Naomi Wright

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=177 BGCOLOR="#CCCCFF" TEXT="#080000"> <bR> <div> <B><U>Site Index</U></B></div> <bR> <div> <IMG SRC="3890e0e0.png" border=0 width="14" height="14" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"> <FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><A HREF="id7_naomi.htm" TARGET="_top" TITLE="Babies: Now"><B>Babies: Now</B></A></FONT></div> <div> <IMG SRC="3890e0e0.png" border=0 width="14" height="14" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"> <FONT SIZE="2" COLOR="#FF6600" FACE="Arial" ><B>Naomi Wright</B></FONT></div> </td> <td valign="top" width="100%" style=" border-left: 1px solid #000000;" BGCOLOR="#FFFFFF" TEXT="#080000"> <div>  <script language="JavaScript1.2">  </script><script> if (document.all) document.write('<p align="center"</p><a href="javascript:addbookmark()">Click here to Bookmark this site!</a>') </script>  </div> <bR> <div> <TABLE BORDER="1" CELLPADDING="1" CELLSPACING="1" WIDTH="581" HEIGHT="1%" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#FFFBF0 > <tR> <tD VALIGN=TOP HEIGHT= 111 ><NOBR><div> Beryl Thyer</div> <div> Memorial Africa Trust</div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <div> Go back to:<FONT SIZE="4" COLOR="#111111" FACE="Arial" > </FONT><FONT SIZE="4" COLOR="#0000FF" FACE="Arial" ><A HREF="id7_naomi.htm" TARGET="_top" TITLE="Babies: Now">Babies Now</A></FONT></div> <bR> <div> Naomi Wright</div> <bR> <div> 1</div> <DIV ALIGN="LEFT"></DIV> <div> The evaluation of low-technology radiant heaters for low-income countries</div> <div> <I>Naomi Wright</I></div> <div> <B>Summary</B></div> <div> <B>Background: </B>98% of the 4 million annual neonatal deaths are in developing countries. High-technology radiant heaters contribute significantly to the lower neonatal mortality rates in developed countries, but they are inappropriate for developing countries and hence low-technology radiant heaters are being produced. However, low-technology radiant heaters have not been investigated to ensure they are effective, usable, useful and safe.</div> <div> <B>Aim: </B>To evaluate the effectiveness, usability, utility and safety of a low-technology radiant heater in the Bansang Hospital, The Gambia.</div> <div> <B>Methodology: </B>Task 1: All neonates born or admitted to the Bansang Hospital during the 5-week study were placed on the radiant heater and those requiring observation or resuscitation remained on it where their rectal temperature was monitored every 3 minutes. These recordings were utilised to evaluate the effectiveness of the radiant heater at maintaining neonates within the limits of thermoneutrality. Task 2: A survey administered to all staff trained to use the radiant heater to evaluate its usability, utility, and safety.</div> <div> <B>Findings: </B>112 neonates were included in the study; 30 required use of the radiant heater; 17 required use of the radiant heat. 15/17 neonates requiring radiant heat were kept within the limits of thermoneutrality or very close giving a success rate of 88% ± 15%. Trained staff stated the radiant heater was easy to use, however some staff had an imperfect knowledge of how to use it. The radiant heater was useful and contributed to saving 30 neonatal lives during the study. Hyperthermia is the main safety risk but it can be eliminated with adequate staff training.</div> <div> <B>Conclusion: </B>Low-technology radiant heaters are effective at aiding neonatal resuscitation and maintaining neonates within the limits of thermoneutrality and hence have the potential to help significantly decrease neonatal mortality rates in the developing world. However, they will only be effective, usable and safe if implemented with sufficient training.</div> <div> 2</div> <div> <B>Introduction</B></div> <div> Of the 10 million children under-5 that die in the world every year, 4 million die within the first 4 weeks of life, the neonatal period <FONT SIZE="1" COLOR="#000000" FACE="Arial" >1-6</FONT>. The World Health Organisation (WHO) believe that a failure to address neonatal mortality is what has slowed the decline in childhood mortality in recent years and at the fifty-sixth world assembly (2003) called upon Member States to `make improvements in neonatal health a priority' <FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>. Public health experts have predicted that unless neonatal mortality is at least halved by 2015, the Millennium Development Goal (MDG) to reduce under-5 mortality by two-thirds will not be met <FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>.</div> <div> The WHO has identified immediate post-natal neonatal resuscitation and thermal control in neonates as key interventions to improving neonatal survival <FONT SIZE="1" COLOR="#000000" FACE="Arial" >2, 7</FONT>. In the developed world, high-technology radiant heaters are used in routine neonatal care to aid assessment and resuscitation of neonates immediately after birth while preventing hypothermia using overhead heat <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7-22</FONT>. However, high-technology radiant heaters are inappropriate and unsustainable in developing countries, where 98% of all neonatal deaths occur, and hence low-technology radiant heaters are gradually being introduced. However, as far as I am aware no research has been undertaken on lowtechnology radiant heaters to ensure they are safe, effective and usable like their hightechnology counterparts. </div> <div> In this study I have evaluated the effectiveness, usability and safety of a lowtechnology radiant heater in the Bansang Hospital, The Gambia. The study consists of a comprehensive literature review of previous research into this area, a methodology, findings, and a discussion of the outcomes and policy recommendations for low-income countries.</div> <div> Photograph 1: Naomi Wright Standing next to the Low-Technology Radiant Heater in the Labour Ward at the Bansang Hospital, The Gambia </div> <div> 3</div> <div> Phototgraph 2: A High-Technology Radiant Heater 64</div> <div> Photograph 3: The Low-Technology Radiant Heater (without mattress and light-bulbs in this photograph: see</div> <div> photograph 1)</div> <div> <B>Background</B></div> <div> The Importance of Neonatal Resuscitation</div> <div> Approximately 5-10% of newborns require some degree of active resuscitation at birth and a further 15-25% require observation until stabilised before being handed to their mother <FONT SIZE="1" COLOR="#000000" FACE="Arial" >23</FONT>. An estimated 19% of the annual 4 million neonatal deaths are attributed to birth asphyxia and the American Heart Association has stated that these can be eliminated using simple resuscitative techniques <FONT SIZE="1" COLOR="#000000" FACE="Arial" >23, 24</FONT>.</div> <div> 4</div> <div> The Importance of Preventing Neonatal Hypothermia</div> <div> Neonatal hypothermia is a worldwide problem across all climates <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 14, 25-28</FONT>. Neonates are highly prone to heat loss due to a large surface area relative to weight, an inability to shiver and little insulating fat particularly during resuscitation and observation after birth due to evaporation of amniotic fluid from the skin and the transition from a warm uterus to the cooler, drier delivery room <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 8, 10, 13, 14, 29-32</FONT>. Although immediate cold stress may be important to initiate breathing it should be kept to a minimum because prolonged exposure to cool can cause <FONT SIZE="1" COLOR="#000000" FACE="Arial" >8, 30, 33</FONT>.</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Increased oxygen consumption </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >13, 34, 35</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Hypoxia </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >13, 14, 36</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Metabolic acidosis </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >13, 14, 36</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Hypoglycaemia </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >13, 14, 35, 37</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Coagulative defects </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >14, 38</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Acute renal failure </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >14</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Necrotizing enterocolitis </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >14</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Death </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >14, 37</FONT></div> <div> There is plentiful evidence to suggest that infants who are not thermally regulated have a significantly higher risk of morbidity and mortality <FONT SIZE="1" COLOR="#000000" FACE="Arial" >10, 11, 15, 39-47</FONT>. Preterm, LBW or distressed neonates are more susceptible to hypothermia than healthy, term neonates because they have less fat for heat production and insulation, decreased glycogen stores, immature skin and poor vascular control and asphyxiated neonates have restricted oxygen supplies <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 13, 14, 18, 40, 41, 44, 45, 47, 48</FONT>. Hence, these neonates require warmer environmental conditions than healthy newborns to maintain the same body temperature <FONT SIZE="1" COLOR="#000000" FACE="Arial" >10, 39, 41, 49, 50</FONT>.</div> <div> The optimum temperature for healthy, term neonates has been defined as between 36·5-37·5ºC with a skin temperature of 0·5-1·0ºC lower <FONT SIZE="1" COLOR="#000000" FACE="Arial" >5, 14, 39</FONT>. The optimum temperature for preterm infants however has yet to be defined due to an ongoing debate about the most accurate method of temperature measurement <FONT SIZE="1" COLOR="#000000" FACE="Arial" >14, 51, 52</FONT>. The WHO classifications for hypothermia are shown in Table 1 <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>. Table 1: WHO's Classifications for Hypothermia <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT></div> <div> <B>Category of hypothermia Temperature of neonate (ºC)</B></div> <div> Mild 36-36.4</div> <div> Moderate 32-35.9</div> <div> Severe <32</div> <div> Interventions to Prevent Hypothermia during Observation and</div> <div> Resuscitation of Neonates</div> <div> Initial standard care for all neonates includes: a warm delivery room at 25ºC or more <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>, drying immediately after birth <FONT SIZE="1" COLOR="#000000" FACE="Arial" >29, 53</FONT>, wrapping in a pre-warmed blanket, prewarming any contact surfaces and eliminating draughts <FONT SIZE="1" COLOR="#000000" FACE="Arial" >14, 39, 54</FONT>. Following this, evidence suggests that full-term, healthy neonates should be placed in skin- to-skin</div> <div> 5</div> <div> contact between the mothers breasts in a method called Kangaroo Mother Care (KMC) <FONT SIZE="1" COLOR="#000000" FACE="Arial" >8, 10, 14, 55-63. </FONT>Neonates requiring observation or resuscitation however must be easily accessible in the minutes following birth and hence KMC is impractical <FONT SIZE="1" COLOR="#000000" FACE="Arial" >16</FONT>. The radiant heater provides such access and has been proven to effectively maintain neonates within the limits of thermoneutrality and hence is used as part of routine neonatal care in all parts of the world that can afford one <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7-9, 12-22, 46</FONT>. Photograph 2 shows the design of a typical high- technology radiant heater <FONT SIZE="1" COLOR="#000000" FACE="Arial" >64</FONT>. There are three reported problems with radiant heaters: increased evaporation and hence insensible water loss, continued risk of hypothermia and the additional risk of hyperthermia. Insensible water loss (IWL) is increased under a radiant heater, but is only clinically relevant for longer-term care <FONT SIZE="1" COLOR="#000000" FACE="Arial" >10, 22, 32, 40, 65-72</FONT>. Evaporative heat loss is also increased but Marks et al has shown that energy expenditure in the form of evaporation is balanced by an increase in heat gain from the heater and hence does not significantly increase total energy expenditure or risk of mortality <FONT SIZE="1" COLOR="#000000" FACE="Arial" >14, 45, 65, 73</FONT>. Hyperthermia is a potential problem since neonates are prone to overheating with a large surface area, limited insulation and limited sweating ability <FONT SIZE="1" COLOR="#000000" FACE="Arial" >30, 41, 45, 50, 74</FONT>. Overheating increases fluid loss and frequency of apnoea and can raise metabolic rate to potentially fatal levels, resulting in an increased risk of mortality <FONT SIZE="1" COLOR="#000000" FACE="Arial" >30, 45, 75</FONT>. WHO's definition for hyperthermia is above 37·5ºC <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 75</FONT>.