Over the past week, I have had the opportunity to think a lot about obstacles to implementing sustainable projects, especially in regards to the bCPAP project. When traveling and collecting data, it is easy to focus on what is working now, and to find temporary solutions to projects. However, the CPAP, like any other new device, will be in hospitals long after our study is over. Therefore, when working with different hospitals, it is important that we focus on more than just getting good data; rather, while we are still equipped by the generous funding resources that our study has been given, we must focus on preparing hospitals to use CPAP many years from now, when Rice is no longer making follow up visits and checking in on hospitals every week.

 

In my opinion, the first step to achieving this goal is integrating CPAP as a hospital norm. When the device was first introduced, it was novel and new. Many nurses had never been trained on CPAP, and Rice developers had to work with clinicians to develop regulations, indications, and best practices for CPAP use. This meant, as I mentioned in my previous post, that many nurses were hesitant about using the device, unsure if it would make a difference. Frequently, the CPAP coordinator was the only individual putting the baby on CPAP.

 

However, now we need to work on moving the device away from being novel – it needs to become routine. When new nurses come into the nursery, CPAP should be a routine part of training. When a baby with respiratory distress is admitted, CPAP needs to be considered immediately as a possible treatment, not only by the coordinator, but by any staff that happens to be on call. Putting an infant on CPAP when necessary should become the norm, not the exception.

 

This week, the hospitals that Aakash and I have visited have had varying success in integrating CPAP as a nursery norm. On one end of the spectrum, Queens has done an exceptional job. On my rotations there, I watched as our four CPAP nurses personally oriented nursing students to use the device. The next day, when I came on the ward, these same students were putting neonates on the device, on their own initiative and almost unassisted. And even when the delegated CPAP nurses were not around, clinicians and nurses alike were putting babies on CPAP and weaning them appropriately. At Queens, it is clear to see that CPAP will be in use long after Rice is gone.

 

However, on the other end of the spectrum, some of the hospitals we have seen are struggling to use CPAP effectively. A small few of the hospitals only had a handful of patients on CPAP in the past month, despite the large volume of patients they have in and out of the nursery. At first I was surprised at the stark contrast between these hospitals and Queens, before I realized that there are several key differences between our “home base” hospital and these other institutions.

 

1. Time – CPAP has been at Queens longer than any other hospital. This means that clinicians, nurses, and patients alike have been given more time to adjust to the device. They have been able to observe, over a long period of time, that CPAP is effective, and there has been time to integrate CPAP usage into nursery culture. I believe that time, and familiarity with the device, is one of the most essential things necessary to create sustainability. When practitioners at other hospitals begin to habitually use CPAP, it will be passed on to future generations of clinicians as a norm.
2. Support – With essentially all of our program associates posted in Blantyre, it is easy to check up on the progress of CPAP at Queens. In the early stages of the clinical trials, if clinicians had doubts or questions about the device, we could stop by the nursery almost daily to encourage them. Additionally, many of the doctors who head up the CPAP study are well known, well liked, and well respected doctors at Queens. Nurses who may feel uncomfortable trusting us have trusted these familiar faces, who act as an additional in hospital resource. Program associates here do an excellent job of providing support to the other district and regional hospitals, making monthly visits and weekly phone calls, but it is impossible to provide daily support as was initially done at Queens. This is why our hospital coordinators are so helpful, they provide daily support for CPAP in the nursery. However, this is a big job for one person to have. Hopefully, moving forward, we can get more clinicians at each hospital involved in our network of support for CPAP, with the bonus of having a sustained and unofficial CPAP support team at each hospital by the end of our study.
3. Feedback – At Queens hospital, clinicians have been able to see how CPAP drastically improves the mortality rates of babies with respiratory distress. This has been seen by personal experience, over time, and it has also been seen through the data that we have gathered. Hospitals who have only received CPAP several months ago, and therefore who have limited time and exposure with this device, have yet to see these positive results. One of the projects that Aakash is working on while we are here is a computer program that automatically generates a feedback report from the data we gather. Upon successful programming of his program, hopefully we will be able to take a monthly data summary to each hospital on our follow up visits, providing them with better, more hospital specific feedback than we currently have been able to give. This, along with more time with the device, will allow them to see the benefits to using CPAP on their patients.

 

One of the great things about the CPAP study is that everyone involved cares about integration of CPAP. In some clinical studies, the three things I mentioned above would definitely be ignored, shoved under a rug while field workers strove to get publishable data. Then, when the study was over and the papers were written, researchers would move onto a new project. However, all of the individuals involved in our project, from BTB to GSK, truly care about the success of the device beyond the study. On our way home from Mzuzu last week, Aakash, Shannon, Carol and I had a long brainstorming session in the car, discussing ways to personalize support for hospitals, and figuring out new ways for hospitals to take ownership of their own CPAP success. It truly is encouraging to see how much everyone is investing into the sustainability of this project.

 

In other news, I am still working on reading A Heart for the Work – I highly recommend it to anybody even remotely interested in public health. For me, I am so glad I waited to begin reading it until I arrived in Malawi. It is exciting to read about towns, hospitals, and streets, realizing that I have been where the author has. The history and insights the book provides have definitely enriched my understanding of Malawian culture, and hopefully will impact my work here as an intern, and my work as a doctor in the future.