Audit of care for children aged 6 to 59 months admitted with severe malnutrition at kenyatta national hospital, kenya

"Prevalence, outcome and factors associated with dysglycemia among critically ill children presenting to Fort Portal Regional Referral Hospital: A cross sectional study"

Introduction

Dysglycemia has been shown to influence outcome among critically ill children. We aimed to determine the prevalence, outcome and factors associated with dysglycemia among critically ill children aged one month to 12 years presenting to Fort Portal regional referral hospital.

Methods

The study employed a descriptive, cross-sectional design for prevalence and factors associated, and longitudinal observational study design to determine the immediate outcome. Critically ill children aged one month to 12 years were systematically sampled and triaged at outpatient department using World Health Organization emergency signs. The random blood glucose was evaluated on admission and at 24 hours. Verbal and written informed consent/assent were obtained after stabilization of the study participants. Those that had hypoglycemia were given Dextrose 10% and those with hyperglycemia had no intervention.

Results

Of the 384 critically ill children, dysglycemia was present in 21.7% (n = 83), of those 78.3% (n = 65) had hypoglycemia and 21.7% (n = 18) had hyperglycemia. The proportion of dysglycemia at 24 hours was 2.4% (n = 2). None of the study participants had persistent hypoglycemia at 24 hours. The cumulative mortality at 48hours was 3.6% (n = 3). At 48 hours 33.2% (n = 27) had stable blood glucose levels and were discharged from the hospital. After multiple logistic regression, obstructed breathing (AOR 0.07(0.02-0.23), inability to breastfeed/drink (AOR 2.40 (1.17-4.92) and active convulsions (AOR 0.21 (0.06-0.74), were the factors that were significantly associated with dysglycemia among critically ill children. The results will guide in the revision of policies and treatment protocols to facilitate better management of children at risk of dysglycemia nationally.

Conclusions

Dysglycemia was found to affect one in five critically ill children aged one month to 12 years presenting to Fort Portal Regional Referral Hospital. Dysglycemia outcomes are good with early intervention.

Predictors of Death from Complicated Severe Acute Malnutrition in East Ethiopia: Survival Analysis

BACKGROUND

Severe acute malnutrition (SAM) is still the leading cause of global child morbidity and mortality, with a greater burden in sub-Saharan Africa. A facility-based treatment of SAM demands critical care for improved outcomes and survival of children. However, there is a need to understand predictors for time to death among SAM children for effective interventions.

OBJECTIVE

To assess the predictors of death from complicated severe acute malnutrition among admitted children treated in East Ethiopia.

METHODS

A 31-month retrospective cohort study was conducted among a total of 665 under-five children admitted with complicated SAM in Dilchora hospital, eastern Ethiopia. The data was extracted from the patient register and medical charts using the kobo tool. The life table, survival, and hazard curves were plotted. Kaplan-Meier with Log rank tests was used to estimate and compare the mean survival time. The bivariable and multivariable Cox proportional hazards models were used to identify predictors of time to death. Crude and adjusted hazard ratios with 95% confidence intervals and p-values were reported.

RESULTS

A total of 665 full medical charts were reviewed with a total of 60 (9%; 95% CI: 6.8-11.2%) deaths were observed, where most of the deaths occurred during the first two weeks of admission, while 74 (11%) and 449 (68%) were cured and recovered (stabilized and transferred to outpatient), respectively. Admitted children having good appetite (AHR=0.15; 95% CI: 0.64-0.33), pneumonia (AHR=2.46, 95% CI: 1.436, 4.22), diarrhea (AHR=2.16, 95% CI: 1.16, 4.06), tuberculosis (AHR=2.86, 95% CI: 1.08, 7.63) and having a nasogastric tube inserted (AHR=2.33, 95% CI: 1.15, 4.72) were significant predictors of time to death among SAM children.

CONCLUSION

There is unacceptably high under-five mortality due to SAM, which is predicted by co-morbidities (pneumonia, diarrhea, and tuberculosis), with medical complications and nasogastric tubes.