</div> <div> Appropriateness of Low-Technology rather than High-Technology</div> <div> Radiant Heaters for Low-Income Countries</div> <div> High-technology equipment from developed countries is inappropriate for lowincome countries not only because it is expensive but also because it requires sophisticated management, organisation, trained technicians and supplies to operate, monitor and repair it, which are scarcely available <FONT SIZE="1" COLOR="#000000" FACE="Arial" >76-82</FONT>. Radiant heaters in the UK are currently on the market from £8,120 - £11,680 each and even if donated are often outdated and money is not spent on proper packaging and shipping which limits their lifespan <FONT SIZE="1" COLOR="#000000" FACE="Arial" >83-86</FONT>. In Sub-Saharan Africa up to 70% of equipment lies idle for these reasons <FONT SIZE="1" COLOR="#000000" FACE="Arial" >87</FONT>. In response, many doctors have started to develop much cheaper and simpler low-technology equipment which is far more usable and sustainable in developing countries <FONT SIZE="1" COLOR="#000000" FACE="Arial" >74, 78, 88-94 </FONT>. A 5-year project on a neonatal ward in China showed that Western equipment is inappropriate and equipment that can be maintained and repaired using local resources is most effective <FONT SIZE="1" COLOR="#000000" FACE="Arial" >95, 96</FONT>. Daga has shown how the introduction of low-technology equipment in a neonatal unit in Bombay has led to a significant decline in neonatal mortality <FONT SIZE="1" COLOR="#000000" FACE="Arial" >89, 97</FONT>.</div> <div> A Gap in the Research</div> <div> Although many studies have been performed on high-technology radiant heaters I have found no research on their low-technology counterpart. One paper explains how to make a low-technology `Kira Kira' radiant heater but no trials have been performed on it <FONT SIZE="1" COLOR="#000000" FACE="Arial" >94</FONT>. This is a concern because potentially these low-technology radiant heaters could be unbeneficial, and hence a waste of time and efforts, or even harmful to neonates. Alternatively, they could be highly effective in preventing hypothermia and aiding resuscitation whilst being affordable, usable and sustainable and hence should be produced and promoted worldwide. It is for these reasons that I propose to perform</div> <div> 6</div> <div> an evaluation of a low-technology radiant heater in the Bansang Hospital, The Gambia.</div> <div> The Situation at Bansang</div> <div> Before this study, if a neonate was distressed or not breathing at birth at the Bansang hospital it would be `wobbled' or sometimes suctioned if available; no staff were trained in neonatal resuscitation, no resuscitation equipment was available and no interventions were used to prevent hypothermia. In May 2005, McCormick introduced a low-technology radiant heater containing resuscitation equipment to the labour ward (Appendix 1: list of equipment). It was implemented with on-the-job training for the current nurses and midwives and a neonatal course at the State Enrolled Nursing School for future staff. The radiant heater consists of 6 x 100 Watt light bulbs, each with an individual switch, situated 60cm above the mattress (Photographs 1 and 3: the low-technology radiant heater, Appendix 2: Design details).</div> <div> <B>Statement of Problem</B></div> <div> Neonates, even in tropical countries, are prone to hypothermia, particularly during resuscitation and observation after birth. Hypothermia leads to an increased risk of neonatal morbidity and mortality. High-technology radiant heaters used to prevent neonatal hypothermia during resuscitation and observation in developed countries are inappropriate and unsustainable in developing countries. Low-technology radiant heaters being produced for the developing world have not been investigated to ensure they are effective, usable, useful and safe.</div> <div> <B>Aim</B></div> <div> To evaluate whether the low-technology radiant heater at the Bansang Hospital is effective at maintaining neonates wit hin the limits of thermoneutrality (36·5-37·5ºC) and whether it is usable, useful and safe.</div> <div> <B>Objectives</B></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >To record measurements of the rectal temperatures of all the neonates placed on the radiant heater within the 5-week study period in order to analyse whether they are kept within the limits of thermoneutrality.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >To evaluate the usability, utility and safety of the radiant heater through surveying all the staff that have been trained to use it. </FONT></div> <div> <B>Assumptions</B></div> <div> 7 </div> <div> Using evidence from previous studies, it was assumed that neonates would become cold after birth in Bansang, The Gambia <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 14, 25-28</FONT>.</div> <div> <B>Methodology</B></div> <div> Literature Review</div> <div> Initially, I undertook a systematic and thorough literature search on neonatal thermoregulation, resuscitation, low-technology equipment and radiant heaters using grey literature, peer reviewed literature, journal articles and the World Wide Web.</div> <div> Research Design</div> <div> I used a combination of quantitative and qualitative research methods to ensure a comprehensive evaluation of the radia nt heater. This consisted of two tasks: Task 1: An Evaluation of the Effectiveness of the Low-Technology Radiant Heater at Maintaining Neonates within the Limits of Thermoneutrality. All neonates born by normal delivery, by caesarean section or diagnosed with hypothermia at the Bansang Hospital within the 5-week study period were included in the study. Neonates born in the labour ward were dried and wrapped after birth and placed directly on the radiant heater. Stable neonates were returned to their mother after 2-3 minutes. Neonates requiring observation or resuscitation remained on the radiant heater until stable or transferred to the paediatric ward for incubator care. Neonates diagnosed with hypothermia (primarily due to poor thermal maintenance following a home delivery or washing the neonate in cold water) were kept on the radiant heater until their temperature was stabilised or until the mother was available and willing to provide KMC. Neonates born by caesarean section had to be resuscitated in theatre and carried over to the radiant heater in the labour ward when stable enough.</div> <div> While on the radiant heater neonates had their rectal temperature measured every 3 minutes using a flexible neonatal thermometer inserted 2cm into the rectum <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 98, 99 </FONT>(Appendix 3: details of the thermometer). The first temperature reading was measured 10 minutes after birth because it was established that it took this amount of time to fall from the intra-uterine temperature of 38·1-38·5ºC to within the normal range. A staff member controlled the neonate's temperature by turning light bulbs situated above the neonate on and off according to the rectal temperature readings (Appendix 4: details of how to use the radiant heater). The staff member was initially a doctor, but after 2- 3 weeks the midwives and nurses were trained in resuscitation of the newborn and use of the radiant heater and took over the role to ensure sustainability after the study.</div> <div> Other details recorded included: mode of delivery, gestational age, weight, whether the neonate was dried and wrapped adequately, whether the neonate required</div> <div> 8</div> <div> resuscitation, and whether the electricity went off at any point during use of the radiant heater (Appendix 5: the results sheet filled in for each neonate).</div> <div> Initially, a Thermospot was applied to the upper right quadrant of the neonate's abdomen to additionally monitor the skin temperature. However, subsequently this was discontinued due to inaccurate readings (Appendix 6). If the electricity went off while the neonate was on the radiant heater, the neonate would be returned to the mother for KMC if she was available and the neonate stable, or the neonate would remain on the radiant heater and the generator sent for if unstable, which took approximately 10 minutes.</div> <div> Constants maintained throughout the study</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >The time of birth (time zero) was marked by the complete delivery of the neonate, when all body parts were free and visible.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Temperature readings were taken to an accuracy of 0·1ºC</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >The two digital rectal thermometers used were regularly calibrated against two mercury thermometers.</FONT></div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Wingdings" >? </FONT>Each neonate was exposed to the same external conditions of drying, being placed on a warm towel and remaining naked while on the radiant heater <FONT SIZE="1" COLOR="#000000" FACE="Arial" >100</FONT>.</div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Wingdings" >? </FONT>The radiant heater was placed out of direct sunlight to avoid false recordings from an additional source of radiant heat <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>.</div> <div> Data Analysis</div> <div> Each neonate that received radiant heat to maintain their temperature was categorised into a success or a failure. A success was initially defined as, `the neonate's temperature remaining within the limits of thermoneutrality (36·5-37·5ºC) once it had initially dropped within these limits from the higher intra- uterine temperature'. However, during the study the definition was adapted to allow for neonates born by caesarean section, at home and those with hypothermia. For these neonates success was defined as, `a neonate warmed to within the limits of thermoneutrality within 3- hours of being placed on the radiant heater and remaining within these limits whilst on the radiant heater'.</div> <div> 95% confidence intervals were calculated using the following formula:</div> <div> P ± 1.96v(P (1-P)/N)</div> <div> P = proportion of successes or failures</div> <div> N = sample size</div> <div> Excel was used to collate the rectal temperatures of neonates born by normal delivery, caesarean section, home delivery and those with hypothermia into graphs.