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Fitzgerald E, Ciccone EJ, Mvalo T, Chiume M, Mgusha Y, Mkaliainga TB, Tilly AE, Chen J, Bell G, Crouse H, Robison JA, Eckerle M. Comprehensive assessment of pediatric acute and inpatient care at a tertiary referral hospital in Malawi: opportunities for quality improvement. BMJ Paediatr Open 2024; 8:e002404. [PMID: 38719563 PMCID: PMC11086186 DOI: 10.1136/bmjpo-2023-002404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/28/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the reduction in global under-5 mortality over the last decade, childhood deaths remain high. To combat this, there has been a shift in focus from disease-specific interventions to use of healthcare data for resource allocation, evaluation of performance and impact, and accountability. This is a descriptive analysis of data derived from a prospective cohort study describing paediatric admissions to a tertiary referral hospital in Malawi for the purpose of process evaluation and quality improvement. METHODS Using a REDCap database, we collected data for patients admitted acutely to Kamuzu Central Hospital, a tertiary referral centre in the central region. Data were collected from 17 123 paediatric inpatients from 2017 to 2020. RESULTS Approximately 6% of patients presented with either two or more danger signs or severely abnormal vital signs. Infants less than 6 months, who had the highest mortality rate, were also the most critically ill on arrival to the hospital. Sepsis was diagnosed in about 20% of children across all age groups. Protocols for the management of high-volume, lower-acuity conditions such as uncomplicated malaria and pneumonia were generally well adhered to, but there was a low rate of completion for labs, radiology studies and subspecialty consultations required to provide care for high acuity or complex conditions. The overall mortality rate was 4%, and 60% of deaths occurred within the first 48 hours of admission. CONCLUSION Our data highlight the need to improve the quality of care provided at this tertiary-level centre by focusing on the initial stabilisation of high-acuity patients and augmenting resources to provide comprehensive care. This may include capacity building through the training of specialists, implementation of clinical processes, provision of specialised equipment and increasing access to and reliability of ancillary services. Data collection, analysis and routine use in policy and decision-making must be a pillar on which improvement is built.
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Affiliation(s)
- Elizabeth Fitzgerald
- Department of Pediatrics, Division of Emergency Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Emily Jane Ciccone
- Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Tisungane Mvalo
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Yamikani Mgusha
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Alyssa Evelyn Tilly
- Divisions of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Jane Chen
- Institute for Global Health and Infectious Disease, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Griffin Bell
- Epidemiology, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Heather Crouse
- Department of Pediatrics, Division of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jeff A Robison
- Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michelle Eckerle
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Moher JM, Morales-Pérez L, Chiume M, Crouse HL, Mgusha Y, Betchani F, D'Amico BM. Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi. Trop Med Int Health 2023; 28:17-24. [PMID: 36416491 DOI: 10.1111/tmi.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings. METHODS Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded. RESULTS In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%). CONCLUSIONS POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.
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Affiliation(s)
- Justin M Moher
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Heather L Crouse
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Yamikani Mgusha
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Fanuel Betchani
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Beth M D'Amico
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Crehan C, Chiume M, Mgusha Y, Dinga P, Hull-Bailey T, Normand C, Sassoon Y, Nkhoma D, Greenwood K, Lorencatto F, Lakhanpaul M, Heys M. Usability-Focused Development and Usage of NeoTree-Beta, an App for Newborn Care in a Low-Resource Neonatal Unit, Malawi. Front Public Health 2022; 10:793314. [PMID: 35570891 PMCID: PMC9096438 DOI: 10.3389/fpubh.2022.793314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Neonatal mortality is high in low-resource settings. NeoTree is a digital intervention for neonatal healthcare professionals (HCPs) aiming to achieve data-driven quality improvement and improved neonatal survival in low-resource hospitals. Optimising usability with end-users could help digital health interventions succeed beyond pilot stages in low-resource settings. Usability is the quality of a user's experience when interacting with an intervention, encompassing their effectiveness, efficiency, and overall satisfaction. Objective To evaluate the usability and usage of NeoTree beta-app and conduct Agile usability-focused intervention development. Method A real-world pilot of NeoTree beta-app was conducted over 6 months at Kamuzu Central Hospital neonatal unit, Malawi. Prior to deployment, think-aloud interviews were conducted to guide nurses through the app whilst voicing their thoughts aloud (n = 6). System Usability Scale (SUS) scores were collected before the implementation of NeoTree into usual clinical care and 6 months after implementation (n = 8 and 8). During the pilot, real-world user-feedback and user-data were gathered. Feedback notes were subjected to thematic analysis within an Agile “product backlog.” For usage, number of users, user-cadre, proportion of admissions/outcomes recorded digitally, and median app-completion times were calculated. Results Twelve overarching usability themes generated 57 app adjustments, 39 (68%) from think aloud analysis and 18 (32%) from the real-world testing. A total of 21 usability themes/issues with corresponding app features were produced and added to the app. Six themes relating to data collection included exhaustiveness of data schema, prevention of errors, ease of progression, efficiency of data entry using shortcuts, navigation of user interface (UI), and relevancy of content. Six themes relating to the clinical care included cohesion with ward process, embedded education, locally coherent language, adaptability of user-interface to available resources, and printout design to facilitate handover. SUS scores were above average (88.1 and 89.4 at 1 and 6 months, respectively). Ninety-three different HCPs of 5 cadres, recorded 1,323 admissions and 1,197 outcomes over 6 months. NeoTree achieved 100% digital coverage of sick neonates admitted. Median completion times were 16 and 8 min for admissions and outcomes, respectively. Conclusions This study demonstrates optimisation of a digital health app in a low-resource setting and could inform other similar usability studies apps in similar settings.
