Comprehensive assessment of pediatric acute and inpatient care at a tertiary referral hospital in Malawi: opportunities for quality improvement.

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.

Mortality by Admission Diagnosis in Children 1-60 Months of Age Admitted to a Tertiary Care Government Hospital in Malawi.

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.

Social Needs Screening During Pediatric Emergency Department Visits: Disparities in Unmet Social Needs.

OBJECTIVE: To determine the prevalence of unmet social needs (USN) in a pediatric emergency department (PED) patient population and examine disparities in USN by self-selected language and patient demographics. METHODS: We surveyed a convenience sample of English- and Spanish-speaking caregivers of patients <18-years-old presenting to a free-standing children's hospital in Salt Lake City, Utah. In the caregiver's self-selected language, the pediatric version of the Screener for Intensifying Community Referrals for Health (p-SINCERE) assessed patient demographics and 10 areas of social needs. The primary outcome was presence of USN. Descriptive statistics compared 1) self-selected languages and 2) absence versus presence of USN. Patient and caregiver-level risk factors associated with USN were identified using multivariable logistic regression. RESULTS: Of the 10,156 patients seen in our PED from 04/01/2021 to 08/03/2021, there were 9922 eligible, 5357 approached, and 3987 enrolled caregivers. Of the 3987 caregivers enrolled, self-selected language was English for 3662 (91.8%) and Spanish for 325 (8.2%). There were 1680 enrolled caregivers with ≥1 USN, representing 39.7% of English-speaking and 70.2% of Spanish-speaking caregivers (P < .001). The odds of having ≥1 USN was more than 2 times higher in Spanish-speakers than in English-speakers after adjustment. CONCLUSIONS: USN are common for families presenting for care to a PED, especially among Spanish-speaking caregivers. Furthermore, this study demonstrates disparities in limited English proficiency, race and ethnicity, and child insurance status. These findings support the practicality of utilizing the PED as an access point to initiate social need screening and referrals to address social determinants of health and health disparities.

Blood transfusion and mortality in children with severe anaemia in a malaria-endemic region.

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.

Relationship between distance of referring facilities and haemoglobin change in children in Malawi.

BACKGROUND: Anaemia is a significant cause of mortality in children in sub-Saharan Africa where blood transfusion is often available only at referral hospitals. Understanding the pattern of referrals by health facilities is essential to identify the delays that affect child survival. AIM: To determine if there was a correlation between change in haemoglobin (Hb) level and distance from referring facilities to Kamuzu Central Hospital (KCH) in Malawi, and whether distance affected mortality rates. METHODS: This was a retrospective cohort study of 2259 children referred to KCH whose Hb was measured at the referring facility or at KCH. Maps were created using ArcGIS® software. The relationship between distance from KCH and change in Hb was assessed by χ2 analysis and multiple linear regression with SAS© software. RESULTS: The majority of children were referred by health facilities in the Lilongwe District. When categorised as Hb <4, 4-6 or >6 g/dL, 87.0% of children remained in the same category during transfer. There was no significant relationship between Hb drop and distance from KCH. Distance from KCH was not a significant predictor of Hb level at KCH or Hb change. However, mortality rates were significantly higher in facilities that were 10-50 km from KCH than in those which were <10 km away. CONCLUSIONS: Using distance as a proxy for time, this suggests that referring facilities are transferring children sufficiently quickly to avert significant reductions in Hb. Despite this, there is a need to identify the factors that influence the decision to transfer anaemic children.

Decreased Mortality After Establishing a Pediatric Emergency Unit at an Urban Referral Hospital in Ghana.

