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Early and Total Inpatient Deaths Before and After the Intervention to Improve Pediatric Emergency Care
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Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in the developing world. This deficiency contributes to high inpatient mortality rates, particularly early during hospitalization. Our referral hospital in Lilongwe, Malawi, experiences high volume, acuity, and mortality rates. The entry p...
Citations
... Infectious causes are predominant in lower-and middle-income countries, particularly in Sub-Saharan Africa [5,[10][11][12][13]. Improvement of health services has supported early detection and treatment of most clinical conditions during hospitalization with improved survival and discharge [12,14]. There is limited information on the mortality after discharge, especially for children aged 5-14 years. ...
Introduction
Globally, millions of children and adolescents die every year from treatable and preventable causes. Sub-Saharan Africa accounted for 55% of deaths of children aged 5–14 years in 2017. Despite this high burden, minimal effort has been directed toward reducing mortality among older children and adolescents in comparison to under-fives. Mortality rates of children post-discharge vary between 1–18% in limited-resource countries and are reported to exceed in-hospital mortality. In Tanzania, there is limited data regarding post-discharge mortality and its predictors among children aged 5–14 years.
Objectives
This study aims to determine the post-discharge mortality rate and its predictors among children aged 5–14 years admitted to pediatric wards at MNH, MOI, and JKCI.
Methods and analysis
This will be a prospective observational cohort study that will be conducted among children aged 5–14 years admitted to pediatric wards at Muhimbili National Hospital, Jakaya Kikwete Cardiac Institue, and Muhimbili Orthopedic Institue in Dar-Es-Salaam, Tanzania. Data will be collected using a structured questionnaire and will include socio-demographic characteristics, clinical factors, and patients’ outcomes. Post-discharge follow-up will be done at months 1, 2, and 3 after discharge via phone call. Data will be analyzed using SPSS version 23. The association of demographic, social economic, and clinical factors with the outcome of all causes, 3 months post-discharge mortality will be determined by Cox regression, and survival rates will be displayed through Kaplan-Meier curves.
Discussion
This study will determine post-discharge mortality among children aged 5–14 years and its predictors in Tanzania. This information is expected to provide baseline data that will be useful for raising awareness of clinicians on how to prioritize and plan a proper follow-up of children following hospital discharge. These data may also be used to guide policy development to address and reduce the high burden of older children and adolescent mortality and may be used for future studies including those aiming to develop prediction models for post-discharge mortality among older children and adolescents.
... Such initiatives have shown reductions in inpatient mortality rates in Malawi and Ghana. 57,58 Additionally, studies are needed to better understand the reasons for delays in diagnostics and therapeutics early during hospital admission. ...
Background: Most childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe adherence to World Health Organization recommendations for the management of leading causes of death among children.
Methods: We conducted a retrospective, descriptive study examining clinical data for children aged 1–59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment,December 2016–June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration.
Findings: CHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h.
Interpretation: Provision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence.
... In high income countries, evidence-based triage strategies aimed at expediting sepsis treatment [6] involve laboratory investigations often inaccessible in LMIC settings, where delays in treatment leading to a high case fatality ratio are commonplace [7]. LMIC-specific guidelines such as the Emergency Triage Assessment and Treatment (ETAT) [8] and others [9,10], show good predictive power for mortality and improve clinical outcomes when successfully implemented [11][12][13]. However, the complexity of these guidelines face challenges in implementation, particularly in resource-poor environments where patient throughput and new-staff turnover is high [14,15]. ...
... LMIC analyses that do exist may report partial costs only [14], or report intermediate outcomes such as quality improvement scores with limited clinical interpretability [22]. In addition, these analyses focus on the perspective of the healthcare system [13,22,23], but do not consider outof-pocket costs and productivity losses. In LMICs such as Uganda that are yet to implement universal health coverage (UHC), where patients may incur out-of-pocket costs near or exceeding that of monthly earnings [24], inclusion of the societal perspective is important to explore the economic impact of healthcare interventions on patients. ...
