A study of self-reported handwashing practices of caregivers in relation to acute respiratory infections and gastroenteritis in infants in a peri-urban community in KwaZulu-Natal Province, South Africa

Background. Handwashing is a recognised cost-effective intervention for the prevention of common childhoodinfections, including pneumonia and diarrhoeal disease. Globally, handwashing practices may be poor and little is known about handwashing practices in South Africa.Objectives. To describe and compare handwashing practises of caregivers whose infants are admitted with acute gastroenteritis and acute lower respiratory tract infection with those of healthy infants who are attending primary healthcare clinics for routine immunisation.Methods. A cross-sectional study of self-reported handwashing practices was conducted among caregivers of infants from the Vulindlela area,Pietermaritzburg. Respondents were interviewed regarding household structure, services and handwashing practices.Results. During the 3-month study period, 137 respondents were interviewed. Of these, 41 (30%) had infants with pneumonia, 41 (30%) with diarrhoea and 55 (40%) had healthy infants. A high rate of handwashing with soap and water (81.8%) was found in this study, with 58.4% of the respondents using running rather than stagnant water. Logistic regression identified some variables associated with higher odds of having a healthy infant, namely: a monthlyhousehold income >ZAR2 000 (odds ratio (OR) 4.74; 95% confidence interval (CI)1.99 - 11.25); washing hands with soap and running water (OR 3.88; 95% CI 1.55 - 9.76); washing hands before eating (OR 7.41; 95% CI 0.79 - 68.76), and washing hands after household chores (OR 9.24; 95% CI 1.85 - 46.25).Conclusion. A higher than anticipated number of participants washed their hands with soap and running water and at critical moments

Short-term outcomes of infants with an extremely low birth weight in a resource-limited neonatal intensive care unit, Grey's Hospital, KwaZulu-Natal

Background. Neonates with an extremely low birth weight (ELBW) constitute a small proportion of live births. However, there is limited information about the outcome of this specific group in developing countries, including South Africa (SA). Objective. To determine the outcome to discharge of ELBW neonates admitted to a resource-limited neonatal intensive care unit (NICU). Methods. A retrospective chart review was conducted of neonates admitted to the NICU at Grey's Hospital between 1 July 2011 and 30 June 2014. All neonates with a birth weight of <1 000 g and admitted to the unit within 24 hours of birth were included. Results. A total of 142 neonates met the inclusion criteria. Owing to lost files or incomplete data, 105 files were analysed in the final sample. The mean birth weight was 819.1 g and the mean gestational age was 27.5 weeks. The survival rate to discharge was 49.5%. Neonates born after 28 weeks of gestation and those with a birth weight of >900 g had better outcomes but without statistical significance. There were no statistically significant associations between outcome and any maternal variables. Nasal continuous positive airway pressure ventilation was associated with higher survival, but without statistical significance. Conclusion. The survival rate of ELBW neonates in this study is comparable to what has been reported in other developing countries, but higher than for other NICUs in SA with similar resource limitations. More studies are required to determine factors that may influence the survival rate of the ELBW neonates

Factors underlying the changing of antibiotics in a paediatric intensive care unit in Pietermaritzburg, KwaZulu-Natal

Background. Antibiotics are among the most commonly used drugs in a paediatric intensive care unit (PICU). Despite guidelines and protocols for the use of antibiotics, inappropriate use may contribute to an increase in antibiotic resistance. The factors behind changes in antibiotic prescriptions in the PICU at Grey's Hospital are unknown. Objective. To establish the frequency, process and rationale behind antibiotic prescription changes in the picu. Methods. A retrospective descriptive study of all eligible patients admitted to the PICU during a 6-month period.Results. Three-quarters of patients admitted to the PICU received antibiotics during their stay. The ofantibiotic prescription was changed in 80 (58%) of the138 patients, with most changes (63.4%) occurring within 3 days of admission. Patients younger than 1 year and those who were malnourished accounted for 57% of the changes. The majority (65%) of the changes entailed the escalation of antibiotics and 89% of these were empiric therapy. De-escalation accounted for 35% of the changes. The rationale for a prescription change was not documented in 80% of cases.Conclusion. Antibiotic use in this PICU and changes to prescriptions were common. Changes were generally made on an empirical basis soon after admission and were more likely to occur in young malnourished children and patients admitted for a medical reason or surgical emergency