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Affiliation(s)
- Caroline Crehan
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Msandeni Chiume
- Paediatric Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Yamikani Mgusha
- Paediatric Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Precious Dinga
- Paediatric Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Tim Hull-Bailey
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | | | | | - Deliwe Nkhoma
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | - Fabiana Lorencatto
- Centre for Behaviour Change, University College London, London, United Kingdom
| | - Monica Lakhanpaul
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Michelle Heys
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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Mgusha Y, Nkhoma DB, Chiume M, Gundo B, Gundo R, Shair F, Hull-Bailey T, Lakhanpaul M, Lorencatto F, Heys M, Crehan C. Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App and Dashboard: A 1-Year Digital Perinatal Outcome Audit. Front Digit Health 2021; 3:761128. [PMID: 35005696 PMCID: PMC8732863 DOI: 10.3389/fdgth.2021.761128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/09/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction: Understanding the extent and cause of high neonatal deaths rates in Sub-Saharan Africa is a challenge, especially in the presence of poor-quality and inaccurate data. The NeoTree digital data capture and quality improvement system has been live at Kamuzu Central Hospital, Neonatal Unit, Malawi, since April 2019. Objective: To describe patterns of admissions and outcomes in babies admitted to a Malawian neonatal unit over a 1-year period via a prototype data dashboard. Methods: Data were collected prospectively at the point of care, using the NeoTree app, which includes digital admission and outcome forms containing embedded clinical decision and management support and education in newborn care according to evidence-based guidelines. Data were exported and visualised using Microsoft Power BI. Descriptive and inferential analysis statistics were executed using R. Results: Data collected via NeoTree were 100% for all mandatory fields and, on average, 96% complete across all fields. Coverage of admissions, discharges, and deaths was 97, 99, and 91%, respectively, when compared with the ward logbook. A total of 2,732 neonates were admitted and 2,413 (88.3%) had an electronic outcome recorded: 1,899 (78.7%) were discharged alive, 12 (0.5%) were referred to another hospital, 10 (0.4%) absconded, and 492 (20%) babies died. The overall case fatality rate (CFR) was 204/1,000 admissions. Babies who were premature, low birth weight, out born, or hypothermic on admission, and had significantly higher CFR. Lead causes of death were prematurity with respiratory distress (n = 252, 51%), neonatal sepsis (n = 116, 23%), and neonatal encephalopathy (n = 80, 16%). The most common perceived modifiable factors in death were inadequate monitoring of vital signs and suboptimal management of sepsis. Two hundred and two (8.1%) neonates were HIV exposed, of whom a third [59 (29.2%)] did not receive prophylactic nevirapine, hence vulnerable to vertical infection. Conclusion: A digital data capture and quality improvement system was successfully deployed in a low resource neonatal unit with high (1 in 5) mortality rates providing and visualising reliable, timely, and complete data describing patterns, risk factors, and modifiable causes of newborn mortality. Key targets for quality improvement were identified. Future research will explore the impact of the NeoTree on quality of care and newborn survival.