... We conducted our base case analysis from the societal perspective, with a sub-analysis from the patient perspective, to capture the economic impact of Smart Triage on patients, not just on the healthcare system like previous analyses [13,22] UHC. In a Ugandan cross-sectional survey of pediatric sepsis patients, the hospital fee and medications alone cost $15 USD, increasing to $59 USD in private not-forprofit facilities [24]. ...
Background
Sepsis, characterized by organ dysfunction due to presumed or proven infection, has a case-fatality over 20% in severe cases in low-and-middle income countries. Early diagnosis and treatment have proven benefits, prompting our implementation of Smart Triage at Jinja Regional Referral Hospital in Uganda, a program that expedites treatment through a data-driven triage platform. We conducted a cost-effectiveness analysis of Smart Triage to explore its impact on patients and inform multicenter scale up.
Methods
The parent clinical trial for Smart Triage was pre-post in design, using the proportion of children receiving sepsis treatment within one hour as the primary outcome, a measure linked to mortality benefit in existing literature. We used a decision-analytic model with Monte Carlo simulation to calculate the cost per year-of-life-lost (YLL) averted of Smart Triage from societal, government, and patient perspectives. Healthcare utilization and lost work for seven days post-discharge were translated into costs and productivity losses via secondary linkage data.
Results
In 2021 United States dollars, Smart Triage requires an annuitized program cost of only $0.05 per child, but results in $15.32 saved per YLL averted. At a willingness-to-pay threshold of only $3 per YLL averted, well below published cost-effectiveness threshold estimates for Uganda, Smart Triage approaches 100% probability of cost-effectiveness over the baseline manual triage system. This cost-effectiveness was observed from societal, government, and patient perspectives. The cost-effectiveness observed was driven by a reduction in admission that, while explainable by an improved triage mechanism, may also be partially attributable to changes in healthcare utilization influenced by the coronavirus pandemic. However, Smart Triage remains cost-effective in sensitivity analyses introducing a penalty factor of up to 50% in the reduction in admission.
Conclusion
Smart Triage’s ability to both save costs and avert YLLs indicates that patients benefit both economically and clinically, while its high probability of cost-effectiveness strongly supports multicenter scale up. Areas for further research include the incorporation of years lived with disability when sepsis disability weights in low-resource settings become available and analyzing budget impact during multicenter scale up.
Trial registration
NCT04304235 (registered on 11/03/2020, clinicaltrials.gov).
... 6,7 Typically, hospital-level data describe aggregate mortality rates in children and diagnoses associated with the largest number of deaths. 8,[12][13][14][15] The cause-specific mortality rate, or case fatality rate, is often not reported because it is challenging to attribute a primary diagnosis in patients with multiple comorbidities in settings with limited diagnostic testing. Studies recruiting patients with a single disease can report these measures but are often unable to place the single disease mortality rate in context with the mortality rates of other diseases. ...
... The overall mortality rate and prevalence of diagnoses approximate the results of prior studies from Malawi. 8,12,13,24 Children with surgical conditions, malnutrition, congenital heart disease, and dehydration had the highest mortality rates in our analysis. Children with the co-diagnoses of anemia, dehydration, and malnutrition also had higher mortality rates, which may indicate that these diagnoses are pathogenic consequences of other diagnoses and are markers of illness severity. ...
... Throughout sub-Saharan Africa and within our own hospital, quality improvement initiatives, audits, post-graduate training programs, and clinical information systems are being established to reduce child hospital mortality. 12,14,[64][65][66][67] Accurate measurement of the impacts of these interventions will be essential in allocating the limited resources in these settings. 5 ...