Factors Present on Admission Associated with Increased Mortality in Children Admitted to a Paediatric Intensive Care Unit (PICU)

Background. The admission of children to an intensive care unit (ICU) necessitates the selection of children who will benefit most from scarce ICU resources. Decisions should be based on objective data available on outcomes related to particular conditions and resource availability. Objective. To determine which sociodemographic factors and paediatric scoring systems can be used on admission to identify patients who would derive the most benefit.Methods. A retrospective review was undertaken of the charts of children admitted to a paediatric ICU (PICU) over a 6-month period. Charts were analysed according to health status; biographical and demographic data; as well as Pediatric Risk of Mortality (PRISM); Pediatric Logistic Organ Dysfunction (PELOD) and Paediatric Index of Mortality 3 (PIM3) scores to determine which factors were associated with an increased mortality risk.Results. Two hundred and two children were admitted during the study period. Ninety-six children were included in the study; 79 files were not found and 27 children were ineligible. The median age was 14 months and the mortality rate was 15.6%. The significant factor associated with mortality was severe malnutrition. In total 88% of required data were available for the calculation of both the PRISM and PELOD scores and 95% for PIM3 score. The PRISM; PELOD and PIM3 standardised mortality ratios were 2.5; 4.8 and 2.9; respectively. P-values for PRISM; PELOD and PIM3 were 0.05.Conclusion. Severe malnutrition is a statistically significant factor in predicting mortality. This possibly reflects the social context in which the children live. PRISM; PELOD and PIM3 underpredict mortality in our setting. A larger sample is required to verify these outcomes and to determine whether other factors play a role

The Existence of Policies; Practices and Perceptions Regarding Children as Visitors to Public Hospitals in uMgungundlovu; KwaZulu-Natal Province

Background. Current policies and practices regarding child visitors in hospitals in uMgungundlovu; KwaZulu-Natal Province; South Africa; are unknown. Existing literature focuses on provision for child visitors in specialised units in well-resourced countries.Objective. To identify policies; describe current practices and determine the perceptions of healthcare workers to child visitors.Methods. Interviews were conducted with 7 nursing managers regarding the existence and content of a hospital visitors' policy; 12 operational managers (OMs) to describe ward practices regarding child visitors; and 12 professional nurses and 11 doctors to determine their attitudes towards children as visitors in all four general state hospitals in uMgungundlovu between October 2013 and July 2015.Results. Five out of seven nursing managers were aware of a visitors' policy in their hospital. These policies allowed children to visit family or parents in adult wards; but only 2 would allow children to visit a family member and only 1 would allow visits to a friend in the children's wards. According to the nursing managers; policy was that the visitor must be over 5 years of age to visit in an adult ward while 2 out of 3 nursing managers allowed only children over 12 years of age to visit in children's wards. Visits must occur during prescribed visiting times and the visitor must be accompanied by an adult. In practice; 7 out of 12 OMs allow child visitors in their wards. Only 2 out of 7 OMs allow unrestricted visitation by children and only to non-infectious patients in children's wards - this is subject to variable age restrictions in adult wards and an age limit of 12 years in children's wards. In all wards; visits by children are restricted to prescribed visiting times and conditional on an adult escort. Three out of seven OMs allow 2 visitors only; although most (5 out of 7) allow visits of unlimited duration. Staff who favoured child visitors were more likely to be younger; male and employed as health professionals for 5 years. More doctors than nurses believed that children should be allowed to visit family and/or friends in hospital. Justifications for not allowing children to visit centred on infection risks and the emotional trauma of visiting a sick loved one. The child; patient and health professional were seen to benefit socially from child visitors; although there are positive and negative emotional consequences for the patient and the child.Conclusion. Hospitals do make provisions for visitors; but most exclude young children; particularly those who are most vulnerable to the negative consequences of separation from a parent or family member. While policies do exist to guide child visitation in uMgungundlovu; such policies are restrictive; inconsistent and do not necessarily reflect day-to-day practices