</div> <div> Task 2: An Evaluation of the Usability, Utility and Safety of the Low-Technology</div> <div> Radiant Heater through a Survey of the Staff Trained to use it.</div> <div> During the first 2-4 weeks of the study, all the nurses and midwives who worked on the maternity unit and in theatre at the Bansang Hospital were trained how to use the radiant heater and the resuscitation equipment inside it. Subsequently, they were</div> <div> 9</div> <div> asked to answer a verbal survey on their knowledge of how to use the radiant heater and their opinion of its usability, utility and safety. The survey was administered verbally rather than in the written form in order to make the process quicker and easier for the staff and to help improve compliance rates. </div> <div> Initially, I piloted the survey on two nurses to ensure the questions were comprehensive, useful, understandable and suitable (Appendix 7). In response to this I adapted and added questions and surveyed the remaining staff with the modified version (Appendix 8). All the staff were asked to read an information sheet about the study (Appendix 9), were given the opportunity to ask questions about the study and were asked to sign a consent form before the survey was initiated (Appendix 10).</div> <div> Data analysis consisted of adding the number of ticks in each box and summarising longer-answer questions.</div> <div> Ethical Consideration</div> <div> With regards to task 1, data on neonatal temperatures was collected from an intervention already in place because rectal temperatures were routinely recorded to control the radiant heater, and hence no additional harm or distress was caused to the neonates. With regards to task 2, I gained fully informed consent from every staff member before completing the survey. All data collected and used throughout the study will remain anonymous. The study design was ethically approved by the ethics board at the Nuffield Centre for International Health and Development, Leeds.</div> <div> Ethical Approval was not required by an ethics board in The Gambia.</div> <div> Methodological Study Limitations</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Though Randomised Controlled Trials are the gold standard for research it was not possible in this study because it would not be ethical to expose some neonates to hypothermia.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >The short or long-term clinical outcomes of the neonates on the radiant heater were not assessed. However, arguably there is plentiful evidence already available to prove the benefits of keeping a neonate within the limits of thermoneutrality. This study sought to evaluate whether the radiant heater is effective at keeping the neonates within this range.</FONT></div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Wingdings" >? </FONT>Air flow rate, humidity, and ambient air temperature were not measured in this study but they do affect the optimum environment for a neonate <FONT SIZE="1" COLOR="#000000" FACE="Arial" >10, 30, 39, 41, 44, 49, 65, 101</FONT>. However, it has been shown that if temperature is maintained at a constant level then these other factors do not affect the survival of premature neonates <FONT SIZE="1" COLOR="#000000" FACE="Arial" >45</FONT>. Also, the study represents a true evaluation of the radiant heater because the above factors would not be controlled in clinical practice. </div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Wingdings" >? </FONT>IWL was not monitored during this study, however previous research suggests it is not relevant for short-term care <FONT SIZE="1" COLOR="#000000" FACE="Arial" >10, 22, 32, 65-72</FONT>.</div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Wingdings" >? </FONT>The accuracy of the rectal temperature recordings can be affected by the depth of insertion of the thermometer and whether the neonate had passed stool <FONT SIZE="1" COLOR="#000000" FACE="Arial" >102</FONT>.</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >The results are dependant on the weather conditions at Bansang during the study and may not represent an accurate evaluation of the radiant heater for other climates.</FONT></div> <div> 10</div> <div> <B>Findings</B></div> <div> Task 1: The Effectiveness of the Low-Technology Radiant Heater at</div> <div> Maintaining Neonates within the Limits of Thermoneutrality</div> <div> 112 neonates were included in the study; 87 (78%) were born by normal delivery in the labour ward, 20 (18%) were born by caesarean section, 3 (3%) were delivered at home and admitted later and 2 (2%) were treated for hypothermia. 64/112 (57%) were normal at birth and were given directly to the mother, 18/112 (16%) were stillborn and 30/112 (27%) required resuscitation and/or observation on the radiant heater (15/30 resuscitation and 15/30 observation).</div> <div> Of the 30 neonates requiring care on the radiant heater, 15 (50%) were delivered normally (Figure 1), 10 (33%) were delivered by caesarean section (Figure 2), 3</div> <div> (10%) were delivered at home and admitted later (Figure 3) and 2 (7%) were neonates with hypothermia (Figure 4).</div> <div> Figure 1: The Rectal Temperatures of the Neonates born by Normal Delivery whilst on the Low-Technology Radiant Heater</div> <div> 32</div> <div> 32.5</div> <div> 33</div> <div> 33.5</div> <div> 34</div> <div> 34.5</div> <div> 35</div> <div> 35.5</div> <div> 36</div> <div> 36.5</div> <div> 37</div> <div> 37.5</div> <div> 38</div> <div> 38.5</div> <div> 39</div> <div> 39.5</div> <div> 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85</div> <div> Time After Birth (Minutes)</div> <div> Rectal Temperature (Celcius)</div> <div> Neonate 1</div> <div> Neonate 2</div> <div> Neonate 3</div> <div> Neonate 4</div> <div> Neonate 5</div> <div> Neonate 6</div> <div> Neonate 7</div> <div> Neonate 8</div> <div> Neonate 9</div> <div> Neonate 10</div> <div> Neonate 11</div> <div> Neonate 12</div> <div> Neonate 13</div> <div> Neonate 14</div> <div> Neonate 15</div> <div> 17/30 of the neonates on the radiant heater required radiant heat to maintain their temperature; these consisted of 4/15 born by normal delivery, 8/10 born by caesarean section, 3/3 admitted after a home delivery and 2/2 with hypothermia. Of the 17/30 requiring radiant heat for temperature maintenance, for 12/17 (71%) it was successful and for 5/17 (29%) it was a failure (Figure 5). However, the rectal temperature in 2 of the failure cases only fell to 36·4ºC temporarily and was soon corrected (Neonates 23 and 25, Figure 5), and in 1 case the temperature dropped to 36·2ºC before correction within 6 minutes (neonate 3, figure 5). In the other 2 failure cases the radiant heater</div> <div> 11</div> <div> had not been used correctly, the rectal temperatures were not measured and the light bulbs not used (Neonates 14 and 15, Figure 5). When a member from the study arrived and measured the rectal temperatures the decision was made to warm the neonates by KMC.</div> <div> Figure 2: The Rectal Temperatures of the Neonates born by Caesarean Section whilst on the Low-Technology Radiant Heater </div> <div> 32</div> <div> 32.5</div> <div> 33</div> <div> 33.5</div> <div> 34</div> <div> 34.5</div> <div> 35</div> <div> 35.5</div> <div> 36</div> <div> 36.5</div> <div> 37</div> <div> 37.5</div> <div> 38</div> <div> 38.5</div> <div> 39</div> <div> 39.5</div> <div> 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180</div> <div> Time After Birth (Minutes)</div> <div> Rectal Temperature (Celcius)</div> <div> Neonate</div> <div> 16</div> <div> Neonate</div> <div> 17</div> <div> Neonate</div> <div> 18</div> <div> Neonate</div> <div> 19</div> <div> Neonate</div> <div> 20</div> <div> Neonate</div> <div> 21</div> <div> Neonate</div> <div> 22</div> <div> Neonate</div> <div> 23</div> <div> Neonate</div> <div> 24</div> <div> Neonate</div> <div> 25</div> <div> Figure 3: The Rectal Temperatures of Neonates born at Home and admitted later whilst on the Low-Technology Radiant Heater</div> <div> 32</div> <div> 32.5</div> <div> 33</div> <div> 33.5</div> <div> 34</div> <div> 34.5</div> <div> 35</div> <div> 35.5</div> <div> 36</div> <div> 36.5</div> <div> 37</div> <div> 37.5</div> <div> 38</div> <div> 38.5</div> <div> 39</div> <div> 39.5</div> <div> 0 10 20 30 40 50 60 70</div> <div> Time After Admittance to Hospital (Minutes)</div> <div> Rectal Temperature (Celcius)</div> <div> Neonate</div> <div> 26</div> <div> Neonate</div> <div> 27</div> <div> Neonate</div> <div> 28</div> <div> 12</div> <div> In 2/30 cases the electricity failed whilst the neonate was on the radiant heater. This was potentially life-threatening for one neonate who required suction at birth but had to wait 10 minutes for the generator to be turned on. 9/30 neonates were not dried and wrapped adequately at birth, of which 8/9 (89%) became hypothermic and required radiant heat. Of the 21/30 who were dried adequately, only 6/21 (29%) became hypothermic. </div> <div> 42/112 (38%) of the neonates in the study were LBW (= 2·5kg). 11/30 (37%) of neonates requiring care on the radiant heater were LBW. 8/11 (73%) of the LBW neonates requiring resuscitation or observation on the radiant heater required use of the radiant heat, compared to 9/19 (47%) of term neonates.</div> <div> Figure 4: The Rectal Temperatures of Neonates requiring Treatment for Hypothermia whilst on the Low-Technology Radiant Heater </div> <div> 32</div> <div> 32.5</div> <div> 33</div> <div> 33.5</div> <div> 34</div> <div> 34.5</div> <div> 35</div> <div> 35.5</div> <div> 36</div> <div> 36.5</div> <div> 37</div> <div> 37.5</div> <div> 38</div> <div> 38.5</div> <div> 39</div> <div> 39.5</div> <div> 0 10 20 30 40 50 60 70</div> <div> Time after Diagnosis of Hypothermia (Minutes)</div> <div> Rectal Temperature (Celcius)</div> <div> Neonate</div> <div> 29</div> <div> Neonate</div> <div> 30</div> <div> 13</div> <div> Figure 5: The Rectal Temperatures of the Neonates whose Temperatures Failed to remain within the Limits of Thermoneutrality</div> <div> 32</div> <div> 32.5</div> <div> 33</div> <div> 33.5</div> <div> 34</div> <div> 34.5</div> <div> 35</div> <div> 35.5</div> <div> 36</div> <div> 36.5</div> <div> 37</div> <div> 37.5</div> <div> 38</div> <div> 38.5</div> <div> 39</div> <div> 39.5</div> <div> 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85</div> <div> Time after Birth or Admittance (Minutes)</div> <div> Rectal Temperature (Celcius)</div> <div> Neonate</div> <div> 3</div> <div> Neonate</div> <div> 14</div> <div> Neonate</div> <div> 15</div> <div> Neonate</div> <div> 23</div> <div> Neonate</div> <div> 25</div> <div> Task 2: A Survey of the Usability, Utility and Safety of the Low</div> <div> Technology Radiant Heater</div> <div> 10 midwives and nurses at the Bansang Hospital were surveyed in total. All staff had been trained in the use of the radiant heater, but only 5 staff members had used it in clinical practice. The survey findings are shown in Table 2.</div> <div> Table 2: The Results of the Verbal Survey administered to 10 Staff Trained in the use of the Radiant Heater at the Bansang Hospital.</div> <div> <B>Subject Survey Question Answers</B></div> <div> Usability How easy is the radiant heater to use?</div> <div> 3 OK</div> <div> 1 Easy</div> <div> 6 Very Easy</div> <div> Could the radiant heater be improved to make it easier to use? Yes/ No</div> <div> If Yes, how?</div> <div> 10 No</div> <div> Is using the radiant heater too timeconsuming? Yes/ No</div> <div> If Yes, why?</div> <div> 4 Yes</div> <div> 6 No</div> <div> Key comments: Staff shortages is a problem because at times there could be only one staff member working in maternity and their time has to be prioritised between the neonate and the mother.