Article Text

Decreasing incidence of admission neonatal hypothermia in Gandhi Memorial Hospital, Addis Ababa, Ethiopia: quality improvement project
  1. Biniam Yohannes Wotango1,
  2. Wubet Mihretu Workineh1,
  3. Tariku Deressa Abdana1,
  4. Hailegebriel Kidane1,
  5. Aynekulu Aragaw2,
  6. Bisrat Tamene Bekele3
  1. 1Gandhi Memorial Hospital, Addis Ababa, Ethiopia
  2. 2IHI Ethiopia, Addis Ababa, Ethiopia
  3. 3Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia
  1. Correspondence to Dr Biniam Yohannes Wotango; biniamy50{at}


Background WHO reported that neonatal hypothermia accounts for about 27% of newborn deaths worldwide. It is a serious concern in Ethiopia and other parts of sub-Saharan Africa; it poses a serious threat to global health, increasing morbidity and mortality. Hypothermic neonates are more likely to experience respiratory distress, infections and other issues that could result in longer hospital stays and delayed development. The objective of this quality improvement project was to minimise intensive medical treatments, maximise resource usage and enhance overall health outcomes for newborns at Gandhi Memorial Hospital by reducing neonatal hypothermia.

Methods Over 10 months (from 1 March 2021 to 30 January 2022), neonatal hypothermia incidence was assessed using Quality Supervision Mentoring Team and Health Management Information System data. Root cause analysis and literature review led to evidence-based interventions in a change bundle. After team training and neonatal intensive care unit (NICU) relocation, Plan-Do-Study-Act cycles tested the bundle. Close temperature monitoring and data collection occurred. Run charts evaluated intervention success against baseline data, informing conclusions about effectiveness.

Result The quality improvement project reduced neonatal hypothermia in NICU admissions from a baseline median of 80.6% to a performance median of 30%.

Conclusion and recommendation The quality improvement project at Gandhi Memorial Hospital effectively reduced neonatal hypothermia through interventions such as the temperature management bundle and NICU relocation, leading to improved patient care, fewer hypothermic neonates and enhanced body temperature management. Continuous monitoring, adherence to best practices, sharing success and outcome assessment are crucial for enhancing the project’s effectiveness and sustaining positive impacts on neonatal hypothermia reduction and patient outcomes.

  • Quality improvement
  • Quality improvement methodologies
  • Quality measurement
  • Continuous quality improvement
  • Control charts/Run charts

Data availability statement

Data are available on reasonable request. Data may be obtained from a third party and are not publicly available.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Admission hypothermia is a common problem for newborns, contributing to increased morbidity and mortality. While various temperature management protocols exist, their effectiveness in reducing admission hypothermia and the impact of neonatal intensive care unit (NICU) relocation remain unclear.


  • This quality improvement project demonstrates that implementing a temperature bundle management protocol and relocating the NICU closer to the labour ward significantly reduces the incidence of admission hypothermia.


  • These findings highlight the potential benefits of standardised temperature management protocols and strategic NICU placement for improving newborn outcomes. This could inform future research, clinical practice guidelines and hospital policies aiming to decrease admission hypothermia and its associated complications.


Problem description

Neonatal hypothermia is a global health issue, causing around 27% of neonatal deaths, as per WHO.1 Neonatal hypothermia is a major concern in sub-Saharan Africa, including Ethiopia.2 A significant concern for global health, neonatal hypothermia raises morbidity and mortality rates. Hypothermic infants are more likely to experience respiratory distress, infections and other issues that could result in longer hospital stays and delayed development.3 The objective of this quality improvement project was to minimise intensive medical treatments, maximise resource usage and enhance overall health outcomes for newborns at Gandhi Memorial Hospital by reducing neonatal hypothermia.

Population unit

All neonates admitted to Gandhi Memorial Hospital, regardless of gestational age or birth weight, make up the project’s population unit.


Addressing alarming neonatal hypothermia (80.6%) at Gandhi Memorial Hospital’s neonatal intensive care unit (NICU) with evidence-based interventions to improve neonatal outcomes and community health.

Project context/settings

The project at Gandhi Memorial Hospital targeted NICU, operation room and labour and delivery ward to improve care for newborns. The team involved healthcare professionals from these departments to implement evidence-based interventions for at-risk infants. The project aims to enhance their health outcomes through best practices, focusing on reducing neonatal hypothermia.

Problem statement

The analysis of Quality Supervision Mentoring Team (QSMT) 24 hours activity and Health Management Information System register data from 1 March 2021 to 30 January 2022 revealed an alarmingly high incidence of hypothermia (baseline median of 80.6%) among neonates admitted to the NICUs at Gandhi Memorial Hospital. This raised serious concerns about the quality of care for fragile newborns, potentially leading to increased neonatal mortality and morbidity.

Aim statement

This healthcare quality improvement project aimed to reduce incidence of admission neonatal hypothermia from baseline performance of 80.6% to performance median of 32.2% from 1 February 2022 to 2 August 2022.

Assessment of problem and analysis of its causes

A root cause analysis identified factors contributing to neonatal hypothermia. The multidisciplinary team, including paediatricians and nurses, shared the analysis with staff, leading to targeted interventions for comprehensive issue resolution.


Interventions tested

A temperature management bundle was developed to improve neonatal care, including elements like immediate wrapping, radiant warmer use, prewarming flannel, temperature documentation, accompanied transportation, plastic wrap availability and room heater functionality.

Meticulous measurement using an Excel template recorded and analysed each neonate’s care. Aspects of care were assigned 1 or 0 based on their presence, and columns represented individual neonates under their care. Another change proposed was relocating the NICU to the labour ward’s building for improved communication, efficiency and timely transfer of newborns requiring specialised care.