A Retrospective Review of the Transfer of Critically ill Children to Tertiary Care in KwaZulu-Natal; South Africa

Background. Obtaining care for an acutely ill child in specialised paediatric services relies on referral from lower-level facilities. In South Africa; it is common practice for acutely ill children to be transported far distances by non-specialist teams with limited equipment; knowledge and skills. Objectives. To describe the transfer of these children and to determine whether they deteriorate from the time of referral to the time of arrival at a tertiary centre. Furthermore; we sought to identify modifiable factors that might improve outcomes during resuscitation and transfer. Methods. The study was a retrospective review of emergency referrals of children aged 1 month - 12 years to Grey's Hospital paediatric ward or paediatric intensive care unit (PICU); from lower-level facilities in KwaZulu-Natal between January and June 2012. In conjunction with an assessment by the receiving clinician at Grey's Hospital; Triage Early Warning Signs (TEWS) scores were obtained during telephonic referral and compared with the TEWS score on arrival in order to determine if a deterioration had occurred.Results. A total of 57 PICU referrals and 79 ward referrals were analysed. The mortality rate prior to transportation was 8.8%. Mean transfer distance was 131 km and mean transfer time 9 hours. Advanced life support teams undertook transportation in 76.7% of PICU and 25% of ward transfers and few adverse events were reported in transfer logs. However; 31.5% of PICU and 11.3% of ward referrals required immediate resuscitation on arrival. When the TEWS scoring system was applied 78.5% of PICU and 30.4% of ward referrals fell into the 'very urgent' and 'emergency' categories. Conclusion. Pretransport and in-transit care failed to stabilise children and this may reflect lack of skill of attending healthcare workers; transport delays or illness progression. Interventions to improve resuscitation and transfer are needed; and the use of retrieval teams should be investigated

Hospital-Acquired Klebsiella Pneumoniae Infections in a Paediatric Intensive Care Unit

Background. Hospital-acquired infections (HAI) are a significant problem in the delivery of intensive care services. Each nosocomial infection prolongs an affected patient's stay in hospital by 5 - 10 days. Methods. A retrospective case control chart review of children admitted to the paediatric intensive care unit (PICU) in Grey's Hospital between July 2003 and December 2010; who developed a hospital-acquired Klebsiella pneumoniae infection; was undertaken to describe the trend in HAI in a newly commissioned PICU and to identify any association with the patient demographics and modalities of care. Patients with a K. pneumoniae infection were identified through the PICU infection control surveillance system. Each case was matched to a control of the same age admitted during the same period; with a similar clinical diagnosis. Results. During the 7.5-year period; 2 266 children 12 years of age were admitted to the PICU. Of these; 113 had K. pneumoniae cultured from a body fluid 48 h after admission; including 23 cultured from the blood. Clinical records were obtained for 14 of these patients and matched to control cases of similar age and gender who were admitted at the same time. The length of stay in both the PICU and hospital was longer in children with an HAI compared with the control group (3.7 v. 2.9 and 18.5 v. 9.14; respectively; p=0.04). There was no significant difference in the treatment modalities provided to the two groups; although most patients in the sample group required invasive treatment. Conclusion. K. pneumoniae nosocomial infection was a significant problem encountered in Grey's Hospital paediatric intensive care. It has major cost implications; as it prolongs the length of stay in intensive care and hospital