</div> <div> Knowledge of What is the minimum temperature 7 36.5ºC</div> <div> 14</div> <div> how to use the Radiant Heater.</div> <div> the neonate should be? 1 35.5ºC</div> <div> 1 34.5ºC</div> <div> 1 could not remember </div> <div> What would you do if the neonate's temperature fell below this limit whilst on the radiant heater?</div> <div> 8 turn the light bulbs on</div> <div> 2 nothing</div> <div> What is the maximum temperature the neonate should be whilst on the radiant heater?</div> <div> 7 37.5ºC</div> <div> 1 37ºC</div> <div> 1 36ºC</div> <div> 1 could not remember</div> <div> What would you do if the neonate's temperature rose above this limit whilst on the radiant heater?</div> <div> 9 turn the light bulbs off</div> <div> 1 call the doctor because the neonate may have a fever</div> <div> What would you do if the electricity went off while the neonate was receiving temperature maintenance on the radiant heater?</div> <div> 5 wrap the neonate and send for the generator to be turned on</div> <div> 3 just wrap the neonate</div> <div> 1 put the neonate in KMC and send for the generator if need be.</div> <div> 1 wrap the neonate and place a hot water bottle beside it</div> <div> How long should a healthy neonate remain on the radiant heater?</div> <div> 10 a few minutes</div> <div> Where should it go after that?</div> <div> 10 with the mother </div> <div> Where should it go if the mother is not available?</div> <div> 7 cot beside the bed</div> <div> 2 returned to the radiant heater</div> <div> 1 with a family member</div> <div> How long should a neonate requiring observation or resuscitation remain on the radiant</div> <div> heater?</div> <div> 3 until the neonate is stable</div> <div> 3 30 minutes</div> <div> 1 15 minutes</div> <div> 1 10 minutes</div> <div> 2 5 minutes</div> <div> Where should it go once stabilised?</div> <div> 10 to the mother</div> <div> When should the first temperature reading be taken whilst on the radiant heater?</div> <div> 4 after 10 minutes</div> <div> 3 immediately</div> <div> 1 after 3 minutes</div> <div> 1 after 15 minutes</div> <div> 1 not sure</div> <div> How frequently should temperature readings be taken whilst the neonate is on the radiant heater?</div> <div> 6 3 minutes</div> <div> 2 5 minutes</div> <div> 1 10 minutes</div> <div> 1 not sure</div> <div> Usefulness Does the radiant heater provide a useful working area? Yes/ No</div> <div> If Yes, why?</div> <div> 10 Yes</div> <div> Key comments: “all the equipment is at hand”, “the baby can be kept warm while resuscitating”, “it provides easy access to the baby”.</div> <div> 15</div> <div> Do you feel confident using the resuscitation equipment in the radiant heater? Yes/ No</div> <div> 10 Yes</div> <div> Has the radiant heater improved the care for neonates at the Bansang Hospital? Yes/ No</div> <div> 10 Yes</div> <div> Will the radiant heater save lives?</div> <div> Yes/ No</div> <div> 10 Yes</div> <div> Safety How often should the mattress cover be cleaned?</div> <div> 10 between every use</div> <div> How often should the resuscitation equipment be cleaned?</div> <div> 10 between every use</div> <div> How often should inside the drawers and cupboard be cleaned?</div> <div> 6 once a day</div> <div> 3 every few days</div> <div> 1 between every use</div> <div> Have you been involved in cleaning the radiant heater before? Yes/ No</div> <div> 5 Yes (the staff that have used it in practice)</div> <div> 5 No</div> <div> If Yes, how easy is the mattress cover to clean?</div> <div> 2 OK</div> <div> 3 very easy</div> <div> How easy is it to clean the inside of the drawers and cupboard?</div> <div> 1 OK</div> <div> 1 easy</div> <div> 3 very easy</div> <div> Are there any safety concerns for the neonate whilst on the radiant heater?</div> <div> Yes/ No</div> <div> 6 Yes</div> <div> 4 No</div> <div> If yes, what are they?</div> <div> 3 hyperthermia</div> <div> 2 neonate rolling off the mattress</div> <div> 2 infection control</div> <div> Improvements How were you trained to use the radiant heater?</div> <div> 9 on-the-job training</div> <div> 1 neonatal course</div> <div> Could you improve the training you received? Yes/ No</div> <div> 8 Yes</div> <div> 2 No</div> <div> If Yes, how?</div> <div> 4 a few more weeks assistance</div> <div> 3 refresher course after 6 months</div> <div> 1 who was trained through the neonatal course would have liked on-the-job training too.</div> <div> Comments: “all the staff are regularly rotated in the hospital so continued training is vital to the sustainability</div> <div> of its use”.</div> <div> Could the design of the radiant heater be improved? Yes/ No</div> <div> 5 Yes</div> <div> 5 No</div> <div> 16</div> <div> If Yes, how?</div> <div> 3 sides to prevent the neonate rolling off</div> <div> 2 the light bulbs should be a locally manufactured brand</div> <div> 1 battery back-up</div> <div> 1 inbuilt suction and oxygen machines</div> <div> <B>Discussion</B></div> <div> Is there a need for Radiant Heaters in The Gambia?</div> <div> During the study 30/112 (27%) neonates required observation and/or resuscitation on the radiant heater, identifying a need for such apparatus in that setting. 17/30 neonates required use of the radiant heat to maintain their temperature, despite the ambient air temperature in the labour ward remaining between 29-39ºC throughout the study, which supports previous evidence that neonatal thermoregulation is required even in tropical climates <FONT SIZE="1" COLOR="#000000" FACE="Arial" >77, 11, 25-28</FONT>. It is important to note that this study was undertaken during the warmest season in The Gambia and hence the radiant heat will be required at the same level or more frequently during the other seasons when the ambient air temperature can fall as low as 7ºC <FONT SIZE="1" COLOR="#000000" FACE="Arial" >103</FONT>.</div> <div> Is the Low-Technology Radiant Heater Effective?</div> <div> This was evaluated by analysing the rectal temperatures of the neonates placed on the radiant heater to determine whether they remained within the limits of thermoneutrality (36·5-37·5ºC). Of the 17/30 neonates requiring radiant heat, 12 remained constantly within the boundaries of thermoneutrality and a further three remained very close (Neonates 3, 23 and 25, Figure 5), which if counted collectively give an overall success rate of 88% ± 15%. Hence, 15/17 neonates were given a better standard of care and a lowered risk of morbidity and mortality through the use of the radiant heater. This is demonstrated by the 2 neonates that did not have their temperatures measured or radiant heat provided whilst on the radiant heater and subsequently became hypothermic (Neonates 14 and 15, Figure 5). It must be noted that these two failure cases were caused by a failure in the staff training, which prevented proper use of the radiant heater, rather than the radiant heater being ineffective. Hence, this radiant heater has the potential to lower the incidence of neonatal hypothermia and therefore neonatal morbidity and mortality at the Bansang Hospital and other developing countries if used correctly. However, the sample size in this study was relatively small and a larger study would be useful to confirm these findings.</div> <div> The radiant heater may be less effective in countries with cooler climates or in Bansang during the cooler seasons, which warrants further investigation. However, the 600-Watt output of this radiant heater is comparable to high-technology radiant heaters in developed countries with cooler climates, which range from 400 - 750 Watts, and hence it should be powerful enough <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 13, 29, 46, 64, 104</FONT>. If required, the radiant heater could be adapted to include more light bulbs for countries with cooler climates.</div> <div> 17</div> <div> The effectiveness of the radiant heater could also be affected by the method of thermometry used to measure neonatal core temperature. After reviewing the literature, rectal thermometry was concluded to be the most accurate and appropriate method to use. This is supported by many paediatricians and a recent systematic review <FONT SIZE="1" COLOR="#000000" FACE="Arial" >102, 105-122</FONT>.</div> <div> Is the Low-Technology Radiant Heater Usable?</div> <div> This was evaluated using the staff's opinion of how easy the radiant heater is to use, their knowledge of how to use it and any problems they encountered. </div> <div> Staff Opinion</div> <div> All the staff stated that the radiant heater was very easy, easy or OK to use and no one could suggest any improvements to make it easier to use.</div> <div> Staff Knowledge</div> <div> Not all the staff answered the questions correctly on how to use the radiant heater. 2/10 staff thought the minimum rectal temperature for the neonate should be 35ºC and 34·5ºC and stated if the temperature were to fall below this level they would do nothing. This would result in neonates becoming hypothermic despite the availability of the radiant heater. Similarly 3/10 staff did not know the maximum rectal temperature for neonates on the radiant heater, however none of the answers were above 37·5ºC suggesting the neonates would not be at risk of hyperthermia. 9/10 staff stated they would turn the light bulbs off if the temperature rose above 37.5ºC to prevent hyperthermia. However, one stated they would call a doctor in case the neonate had a fever. Although this is not the correct answer, it is a sensible response because some neonatal temperatures were higher than normal due to neonatal or maternal infection and in these cases the doctor should be informed. It is unclear whether this staff member knew whether to turn the light bulbs off if the temperature rose above 37·5ºC, which is a potential danger. It is important to note that the boundaries of thermoneutrality are clearly displayed on the radiant heater to inform the staff at the point of use, as are the instructions of how to use it. There was some confusion regarding when the temperature readings should be taken. 8/10 stated the first temperature reading should be taken at or before 10 minutes, which would ensure good temperature maintenance, however, 1/10 staff stated after 15 minutes, which could potentially allow the neonate to become hypothermic before receiving radiant heat. 6/10 staff knew to take the rectal temperature every 3 minutes, however, 2/10 stated every 5 minutes and 1/10 every 10 minutes, which are acceptable but could result in larger temperature fluctuations. There were mixed views on how long the neonate should remain on the radiant heater. This could have been because the y did not know or it could have been a confusing question because although only 3/10 correctly stated `until the neonate is stable', the answers given by the other 7/10 staff were between 5-30 minutes which could be correct from their experience; it varies for every neonate. It is unlikely that a staff member would return a neonate to the mother before they had finished caring for it</div> <div> 18</div> <div> and none of the times given would keep the neonate separated from the mother for an unacceptable length of time.</div> <div> Training</div> <div> It is clear that adequate staff training is vital for the effective use of this lowtechnology radiant heater, since although none of the staff's answers exposed any serious dangers to the neonates, their knowledge of how to use it was imperfect. The staff member who had not received on-the-job training knew least about how to use the radiant heater, proving its value. 