Both this week and next week Aakash and I have been traveling and collecting bCPAP data with Shannon and Carol, two of the BTB associates here in Malawi. The hospitals that we have been visiting are in phase 2 of the bCPAP trials, which means that they were the second group of hospitals throughout Malawi to become part of the bCPAP study. The study has two parts: First, hospitals are provided with an oxygen concentrator and tasked with gathering baseline data for infant survival on oxygen alone. Then, after several months of accurate data acquisition, they are supplied with two bCPAPS, training, and supplies. The hospitals are asked to keep track of the number of patients with respiratory distress, following how many of these patients are put on oxygen, how many are put on CPAP, and what the outcomes of these patients are. This information allows BTB to assess the efficacy of the bCPAP, and will hopefully provide us with data to justify an even larger scale rollout.
Currently, the hospitals we visit are working on implementing CPAP. Our visits are follow-up visits; we replenish disposable supplies, gather new patient data, and ask for feedback on CPAP execution. If a hospital is having difficulty implementing CPAP or collecting data, we work with the hospital coordinators to develop plans and provide resources to improve CPAP use. So far, I have seen two common key barriers to CPAP use and data collection.
1. Lack of infrastructure
a. Missing files, changing coordinators, and rotating nurses all prove to be a problem when introducing CPAP.
i. When CPAP is rolled out at a hospital, it adds more paperwork to what nurses must already complete – they have to track the treatments and progress of each child on a sheet we provide, and ensure that the files are stored until we can scan it into our computers. Like any human-based system, this can result in missing or incomplete files, leaving our data lacking. To combat this problem, Carol makes follow up calls with all of the hospitals on a weekly basis, working with nurses via the phone to ensure all data is accounted for.
ii. Our CPAP coordinators are also known as ARI (acute respiratory infection) coordinators. They are appointed by the ministry of health to handle acute respiratory care in the hospital, so the CPAP falls under their jurisdiction. The degree to which a coordinator is invested in CPAP can make or break the project, and when coordinators go on leave or change hospitals, it can take weeks or month for a hospital to get back on track collecting data. Ideally, in the long run, the CPAP program will become ingrained in the infrastructure of the hospitals, like it is at queens, so that changing coordinators will have no effect of the success of the device, but in the beginning stages, much relies on the presence of a knowledgeable leader. For now, Carol and Shannon seem to always have at least one other person at each hospital who is invested in and knowledgeable about CPAP, which helps the operations run smoothly when coordinators change.
iii. Nurses and doctors frequently rotate throughout hospitals and the wards in the hospitals. This means that, in some cases, many of the nurses who were originally trained on CPAP are no longer around. Fortunately, many of the hospitals that we have visited have retained at least half of their trained staff. While we can continue to provide site-specific training, our ultimate goal is for the remaining nurses at each site will pass along their knowledge of CPAP when new nurses enter the wards.
2. Fear of the unknown
a. Introduction of something new is always tricky. In the case of the CPAP, mothers frequently fear that this noisy and new device, which they don’t quite understand, will hurt their child or make them worse. Because of this, some parents may be resistant to the idea of trying CPAP on their children. Because the nurseries in Malawi are so crowded, if one mother has a distrust in the device, this distrust can spread throughout the ward. Therefore, one of our projects while here is to create educational materials for mothers, informing them about the benefits of CPAP. BTB has also put together a video in Chichewa that contains testimonials from mothers about the effectiveness of CPAP.
b. Nurses also fear putting children on CPAP. While nurses were trained to put babies on oxygen, CPAP is new. In the trainings we provide, many contraindications for CPAP are also listed. In our rounds this week, Aakash and I noticed that many nurses were scared to try the device on a sick infant, being scared that they may apply the device incorrectly, or be overlooking a contraindication. To combat this problem, some of the coordinators at the hospitals have begun weekly meetings, reminding their staff to use CPAP and fostering a supportive environment. These meetings also allow nurses to ask questions or voice concerns about the device, allowing for increased confidence in CPAP.
While there are still areas that could see improvement, overall I have been very impressed with the physicians and nurses that we have worked with. While things may be disorganized at times, everyone we have spoken with has been willing to work with us. The coordinators actively engage us in conversations about ways to increase CPAP use at the hospitals, are open to new ideas, and are friendly and helpful. Implementing CPAP on such a large scale is definitely ambitious, and it requires the coordination of a complex network of people working towards a common goal. However, from the hospital visits we have completed so far, I believe that our goal can definitely become a reality.
Side Note:
Our journeys to the hospitals take us all throughout Malawi! This allows Aakash and I to soak in culture throughout the country, not just in Blantyre. For example, on Monday night we stayed in a pottery lodge that was also a school for local pottery students. Additionally, our long road trips frequently provide us with breathtaking views, one of which can be seen below!
