HOSPITAL FEATURE | Tondo Medical Center: Commitments that Effect Change

by Donna Miranda | photos by Bernie Cervantes

These days the staff of Tondo Medical Center (TMC) can only recall with nostalgia what was once the harried and busy atmosphere of its Neonatal Intensive Care Unit, but not without relief.

At TMC newborn babies receive warmth from their mothers through immediate skin-to-skin contact

In fact if there were anything noticeable, it was the great deal of pride, satisfaction and enthusiasm beaming from hospital director Dr.  Victor de la Cruz who together with his hospital staff has managed to successfully initiate change within a short period of time. Nowadays the nurses at the NICU jokingly lament how awfully quiet it has become since NICU admissions have begun to dramatically decrease to 10.9 % of total deliveries from January to March 2011. In fact at the time of our visit, there were only two babies. The two nurses stationed at the NICU candidly inform us, “we don’t seem to have any use for that here anymore” pointing to the warmer where a queue would usually form to warm delivered babies.

And indeed they don’t – since they’ve started implementing the EINC program in the hospital where the only warmth that babies receive mostly come from their mothers through immediate skin-to-skin contact.

The staff also seemed much more satisfied now that some of the unnecessary workload such as cord care and routine bathing of the babies have been done away with. Instead more attention is being reallocated to breastfeeding support and monitoring. Not only was it reassuring to see that non-separation of mothers and babies conscientiously practiced but that it was also a relief to know that even those weighing between 1.5 to 1.8 kg who needed closer monitoring and care were kept with their mothers in the newly created EINC room right beside the NICU. Thanks to complete staffing realignment, mother-baby dyads are now closely monitored at least 9 times a day, ensuring that the sufficient support and care is given to mothers and during recovery.

The mothers seemed to be pleased, as evident in the following quotations:

                     Nakakapanibago po, kasi yung mga narakaraan kong panganganak di

                     naman ganito ang ginawa…Pero para sa akin, maganda po ito sapagkat

                     nakakasiguro ako na di mapalitan ang anak ko, kasi pag sa hospital ka

                     nanganganak masarap po ang pakiramdam, kasi nakabonding ko na

                     kaagad ang anak ko… -- Marie Claire De Leon – 33 F, G7P3 NSD

                     Happy–happy ako, damang dama ko na anak ko talaga siya. Hindi siya          

                     napapalitan.—Mrs. De Leon

                     Pakiramdam ko, relax ako. Masarap ang pakiramdam kasi namalayan ko nasa              

                     dibdib ko ang baby ko.—Mary Ana Labayani – 25 F, G1P1 CS

After only four months since the EINC Orientation Workshop conducted last January 2011, TMC has already made remarkable progress in reducing sepsis, preterm and maternal deaths reporting reporting zero cases in the last week of March.  As early as eleven weeks after training and weekly supportive supervision meetings its performance of the 4 core steps of EINC has been >95% in their normal deliveries and >90% in their cesarean deliveries. Moreover, the rates of allowing mother to eat and walk without routine IVF placement (83%) and delivering in semi-upright position (97%) have been equally impressive. And while these numbers have yet to reflect the true statistical impact of EINC on outcome indicators, the consistent drop in TMC’s NICU admissions and increase in directly room-in babies hint at future improvement in the statistics if the EINC program is continually implemented as standard of care in hospitals.

The TMC in Manila is a tertiary public medical center established in 1971 operating under the supervision of the Philippine Department of Health (DOH). Currently, it has eight hospital departments, and a 200-authorized bed capacity, 60 of which is allotted to the OB-Gyne Department. Spontaneous vaginal deliveries is the leading cause of admission in TMC. In 2009, obstetric cases alone comprised 47% of the total admissions. Located at North Bay Boulevard, Balut, Tondo, Manila, TMC caters to the health needs of the residents of Tondo and CAMANAVA (Caloocan, Malabon, Navotas, Valenzuela) area.  