4/10 stressed they would have liked a few more weeks of on-the-job assistance, 3/10 suggested the need for a refresher course and it was also stressed that the nurses at the hospital are regularly rotated and hence continued training would be required. One solution for this could be for two permanent, senior members of staff to be highly trained and examined on the use of the radiant heater and resuscitation equipment, and own literature detailing these for future use, and for these staff members to be in charge of continued training and refresher courses. The Neonatal Resuscitation Program implemented across India utilised this technique and led to a significant decline in asphyxiated deaths <FONT SIZE="1" COLOR="#000000" FACE="Arial" >123</FONT>. Dunn performed a one-day resuscitation programme with 190 nurses and showed it significantly increased their knowledge and skill performance, however this was not maintained at 6 months, confirming the need for refresher training at Bansang <FONT SIZE="1" COLOR="#000000" FACE="Arial" >124</FONT>. It is important to note the value of this survey in improving the knowledge of the staff; it allowed all problem areas to be identified and for incorrect answers to be explained. Hence, staff should be examined at the end of training and refresher courses. Time Constraints 4/10 staff thought the radiant heater was too time-consuming, and at times, when only one staff member is working, the radiant heater would not be used. There are two ways to reduce the time-consuming process of measuring rectal temperatures: setting the radiant heater at one temperature for all neonates or servo-control. It has been well established that neonates of different weights and gestational ages require different levels of radiant heat and to set the radiant heater at one temperature could overheat some neonates and continue to expose others, particularly LBW neonates, to hypothermia <FONT SIZE="1" COLOR="#000000" FACE="Arial" >10, 13, 32, 35, 39, 41, 45, 47, 49, 50</FONT>. This is supported by the 73% (8/11) of LBW neonates requiring use of the radiant heat on the radiant heater, compared to 47% (9/19) of term neonates. Servo-control is not possible because it requires hightechnology equipment <FONT SIZE="1" COLOR="#000000" FACE="Arial" >64, 125, 126</FONT>. Hence, the manual method used is most appropriate for low-income countries. Furthermore, this radiant heater was not designed to provide long-term care; its purpose is to keep neonates warm during resuscitation and observation immediately after birth, a time when it is vital for the staff member to remain with the neonate anyway.</div> <div> Is the Low-Technology Radiant Heater Useful?</div> <div> All of the staff stated that the radiant heater provides an ideal working area for resuscitating newborns; the surface provides access to the neonate from three sides, the resuscitation equipment is readily assessible and the neonate can be maintained at the optimum temperature for survival. All of the staff stated they were confident in using the resuscitation equipment, and in combination with the decreased risk of</div> <div> 19</div> <div> morbidity and mortality provided by the radiant heat, the low-technology radiant heater has the potential to improve the care and save many neonatal lives at the Bansang Hospital, as stated by all 10 staff. This is demonstrated by the 15/112 neonates that were successfully resuscitated and the further 15/112 neonates observed on the radiant heater during the study, who previously would have received no neonatal care or thermoregulation. Using the hospital records it can be estimated that if used correctly, approximately 389 (27%) of the 1442 neonates born at the Bansang Hospital each year will benefit from a lower risk of morbidity and mortality through these interventions <FONT SIZE="1" COLOR="#000000" FACE="Arial" >127</FONT>.</div> <div> Is the Low-Technology Radiant Heater Safe?</div> <div> Hyperthermia</div> <div> As mentioned above, lack of knowledge and awareness about the hazards of using the radiant heater could be dangerous to the neonate if allowed to become hyperthermic, and hence an examination at the end of the training course should be mandatory to ensure this knowledge. Only 3/10 staff stated that hyperthermia was a risk factor for the neonate, however this could have been a misleading question because it did not directly ask about the risk of hyperthermia and they could have just not mentioned it. Le Blanc describes cases where neonates have died of heat stroke on radiant heaters but these involved neonates receiving long-term care on servo-controlled radiant heaters where the alarm failed <FONT SIZE="1" COLOR="#000000" FACE="Arial" >128</FONT>. This radiant heater has no alarm and is designed only for short-term attended use and hence even if temperature measurements were not taken correctly the staff member would see if the neonate became distressed. All staff members were taught that if for any reason they must leave the neonate unattended on the radiant heater they must turn the lights off because the risks of hyperthermia are as great as the risks of hypothermia <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>.</div> <div> Re-warming Hypothermic Neonates</div> <div> Rapid re-warming of hypothermic neonates has been associated with convulsions, apnoea and worsening of metabolic acidosis <FONT SIZE="1" COLOR="#000000" FACE="Arial" >11, 73, 129</FONT>. However, Tafari and Gentz and Sarman et al have shown that rapid re-warming over hours is associated with a lower neonatal death rate than slow re-warming over days and hence the WHO advise rapid re-warming <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 130, 131</FONT>. The two neonates in this study who were admitted with hypothermia at 35·6ºC and 36·3ºC were warmed to within the normal temperature range within 52 and 38.5 minutes respectively and showed no signs of apnoea or seizures (Figure 4).</div> <div> Infection </div> <div> Spread of infection is a risk with all hospital equipment. 10/10 staff stated they would clean the mattress cover of the radiant heater and resuscitation equipment between every use and 10/10 stated the inside of the draws and cupboard should be washed every few days or more frequently. All these answers provide a sufficient level of cleanliness; however even in developed countries with well-developed infection control systems cases of cross- infection from radiant heaters have been reported <FONT SIZE="1" COLOR="#000000" FACE="Arial" >132, 133</FONT>. Added concerns for the Bansang Hospital include frequent lack of running water and poor funding for disinfectants. However, placing the neonates on the radiant</div> <div> 20</div> <div> heater surface provides no greater risk of infection than the previous practice of placing 3-4 neonates in one cot, which was rarely cleaned <FONT SIZE="1" COLOR="#000000" FACE="Arial" >134</FONT>. The radiant heater is sufficiently easy to clean, with answers varying from very easy to OK. A greater concern is the rectal thermometer as a route of infection, which must be sterilised between each use. </div> <div> The Neonate Rolling off the Radiant Heater</div> <div> This is not a safety issue since neonates cannot roll until 9-10 weeks of age <FONT SIZE="1" COLOR="#000000" FACE="Arial" >135</FONT>.</div> <div> Is the Low-Technology Radiant Heater Appropriate?</div> <div> This low-technology radiant heater cost less than £100 to produce, does not require technical expertise to operate it and is easy to maintain because the only maintenance problem could be a light-bulb or fuse needing changing. Hence, it is highly appropriate and sustainable in low-income countries.</div> <div> Other Considerations</div> <div> Neonates born by Caesarean Section</div> <div> 20/112 (28%) of neonates in the study were born by caesarean section. 10/20 (50%) of these required resuscitation in theatre and/or observation on the radiant heater when returned to the labour ward. This is a much larger proportion than the 15/87 (17%) neonates born by normal delivery requiring observation and/or resuscitation, which is not surprising because many of the caesarean sections were undertaken due to dystocia and foetal distress and neonates required radiant heat to maintain their temperature until the mother returned from theatre. Hypothermia was a significantly greater problem amongst neonates born by caesarean section than those born by normal delivery, with 8/10 (80%) of the neonates born by caesarean section requiring use of the radiant heat on the radiant heater compared to 4/15 (27%) of neonates born by normal delivery. Reasons for this increased heat loss include: air conditioning in theatre, delay in putting the neonate under the radiant heat, transport of the neonate from theatre to the labour ward, and delay in putting the neonate with the mother. This additional heat loss in caesarean section neonates is illustrated by the number of neonates below 36·5ºC on using the radiant heater in figure 2, compared to the majority of neonates born by normal delivery remaining above 36·5ºC in figure 1. 4/20 (20%) of the neonates born by caesarean section were already hypothermic on arrival to the labour ward, a figure that could be even higher during the colder seasons. This is significant because low admission temperature has been independently associated with an increased risk of morbidity and mortality in preterm neonates, and hence interventions are required to reduce such heat loss <FONT SIZE="1" COLOR="#000000" FACE="Arial" >21, 40, 136.</FONT></div> <div> For the first caesarean section delivery, the radiant heater was pushed over to theatre, the neonate received radiant heat and remained within the limits of thermoneutrality (Neonate 16, Figure 2). However, transporting the radiant heater with an uneven ground surface proved too difficult and hence subsequently it remained in the labour ward. Therefore, a second low-technology radiant heater is required for theatre, not only to keep neonates warm during resuscitation and observation but also to provide a better working area for resuscitation. Currently, neonates are resuscitated on a cold, </div> <div> 21</div> <div> moving trolley with resuscitation equipment borrowed from the radiant heater and with suction and oxygen shared with the surgeon. It is advisable that the radiant heater remains outside the main operating room however to minimise risk of explosion due to ignition of combustible anaesthetic gases by the hot surface of the radiant heater <FONT SIZE="1" COLOR="#000000" FACE="Arial" >137</FONT>.</div> <div> To reduce heat loss during transportation from theatre to the labour ward an occlusive plastic wrapping could be considered, since Baum and Scopes, Hobbs and Besch et al have shown they can significantly reduce heat loss <FONT SIZE="1" COLOR="#000000" FACE="Arial" >46, 138, 139</FONT>. However, these studies were evaluated with the wrapping administered directly from birth and hence further studies are required to evaluate whether they are effective just during transportation. </div> <div> In this situation, it would not be necessary to apply the plastic wrap immediately after birth, as some studies suggest, because this study has shown that neonatal temperature can be maintained on the radiant heater without additional interventions and wrapping could delay the onset of resuscitation and obscure examination of the neonate even if transparent. Furthermore, Björklund noted that a low Apgar score was more common in infants enclosed in plastic bags immediately after birth, possibly due to the removal of an initial cold stimulus and melting of the plastic wrap onto the neonates skin is a further risk <FONT SIZE="1" COLOR="#000000" FACE="Arial" >18</FONT>. If a wrapping is used during transportation it should be removed on arrival to the labour ward because it is unnecessary and could lead to hyperthermia if kept on neonates not requiring additional heat <FONT SIZE="1" COLOR="#000000" FACE="Arial" >110</FONT>.