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Women Making a Difference

Ivonne Gómez, Nicaragua
URC Child Health Advisor, USAID Health Care Improvement Project

By Oscar Nuñez

Dr. Ivonne Gómez, a pediatrician, leads an initiative under URC’s USAID Health Care Improvement Project (HCI) to improve the quality of health care for severely ill and malnourished children in Nicaragua. As technical advisor for the Pediatric Hospital Improvement Initiative (PHI) begun in 2003 by URC’s Quality Assurance Project (QAP), Ivonne provides technical support in pediatric care quality improvement to 17 national and regional hospitals across Nicaragua. The initiative has recently expanded to include 19 health centers, in order to extend care for severely ill children in remote areas where referral to hospitals is difficult.
 
Ivonne and her colleagues at QAP began the initiative by working with the Ministry of Health (MINSA) to update national guidelines for hospital level Integrated Management of Childhood Illness (IMCI) based on international guidelines for referral care of very sick children developed by the World Health Organization. She then supported MINSA in implementing several strategies for making physicians and nurses familiar with the guidelines and for increasing their competency in pediatric care, including developing and widely distributing pediatric care job aids and pocket guides. 

Ivonne helped to establish clinical training centers in three regional hospitals to provide a structure for staff from surrounding hospitals and health centers to undertake clinical rotations to upgrade their skills. She has worked with pediatric departments in each hospital to institute regular clinical updates to staff on topics such as the use of zinc sulfate for diarrhea case management, neonatal resuscitation, management of the severely malnourished child, infection control, and supporting breastfeeding for ill children. She organized with MINSA a series of “Prize for Knowledge” contests which used a quiz show format to have teams of providers from each hospital compete for prizes by answering questions about the national IMCI guidelines and has promoted public recognition for those providers who have demonstrated improvement in their skills and knowledge.

Dr. Gómez (in the white shirt) observing on providers practicing skills in neonatal resuscitation using mannequins.

Ivonne also worked with the management and staff at each hospital to create a team of doctors and nurses who would look in depth at the quality of pediatric care and make changes to continuously improve adherence to clinical guidelines. One of the first areas she worked on with each hospital team was to put in place effective triage assessment and treatment procedures for children. She has also supported the hospital teams in analyzing ongoing compliance with care protocols and case fatality rates for specific pediatric conditions, in order to identify problem areas and take steps to improve specific care processes in each hospital. She also organizes periodic meeting of teams from hospitals in nearby regions to share their results and ideas for improving care.

Beyond the technical quality of care provided to very sick children, one of  Ivonne’s passions is to make pediatric care more “child friendly” by taking into account the psychosocial aspects of child illness in how care is provided in hospitals. Prior to joining QAP in 2003, Ivonne served as the Director General for the National Children’s Hospital in Managua. During her tenure there, she gave a special focus to making the hospital more child and family friendly by addressing not only the technical but also the human aspects of pediatric care, such as better pain management for children and introducing rooming-in for parents of severely ill children. She has continued to act as an advocate for child friendly care in her work with QAP. Ivonne’s professional leadership and vision of a more caring approach to treating sick children have resulted in hospitals creating recreational areas for hospitalized children, increased staff awareness of the importance of sensitivity to sick children’s psychosocial development, and strengthening counseling of parents for home care of discharged children, particularly for infant and young child feeding.

The following story of a young infant taken to La Trinidad Hospital in western Nicaragua illustrates the impact of Ivonne’s work. La Trinidad hospital was among the first six hospitals to join the Pediatric Hospital Improvement initiative in 2003. 

Bismark P. was born in La Trinidad Hospital in September 2006, with a normal birth weight of 3200 grams. But at seven weeks of age, he was brought to La Trinidad Hospital by his mother after five days of diarrhea and vomiting. The young infant arrived at the emergency room that day in critical condition—severely malnourished (weighing 2200 grams, more than 4 Standard Deviations below normal weight for age) and in a state of shock. Fortunately, the triage system which had been instituted in the hospital with Ivonne’s support, facilitated his rapid treatment. Intravenous liquids were immediately administered, and his vital signs were continually monitored in accordance with the Ministry of Health’s Guide for IMCI at the hospital level. Once his condition was stabilized, Bismark was transferred to the pediatric ward and continued to receive treatment in accordance with MINSA guidelines. Hospital staff took special precautions to avoid hypothermia, a key risk for sick infants, helped his mother re-start breastfeeding, and provided short-term supplementation with micronutrient-fortified formula. His mother was counseled extensively by hospital staff on appropriate infant feeding, and Bismark was discharged 16 days after admission with exclusive breastfeeding. He continued to be followed by the hospital’s outpatient clinic, and by six months of age, Bismark had achieved normal weight for his age and was a healthy baby again.

The successful nutritional recuperation of this young child reflects exactly the improvements in care that Ivonne has worked with staff at La Trinidad Hospital and other Nicaragua hospitals to institute. A leader in creating a “culture of quality” among pediatric care providers and in stimulating ongoing efforts of hospital teams to improve care for sick children, Dr. Ivonne Gómez is truly making a difference for sick children in Nicaragua.

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