Diagnosis-specific mortality is a measure of pediatric healthcare quality that has been incompletely studied in sub-Saharan African hospitals. Identifying the mortality rates of multiple conditions at the same hospital may allow leaders to better target areas for intervention. In this secondary analysis of routinely collected data, we investigated hospital mortality by admission diagnosis in children aged 1-60 months admitted to a tertiary care government referral hospital in Malawi between October 2017 and June 2020. The mortality rate by diagnosis was calculated as the number of deaths among children admitted with a diagnosis divided by the number of children admitted with the same diagnosis. There were 24,452 admitted children eligible for analysis. Discharge disposition was recorded in 94.2% of patients, and 4.0% (N = 977) died in the hospital. The most frequent diagnoses among admissions and deaths were pneumonia/bronchiolitis, malaria, and sepsis. The highest mortality rates by diagnosis were found in surgical conditions (16.1%; 95% CI: 12.0-20.3), malnutrition (15.8%; 95% CI: 13.6-18.0), and congenital heart disease (14.5%; 95% CI: 9.9-19.2). Diagnoses with the highest mortality rates were alike in their need for significant human and material resources for medical care. Improving mortality in this population will require sustained capacity building in conjunction with targeted quality improvement initiatives against both common and deadly diseases.
... Causes of mortality among older children and young adolescents differ across the globe, most deaths are attributed to injuries, malignancy, congenital defects, and infectious causes including enteric infections, neglected tropical diseases meningitis, and malaria (1,5,(7)(8)(9).Infectious causes are predominant in lower-and-middle income countries, particularly in Sub-Saharan Africa (5,(10)(11)(12)(13). Improvement of health services has supported early detection and treatment of most clinical conditions during hospitalization with improved survival and discharge (12,14). There is limited information on the mortality after discharge, especially for children aged 5-14 years. ...
Introduction: Globally, millions of children and adolescents die every year from treatable and preventable causes. Sub-Saharan Africa accounted for 55% of deaths of children aged 5–14 years in 2017. Despite this high burden, minimal effort has been directed toward reducing mortality among older children and adolescents in comparison to under-fives. Mortality rates of children post-discharge vary between 1–18% in limited-resource countries and is report to exceed in-hospital mortality. In Tanzania, there is limited data regarding post-discharge mortality among children aged 5–14 years.
Methods and analysis: This will be a prospective observational cohort study that will be conducted among children aged 5–14 years admitted to pediatric wards at Muhimbili National Hospital, Jakaya Kikwete Cardiac Institue, and Muhimbili Orthopedic Institue in Dar-es-Salaam, Tanzania. Data will be collected using a structured questionnaire and will include socio-demographic characteristics, clinical factors, and patients’ outcomes. Post-discharge follow-up will be done at month 1, 2, and 3 after discharge via phone call. Data will be analyzed using SPSS version 23.
The association of demographic, social economic, and clinical factors with the outcome of all causes, 3 months post-discharge mortality will be determined by cox regression, and survival rates will be displayed through Kaplan-Meier curves.
Discussion: This study will determine post-discharge mortality among children aged 5–14 years and it’s predictors in Tanzania. This information is expected to provide baseline data that will be useful for raising awareness of clinicians on how to prioritize and plan a proper follow-up of children following hospital discharge. These data may also be used to guide policy development to address and reduce the high burden of older children and adolescent mortality and may be used for future studies including those aiming to develop prediction models for post-discharge mortality among older children and adolescents.
... In addition, audit of the current standards can highlight areas of deficiency, identify potential targets for process improvement and ultimately lead to improved patient outcomes [1]. Studies in Malawi, Kenya, and Tanzania have shown that improving the systems and training in paediatric emergency care can significantly reduce in-hospital mortality [9][10][11]. Recent studies have shown that Nigeria's health service is far from being optimally designed and prepared to deliver optimal emergency care to its children [12,13]. ...
... A useful approach to improving paediatric medical systems identified by Khan and colleague include the establishment of a coordinated approach to patient care, and increased inter-departmental cooperation and collaboration within hospitals [39]. In a hospital in Lilongwe Malawi, Simple, inexpensive interventions such as posting of senior doctors to supervise pediatric services in under-five clinics, institution of a formal triage process that improved patient flow, and treatment and stabilization of patients before transfer to the inpatient ward improved pediatric emergency care and decreased hospital mortality rates [11]. Such simple but effective interventions can be enthroned in paediatric departments in Nigeria. ...
