News and Opinions  –  2020

Nurse Dorce, Indonesia: Treating small patients with much love and infection prevention – a success story

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Nurse Dorce Datu, head of the Neonatal Intensive Care Unit at Biak Hospital, Indonesia, has been working in the unit since the first day it was founded. She has seen the days when the death rate of premature babies with infection was 100%, and now she is the one who keeps the Infection Prevention Control Program at the unit running.

Her main goal is to create a supportive environment for the staff and she is not afraid of going the extra mile to help them and their small patients. She is a nurse who - together with the unit and the hospital - acts conscientiously on antibiotic resistance. We need more nursing professionals like Nurse Dorce and her team.

Neonatal Intensive Care Unit staff at Biak Hospital wearing t-shirts saying “treating small (patients) with much love”. Photo: Rifan Oktavianus

Nurse Dorce, tell us a little about yourself

– I am 47 years old and have 4 children. My oldest child is 25 years old, and the youngest is 7 years old. I graduated from the midwifery academy in Kediri district, East Java province. I continued my study and received my bachelor’s degree in nursing in Makassar, South Sulawesi province. I moved to Biak in the 1980s because of my parents.

Why do you like working as a nurse?

Nurse Dorce (second left) and her colleagues. Photo: Personal collection

– To me, being a nurse means that I get to do a wider range of activities than being a midwife. I love working with newborns.I feel like I belong to the perinatal section and blend well with newborns. I also like working with my team.

How was the situation like at NICU in Biak Hospital regarding neonatal death rate during the past five years?

– The Neonatal Intensive Care Unit (NICU) in Biak Hospital, Papua province in Indonesia, was founded in 2013. Until 2015 the survival rate of very premature babies was 0%. About five years ago, neonatal death rate was quite high at 35 per 1000 the NICU in Biak Hospital, while the national number was 19 per 1000. The unit had very limited resources and facilities (lack of clean water, no culture facility, limited antibiotics) including lack of routines on infection prevention control amongst the health care workers.

What did the hospital do to change the situation?

Nurse Dorce demonstrates sterile intravenous procedures as part of the infection control program. Photo: Personal collection

– In 2016 the unit set up a training program with many strategies for infection control. The result was better than expected. In 2017, the very premature baby survival rate increased to 64%, in concordance with the decreased use of broad spectrum antibiotics (meropenem) from 40% to 6% after training was held. The mortality rate of very premature baby was down from 100% to 36%.

– Those programs are still running, now with survival rate number around 60%, while number of neonatal death decreased to 13/1000. In 2017, many Neonatal Units in Papua and West Papua made Biak NICU a model unit for infection control and reduced number of antibiotics usage.

– The infection prevention control program includes: hand hygiene, sterile procedures, sterile injection and intravenous treatment, one equipment for one patient (stethoscope, thermometer) and hand rub for each patient. The behavior change was observed after the training and coaching.

How long did it take until you started to notice change in the neonatal’s survival rate?

Preterm baby at NICU , Biak Hospital. Photo: Rifan Oktavianus

– Previously, before the training and a visit from the Ministry of Health, the mortality rate was very high in Papua province, including in Biak island. After the training (infection control training), the neonatal mortality rate decreased, including the low-birth-weight babies. I witnessed the change from 2014 when doctor Windhi Kresnawati (the previous pediatrician who was assigned to manage the NICU in Biak Hospital), started working here and until 2017 when she completed her assignment. Starting 2017, the mortality rate went down, and the situation improved. Currently, the life expectancy of a very low birth weight baby has increased from 0% to 60%. We have also received babies who were referred to us from other hospitals or primary healthcare centers.

Did you start other routine work as well?

– Besides the training, we also conducted tests and monitoring of the medical procedures such as resuscitation, hand hygiene, and infection prevention and control. All of the NICU staff participated in the training. Initially, our focus was to reduce the mortality rate. Now, we try to maintain the infection control program to lower the mortality rate, increase the survival rate preterm babies, reduce the health care associated infection in NICU, and decrease of the use of antibiotics.

