Improving Care Quality to Respond to the Zika Outbreak in Latin America. Jorge Hermida, MD Regional Director for the Latin America Region

Transcription

1 Improving Care Quality to Respond to the Zika Outbreak in Latin America Jorge Hermida, MD Regional Director for the Latin America Region 1

2 Facts and challenges Transmitted by Aedes mosquito bite Sexual transmission 580,742 suspected and 221,341 confirmed cases across 69 countries or territories 3,720 congenital syndrome confirmed cases in LAC, January 2018 Vertical transmission from mother to baby Only 1 in 5 people infected will become ill Diagnostic test expensive, only done at central labs No treatment or vaccine available Associated with microcephaly, Guillain-Barré Syndrome 2

3 The epidemic s burden is on the poorest people, poorest regions, women and babies Epidemic s toll on poorest regions and people Northeast region of Brazil has the lowest household income / person, and the highest rate of illiteracy (1) Nearly half of women and girls who gave birth to babies with microcephaly are single Consequences severe for pregnant women and babies Nearly half of pregnancies in Brazil are unplanned or unwanted, indicating unmet contraceptive need (2) 580,742 suspected and 221,341 confirmed Zika cases 3,720 confirmed Zika-associated congenital syndrome Impact on LAC countries economies (3): Short-term cost of the epidemic: USD $9,000 million 70% impact on tourism; 30% cost of health care Long-term costs (congenital syndrome and G-B syndrome care): USD $900 million 1. Brazilian Institute of Geography and Statistics 2. Ministério da Saúde, Centro Brasileiro de Análise e Planejamento 3. UNDP: Socioeconomic iimpact of the Zika epidemic, LAC region, 2017

4 Health system challenges at start of project - Only 3-18% of women of reproductive age (WRA) know that Zika can be sexually transmitted - Only 10% of WRA can identify condoms as a Zika prevention measure - Less than 8% of healthcare facilities are distributing condoms as a Zika prevention method - <20% of healthcare providers are screening pregnant women for Zika during antenatal care (ANC) sessions - <15% of healthcare providers are counseling pregnant women about Zika during ANC sessions - <30% of newborns screened cephalic perimeter for microcephaly Data source: ASSIST baseline assessment from January March 2017 (Dominican Republic, El Salvador, Guatemala and Honduras) 4

5 Quality improvement in the times of Zika: the challenge and the opportunity The challenge: How do we change the traditional way care is given to women in reproductive age/fp, pregnant women, newborns, to include Zika prevention, detection and management? In a way that is fast, large-scale from start, effective, and coordinated? The opportunity: Adapt the Quality Improvement Strategy to the Zika Epidemic Emergency 5

6 ASSIST s Zika objectives Prevention: Improve Zika-related care in antenatal care: Counseling including Zika contents to pregnant women Delivery of condoms together with counseling Improve clinical diagnosis of Zika in pregnancy Screening all newborns for microcephaly: Improve head circumference measuring, interpreting and taking initial actions Care for affected babies and mothers: Identify and locate affected babies in supported regions Improve linking affected babies to hospital care (hub) Improve quality of care for affected babies and mothers Improve provision of psychoemotional support for mothers Coordination with other key actors (UNICEF, CARE) 6

7 ASSIST s Zika interventions Development/updating of evidence-based guidelines Development and distribution of Counseling Guide In-person and online structured training Development and production of job aids Formation and support of quality improvement teams Recruitment and training of cadres of facilitators in each country Organization of three improvement collaboratives for continued sharing and learning about improvement 7

8 Improve care at scale from the start MOH, ISS, ACOG, AAP, FHI 360, MCSP, AIUM, SMFM, SIPFO/IPPF, SIPFO/PSI, HC3, K4H, WHO/PAHO, UNICEF, UNFPA, CDC, IHI, Project ECHO Country # Departments / Provinces # Health Care Facilities # QI Teams # Health Care Providers # Women of Reproductive age, 2017 Dominican Republic ,515 5,555,772 Honduras ,165 5,142,075 El Salvador ,431,364 Guatemala ,761,452 Nicaragua 5 64* - 1,413 3,407,464 Paraguay ,630,263 Peru ,918,790 Ecuador ,678,250 TOTALS ,271 55,525,430 *The Nicaragua team is working with universities and NGOs in addition to health care facilities 8

9 Zika Tutored Virtual Course: Leveraging the internet Modules 1. Introduction to the Zika epidemic 2. Zika detection, diagnosis and referral 3. Family Planning & Zika 4. Prenatal care & Zika 5. Congenital Zika Syndrome Number of virtual course participants: El Salvador 410 Guatemala 198 Honduras 171 Dominican Republic 214 Nicaragua 260 Paraguay 154 Total Psychosocial and emotional support New online courses Psycho-emotional support Quality Improvement applied to Zika care Neurodevelopment screening in small children 9