Abstract
The practice of paediatric emergency medicine in Nigeria is still evolving, and laden with enormous challenges which contribute to adverse outcomes of childhood illnesses in emergency settings. Deaths from childhood illnesses presenting as emergencies contribute to overall child mortality rates in Nigeria. This narrative review discusses existing structures, organization, and practice of paediatric emergency in Nigeria. It highlights some ofthe challenges and suggests ways of surmounting them in order to reduce deaths in the children emergency units in Nigerian hospitals. Important aspects of this review include current capacity and need for capacity development,equipment needs for emergency care, quality of service in the context of inadequate healthcare funding and theneed for improvement.Keywords Paediatric, Emergency medicine, Practice, Quality of service, Capacity needs, Funding, Nigeria Paediatric
(PDF) R E V I E W Open Access. Available from: https://www.researchgate.net/publication/369295740_R_E_V_I_E_W_Open_Access [accessed Mar 16 2023].
... Study conducted in Rwanda stated that previous research has showed insufficient emergency equipment, triage, assessment, and treatment for severely ill children which is one of the major contributing factors to high hospital mortality rates among children younger than five years (23). Moreover, the findings from one study in Malawi showed that the training of hospital staff in emergency, triage assessment and treatment had reduced early hospital mortality in children under-five, from 47.6 to 37.9 deaths per 1000 admissions (20). ...
Introduction: Critical pediatric patients have specific needs, which require special skills, training, equipment, supplies, personnel, and medications. While the knowledge related to enhance survival rate of newborn and children has improved over the past few decades. This study conducted to assess the emergency care capacity in pediatric hospitals at Khartoum state, Sudan. Methods: This is a descriptive cross-sectional hospital-based study, it was conducted in three hospitals at Khartoum, Sudan 2017-2018, to assess emergency care capacity in pediatric hospitals. Data was collected using open-ended questionnaire, and observational checklist. The data scored using dichotomous indicators (absent or present). Results: The study showed that there is shortage in human resources necessary to provide emergency care. However, much essential equipment for emergency care of children was absent in most hospitals, moreover, only 33% of hospitals had Triage system staffed by a trained person. Further, the clinical practice protocols for managing dehydration, neonatal sepsis, and neonatal resuscitation were not traced at the three hospitals. There are a limited laboratory services in one hospital. Conclusion: It is concluded that pediatric specialized hospitals, in Khartoum state, Sudan, have low capacity to provide emergency care for children. Further efforts are needed to improve the emergency care capacity in Khartoum hospitals.
... Study conducted in Rwanda stated that previous research has showed insufficient emergency equipment, triage, assessment, and treatment for severely ill children which is one of the major contributing factors to high hospital mortality rates among children younger than five years (23). Moreover, the findings from one study in Malawi showed that the training of hospital staff in emergency, triage assessment and treatment had reduced early hospital mortality in children under-five, from 47.6 to 37.9 deaths per 1000 admissions (20). ...
Introduction: Critical pediatric patients have specific needs, which require special skills, training, equipment, supplies , personnel, and medications. While the knowledge related to enhance survival rate of newborn and children has improved over the past few decades. This study conducted to assess the emergency care capacity in pediatric hospitals at Khartoum state, Sudan. Methods: This is a descriptive cross-sectional hospital-based study, it was conducted in three hospitals at Khartoum, Sudan 2017-2018, to assess emergency care capacity in pediatric hospitals. Data was collected using open-ended questionnaire, and observational checklist. The data scored using dichoto-mous indicators (absent or present). Results: The study showed that there is shortage in human resources necessary to provide emergency care. However, much essential equipment for emergency care of children was absent in most hospitals, moreover, only 33% of hospitals had Triage system staffed by a trained person. Further, the clinical practice protocols for managing dehydration, neonatal sepsis, and neonatal resuscitation were not traced at the three hospitals. There are a limited laboratory services in one hospital. Conclusion: It is concluded that pediatric specialized hospitals, in Khartoum state, Sudan, have low capacity to provide emergency care for children. Further efforts are needed to improve the emergency care capacity in Khartoum hospitals.