What actions did the hospital take to reduce antibiotic use at the unit?

As the head of NICU, Dorce checks the infection control procedures for newborns, such as sterile equipment and procedures. Photo: Personal collection

– We have learned that not all newborns need to be treated with antibiotics. As part of the program we started to use antibiotics more carefully. Antibiotics are only given to those with bacterial infections. We also start with the level 1 and 2 antibiotics, unless it is very necessary to use the level 3 (such as meropenem). A few staff members were trained to monitor use of antibiotics. We saw the reduction in the use of level 3 antibiotics.

–  We created internal guidelines (checklist) for routine daily monitoring of infection prevention. A dedicated nurse is assigned to be in charge of the monitoring. This has proven to be effective in changing the behavior of the health workers in infection prevention. When we reduce the infection, we reduce the use of antibiotics, and this reduces the risks of antibiotic resistance.

– We learned a lot about antibiotic resistance from the training with doctor Windhi. She also demonstrated how to use antibiotics carefully – only use them for babies with certain conditions (based on the guidelines). Previously, almost all babies were given antibiotics orally. Antibiotics were even prescribed to be given at home. It is different now – we use less antibiotics.

Preterm baby at NICU , Biak Hospital. Photo: Rifan Oktavianus

When the newborns’ conditions are worsening or they have symptoms such as vomit, high fever, shortness of breath, the physicians tend to treat those symptoms with broad spectrum antibiotics (over treatment) because newborns are fragile, or the physicians are uncertain of the diagnosis. The nurses were trained to evaluate the possible factors that cause the worsening conditions of those babies, other than infections. Many factors could cause those symptoms. A guideline was developed to list down those possible factors. Although the nurses do not determine the treatment, they can remind the physicians of those possible factors other than infections. They could be the temperature of the incubator, the installation of the ventilators, dehydration, etc.

What do you do to keep the infection control program “alive”?

Stethoscope and medical equipment are used for only one patient. The red line is for patients with infections, so the health workers are more alert and reminded of the risk of spreading the infections to other patients. Photo: Rifan

– To maintain the infection control program, we remind each other to always monitor the resuscitation, check whether the required equipment is available in the treatment areas, and within reach when they are needed. For example, we make sure that hand rubs are available by the beds, we check our nails to make sure they are clean, we ensure that we wash our hands properly. We practice a technique called “mystery shopper”. We mysteriously monitor our colleagues without them knowing that we observe – this to see whether they comply with the procedures. This way, we know that we are watched, and this works for us to be compliant. Those who don’t comply will be warned. In addition, for each death case, we sit together and discuss what was the cause, and how could we prevent that from happening again.

– Although doctor Windhi is no longer with us, we continue to follow her guidelines. She continues to share updated relevant information with us through WhatsApp messages. She even makes quizzes for us once in 6 months. Those with high scores will get some rewards like food or phone vouchers. We are excited to participate in these quizzes.

Nurse Dorce (back row, second from left) and her team at the hospital. Photo: Rifan.

– Our staff consists of 18 people. Biak Hospital has been very supportive, and made sure that we have the required supplies for hand hygiene such as the sterile gloves, sanitizers, hand rubs.

Have you shared your experiences with other hospitals in your region?

NICU team of Biak Hospital demonstrates the procedures to prepare and give injectable drugs to the health workers from other hospitals, as Biak Hospital was selected as the benchmark in infection control program. Photo: Dr. Windhi

– I have always wanted to visit the primary health care and share my knowledge and experience with the health workers in Puskesmas (primary health care at the sub-district level). My team and I have visited several Puskesmas and discussed with the health workers about the equipment they need and how to use them. Most of the time, they have the equipment but do not know how to use them properly.

– We have also been invited by the district health offices from the other district because they heard about what we did at the NICU in Biak Hospital.  They heard that we managed to reduce the newborn mortality rate, and wanted to learn from us.

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