Improving the quality of care for inpatient management of childhood pneumonia at the first level referral hospital : a country wide programme

Enarson, Penelope Marjorie (2015-04)

Thesis (MCur)--Stellenbosch University, 2015.


ENGLISH ABSTRACT: Pneumonia is the greatest single cause of mortality in children less than five years of age throughout the world causing more deaths than those due to AIDS, malaria and tuberculosis combined. Approximately 50% of all childhood pneumonia deaths occur in sub-Saharan Africa. Children in developing countries being treated for pneumonia frequently have one or more comorbid conditions which increases their risk of dying. The proper management of the child with severe or very severe pneumonia is essential to reduce case fatality. Standard case management (SCM) of pneumonia, has been shown to be an effective intervention to reduce deaths from pneumonia, but what is lacking is a means of delivering it in low-resource/high burden countries. A major barrier to wide application of this intervention in low-income countries is weak health-care systems with insufficient human and financial resources for implementing SCM to a sufficient number of children at a level of quality and coverage that would result in a significant impact. The objective of this dissertation is to address this issue by investigating ways of improving delivery of standard case management of pneumonia in district hospitals throughout Malawi, a high HIV-prevalent country which would result in a decrease in the in-hospital case fatality rates (CFR) from pneumonia in children less than five years of age. We reviewed the evidence base for SCM. Then we evaluated the development and implementation of a national Child Lung Health Programme (CLHP) to deliver SCM of severe and very severe pneumonia and a programme to provide uninterrupted oxygen supply in all paediatric wards at District Hospitals throughout Malawi. We demonstrated that it was feasible to implement and maintain both programmes country-wide. Thirdly we evaluated the trend in case fatality rates in infants and young children (0 to 59 months of age) hospitalized and treated for severe and very severe pneumonia over the course of the implementation of the CLHP. The findings from this study showed that in the majority (64%) of cases, who were aged 2-59 months with severe pneumonia there was a significant effect of the intervention that was sustained over time whereas in the same age group children treated for very severe pneumonia there was no interventional benefit. No benefit was observed for neonates. Fourthly we investigated factors associated with poor outcome reported in the previous study, in a subset of this cohort to determine the individual factors including demographics of the study population, recognised co-morbidities and clinical management that were associated with inpatient death. This study identified a number of factors associated with poor pneumonia-related outcomes in young infants and children with very severe pneumonia. They included co-morbidities of malaria, malnutrition, severe anaemia and HIV infection. The study found that the majority of reported comorbid conditions were based on clinical signs alone indicating a need for more accurate diagnosis and improved management of these comorbidities that may lead to improved outcomes. Other identified factors included a number of potentially modifiable aspects of care where adjustments to the implementation of SCM are indicated. These included enhancing correct classification of the severity of the disease, the use of correct antibiotics according to standard case management, more extensive availability and use of oxygen together with oximetry to guide its use,. Finally recommendations were made to address the identified reasons for poor outcomes and suggested future research.

AFRIKAANSE OPSOMMING: Pneumonie is die grootste enkele oorsaak van sterftes by kinders jonger as 5 jaar in die wêreld en veroorsaak meer kindersterftes as die menslike immuungebrekvirus (MIV), malaria en tuberkulose saam. Ongeveer 50% van kindersteftes van pneumonie kom in sub-Sahara-Afrika voor. Kinders in ontwikkilende lande, wie vir pneumonie behandel word, het dikwels een of meer bydraende toestande wat die doodsrisiko verhoog. Kinders wie ernstige of baie ernstige pneumonie onderlede het moet korrek behandel word om sterfte te voorkom. Die standaard protokolle om kinderpneumonie korrek te behandel het getoon om effektief te wees om die sterftesyfers te verlaag. In lae inkomste lande bestaan die strategieë nie om die protokolle aan te wend nie. ‘n Groot struikelblok in die aanwending van die pneumonie behandelingsprotokolle in lae-inkomste lande is die swak gesondheidsorgsisteme met onvoldoende menslike en finansiële hulpbronne. Die tekorte gee aanleiding tot die beperkte implementering van pneumonie protokolle wat die omvang en kwaliteit van die pneumonie protokolle beperk en daarom impakteer die protokolle nie op die kindersterftesyfer nie. Die doel van die verhandeling is om hierdie probleem aan te spreek deur navorsing hoe om die pneumonie protokolle landwyd in alle distrikhospitale in Malawi, ‘n land met ‘n hoë MIV prevalensie, aan te wend om sodoende die kindersterftesyfer (kinders jonger as 5 jaar) as gevolg van pneumonie te verlaag. Ons het die getuienis van die pneumonie protokolle ondersoek. Hierna is ‘n nasionale Kinderlong Gesondheidsprogram ontwikkel en landwyd geïmplementeer. Volgens die program is kinders met ernstige en baie ernstige pneumonie volgens Wêreldgesondheidsorganisasie (WGO) protokolle behandel. Ononderbroke suurstoftoevoer in alle pediatriesesale in distrikshospitale in Malawi veskaf. Die navorsing het getoon dat die implementering en instandhouding van pneumonie behandelingsprotokolle is landwyd moontlik. Verder het ons die tendens ondersoek of die kindersterftesyfer in babas en jong kinders (0 tot 59 maande) wat in die hospital opgeneem en behandel is vir ernstige en baie ernstige pneumonie tydens die implementering van pneumonie protokolle verminder het. Die bevindinge van hierdie verhandeling wys dat in die meerderheid (64%) van die kinders tussen 2 en 59 maande met ernstige pneumonie, en met die toepassing van die pneumonie protokolle, statistiesbetekenvol die sterfte syfer verlaag het. Die protokolle vir die behandeling van baie erstige pneumonie het nie dieselfde wenslike effek gehad nie. In neonate (jonger as 2 maande) was daar ook geen verlaging in die sterftesyfer nie. Laastens het ons die redes vir die swak uitkomste ondersoek in ‘n substudie en veral klem gelê op bydraende siektes en kliniesesorg tekorte geassosieer met pneumonie sterftes. Die studie het ‘n aantal faktore geïdentifiseer wat bygedra het tot die sterftesyfer in kinders met baie ernstige pneumonie en in neonate. Die geïdentifiseerde bydraende faktore het malaria, wanvoeding, erge anemie en MIV-infeksie ingesluit. Voorkomende maatreëls moet vir die geïdentifiseerde faktore ingestel word. Aanpassings in die pneumonie protokolle is voorgestel. Ten slotte word aanbevelings gemaak om die geïdentifiseerde redes vir swak uitkomste aan te spreek en verdere navorsingidees word aanbeveel.

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