Mothers' Handwashing Knowledge as a Predictor of Diarrheal Disease Among Under-Five Children Visiting Pediatric Ward in University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2019

Background

Diarrheal disease is one of the leading causes of mortality and morbidity among under-five children in the world and often results from contaminated food and water. The aim of this study was to assess the prevalence of diarrheal disease among under-five children visiting the pediatric ward in University of Gondar Comprehensive Specialized Hospital and its association with their mothers’ handwashing knowledge.

Methods

An institutional-based cross-sectional study was conducted from May to July 2019 among under-five children visiting the pediatric ward in University of Gondar Comprehensive Specialized Hospital. An interviewer-administered questionnaire was used to collect the data. Chart review was undertaken using a data abstraction form. A simple random sampling technique was used to select the study participants. Data were entered using Epi Info version 7 and analyzed using STATA version 14.0. A binary logistic regression analysis was employed between dependent and independent variables to determine association. The statistical significance was declared at P<0.05.

Results

In this study, the prevalence of diarrheal disease among under-five children visiting the pediatric ward in University of Gondar Comprehensive Specialized Hospital was 30.09% (95% CI: (26%, 35%)). Age of mothers (AOR=3.72, 95% CI: (1.67, 8.28)), mothers’ educational status (AOR=0.44, 95% CI: (0.23, 0.80)), malnutrition (AOR=6.72, 95% CI: (3.44, 13.11)), and maternal knowledge of handwashing (AOR=0.49, 95% CI: (0.27, 0.90)) were factors associated with diarrheal disease among under-five children.

Conclusion

The prevalence of diarrheal disease was higher in the current study, which is a major public health concern. Age of mothers, malnutrition, and mothers’ handwashing knowledge and educational status were significantly associated with diarrheal disease of under-five children. In order to reduce diarrheal disease and improve child health, attention should be given to improving mothers’ educational status and knowledge regarding handwashing.

Prevalence, outcome and quality of care among children hospitalized with severe acute malnutrition in Kenyan hospitals: A multi-site observational study

Background

Severe acute malnutrition (SAM) remains a major cause of admission and inpatient mortality worldwide in children aged less than 5 years. In this study, we explored SAM prevalence and outcomes in children admitted in 13 Kenyan hospitals participating in a Clinical Information Network (CIN). We also describe their immediate in-patient management.

Methods

We analyzed data for children aged 1–59 months collected retrospectively from medical records after discharge. Mean, median and ranges were used to summarize pooled and age-specific prevalence and mortality associated with SAM. Documentation of key signs and symptoms (S/S) and performance of indicators of quality of care for selected aspects of the WHO management steps were assessed. Logistic regression models were used to evaluate associations between documented S/S and mortality among SAM patients aged 6–59 months. Loess curves were used to explore performance change over time for indicators of selected SAM management steps.

Results

5306/54140 (9.8%) children aged 1–59 months admitted with medical conditions in CIN hospitals between December 2013 and November 2016 had SAM. SAM prevalence identified by clinicians and case fatality varied widely across hospitals with median proportion (range) of 10.1% (4.6–18.2%) and 14.8% (6.0–28.6%) respectively. Seventeen variables were associated with increased mortality. Performance change over time of management steps varied across hospitals and across selected indicators but suggests some effect of regular audit and feedback.

Conclusion

Identification of SAM patients, their mortality and adherence to in-patient management recommendations varied across hospitals. An important group of SAM patients are aged less than 6 months. Continued efforts are required to improve management of SAM in routine settings as part of efforts to reduce inpatient mortality.

Severe malnutrition in children in Papua New Guinea: effect of a multi-faceted intervention to improve quality of care and nutritional outcomes

BACKGROUND AND AIMS

Severe malnutrition remains a major problem in Papua New Guinea; it is associated with 11% of paediatric hospital admissions and 33% of all child deaths, with a case fatality rate around 20%. This article aims to evaluate the effectiveness of a multi-faceted intervention for improving care for children with severe malnutrition.