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Affiliation(s)
- Yamikani Mgusha
- Paediatric Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Deliwe Bernadette Nkhoma
- Paediatric Department, Kamuzu Central Hospital, Lilongwe, Malawi
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Msandeni Chiume
- Paediatric Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Beatrice Gundo
- Paediatric Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Rodwell Gundo
- Medical and Surgical Nursing Department, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
| | - Farah Shair
- Royal College of Science, Imperial College London, London, United Kingdom
| | - Tim Hull-Bailey
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Monica Lakhanpaul
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Fabianna Lorencatto
- Centre for Behaviour Change, University College London, London, United Kingdom
| | - Michelle Heys
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Specialist Children's and Young People's Services, East London National Health Service Foundation Trust, London, United Kingdom
| | - Caroline Crehan
- Population Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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Ciccone EJ, Tilly AE, Chiume M, Mgusha Y, Eckerle M, Namuku H, Crouse HL, Mkaliainga TB, Robison JA, Schubert CJ, Mvalo T, Fitzgerald E. Lessons learned from the development and implementation of an electronic paediatric emergency and acute care database in Lilongwe, Malawi. BMJ Glob Health 2021; 5:bmjgh-2020-002410. [PMID: 32675067 PMCID: PMC7368472 DOI: 10.1136/bmjgh-2020-002410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/23/2020] [Accepted: 05/09/2020] [Indexed: 11/29/2022] Open
Abstract
As the field of global child health increasingly focuses on inpatient and emergency care, there is broad recognition of the need for comprehensive, accurate data to guide decision-making at both patient and system levels. Limited financial and human resources present barriers to reliable and detailed clinical documentation at hospitals in low-and-middle-income countries (LMICs). Kamuzu Central Hospital (KCH) is a tertiary referral hospital in Malawi where the paediatric ward admits up to 3000 children per month. To improve availability of robust inpatient data, we collaboratively designed an acute care database on behalf of PACHIMAKE, a consortium of Malawi and US-based institutions formed to improve paediatric care at KCH. We assessed the existing health information systems at KCH, reviewed quality care metrics, engaged clinical providers and interviewed local stakeholders who would directly use the database or be involved in its collection. Based on the information gathered, we developed electronic forms collecting data at admission, follow-up and discharge for children admitted to the KCH paediatric wards. The forms record demographic information, basic medical history, clinical condition and pre-referral management; track diagnostic processes, including laboratory studies, imaging modalities and consults; and document the final diagnoses and disposition obtained from clinical files and corroborated through review of existing admission and death registries. Our experience with the creation of this database underscores the importance of fully assessing existing health information systems and involving all stakeholders early in the planning process to ensure meaningful and sustainable implementation.
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Affiliation(s)
- Emily J Ciccone
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Alyssa E Tilly
- Departments of Medicine and Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Yamikani Mgusha
- Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Howard Namuku
- Department of Information Communication Technology, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Heather L Crouse
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Jeff A Robison
- Division of Pediatric Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Charles J Schubert
- Departments of Pediatrics and Family/Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tisungane Mvalo
- UNC Project-Malawi, Lilongwe, Malawi.,Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elizabeth Fitzgerald
- Division of Emergency Medicine, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Keating EM, Chiume M, Fitzgerald E, Mgusha Y, Mvalo T, Fino N, Crouse HL, Eckerle M, Gorman K, Ciccone EJ, Airewele G, Robison JA. Blood transfusion and mortality in children with severe anaemia in a malaria-endemic region. Paediatr Int Child Health 2021; 41:129-136. [PMID: 33874852 PMCID: PMC8523581 DOI: 10.1080/20469047.2021.1881270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND In children in sub-Saharan Africa, severe anaemia (SA) is an important cause of mortality, and malaria is a primary cause. The World Health Organization (WHO) recommends blood transfusion for all children with haemoglobin (Hb) <4 g/dL and for those with Hb 4-6 g/dL with signs of instability. In sub-Saharan Africa, evidence of the effect on mortality of transfusion in children with SA with and without malaria is mixed. AIM To determine in children with and without malaria whether receipt of transfusion was associated with lower mortality at WHO transfusion thresholds. METHODS This was a retrospective cohort study of 1761 children with SA (Hb ≤6 g/dL) admitted to Kamuzu Central Hospital in Malawi. In those whose Hb was 4-6 g/dL, mortality was compared by transfusion, stratified by haemoglobin, malaria status and signs of instability. RESULTS Children with profound anaemia (Hb <4 g/dL) and malaria were the only subgroup who had a significant decrease in the odds of in-hospital death if they received a transfusion (OR 0.43, p = 0.01). Although children with Hb 4-6 g/dL and at least one sign of instability had higher mortality than children with none, there was no difference in the odds of mortality between those who received a transfusion and those who did not (OR 1.16, p = 0.62). CONCLUSIONS This study suggests that transfusion of children with profound anaemia and malaria may confer increased in-hospital survival. An understanding of the factors associated with mortality from SA will allow for interventions to prioritise the provision of limited blood.
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Affiliation(s)
- Elizabeth M. Keating
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, USA;,Department of Family and Preventive Medicine, Division of Public Health, University of Utah, Salt Lake City, USA
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Elizabeth Fitzgerald
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of North Carolina, Chapel Hill, USA
| | - Yamikani Mgusha
- Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi;,Department of Pediatrics, University of North Carolina, School of Medicine, Chapel Hill, USA
| | - Nora Fino
- University of Utah, Department of Internal Medicine, Division of Epidemiology, Salt Lake City, USA
| | - Heather L. Crouse
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
| | - Michelle Eckerle
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, USA;,University of Cincinnati College of Medicine, Cincinnati, USA
| | | | - Emily J. Ciccone
- Department of Medicine, Division of Infectious Diseases, University of North Carolina, Chapel Hill, USA
| | - Gladstone Airewele
- Department of Pediatrics, Division of Hematology and Oncology, Baylor College of Medicine, Houston, USA
| | - Jeff A. Robison
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, USA
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