 2. 4 million annual neonatal deaths worldwide. Simple, evidence-based interventions such as temperature control could prevent approximately two-thirds of these deaths. However, key problems in implementing these interventions are a lack of newborn-trained healthcare workers and a lack of data collection systems. NeoTree is a digital platform aiming to improve newborn care in low-resource settings through real-time data capture and feedback alongside education and data linkage. This project demonstrates proof of concept of the NeoTree as a real-time data capture tool replacing handwritten clinical paper notes over a 9-month period in a tertiary neonatal unit at Harare Central Hospital, Zimbabwe. We aimed to deliver robust data for monthly mortality and morbidity meetings and to improve turnaround time for blood culture results among other quality improvement indicators. There were 3222 admissions and discharges entered using the NeoTree software with 41 junior doctors and 9 laboratory staff trained over the 9-month period. The NeoTree app was fully integrated into the department for all admission and discharge documentation and the monthly presentations became routine, informing local practice. An essential factor for this success was local buy-in and ownership at each stage of the project development, as was monthly data analysis and presentations allowing us to rapidly troubleshoot emerging issues. However, the laboratory arm of the project was negatively affected by nationwide economic upheaval. Our successes and challenges piloting this digital tool have provided key insights for effective future roll-out in Zimbabwe and other low-income healthcare settings.

Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App and Dashboard: A 1-Year Digital Perinatal Outcome Audit

“…Currently, it would be technically feasible to add Days 2 and 3 ward-round forms to the current set of forms, improve longitudinal data collection, and potentially impact the 40% of deaths occurring within 72 h of admission. Implementation experience in SMCH in Zimbabwe has already been reported ( 23 ), and NeoTree is now live in a third site (Chinhoyi provincial hospital, Zimbabwe). Next steps include large scale modelling of the causes of neonatal mortality from all NeoTree data, and further refinement and testing of the NeoTree clinical algorithms are in progress.…”

“…Late administration of antibiotics was the most common sepsis management issue, suggesting that timely antibiotic administration might have saved 19 of the 116 sepsis-related deaths. In Zimbabwe, preliminary NeoTree audits of antibiotic administration have shown improved adherence to appropriate first-line antibiotic therapy ( 22 ), and laboratory forms were piloted, aiming to reduce blood culture turnaround time and improve timeliness of antibiotics ( 23 ). Responding to learning from this pilot ( 23 ) deployment of laboratory forms at KCH is now underway and could facilitate timeliness of antibiotic administration according to sensitivities, in conjunction with a baseline antibiotic audit.…”

“…The NeoTree system ( Figure 2 ) has been and continues to be developed collaboratively with health workers in Bangladesh (2015), Malawi ( 19 ) (2016–2017 and 2019 onwards), and Zimbabwe ( 23 ) (2018 onwards) and has been shown to have good acceptability, feasibility, usability ( 19 ), and impact on measure of quality of care ( 22 , 23 ). Data collected on the app are printed in hard copy (including identifiable data) and filed in each patient's paper record.…”

“…A larger 1-year audit of neonatal mortality rates has been conducted more recently at KCH; however, this utilised a data clerk to enter paper records into a database after admissions had taken place and did not report monthly trends in detail ( 20 ). Since the ZCH pilot ( 21 ), the NeoTree has been iteratively co-developed, implemented, and evaluated at Sally Mugabe Central Hospital, Zimbabwe (from October 2018) ( 22 , 23 ), KCH (from April 2019) ( 21 , 24 ) and in Chinhoyi Provincial Hospital, Zimbabwe (from November 2020). During the implementation at KCH, a dashboard prototype was developed to visualise data on a screen on the neonatal unit and provide a monthly slide deck of morbidity and mortality (M&M) data ( 25 ).…”

Usability-Focused Development and Usage of NeoTree-Beta, an App for Newborn Care in a Low-Resource Neonatal Unit, Malawi

“…Prior to being implemented in Malawi and Zimbabwe central hospitals ( 19 , 22 ), the NeoTree app was piloted in Zomba Central Hospital (ZCH), Malawi ( 20 ). This 1-month pilot included some preliminary usability testing which resulted in early adjustments to the app and produced the beta-app, “Minimum Viable Product 1” (MVP1), the most basic working version that can be safely launched and tested ( 23 ).…”