METHODS

Severe malnutrition was defined as weight-for-age (WFA) <-3 Z-scores with severe wasting or mid upper arm circumference <115 mm or generalised oedema owing to malnutrition. The intervention included training for health-care workers on WHO guidelines for severe malnutrition, ward-round checklists, posters and support for nurses to provide better patient nutrition. Three point prevalence surveys were conducted; one before the intervention and two afterwards at 3-month intervals. The main outcomes were weight change since admission, energy intake and the proportion of the calculated required energy intake in the previous 24 hours. Each stage of the WHO guidelines for severe malnutrition management was assessed for adherence.

RESULTS

There were significant improvements in the WHO steps for the management of severe malnutrition. At pre-intervention baseline, children received a median of 356 ml/day (IQR 178-450): 31% (95% CI 21-48) of their estimated daily energy requirements for weight. In the first follow-up survey, children received a median of 820 (IQR 600-1110) ml/day: 98% (95% CI 67-100) of daily energy requirements; and in the second follow-up survey they received 780 (IQR 480-900) ml/day: 86% (95% CI 46-100%) of daily requirement (P<0.001 both for volume received and percentage of energy requirements). Median weight gain prior to the intervention was 1.55 g/kg/day (IQR -4.3-6.0) which increased to 5.56 g/kg/day (IQR -3.7-12.0) and 10.19 g/kg/day (IQR 0-16.0) in the first and second follow-up surveys, respectively (P=0.013).

CONCLUSION

Implementation of a multi-faceted intervention to improve the management of children with severe malnutrition was associated with improved quality of care and improved weight gain.

Large-scale data reporting of paediatric morbidity and mortality in developing countries: it can be done

Although the WHO recommends all countries use International Classification of Diseases (ICD)-10 coding for reporting health data, accurate health facility data are rarely available in developing or low and middle income countries. Compliance with ICD-10 is extremely resource intensive, and the lack of real data seriously undermines evidence-based approaches to improving quality of care and to clinical and public health programme management. We developed a simple tool for the collection of accurate admission and outcome data and implemented it in 16 provincial hospitals in Papua New Guinea over 6 years. The programme was low cost and easy to use by ward clerks and nurses. Over 6 years, it gathered data on the causes of 96,998 admissions of children and 7128 deaths. National reports on child morbidity and mortality were produced each year summarising the incidence and mortality rates for 21 common conditions of children and newborns, and the lessons learned for policy and practice. These data informed the National Policy and Plan for Child Health, triggered the implementation of a process of clinical quality improvement and other interventions to reduce mortality in the neediest areas, focusing on diseases with the highest burdens. It is possible to collect large-scale data on paediatric morbidity and mortality, to be used locally by health workers who gather it, and nationally for improving policy and practice, even in very resource-limited settings where ICD-10 coding systems such as those that exist in some high-income countries are not feasible or affordable.

Evaluating the level of adherence to Ministry of Health guidelines in the management of severe acute malnutrition at Garissa Provincial General Hospital, Garissa, Kenya

Introduction

Half of Kenya's high infant and under five mortality rates is due to malnutrition. Proper implementation of World Health Organization's (WHO) Evidence Based Guidelines (EBG) in management of severe acute malnutrition can reduce mortality rates to less than 5%. The objectives were to establish the level of adherence to WHO guideline and the proportion of children appropriately managed for severe acute malnutrition (steps 1-8) as per the WHO protocol in the management of severe acute malnutrition. This was a short longitudinal study of 96 children, aged 6-59 months admitted to the pediatric ward with diagnosis of severe acute malnutrition.

Methods

Data was extracted from patients’ medical files and recorded into an audit tool to compare care provided in this hospital with WHO guidelines.

Results

Non-edematous malnutrition was the commonest presentation (93.8%). A higher proportion (63.5%) of patients was male. Most (85.4%) of patients were younger than 2 years. Patients with non-edematous malnutrition were younger (mean age for non-edematous malnutrition was 16 (± 10.6) months versus 25 (± 13.7) months in edematous malnutrition). The commonest co- morbid condition was diarrhea (52.1%). Overall, 13 children died giving an inpatient case fatality rate of 13.5%. Appropriate management was documented in only 14.6% for hypoglycemia (step1), 5.2% for hypothermia (step 2) and 31.3% for dehydration (step 3).

