Browsing by Author "Freyner, Bridget"
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- ItemRestrictedPilot Implementation of a multi-faceted COVID-19 response at the department of paediatrics, QECH(Kamuzu University of Health Sciences, 2020-09-16) Freyner, BridgetType of Study This is a mixed-methods pilot implementation study Problem COVID-19 is the current major disease of concern globally. The guidance developed by the World Health Organisation (WHO) to help in the implementation of infection prevention and case management of COVID-19 must be locally relevant for it to be effective in Malawi. This study will apply the RE-AIM framework to assess key process and implementation outcomes of the QECH Paediatric COVID-19 response. The QECH Paediatric departmental response to COVID-19 has three elements (i) the implementation of WHO guidance on infection prevention, rationale use of PPE and case management of children with suspected COVID-19 disease (ii) ongoing monitoring and evaluation of in-patient case load, case fatality rate and quality of care and (iii) the development of strategies to minimise in-patient length of stay. Underpinning these three elements are ongoing communication strategies, logistics support and real-time data utilisation through audit-feedback. The aim of this study is to describe the implementation of this response and to pilot strategies for (i) real time data utilisation and (ii) reduction of in-patient length of stay to mitigate against both the direct and indirect effects of COVID-19. Specific Objectives I. To evaluate the implementation of COVID-19 specific guidance (infection prevention, environmental cleaning and the rationale use of PPE) and how it changes over the course of the epidemic. II. To evaluate the pilot implementation of a data dashboard and associated learning system on (i) compliance with COVID-19 guidance and (ii) in-patient quality of care. III. To describe the effect of the COVID-19 epidemic on the in-patient caseload, case fatality rate and in-patient quality of care compared to baseline. IV. To determine the optimal strategies for minimising in-patient length of stay in our department with the aim of reducing unnecessary patient exposure to COVID-19. IV.V. To generate pilot effectiveness data on the utility of a “learning system” to support the COVID- 19 response at the QECH paediatric department. Methods: All elements of the COVID-19 response (the intervention) will be described at baseline using the TiDieR checklist. The implementation of this response will be assessed using a modified RE-AIM framework, supplemented with qualitative enquiry based on the Consolidated Framework for Implementation Research. A key element of the intervention is real time data utilisation via implementation of a data dashboard. The dashboard will be updated weekly. The aim of the dashboard is to provide a “learning” system to inform ongoing COVID-19 specific activities and maintain in-patient quality of care through identification of key indicators requiring improvement on a weekly basis which will be entered into a PDSA cycle. The efficacy of the dashboard will be defined as a 20% improvement in the chosen indicator over the following month. A key safety element in the COVID response is minimising unnecessary length of stay (LOS) for in-patients. We will pilot two strategies to reduce inpatient LOS; (i) IV-PO switch antibiotic ward rounds and a (ii) care pathway for complex patients. These interventions will be developed through (i) audit of existing practices including 6 months of retrospective data review and (ii) participatory work-shops with clinicians and nurses in the department. Pilot efficacy of these interventions will be assessed by comparing length of stay and changes in antibiotic prescribing days in the department. The interventions will be refined through feedback from key users and developed for future formal process evaluation.
- ItemRestrictedSexually Transmitted Infection (STI) in Pregnancy and Adverse Birth Outcomes; A Case-control Study(Kamuzu University of Health Sciences, 2023-01-19) Freyner, BridgetType of Research Study: A cross-sectional survey and nested case-control study. The problem: Sexually transmitted infections (STIs) are associated with increased rates of preterm birth, stillbirth and low birth weight (LBW). In Malawi STIs are diagnosed by syndromic ascertainment which has poor sensitivity in antenatal mothers. The prevalence of these diseases in the antenatal period and their contribution to adverse birth outcomes are not known in Malawi. This is critical as they are highly modifiable. This study will be done as part of the DIPLOMATIC collaboration. Through the COMREC approved TUDA study (P06/19/2714), the DIPLOMATIC collaboration has established midwife capacity in antenatal ultrasound for the determination of gestational age at Queen Elizabeth Central Hospital (QECH). This platform will be utilised in the current study to accurately ascertain the outcomes of prematurity and low birth weight. The DIPLOMATIC group is committed to the implementation of evidence-based practices with the aim of reducing preterm birth, stillbirth and neonatal mortality in Malawi and Zambia. Aim: To determine the contribution of sexually transmitted infections (STI) in the antenatal period to adverse birth outcomes at QECH Primary objectives: 1. To determine the prevalence of STIs (N. gonorrhea, C. trachomatis, M. genitalium, T. vaginalis, T. pallidum, Herpes Simplex Virus and HIV in women who attend QECH for delivery of their infants. 2. To determine the attributable fraction of adverse birth outcomes at QECH with a confirmed diagnosis of at least one STI in the peripartum period. Secondary objectives: 1. To generate pilot data on the clinical outcomes of mother-infant pairs co-infected with HIV and any other STI 2. To evaluate the accuracy of the syndromic approach to the diagnosis of STIs in pregnancy compared to gold standard laboratory diagnostics. 3. To determine the coverage of antenatal diagnosis, treatment and partner notification and treatment of STIs. 4. To determine the role of rapid point of care tests (POCT) for the differentiation of early versus latent gestational syphilis and the diagnosis and management of congenital syphilis. 5. To generate pilot data on the role of vaginal microbial composition in preterm birth and mother to child transmission of HIV. Methodology: A cross-sectional survey and nested case-control study of pregnant women, recruited at delivery will be done at Queen Elizabeth Central Hospital, Blantyre, Malawi. A composite case definition for adverse birth outcome will include all stillborn, preterm, low birth weight (LBW) infants or infants admitted to NICU within 24 hours of birth. Each case will be matched with a mother of a healthy term infant. Multiplex PCR will be done on vaginal swabs in cases and controls to screen for all common STIs (N. gonorrhea, C. trachomatis, M. genitalium, T. vaginalis, T. pallidum, Herpes Simplex Virus) and HIV and syphilis status will be determined on maternal and infant serum. There is a planned sub-group analysis by HIV sero-status. We will recruit 650 cases and 650 controls to give 80% power to detect a 50% difference between groups, α=0.05 and allow prevalence estimates for each STI with +/-5% margin of error margin of error. Expected Findings: This study will provide prevalence data for curable STIs among postpartum women and assess their contribution to adverse birth outcomes. In addition, this study will provide information on the burden of neonatal disease in newborns exposed to STIs in the pre- and peri-partum period. Dissemination: Research findings will be shared with health care workers at QECH and with participants with the help of the MLW science communication team. Data will be shared with the Malawi College of Medicine and Malawi College of Medicine Research Ethics Committee, Malawi Ministry of Health and published in peer reviewed publications. Data collected at QECH will be presented as standalone findings in conferences and peer-reviewed publications locally and shared with relevant clinicians and policy makers.