ABSTRACT: Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in low- and middle-income countries. Limited reports have shown that process improvements and prioritization of emergency care for children presenting to the hospital can improve pediatric hospital mortality.A dedicated pediatric emergency unit (PEU) was established for nontrauma emergencies at a busy teaching and referral hospital in Kumasi, Ghana, in response to high inpatient mortality early during hospitalization. The PEU was designed to identify and separate critically ill children from more stable children on admission. Locally available hospital resources were reallocated from other areas of the hospital to prioritize staffing and supplies for the PEU.A multiyear data set of nonnewborn inpatient mortality was analyzed with a change point model to find the point at which mortality changed the most within the Department of Child Health or the maximum likelihood estimate. Relative risk of mortality for the periods 1 and 2 years immediately before and after the implementation of the PEU and each individual year compared with its preceding year was analyzed to further establish a temporal correlation of changes in mortality rates to the PEU implementation. Individual years were also analyzed against preimplementation data to establish the durability of mortality improvements.Patient mortality decreased over the analyzed period with the maximum change point strongly associated with implementation of the PEU. Relative risk values of mortality 1 year and 2 years immediately before and after implementation of the PEU were 0.70 (0.62-0.78) and 0.69 (0.64-0.74) respectively, representing a one-third reduction in mortality. The only other mortality improvements seen in the year-to-year analysis were between July 2004-June 2005 compared with July 2005-June 2006 with a relative risk of 0.86 (0.77-0.96).Prioritizing and redirecting limited resources toward pediatric emergency care in low- and middle-income country hospitals is associated with reductions in inpatient mortality that are both immediate and sustained.

Lessons learned from the development and implementation of an electronic paediatric emergency and acute care database in Lilongwe, Malawi.

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.

Improving Pediatric Academic Global Health Collaborative Research and Agenda Setting: A Mixed-Methods Study.

Academic global health collaborations have the potential to improve joint understanding of health issues in low- and middle-income countries (LMICs). Our objective was to elucidate perceptions of benefits and challenges of academic global health collaborations as well as areas for improving collaborative research conducted in LMICs. This cross-sectional, mixed-methods study surveyed investigators' perceptions of benefits and challenges of pediatric academic global health collaborations. Authors of articles from four pediatric journals reporting pediatric research conducted in LMICs published between 2006 and 2015 were surveyed. Responses of LMIC investigators were compared with those of investigators in high-income countries (HICs). Responses to open-ended questions were analyzed using a combined thematic and content analysis approach. Of 1,420 potential respondents, 252 (17.7%) responded to the survey. Collaborative research with investigators from other countries was perceived as beneficial by 88.5% of respondents (n = 223), although this perception was more common among HIC respondents (n = 110, 94.0%) than LMIC respondents (n = 113, 83.7%) (p = 0.014). Sixty-seven percent (n = 170) of respondents perceived that HIC investigators had set the research agenda in work conducted in a LMIC. Respondents identified several critical factors to improve academic global health collaborations, including research capacity building, communication, and early involvement of LMIC investigators with shared decision-making during study conception and grant writing. Pediatric academic global health collaboration was widely perceived as positive. However, despite calls for capacity building and locally generated research ideas, many respondents felt that HIC investigators set the research agenda for work conducted in LMICs. This study provides suggestions for improving collaboration among pediatric academicians globally.

Importance of authorship and inappropriate authorship assignment in paediatric research in low- and middle-income countries.

OBJECTIVE: To understand the importance of authorship and authorship position, and gauge perceptions of inappropriate authorship assignment, among authors publishing paediatric research conducted in low- and middle-income countries (LMICs). METHODS: We conducted a cross-sectional, mixed-methods study using an online survey of both corresponding and randomly selected, non-corresponding authors who published research conducted in LMICs from 2006 to 2015 in the top four paediatric journals by Eigenfactor score. We used chi-square tests to compare responses by authors living in LMICs to authors living in high-income countries (HICs). We analysed qualitative responses using thematic analysis. RESULTS: Of 1420 potential respondents, 19.6% (n = 279) completed the survey. 57% (n = 159) lived in LMICs and 43% (n = 120) in HICs. LMIC authors more commonly perceived first authorship as most important for their academic advancement than HIC authors (74.2% vs. 60.8%, P = 0.017), while HIC authors reported last authorship as most important (25.1% vs. 38.3%, P = 0.018). 65% (n = 181) of respondents believed that their collaborators had been inappropriately assigned authorship positions (no difference in LMIC and HIC responses) and 32.6% (n = 91) reported personally accepting inappropriate authorship positions (more common in HIC respondents, P = 0.005). In qualitative data, respondents questioned the applicability of standard authorship guidelines for collaborative research conducted in LMICs. CONCLUSIONS: LMIC and HIC authors held different perceptions about the importance of authorship position. Reported inappropriate authorship assignment was common among both LMIC and HIC respondents. Alternatives to standard authorship criteria for research conducted in LMICs merit further studies.