The early success of TMC is due to the strong leadership and openness of its medical director Dr. Victor de la Cruz. His “hands-on” management style – sitting in weekly implementation meetings, watching out for potentially conflicting clinical practices that may arise in carrying out the EINC—and his fervent support for the program has been instrumental in the rapid but fine-tuned implementation of the program. As well as making sure that the necessary changes are adapted according to the hospital’s available resources, needs and capacities. Already some significant changes in the hospital’s policy, physical environment and practice have been put in place such as the complete realignment of staffing that allows frequent monitoring of mother-baby dyads; construction of wooden wedges to allow mothers a semi-upright position during delivery; use of a unique EINC wrap for babies in skin-to-skin contact; revision of admission forms and doctors’ orders reflecting EINC practices; and promoting EINC awareness among patients by continuously showing the EINC video material at the outpatients waiting. Additionally, an EINC-friendly floor plan is already underway and included in the hospital’s next renovation budget.

Complete realignment of staffing has allowed close monitoring

of mother-baby dyads at least 9 times a day

Surely change is never easy and Dr. De la Cruz is quick to remark that the process was not one without some resistances. But not enough reason to give up. In fact he proudly shares that “my strategy was to keep close to those who were most resistant (to the changes), constantly convincing them to give it a try. At first they were hesitant but unwavering persuasion eventually won them over.”

This tireless dedication and enthusiasm is something he says he has learned from the EINC Team whose supervised monitoring, committed support and guidance were crucial to TMC’s success.  Dedication he said is not only infectious but inspiring, “how can you think otherwise, when the evidence is indisputable and safety of patients always prioritized over everything else.” 

Dr. De la Cruz receives the same kind of esteem from his staff who considers his openness to change and all-out support for the program as pivotal factors contributing to TMC’s successful and timely implementation of EINC—attitudes that the staff now share with him.

Dr. Macasadia shares marked improvements in their OB & Pedia stats

“The changes were not done abruptly, every week we do our commitments and then commit to do doing better for the following week. The staff is challenged to give our commitments weekly,” shares Dr. Sharon Macasadia, OB, on how they’ve managed to carry out EINC practice at a steady pace in the hospital. She further says that because of this they’ve learned to value these “incremental changes” and see how it affects the big picture. For instance she proudly cites how the use of intravenous fluids among delivering mothers has markedly dropped from 83.65% in February to 39.92 % in the last week of June. 

Adopting the EINC protocols has also made them appreciate the value of teamwork, pedia consultant Dr. Sheryl Joy Gracilla shares that “things are less departmentalized as we have learned to become more responsive in providing for the care of our patients.” Consequently, the non-departmentalization of care has resulted in better relationship between obstetricians and pediatricians, and of course, better satisfaction of its patients. Meanwhile the team is anticipating an even better working rhythm between the pediatrics and OB department as soon as the design of patients’ birth plan forms has been finalized. 

And as if things were not looking bright enough, TMC has not only managed to reduce infant sepsis and mortality rates but also incur savings cost since they’ve adopted EINC at the beginning of the year.  The NICU charges, for instance have dropped from P145.00 to P43.50 and delivery room charges from P345.50 to P83.50. The savings are being reallocated to provide patients with EINC-friendly facilities.  Moreover, a “free blood culture” service has been initiated to created provide free blood CS to indigent patients who cannot afford outside lab (because TMC’s lab has no blood cultures). Upon approval of Dr.  Dela Cruz part of rebates from this outside lab has been converted to “free blood cultures” to selected newborns of indigent mothers.”

The benefits reaped by simple health worker behavior change were so impressive that TMC thought that EINC should not be confined within its walls. As a referral facility, TMC saw the need to share their experiences with other lower level facilities within their catchment area.  In March 2011 TMC initiated an EINC training for 72 participants composed of nurses, pediatricians, obstetricians, administrators, clinical nurse instructors from Tondo’s catchment areas, including nearby Caloocan and Navotas, LGU-operated health units (Ospital ng Tondo, Pagamutan ng Bayan) and guests from tertiary medical centers (Gat Andres, VRPMC, Trinity, Delgado Hospital). The initiative to adopt EINC as the standard of care in all of these facilities is a manifestation of the system-wide effort to decrease the maternal and newborn mortality rates in the area.

Dr. de la Cruz emphasizes, “We want to be part of the achievement of MDG 4 & 5, as I believe that focusing on MG 4 & 5 is a key step in solving the rest of the other MDGs.”