Conclusion

The level of adherence to MOH guidelines was documented in 5 out of the 8 steps. Appropriate management of children with severe acute malnutrition was inadequate at Garissa hospital.

Factors influencing performance of health workers in the management of seriously sick children at a Kenyan tertiary hospital--participatory action research

BACKGROUND

Implementation of World Health Organization case management guidelines for serious childhood illnesses remains a challenge in hospitals in low-income countries. Facilitators of and barriers to implementation of locally adapted clinical practice guidelines (CPGs) have not been explored.

METHODS

This ethnographic study based on the theory of participatory action research (PAR) was conducted in Kenyatta National Hospital, Kenya's largest teaching hospital. The primary intervention consisted of dissemination of locally adapted CPGs. The PRECEDE-PROCEED health education model was used as the conceptual framework to guide and examine further reinforcement activities to improve the uptake of the CPGs. Activities focussed on introduction of routine clinical audits and tailored educational sessions. Data were collected by a participant observer who also facilitated the PAR over an eighteen-month period. Naturalistic inquiry was utilized to obtain information from all hospital staff encountered while theoretical sampling allowed in-depth exploration of emerging issues. Data were analysed using interpretive description.

RESULTS

Relevance of the CPGs to routine work and emergence of a champion of change facilitated uptake of best-practices. Mobilization of basic resources was relatively easily undertaken while activities that required real intellectual and professional engagement of the senior staff were a challenge. Accomplishments of the PAR were largely with the passive rather than active involvement of the hospital management. Barriers to implementation of best-practices included i) mismatch between the hospital's vision and reality, ii) poor communication, iii) lack of objective mechanisms for monitoring and evaluating quality of clinical care, iv) limited capacity for planning strategic change, v) limited management skills to introduce and manage change, vi) hierarchical relationships, and vii) inadequate adaptation of the interventions to the local context.

CONCLUSIONS

Educational interventions, often regarded as 'quick-fixes' to improve care in low-income countries, may be necessary but are unlikely to be sufficient to deliver improved services. We propose that an understanding of organizational issues that influence the behaviour of individual health professionals should guide and inform the implementation of best-practices.

Performance of health workers in the management of seriously sick children at a Kenyan tertiary hospital: before and after a training intervention

Background

Implementation of WHO case management guidelines for serious common childhood illnesses remains a challenge in hospitals in low-income countries. The impact of locally adapted clinical practice guidelines (CPGs) on the quality-of-care of patients in tertiary hospitals has rarely been evaluated.

Methods and Findings

We conducted, in Kenyatta National Hospital, an uncontrolled before and after study with an attempt to explore intervention dose-effect relationships, as CPGs were disseminated and training was progressively implemented. The emergency triage, assessment and treatment plus admission care (ETAT+) training and locally adapted CPGs targeted common, serious childhood illnesses. We compared performance in the pre-intervention (2005) and post-intervention periods (2009) using quality indicators for three diseases: pneumonia, dehydration and severe malnutrition. The indicators spanned four domains in the continuum of care namely assessment, classification, treatment, and follow-up care in the initial 48 hours of admission. In the pre-intervention period patients' care was largely inconsistent with the guidelines, with nine of the 15 key indicators having performance of below 10%. The intervention produced a marked improvement in guideline adherence with an absolute effect size of over 20% observed in seven of the 15 key indicators; three of which had an effect size of over 50%. However, for all the five indicators that required sustained team effort performance continued to be poor, at less than 10%, in the post-intervention period. Data from the five-year period (2005–09) suggest some dose dependency though the adoption rate of the best-practices varied across diseases and over time.

Conclusion

Active dissemination of locally adapted clinical guidelines for common serious childhood illnesses can achieve a significant impact on documented clinical practices, particularly for tasks that rely on competence of individual clinicians. However, more attention must be given to broader implementation strategies that also target institutional and organisational aspects of service delivery to further enhance quality-of-care.