OBJECTIF: Comprendre l'importance de la paternité d'auteur et de la position de l'auteur, et évaluer les perceptions de l'attribution inappropriée de la paternité d'auteur parmi les auteurs qui publient des recherches pédiatriques menées dans des pays à revenu faible ou intermédiaire (PRFI). MÉTHODES: Nous avons mené une étude transversale à méthodes mixtes avec un sondage en ligne auprès d'auteurs de correspondance et sélectionnés au hasard, d'auteurs not de correspondance, ayant publié des recherches menées dans des PRFIde 2006 à 2015 dans les quatre revues pédiatriques les mieux classées par le score d'Eigenfactor. Nous avons utilisé des tests de chi carré pour comparer les réponses des auteurs des PRFI à ceux des aux auteurs des pays à revenu élevé (PRE). Nous avons analysé les réponses qualitatives à l'aide d'une analyse thématique. RÉSULTATS: Sur 1.420 répondants potentiels, 19,6% (n = 279) ont répondu au sondage. 57% (n = 159) vivaient dans des PRFI et 43% (n = 120) dans des PRE. Les auteurs des PRFI estimaient plus souvent que la position de premier auteur était le plus important pour leur avancement universitaire que les auteurs des PRE (74,2% contre 60,8%, P = 0,017), tandis que les auteurs desPRE ont déclaré que le dernier auteur était le plus important (25,1% contre 38,3%, P = 0,018). 65% (n = 181) des répondants estimaient que des positions d'auteur avaient été attribués de manière inappropriée à leurs collaborateurs (aucune différence entre les réponses des PRFI et des PRE) et 32,6% (n = 91) ont déclaré avoir personnellement accepté des positions d'auteurs inappropriées (plus fréquents chez les répondants desPRE, P = 0,005). En ce qui concerne les données qualitatives, les répondants se sont interrogés sur l'applicabilité des directives standards en matière de paternité d'auteur pour la recherche collaborative menée dans les PRFI. CONCLUSIONS: Les auteurs des PRFI et desPREont des perceptions différentes sur l'importance de la position de l'auteur. L'attribution inappropriée de laposition d'auteur signalée était fréquente chez les répondants des PRFI et des PRE. Les alternatives aux critères standards de la paternité d'auteur pour les recherches menées dans les PRFI méritent d'être approfondies.

Defining Global Health Tracks for Pediatric Residencies.

BACKGROUND: Global health (GH) offerings by pediatric residency programs have increased significantly, with 1 in 4 programs indicating they offer a GH track. Despite growth of these programs, there is currently no widely accepted definition for what comprises a GH track in residency. METHODS: A panel of 12 pediatric GH education experts was assembled to use the Delphi method to work toward a consensus definition of a GH track and determine essential educational offerings, institutional supports, and outcomes to evaluate. The panelists completed 3 rounds of iterative surveys that were amended after each round on the basis of qualitative results. RESULTS: Each survey round had 100% panelist response. An accepted definition of a GH track was achieved during the second round of surveys. Consensus was achieved that at minimum, GH track educational offerings should include a longitudinal global child health curriculum, a GH rotation with international or domestic underserved experiences, predeparture preparation, preceptorship during GH electives, postreturn debrief, and scholarly output. Institutional supports should include resident salary support; malpractice, evacuation, and health insurance during GH electives; and a dedicated GH track director with protected time and financial and administrative support for program development and establishing partnerships. Key outcomes for evaluation of a GH track were agreed on. CONCLUSIONS: Consensus on the definition of a GH track, along with institutional supports and educational offerings, is instrumental in ensuring consistency in quality GH education among pediatric trainees. Consensus on outcomes for evaluation will help to create quality resident and program assessment tools.

Lost opportunities to identify and treat HIV-positive patients: results from a baseline assessment of provider-initiated HIV testing and counselling (PITC) in Malawi.