</div> <div> Transport using an incubator is inappropriate at Bansang because there is only one incubator available and the ground surface is too uneven to allow safe pushing <FONT SIZE="1" COLOR="#000000" FACE="Arial" >136</FONT>. However, the WHO has suggested a locally produced insulated box with holes in for ventilation could be used for transport and pre-warmed using a hot-water bottle if required <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>.</div> <div> Obstruction to the Clinical Value of Neonatal Temperature</div> <div> Messaritakis et al has shown that septicaemic neonates show a thermoregulatory reaction, reflected by a widening of the rectal-sole temperature difference of more than 3·5ºC, and Yashiro et al has stated that one major disadvantage of radiant heaters is that they deprive the doctor of this clinical value <FONT SIZE="1" COLOR="#000000" FACE="Arial" >40, 41, 140</FONT>. However, conversely, use of the radiant heater meant that temperature readings were measured routinely, unlike previous practice, and if a neonate's temperature remained abnormally high after birth, the staff were prompted to monitor its temperature at regular intervals and administer antibiotics if need be. This should actually improve diagnosis and treatment of neonatal sepsis at the hospital. Febrile neonates would not receive radiant heat because the lights are only turned on if the rectal temperature is going to drop below 36·5ºC and hence the clinical finding would not be masked. Furthermore, neonates allowed to become chilled following birth are virtually unable to become febrile in response to infection and hence hypothermia is more likely to mask sepsis in neonates than a neonate kept thermally stable on the radiant heater <FONT SIZE="1" COLOR="#000000" FACE="Arial" >17</FONT>.</div> <div> 22</div> <div> The Effect of Socio-Cultural Practices on Hypothermia in Neonates at the Bansang Hospital</div> <div> Warmth during resuscitation and observation is only one of the 10 `warm chain' stages identified by WHO for keeping neonates warm during the first hours of life. </div> <div> Table 3 illustrates the other 9 <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>.</div> <div> Table 3: The WHO Warm Chain <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT></div> <div> Findings from this study support evidence that the drying and wrapping of neonates at birth decreases heat loss, since 8/9 (89%) of the neonates not dried and wrapped properly became hypothermic compared to 6/21 (29%) of the neonates who were adequately dried and wrapped <FONT SIZE="1" COLOR="#000000" FACE="Arial" >11</FONT>. Prior to this study, drying and wrapping was not practiced in Bansang and it required education and persistence to implement it.</div> <div> Availability of towels was a problem because even if donated they were often stolen by staff or patients, resulting in unsustainability. The 3 neonates delivered at home and admitted later in this study were not dried and wrapped properly and became hypothermic (Neonates 26-28, Figure 3), a practice that can only be changed with parental education possibly through trained birth attendants.</div> <div> KMC was also not practiced prior to this study and was difficult to implement because close proximity between mother and child was not the cultural norm. In one case a hypothermic neonate was given to the mother to re-warm with KMC, but an hour later when checked had been placed in the cot and had a core temperature of 36ºC; a common scenario. Conversely, in another case a hypothermic neonate was given to the mother for re-warming with KMC, which was administered, and resulted in the neonate's temperature returning to 36·7ºC within 40 minutes. Evidence suggests that with education of staff and persistence with the patients socio-cultural practices can be changed <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7, 141</FONT>. This was demonstrated by the complete transition from before this study when neonates were separated from their mothers for hours after birth, sometimes in different wards, to after the study when all neonates were kept with their mothers and breast- feeding initiated within half an hour of life if possible. This change was reflected in the survey results, with all staff members stating that healthy neonates should be returned to their mothers within minutes of birth and neonates requiring observation and/or resuscitation as soon as they were stable.</div> <div> <B>THE WARM CHAIN</B></div> <div> 1 Warm delivery room</div> <div> 2 Immediate drying</div> <div> 3 Skin -to-skin contact</div> <div> 4 Breast-feeding</div> <div> 5 Bathing and weighing</div> <div> postponed</div> <div> 6 Appropriate clothing/bedding</div> <div> 7 Mother and baby together</div> <div> 8 Warm transportation</div> <div> 9 Warm resuscitation</div> <div> 10 Training and awareness</div> <div> raising</div> <div> 23</div> <div> Before this study, bathing the neonate in a cold bucket of water after birth was common practice (Neonate 29 and 30, Figure 4). This was difficult to change because it is part of the Muslim culture. However, it was advised that bathing should be delayed for the first 12 hours of life or at least the adverse effects minimised by washing the neonate away from draughts, in warm water, drying it immediately afterwards and placing it in KMC <FONT SIZE="1" COLOR="#000000" FACE="Arial" >10, 39, 142</FONT>.</div> <div> Electricity</div> <div> In 2/30 cases the electricity failed while a neonate was receiving care on the radiant heater, one of the times being potentially fatal. It must become routine practice for the generator to be turned on in advance before every delivery to power the radiant heater, suction and oxygen machines. This routine can be achieved because it is already practiced for operations at the hospital. A separate generator for the labour ward would be at risk of running out of fuel and not functioning anyway. The staff gave mixed responses when asked what they would do if the generator went off while using the radiant heater, however all answers given were safe and acceptable except putting a hot water bottle next to the neonate which can cause dangerous fluctuations in heat <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>. The correct answers were explained.</div> <div> Could the Design of the Low-Technology Radiant Heater be Improved?</div> <div> Sides on the Mattress Surface</div> <div> Having sides on the radiant heater has been proven to decrease air velocity around the neonate and cooling by convection and hence could be useful <FONT SIZE="1" COLOR="#000000" FACE="Arial" >40, 143</FONT>. The sides should be no higher than 4 inches because they could obstruct access to the neonate. </div> <div> Light Bulbs</div> <div> Ideally the light bulbs used on the low-technology radiant heater should be a locally manufactured brand to ensure they are sustainable. In this case the light bulbs are sustainable through Anita Smith running the Bansang Hospital Appeal, but this might not be the case for other low- income facilities.</div> <div> Back-up Source of Power</div> <div> A low-technology anaesthetic machine has been produced which can still function if the electricity and oxygen fails and a similar design could be considered for a radiant heater <FONT SIZE="1" COLOR="#000000" FACE="Arial" >78</FONT>. However, the machine itself is expensive and not appropriate for this lowtechnology radiant heater.</div> <div> In-built Suction and Oxygen Machines</div> <div> This would make the radiant heater too high-technology and liable to break down. It worked well to have the suction machine and oxygen concentrator next to the radiant heater and if any of the two dysfunction they can be replaced separately. </div> <div> 24</div> <div> Further Limitations identified during the Study</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >The sample size was limited to 30 neonates on the radiant heater and 17 requiring radiant heat, which has resulted in relatively wide confidence intervals. However, the results are still useful as an approximate of the success of the radiant heater and will hopefully guide future research.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Initially a doctor controlled the radiant heater and then was present to assist the other staff using it, which could have improved their skills in maintaining the neonates within the limits of thermoneutrality, and hence the results might not be truly representative of the staffs' skills in everyday practice.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Three of the questions in the survey were worded in a way that in use did not give a clear answer. However, I did not want to prompt the staff too much for fear of getting biased results.</FONT></div> <div> <B>Conclusion</B></div> <div> Policy Recommendations</div> <div> The low-technology radiant heater is effective at maintaining neonates within the limits of thermoneutrality and is appropriate for low- income countries. Hence it should be promoted and produced for use in the developing world to help reduce neonatal morbidity and mortality. However, sufficient training is essential to ensure that it is used effectively and safely. All staff members should be trained and examined on how to use the radiant heater and neonatal resuscitation equipment and this should be refreshed every 6months-1year. To ensure the sustainability of this it is advised that two permanent, senior members of staff at the health facility are highly trained and examined in the use of the radiant heater and resuscitation equipment and have literature to consult and hence can ensure continual training and refresher courses for the other staff members.</div> <div> It is recommended that one low-technology radiant heater is situated in the labour ward and another is situated outside the theatre fo r neonates born by caesarean section. An intervention is required to maintain the neonates' temperature between the theatre and the labour ward and evidence suggests an occlusive plastic wrapping or a locally produced, insulated box could be appropriate and effective for this purpose <FONT SIZE="1" COLOR="#000000" FACE="Arial" >46, 138, 139</FONT>. If replicated the design of the radiant heater could be altered to include small sides around the mattress area to shield the neonate and light bulbs manufactured in the country where the radiant heater will be in use. It is vital that the adverse sociocultural practices such as leaving neonates in a wet cloth, separating the mother and baby, and washing the neonate after birth are not re-administered after this study. The Bansang Hospital would greatly benefit from the introduction of the WHO's `warm chain' policy <FONT SIZE="1" COLOR="#000000" FACE="Arial" >7</FONT>.</div> <div> Implications for Future Research</div> <div> The sample size in this study was relatively small and hence a larger study would be useful to substantiate these findings. Further research is required to determine whether this radiant heater would be as effective at maintaining neonates within the limits of </div> <div> 25</div> <div> thermoneutrality in colder climates. 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A List of the Resuscitation Equipment kept in the Low-Technology Radiant Heater as recommended by the Resuscitation Council, UK.