10 Improving Zika care: A systems approach Ensure availability of critical inputs Improve key care processes Results -Trained personnel - Equipment - Supplies - Medicines - Information 10 Evidence-based care contents Standards Protocols Clinical guidelines Manuals Continuous improvement QI teams identify and understand care deficiencies QI teams test changes and learn Improvements are standardized Incentives are aligned Pregnant women empowered to protect them selves and family Pregnant women and newborns diagnosed and cared for Affected babies and mothers receive quality care

11 Quality improvement teams at work: What are we trying to accomplish? How will we know whether a change resulted in improvement? What specific, concrete changes can we test? Plan Act Test Changes and Learn About improvement Do Study 11

12 Facility-based QI teams supported by local QI coaches 181 QI coaches trained on improvement methods: Dominican R: 31; Honduras: 50; Guatemala: 36; El Salvador:40; Paraguay: 10; Perú: 6; Ecuador: 8 Improving Health Care Training Guide: modules translated and adapted from ASSIST 291 QI teams in 263 facilities, supported by 181 QI coaches Bi-weekly internet-based clinical case discussions /ECHO model) 12

13 Testing improvement interventions and learning what works and how Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? A S P D Changes That Result in Improvement in Practice Act Plan Implementation of adapted guideline Study Do A P Wide-scale tests of adaptations Clinical Research or Guidelines S D Adaptation and follow-up Tests Very small scale test 13

14 and subject- Gather culty ecterts aculty Recruit Faculty Recruit Faculty Recruit Faculty bjectxpertmatter experts matter experts matter experts baseline data baseline data baseline data baseline and Gather Collaborative subject- and subject- and subject- Model matter experts for Gather QI Gather baseline data Gather data Spread and Spread scale pic et ion ocal Prevention and Select topic Management and target Identify Develop of local / adapt Identify Develop KEY KEY Zika Enroll population and its Enroll Identify local / adapt Develop local / adapt Develop / adapt / adapt = Learning session LS = Learning session d partners framework complicationspartners participants framework and partners framework and LS1 and LS1 and LS1 participants LS2 LS1 LS3 LS3 LS partners framework and LS1 changes AP = Action Period LS2 LS2 LS3 changes changes changes AP = Action Period changes Planning and preparation Planning and preparation AP1 Implementation AP1 AP2 AP1 Implementation AP2 AP3 AP1 AP2 AP3 Recruit Faculty Spread and scale Spread up AP1 AP2 AP3 and scale up and subjectmatter experts baseline data Gather Gather Support: visits, Support: phone Support: visits, calls, phone active visits, Support: calls, phone active visits, calls, ph baseline data local Identify local ers LS2 LS3 LS4 Develop / adapt Identify local framework and changes Develop / adapt framework LS1 and changes rs partners LS2 LS1 LS3 LS2 LS4 LS3 LS... LS4 AP1 AP2 AP1 AP3 AP months months Finalize change package, dissemination, spread and scale-up AP3 Support: visits, Support: phone Support: coaching calls, visits, active calls, phone active engagement calls, active of engagement of leaders engagement and managers, of leaders data data and collection, managers, analysis data collection, analysis and feedback collection, and feedback analysis and feedback engagement Support: engagement of visits, leaders phone of and calls, leaders mana active collection, engagement collection, analysis of and collection, leaders analysis feedback and managers, and analysi feedd collection, analysis and feedback months months months mo engagement engagement of leaders of and leaders managers, and managers, data data collection, analysis and feedback Finalize change package, dissemination, spread and scale-up months F AP2A Adapted from: Anita. (2003). The Breakthrough Series: The Breakthrough Series. IHI s Collaborative Model for Achieving Breakthrough Improvement. Institute for Healthcare Improvement. 14

15 Results: 90% pregnant women in antenatal care are counseled on Zika and get condoms 15

16 Results: 88% of women exiting antenatal care have been correctly screened for Zika and are able to identify risk of sexual transmission 16

17 Results: 87% of newborns are screened for microcephaly and are correctly referred if positive 17

18 Regional results Seven countries with updated guidelines 9,033 providers trained in six countries Job aids developed for most important care processes Estimated 135,617 pregnant women given condoms in ANC sessions Estimated 52,669 women counseled on Zika prevention during their first ANC session 181 QI coaches trained, supporting 291 QI teams in 263 facilities in six countries Successful international conference on improving Zika care Ongoing strong collaboration and coordination with partners such as UNICEF, Save the Children, PAHO, MCSP, and others 18

19 Thank you Photo credits: New York Times