OBJECTIVE: To assess implementation of provider-initiated testing and counselling (PITC) for HIV in Malawi. METHODS: A review of PITC practices within 118 departments in 12 Ministry of Health (MoH) facilities across Malawi was conducted. Information on PITC practices was collected via a health facility survey. Data describing patient visits and HIV tests were abstracted from routinely collected programme data. RESULTS: Reported PITC practices were highly variable. Most providers practiced symptom-based PITC. Antenatal clinics and maternity wards reported widespread use of routine opt-out PITC. In 2014, there was approximately 1 HIV test for every 15 clinic visits. HIV status was ascertained in 94.3% (5293/5615) of patients at tuberculosis clinics, 92.6% (30,675/33,142) of patients at antenatal clinics and 49.4% (6871/13,914) of patients at sexually transmitted infection clinics. Reported challenges to delivering PITC included test kit shortages (71/71 providers), insufficient physical space (58/71) and inadequate number of HIV counsellors (32/71) while providers from inpatient units cited the inability to test on weekends. CONCLUSIONS: Various models of PITC currently exist at MoH facilities in Malawi. Only antenatal and maternity clinics demonstrated high rates of routine opt-out PITC. The low ratio of facility visits to HIV tests suggests missed opportunities for HIV testing. However, the high proportion of patients at TB and antenatal clinics with known HIV status suggests that routine PITC is feasible. These results underscore the need to develop clear, standardised PITC policy and protocols, and to address obstacles of limited health commodities, infrastructure and human resources.

Economic analysis of rapid and sensitive polymerase chain reaction testing in the emergency department for influenza infections in children.

BACKGROUND: Rapid multiplex polymerase chain reaction (PCR) assays simultaneously detect several respiratory viral pathogens with high sensitivity. Maximizing detection of influenza at the point of care has the potential to reduce unnecessary antibiotic use, laboratory tests and hospitalizations. However, the cost-effectiveness of rapid multiplex PCR assays for influenza has not been compared with other diagnostic methods in children. METHODS: For children presenting to the emergency department with influenza-like illness, we compared costs and outcomes using 4 different testing strategies for detection of influenza: (1) a rapid multiplex PCR platform (FilmArray); (2) traditional PCR; (3) direct-fluorescent antibody and (4) rapid antigen tests. Costs were assessed from the hospital perspective, and effectiveness was defined as quality-adjusted life years (QALYs). Input parameters were obtained from previous studies, and the model was run separately for children aged 3-36 months and 3-18 years. RESULTS: Rapid multiplex PCR testing was the most effective testing strategy for children in both age groups. The incremental cost-effectiveness when compared with rapid antigen tests was $115,556 per QALY for children aged 3-36 months and from $228,000 per QALY for children aged 3-18 years. The cost-effectiveness of rapid multiplex PCR was sensitive to estimates for influenza prevalence, the proportion of patients treated with antivirals and the cost per test. CONCLUSIONS: Our model identifies scenarios in which identification of influenza in the emergency department using rapid multiplex PCR testing is a cost-effective strategy for infants and children 3 months through 18 years. Including detection of other respiratory viruses in the analysis would further improve cost-effectiveness.

Decreased pediatric hospital mortality after an intervention to improve emergency care in Lilongwe, Malawi.

BACKGROUND AND OBJECTIVE: 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 point to our hospital for most children presenting with acute illness is the Under-5 Clinic. We hypothesized that early inpatient mortality and total inpatient mortality rates would decrease with an intervention to prioritize and improve pediatric emergency care at our hospital. METHODS: We implemented the following changes as part of our intervention: (1) reallocation of senior-level clinical support from other areas of the hospital to the Under-5 Clinic for supervision of emergency care, (2) institution of a formal triage process that improved patient flow, and (3) treatment and stabilization of patients before transfer to the inpatient ward. We compared early inpatient and total inpatient mortality rates before and after the intervention. RESULTS: After the intervention, early mortality decreased from 47.6 to 37.9 deaths per 1000 admissions (relative risk 0.80, 95% confidence interval 0.67-0.93). Total mortality also decreased from 80.5 to 70.5 deaths per 1000 admissions after the intervention (relative risk 0.88, 95% confidence interval 0.78-0.98). CONCLUSIONS: Simple, inexpensive interventions to improve pediatric emergency care at this underresourced hospital in sub-Saharan Africa were associated with decreased hospital mortality rates. The description of this process and the associated results may influence practice and resource allocation strategies in similar clinical environments.