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Quality Improvement Reports

Reducing length of stay in hospital for very low birthweight infants by involving mothers in a stepdown unit: an experience from Karachi (Pakistan)

BMJ 2004; 329 doi: (Published 11 November 2004) Cite this as: BMJ 2004;329:1151
  1. Zulfiqar A Bhutta (zulfiqar.bhutta{at}, professor of paediatrics and child health1,
  2. Iqtidar Khan, professor of paediatrics1,
  3. Suhail Salat, assistant professor of paediatrics1,
  4. Farukh Raza, research medical officer, paediatrics1,
  5. Husan Ara, head nurse, Neonatal Intensive Care Unit1
  1. 1 Aga Khan University, Karachi 74800, Pakistan
  1. Correspondence to: Z A Bhutta


    Problem Clinical care of infants with a very low birth weight (less than 1500 g) in developing countries can be labour intensive and is often associated with a prolonged stay in hospital. The Aga Khan University Medical Center in Karachi, Pakistan, established a neonatal intensive care unit in 1987. By 1993-4, very low birthweight infants remained in hospital for 18-21 days.

    Strategies for change A stepdown unit was established in September 1994, with mothers providing all basic nursing care for their infants before being discharged under supervision.

    Key measures for improvement We analysed neonatal outcomes for the time periods before and after the stepdown unit was created (1987-94 and 1995-2001). We compared these two time periods for survival after birth until discharge, morbidity patterns during hospitalisation, length of stay in hospital, and readmission rates to hospital in the four weeks after discharge.

    Effects of change Of 509 consecutive, very low birthweight infants, 494 (97%) preterm and 140 (28%) weighing < 1000 g at birth), 391 (76%) survived to discharge from the hospital. The length of hospitalisation fell significantly from 1987-90, when it was 34 (SD 18) days, to 16 (SD 14) days in 1999-2001 (P < 0.001). Readmission rates to hospital did not rise, nor did adverse outcomes at 12 months of age.

    Lessons learnt Our results indicate that it is possible to involve mothers in the active care of their very low birthweight infants before discharge. This may translate into earlier discharge from hospital to home settings without any increase in short term complications and readmissions.


    • We thank the scores of residents and nurses, and the families who were responsible for the care and follow up of these infants. In addition, several research officers and data managers have been responsible for maintenance of the database over the years, notably Saleem Islam, Kiran Chaudhry, Kamran Yusuf, Rashid Gadet, and Rashida Shaikhali.

    • Contributors ZAB conceived the idea of this intervention and was the director of neonatal services at the Aga Khan University Medical Center from 1989 to 2003. He supervised the data collection, analysis, wrote the manuscript, and is the guarantor. IK and SS contributed to the clinical care of infants in the study and the manuscript review process. FR helped with data collection and analysis and staff nurse HA oversaw the staff training in the stepdown unit and contributed to the manuscript review.

    • Competing interests None declared.

    • Ethical approval Since the creation of the stepdown unit was not a formal “research” initiative, a specific clearance from the ethics review committee at Aga Khan University was not sought. A prospective system for data collection on all high risk admissions to the neonatal care unit was already in place since 1987, and the protocol for the analysis of outcomes of babies with a very low birth weight was approved by the Departmental Research committee. All parents provided written consent for the anonymised use of clinical information for research and audit purposes at admission.

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