</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >2 x Bag and mask - size 0/1 for most neonates, size 00 for the low birthweight neonates</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >2 x Stethoscope</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >2 x neonatal laryngoscope with straight blades</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >A selection of Guedel airways</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Neonatal endotracheal tubes</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >A supply of oxygen</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >A suction machine with suction catheters no less than 12-14 French gauge</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Water manometer to measure the pressure of the air being bagged</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >2 x flexible neonatal rectal thermometers</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Neonatal proformas for the staff to fill in for each neonate</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Pens</FONT></div> <div> 2. Details of the Thermometer used for Task 1 of the Study Omron FlexiTemp Clinical Thermometer: a flexible neonatal rectal thermometer. Measuring range: 32-43·9ºC Accuracy: 0·1ºC.</div> <div> 3. The Details of How to use the Radiant Heater: Worksheet used for Staff Training Newborn babies are highly prone to heat loss and hypothermia. This hypothermia (<36·5ºC) can lead to many adverse effects in the newborn:</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Acidosis</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Hypoglycaemia</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Increased oxygen demand making resuscitation more difficult</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Increased risk of mortality</FONT></div> <div> For this reason the Resuscitaire (trade name for the radiant heater) has been designed to keep newborn babies at the right temperature (36·5-37·5ºC) during examination and resuscitation following birth. Following are the instructions of how to use the Resuscitaire correctly and safely:</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >When the pregnant woman is fully dilated send for the generator to be put on.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >When there is electricity turn on a light bulb and warm 2 towels on the Resuscitaire ready for the delivery.</FONT></div> <div> 35</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Dry and wrap the baby as advised, place the newborn on the Resuscitaire and note the time.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >If the newborn is healthy hand it straight to the mother.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >If it requires extra care keep it on the Resuscitaire. You have 10 minutes for this before thinking about temperature.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >After 10 minutes check the newborn's rectal temperature and write it down.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >If the temperature is below 36·7ºC turn on one more light bulb</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >After 3 minutes check the rectal temperature again. If it is still lower turn another light bulb on. If it is the  same or within 36·7-37·3ºC do not turn on another light bulb. If it is higher than 37·3ºC then turn one off.</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Continue to check the rectal temperature every 3 minutes until you remove the newborn from the Resuscitaire having decided it is now safe to give to the mother.</FONT></div> <div> NEVER leave the neonate unattended on the Resuscitaire because it can become hyperthermic which is very dangerous. Hyperthermia is defined as >37·5ºC and a hyperthermic baby will appear distressed, restless and breathing fast.</div> <div> 4. The Record Sheet filled out for each Neonate Requiring Care on the Radiant Heater</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Date and time of birth:</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Mode of delivery: Gestational Age: Weight:</FONT></div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Drying/ wrapping:</FONT></div> <div> 1. Was the neonate's head dried? Yes/ No</div> <div> 2. Was the neonate's trunk dried? Yes/ No</div> <div> 3. Was the neonate's limbs dried? Yes/ No</div> <div> 4. Was the neonate naked on a warm towel on the Resuscitaire? Yes/ No </div> <div> Any additiona l comments about drying or wrapping:</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Temperature Measurement</FONT></div> <div> <B>Time after birth</B></div> <div> <B>(mins)</B></div> <div> <B>Rectal</B></div> <div> <B>temperature (ºC,</B></div> <div> <B>accuracy 0.1)</B></div> <div> <B>Colour of thermospot</B></div> <div> <B>(red or green?)</B></div> <div> 1</div> <div> 2.5</div> <div> 4</div> <div> 5.5</div> <div> 7</div> <div> 8.5</div> <div> 10</div> <div> 11.5</div> <div> 13</div> <div> 36</div> <div> 14.5</div> <div> 16</div> <div> 17.5</div> <div> 19</div> <div> 20.5</div> <div> ? <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Additional questions</FONT></div> <div> 1. Did the neonate have to be resuscitated whilst on the resuscitaire?</div> <div> Yes/ No</div> <div> If yes, for what duration of time?</div> <div> 2. Did the neonate receive any other care while on the resuscitaire?</div> <div> Yes/ No</div> <div> If yes, please briefly describe.</div> <div> 3. Did the neonate survive during it's time on the resuscitaire?</div> <div> Yes/ No</div> <div> 4. Did the neonate have to be removed at anytime while on the</div> <div> resuscitaire due to hyperthermia?</div> <div> Yes/ No</div> <div> Additional comments:</div> <div> 5. Details of the Thermospot</div> <div> The Thermospot is a simple newborn temperature indicator designed for mothers to know when their baby has become too cold. The Thermospot is designed to turn from a bright green smiling face to black if the neonates skin temperature falls below 36·5<FONT SIZE="3" COLOR="#006600" FACE="Arial" >ºC. </FONT>However, on occasions the thermospot showed a green smiling face when the neonate's core temperature was below 36·5ºC, and hence its use was discontinued.</div> <div> 6. The Original Survey that was Piloted on Two Nurses</div> <div> A Survey about the Radiant Heater for Neonates</div> <div> Section 1: Usability</div> <div> 1. When were you trained to use the radiant heater?</div> <div> 2. How many times have you used it in total?</div> <div> 3. Overall, how easy do you find it to use? (please tick the most appropriate box)</div> <div> Very difficult</div> <div> Difficult</div> <div> 37</div> <div> OK</div> <div> Easy</div> <div> Very easy</div> <div> Please explain why you have given this answer:</div> <div> 4. In what way or ways do you think the radiant heater could be improved to make it easier to use?</div> <div> 5. Do you feel using the radiant heater is too time-consuming?</div> <div> 6. Have you been involved in attaching the skin or rectal thermometers?</div> <div> 7. Have you experienced any problems attaching the skin or rectal thermometers?</div> <div> If yes please explain your answer:</div> <div> 8. Have you experienced any problems with the reading of the thermometers? </div> <div> If yes please explain your answer:</div> <div> 9. Please state any other problems you have experienced with the thermometers:</div> <div> 10. What is the maximum temperature the baby should be whilst under the radiant heater?</div> <div> 11. What would you do if the baby's temperature went above this maximum temperature?</div> <div> 12. What is the minimum temperature the baby should be whilst under the radiant heater?</div> <div> 13. What would you do if the baby's temperature fell below this limit?</div> <div> 14. Would you know what to do if the electricity went off while the baby was on the radiant heater?</div> <div> If yes please could you briefly explain what you would do:</div> <div> 38</div> <div> Section 2: Usefulness</div> <div> 1. Do you feel this radiant heater has improved care for babies in the Bansang Hospital?</div> <div> Please briefly explain your answer:</div> <div> 2. Do you understand why the radiant heater is being used for the care of babies?</div> <div> If yes please can you briefly explain why it is being used:</div> <div> If no how would you improve the training you received in how to use the radiant heater?</div> <div> Section 3: Safety</div> <div> 1. Have you been involved in cleaning the mattress or any other part of the radiant heater?</div> <div> If no, go to question 6.</div> <div> If yes, please state which part and continue to question 2:</div> <div> 2. How easy do you find the mattress to clean? Please tick the most appropriate box:</div> <div> Very difficult</div> <div> Difficult</div> <div> OK</div> <div> Easy</div> <div> Very easy</div> <div> Please explain why you have given this answer:</div> <div> 3. How often does the mattress get cleaned or changed? Please tick the most appropriate box:</div> <div> Between every use</div> <div> After every 2-4 babies</div> <div> After every 5 babies</div> <div> (approximately once a day)</div> <div> After every 30 babies</div> <div> (Approximately once a week)</div> <div> Very rarely</div> <div> never</div> <div> 39</div> <div> 4. How easy do you find the rest of the radiant heater (excluding the mattress) to clean? Please tick the most appropriate box:</div> <div> Very difficult</div> <div> Difficult</div> <div> OK</div> <div> Easy</div> <div> Very easy</div> <div> Please explain why you have given this answer:</div> <div> 5. How often does the rest of the radiant heater (excluding the mattress) get cleaned?</div> <div> Between every use</div> <div> After every 2-4 babies</div> <div> After every 5 babies</div> <div> (approximately once a day)</div> <div> After every 30 babies</div> <div> (Approximately once a week)</div> <div> Very rarely</div> <div> never</div> <div> 6. Do you feel there are any safety concerns with this radiant heater for the babies?</div> <div> If yes please give details:</div> <div> 7. Do you feel there are any safety concerns with this radiant heater for the staff members that use it?</div> <div> If yes please give details:</div> <div> Overall:</div> <div> If there are any other comments you would like to make about the radiant heater or that you feel might be useful for this piece of research please give more details here:</div> <div> 40</div> <div> Thank you again for your time and help. It is very much appreciated. If you have any further questions about this survey, the radiant heater or the research study please do not hesitate to ask Naomi Wright.</div> <div> 7. The Modified Survey administered to the Remaining Staff</div> <div> A Survey about the Radiant Heater (2)</div> <div> Section 1: Usability</div> <div> 9. When were you trained to use the radiant heater?</div> <div> 10. How many times have you used it in total?</div> <div> 11. Overall, how easy do you find the radiant heater to use in terms of keeping the babies warm and providing a useful working area for resuscitation? Please tick the most appropriate box:</div> <div> Very difficult</div> <div> Difficult</div> <div> OK</div> <div> Easy</div> <div> Very easy</div> <div> Please explain why you have given this answer:</div> <div> 12. In what way or ways do you think the radiant heater could be improved to make it easier to use?</div> <div> 13. Do you feel using the radiant heater is too time-consuming?</div> <div> Yes/ no</div> <div> If yes, please explain your answer</div> <div> 14. Have you been involved in using the rectal thermometer?</div> <div> Yes/ no</div> <div> 15. Have you experienced any problems using the rectal thermometer?