A 2023 study in china found that implementing a temperature bundle in an NICU significantly reduced the rate of admission hypothermia (from 62% to 36.9%) and improved the mean body temperature of newborns on admission (from 35.5°C to 36°C). This translated to a lower mortality rate among the infants involved.4 Another conducted in 2022 reported that using a temperature bundle in extremely low birth weight infants led to a dramatic decrease in hypothermia rates (from 92.3% to 2.5%) and increased the number of infants achieving normothermia.5 A meta-analysis study in 2021 reviewed 18 studies and concluded that temperature bundles significantly reduced the risk of hypothermia in newborns compared with standard care.6–8

Intervention design

To carry out the project, we used the nationally adopted framework called model for improvement.

Measurement of improvement

Measures chosen to assess the effects of the changes implemented included outcome measures, process measures and balancing measures.

Outcome measure

  • The proportion of hypothermic neonates at admission.

Process measures

  • The percentage of neonates transported to the NICU according to the temperature bundle management protocol.

  • Whether the NICU was near the labour ward (yes/no).

Balancing measures

  • Assessed the satisfaction of NICU and labour ward staff.

  • The incidence of neonatal hyperthermia.

Methods of data collection

The project’s success was attributed to continuous assessment and monitoring through quality improvement team meetings, coaching sessions and leadership follow-ups. Regular data collection and quality checks were ensured by QSMT duty staff.

Methods of data analysis

The study used run charts to assess process improvement. Ongoing assessment, daily monitoring, data collection and quality checks by QSMT staff facilitated a comprehensive analysis of intervention effects, providing insights into improved outcomes, process performance and system stability.

Results/effects of changes

Process measure

Interpretation of run chart

The first intervention resulted in positive improvement signals, with trend and shift rules evident, and a 71% improvement in process performance as demonstrated in the chart (figure 1).

Figure 1

Process measure for bundle management protocol. This run chart showing percentage of neonates adhered to the bundle management or transportation protocol among neonates admitted to NICU, in Gandhi Memorial Hospital (Corresponding figure file: Process measure for bundle management protocol .tiff). NICU, neonatal intensive care unit.

Outcome measure using run chart

Interpretation of run chart

Intervention led to positive improvement signals as shown by the red oval designating a trend down consisting of 8 consecutive data points and the green oval representing a shift in data consisting of 8 data points below the median, reducing hypothermia incidence from 80.6% to 30% (figure 2).

Figure 2

Run chart showing percentage of hypothermia. This annotated run chart showing percentage of hypothermia admitted to NICU, in Gandhi Memorial Hospital after the interventions. The red oval designates a trend defined as seven or more contiguous data points that change in the same direction and the green oval represents a shift in data defined as seven or more contiguous data points below or above the median (Corresponding figure file: run chart showing percentage of hypothermia. tiff). NICU, neonatal intensive care unit.

Balancing measure

Over the course of the project, two balancing measure was measured. At the project’s onset, the baseline NICU and labour ward staff satisfaction rate were established at 84%, and as the project progressed, satisfaction rate became 87%. One underlying assumption was the potential for a decline in satisfaction, perhaps stemming from the perception that the quality improvement project might be seen as an additional workload by the staff. Significantly, throughout the project’s duration, there were no instances of objectively identified hyperthermia neonates resulting from the implemented intervention.

Significance of this project to neonatal mortality

Neonatal hypothermia plays a significant role in increasing neonatal death by 80% for every 1°C decrease of body temperature, especially in sub-Saharan countries.9

The project addressed neonatal hypothermia, a key factor in neonatal mortality in sub-Saharan countries. It successfully reduced hypothermia incidence in NICU admissions, it improved body temperature management. These changes positively impacted neonatal well-being and mortality rates.

Limitation and lessons learnt


The successful outcomes in reducing neonatal hypothermia had some limitations. Accurate data documentation and protocol adherence were crucial, and incomplete or inconsistent data collection could impact accuracy. The project primarily addressed environmental, system and practice-related factors, not extensively exploring individual patient characteristics or socioeconomic factors that may also contribute to hypothermia.

Lessons learnt

The project provided valuable insights for future quality improvement efforts. Collaboration among experts drove successful change and evidence-based practices like adopting the temperature management bundle were crucial. Data-driven tools objectively measured intervention impact, and continuous monitoring and feedback ensured sustained improvements in neonatal care.

Conclusion and recommendation


The quality improvement project at Gandhi Memorial Hospital successfully reduced neonatal hypothermia incidence. Implementing interventions such as the temperature management bundle and relocating the NICU resulted in improved patient care, reduced hypothermic neonates and better body temperature management.


To enhance the project’s effectiveness, continuous monitoring, adherence to best practices and addressing challenges are recommended. Sharing the success and learnings can promote adoption of similar interventions in other healthcare facilities, contributing to broader neonatal care improvements. Ongoing staff education and outcome assessment are vital in sustaining positive impacts on neonatal hypothermia reduction and patient outcomes.

Supplemental material

Supplemental material

Data availability statement

Data are available on reasonable request. Data may be obtained from a third party and are not publicly available.

Ethics statements

Patient consent for publication


We would like to thank the Mahlet Alemayehu, Dawit Niku, Zafu Belay and all the hospital staff who participated in the quality improvement project.


Supplementary materials

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    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Contributors BYW is a guarantor, and BYW, WMW, TDA, HK, AA and BTB made a significant contribution to the quality improvement project in the conception, execution, acquisition of data, analysis and interpretation; they were involved in drafting, substantially revising and critically reviewing the article; and they agreed on the journal to which the article will be submitted. All authors reviewed and agreed on the revised versions of the article before submission and agreed to take responsibility and be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.