... In recognition of this, the World Health Organization created the Emergency Triage Assessment and Treatment (ETAT) guidelines [1] aimed at identifying and managing severely ill children in low-resource contexts [2]. These guidelines can improve clinical outcomes among pediatric patients when successfully implemented [3,4]. To date, these guidelines have primarily been implemented using paper-based systems. ...
Background
Effective triage at hospitals can improve outcomes for children globally by helping identify and prioritize care for those most at-risk of death. Paper-based pediatric triage guidelines have been developed to support frontline health workers in low-resource settings, but these guidelines can be challenging to implement. Smart Triage is a digital triaging platform for quality improvement (QI) that aims to address this challenge. Smart Triage represents a major cultural and behavioural shift in terms of managing patients at health facilities in low-and middle-income countries. The purpose of this study is to understand user perspectives on the usability, feasibility, and acceptability of Smart Triage to inform ongoing and future implementation.
Methods
This was a descriptive qualitative study comprising of face-to-face interviews with health workers (n = 15) at a regional referral hospital in Eastern Uganda, conducted as a sub-study of a larger clinical trial to evaluate Smart Triage (NCT04304235). Thematic analysis was used to assess the usability, feasibility, and acceptability of the platform, focusing on its use in stratifying and prioritizing patients according to their risk and informing QI initiatives implemented by health workers.
Results
With appropriate training and experience, health workers found most features of Smart Triage usable and feasible to implement, and reported the platform was acceptable due to its positive impact on reducing the time to treatment for emergency pediatric cases and its use in informing QI initiatives within the pediatric ward. Several factors that reduced the feasibility and acceptability were identified, including high staff turnover, a lack of medical supplies at the hospital, and challenges with staff attitudes.
Conclusion
Health workers can use the Smart Triage digital triaging platform to identify and prioritize care for severely ill children and improve quality of care at health facilities in low-resource settings. Future innovation is needed to address identified feasibility and acceptability challenges; however, this platform could potentially address some of the challenges to implementing current paper-based systems.
... Worldwide, about 90% of all deaths due to injury occur in LMICs [2]. The implementation of emergency services decreased mortality in sub-Saharan Africa [3][4][5][6]. However, physical access to emergency hospital care provided by the public sector in Africa remains poor and varies substantially within and between countries [7]. ...
Background
Frequencies of ultrasonographic findings and diagnoses in emergency departments in sub-Saharan Africa are unknown. This study aimed to describe the frequencies of different sonographic findings and diagnoses found in patients with abdominal symptoms or trauma presenting to a rural referral hospital in Tanzania.
Methods
In this prospective observational study, we consecutively enrolled patients with abdominal symptoms or trauma triaged to the emergency room of the Saint Francis Referral Hospital, Ifakara. Patients with abdominal symptoms received an abdominal ultrasound. Patients with an abdominal or thoracic trauma received an Extended Focused Assessment with Ultrasound in Trauma (eFAST).
Results
From July 1 st 2020 to June 30 th 2021, a total of 88838 patients attended the emergency department, of which 7590 patients were triaged as ‘very urgent’ and were seen at the emergency room. A total of 1130 patients with abdominal symptoms received an ultrasound. The most frequent findings were abnormalities of the uterus or adnexa in 409/754 females (54.2%) and abdominal free fluid in 368 (32.6%) patients; no abnormality was found in 150 (13.5%) patients. A tumour in the abdomen or pelvis was found in 183 (16.2%) patients, an intrauterine pregnancy in 129/754 (17.1%) females, complete or incomplete abortion in 96 (12.7%), and a ruptured ectopic pregnancy in 32 (4.2%) females. In males, most common diagnosis was intestinal obstruction in 54/376 (14.4%), and splenomegaly in 42 (11.2%). Of 1556 trauma patients, 283 (18.1%) received an eFAST, and 53 (18.7%) had positive findings. A total of 27 (9.4%) trauma patients and 51 (4.5%) non-trauma patients were sent directly to the operating theatre.
Conclusion
In this study, ultrasound examination revealed abnormal findings for the majority of patients with non-traumatic abdominal symptoms. Building up capacity to provide diagnostic ultrasound is a promising strategy to improve emergency services, especially in a setting where diagnostic modalities are limited.