</div> <div> Yes/ no</div> <div> If yes please explain your answer:</div> <div> 41</div> <div> 16. Have you experienced any problems with reading the rectal thermometer?</div> <div> Yes/ no</div> <div> If yes please explain your answer:</div> <div> 9. Please state any other problems you have experienced with the thermometers:</div> <div> 15. What is the maximum temperature the baby should be whilst under the radiant heater?</div> <div> 16. What would you do if the baby's temperature went above this maximum temperature?</div> <div> 17. What is the minimum temperature the baby should be whilst under the radiant heater?</div> <div> 18. What would you do if the baby's temperature fell below this limit?</div> <div> 19. What would you do if the electricity went off while the baby was on the radiant heater?</div> <div> 20. For how long should a healthy baby remain on the radiant heater?</div> <div> 21. Where should the baby be placed after observation on the radiant heater if it is healthy and the mother is healthy?</div> <div> 22. Where should the baby be placed after observation on the radiant heater if the baby is healthy but the mother is unhealthy?</div> <div> 42</div> <div> 23. For how long should babies that require resuscitation or observation remain on the radiant heater?</div> <div> 24. When should the first temperature reading be taken if the baby remains on the radiant heater for resuscitation or observation?</div> <div> 25. How frequently should the temperatures be taken after that if the baby remains on the radiant heater?</div> <div> 26. Where should the resuscitated or observed baby go once it is stable?</div> <div> Section 2: Usefulness</div> <div> 3. Do you feel the radiant heater provides a useful working area for resuscitating and observing babies?</div> <div> Yes/ No</div> <div> Why?</div> <div> 4. Do you feel confident using the neonatal resuscitation equipment kept in the radiant heater?</div> <div> Yes/ No</div> <div> 5. Do you feel this radiant heater has improved care for babies in the Bansang Hospital?</div> <div> Yes/ no</div> <div> Please briefly explain your answer:</div> <div> 6. Do you think the radiant heater will help to save lives at the Bansang Hospital?</div> <div> Yes/ No</div> <div> 43</div> <div> 7. Do you understand the reason why the radiant heater is being used for the care of babies with regards to temperature regulation and for providing a suitable resuscitation area?</div> <div> Yes/ no</div> <div> If yes please briefly explain why it is being used:</div> <div> 8. How were you trained to use the radiant heater?</div> <div> 9. Are there any ways in which you think the training for the radiant heater could be improved?</div> <div> Yes/ No</div> <div> If Yes, how?</div> <div> Section 3: Safety</div> <div> 8. Have you been involved in cleaning the mattress or any other part of the radiant heater?</div> <div> Yes/ no</div> <div> 9. How easy do you find the mattress cover to clean? Please tick the most appropriate box:</div> <div> Very difficult</div> <div> Difficult</div> <div> OK</div> <div> Easy</div> <div> Very easy</div> <div> Please explain why you have given this answer:</div> <div> 10. How often does/ will the mattress get cleaned or cha nged? Please tick the most appropriate box:</div> <div> Between every use</div> <div> After every 2-4 babies</div> <div> Once a day (approx every 5</div> <div> babies)</div> <div> Once every few days</div> <div> 44</div> <div> Once a week (approx every 30</div> <div> babies)</div> <div> Very rarely</div> <div> Never</div> <div> 11. How often does/ will the resuscitation equipment kept in the draw of the radiant heater be cleaned? (Remember it is not used on all babies)</div> <div> Please tick the most appropriate box:</div> <div> Between every use</div> <div> After use by 2-4 babies</div> <div> Once a day</div> <div> Once every few days</div> <div> Once a week</div> <div> Very rarely</div> <div> Never</div> <div> 12. How easy do you find the rest of the radiant heater (excluding the mattress) to clean? I.e. inside the draws and cupboard were the resuscitation equipment is kept.</div> <div> Please tick the most appropriate box:</div> <div> Very difficult</div> <div> Difficult</div> <div> OK</div> <div> Easy</div> <div> Very easy</div> <div> Please explain why you have given this answer:</div> <div> 13. How often does/ will the rest of the radiant heater (excluding the mattress) get cleaned?</div> <div> Between every use</div> <div> After every 2-4 babies</div> <div> Once a day (approx every 5</div> <div> babies)</div> <div> Once every few days</div> <div> Once a week (approx every 30</div> <div> babies)</div> <div> Very rarely</div> <div> Never</div> <div> 14. Do you feel there are any safety concerns/ dangers with this radiant heater for the babies?</div> <div> If yes please give details:</div> <div> 45</div> <div> 15. Do you feel there are any safety concerns/ dangers with this radiant heater for the staff members that use it?</div> <div> If yes please give details:</div> <div> Overall:</div> <div> If there are any other comments you would like to make about the radiant heater or that you feel might be useful for this piece of research please give more details here:</div> <div> Thank you again for your time and help. It is very much appreciated. If you have any further questions about this survey, the radiant heater or the research study please do not hesitate to ask Naomi Wright.</div> <div> 8. Information Sheet given to Staff before the Survey</div> <div> Information Sheet: An Evaluation of the Radiant Heater</div> <div> at the Bansang Hospital</div> <div> Dear Nurse/ Midwife,</div> <div> If you have been involved in the use of the new radiant heater (or resuscitaire) in the maternity unit at the Bansang Hospital please read on. You are being invited to take part in a research study. This will involve you answering some questions about the new radiant heater for newborn babies. Before you decide it is important that you understand what the study involves and what your input will be. Please read the following information explaining the details of the study. If you have any questions or queries please do not hesitate to discuss it with Naomi Wright, the research coordinator. </div> <div> Please take time to come to a decision on whether you wish to take part in the study.</div> <div> What is the purpose of the study?</div> <div> I am performing a two-part study to evaluate the effectiveness, usability and safety of the radiant heater that has recently been implemented in the maternity unit. The first part of the study involves measuring how effective the radiant heater is at keeping the babies warm. You will have seen Naomi Wright taking temperature readings from the babies on the radiant heater.</div> <div> The second part invites you to answer some questions about the radiant heater. These questions will evaluate how easy the radiant heater is to use, how easy it is to keep</div> <div> 46</div> <div> clean and whether it is safe or not. This is the first time a study has been performed on a radiant heater like this and hence the results will be very useful for other hospitals, doctors and voluntary organisations planning to produce or buy one. If successful this research could help improve the health of babies in Gambia and around the world by promoting the use of such equipment to help prevent hypothermia.</div> <div> Who is conducting this study?</div> <div> This study will be undertaken by Naomi Wright, a student from the University of Leeds studying International Health.</div> <div> Who will take part?</div> <div> All the nurses who have been trained and have used the radiant heater will be asked to answer these questions.</div> <div> Do you have to take part?</div> <div> It is your choice whether you take part or not. If you choose to take part you will be able to keep this information sheet and will be asked to sign a consent form to say you are willing to take part. You will be free to withdraw from the study at any point without having to give a reason. You are free to say no if you do not wish to take part in the study. It will not affect your employment rights and none of your colleagues, Dr McCormick or managerial staff at the Bansang Hospital will be told of your decision.</div> <div> What happens if you do take part?</div> <div> After you have signed the consent form you will be asked to sit down somewhere private with Naomi Wright, the research co-ordinator, and she will ask you some questions about the radiant heater. These questions will not be difficult like an exam; they will simply be about your opinion. The whole process will be very relaxed like a normal conversation and should only take about 15 minutes. The survey will be completely confidential so do not worry about other staff members or Dr McCormick reading you answers. Only Naomi Wright will have access to the answers. Your name will not appear on the survey.</div> <div> What will happen to the results?</div> <div> Naomi Wright will analyse the data from the surveys along with the data from the babies' temperature readings and write up the results in a report. Copies will be made available to you and other staff at the Bansang Hospital, Dr McCormick, Anita Smith (founder of the Bansang Hospital Appeal), examiners at the University of Leeds and the sponsors providing the funding for the survey, The Wolfson Foundation. There is a possibility that it might also get published which would make the information universally available. Once again, it must be stressed that your name will not appear anywhere on this report - this survey is strictly confidential.</div> <div> 47</div> <div> Further Information</div> <div> If you would like any further information please contact Naomi Wright in the maternity unit or volunteers accommodation. For any information after the 8<FONT SIZE="1" COLOR="#000000" FACE="Arial" >th </FONT>June please contact Anita Smith who can put you in contact with Naomi Wright after the study has finished.</div> <div> Thank you very much for your time; it is very much appreciated.</div> <div> 9. The Consent Form Signed by all Nurses and Midwives involved in the Study</div> <div> Consent Form:</div> <div> An Evaluation of the Radiant Heater at the Bansang Hospital</div> <div> Please circle</div> <div> your answer</div> <div> 1. I have read the nurses `Information Sheet'. Yes/ No</div> <div> 2. I have had the opportunity to ask questions and discuss the Yes/ No research study with Naomi Wright.</div> <div> 3. I am satisfied with the answers to my questions. Yes/ No</div> <div> 4. I have received enough information about the study. Yes/ No</div> <div> 5. I understand that I do not have to take part in the study Yes/ No if I do not want to.</div> <div> 6. I understand that I am free to withdraw from the study at any Yes/ No time without giving a reason and without affecting my career.</div> <div> 7. I agree to take part in the research study. Yes/ No</div> <div> Signature of nurse……………………………………..</div> <div> 48</div> <div> Name (block capitals)………………………………….</div> <div> Date…………………………………………………….</div> <div> Signature of research co-ordinator…………………….</div> <div> Name…………………………………………………..</div> <div> Date……………………………………………………</div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>Go back to:</B><FONT SIZE="3" COLOR="#111111" FACE="Arial" ><B> </B></FONT><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="id7_naomi.htm" TARGET="_top" TITLE="Babies: Now"><B>Babies Now</B></A></FONT></div> <bR> <div> (Naomi Wright)</div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <A HREF="id61_m.htm" TITLE="Naomi Wright">top of the page</A></div> <div> Beryl Thyer Memorial Africa Trust, a UK registered charity  ~  1112603</div> <bR> <bR> </td> </tr></table></body>