Tertiary Hospital In Malawi Research Articles

Pharmacist-Led Antimicrobial Stewardship Programme in Two Tertiary Hospitals in Malawi.

The ultimate goal of antimicrobial stewardship (AMS) programmes is to decrease the occurrence and spread of antimicrobial resistance (AMR). In response to this, a pharmacist partnership was established between Malawi and Wales (UK) with the aim of strengthening antimicrobial stewardship (AMS) activities in Malawi, with the initial project focusing on two tertiary referral hospitals. The Global Point Prevalence Survey (GPPS) was undertaken for the first time in Malawi at these sites and demonstrated a prescribing rate slightly lower than the African average, with ceftriaxone indicated for almost every bacterial infection. An educational intervention was also delivered, with a train-the-trainer approach upskilling pharmacists at the two sites, who then cascaded co-produced training sessions to an additional 120 multidisciplinary health professionals. A toolkit to support AMS at an individual patient level was also developed and disseminated to provide an ongoing reference to refer to. Both the trainings and toolkit were well received. Over the course of this project, significant progress has been made with the AMS programmes at the two sites, with local staff empowered to implement AMS activities. These interventions could be easily replicated and scaled and support the delivery of some of the AMS elements of the Malawi Ministry of Health National Action Plan for Antimicrobial Resistance.

Prevalence, mortality, and aetiology of paediatric shock in a tertiary hospital in Malawi: A cohort study.

Shock is considered one of the most important mechanisms of critical illness in children. However, data on paediatric shock in sub-Saharan Africa is limited, which constrains development of effective treatment strategies. We aimed to describe the prevalence, mortality, and aetiology of paediatric shock in a tertiary hospital in Malawi. Children aged two months to 16 years presenting with shock (FEAST criteria; respiratory distress and/or impaired consciousness, and at least one sign of impaired circulation; capillary refill>3 seconds, cold extremities, weak pulse, or severe tachycardia) to the emergency department were included and followed-up prospectively using routinely collected data between February 2019 and January 2020. Prevalence, mortality and aetiology of shock were reported for both the FEAST criteria and World Health Organization (WHO) definition. The association between aetiology and mortality was assessed with univariable analysis. Of all screened admissions (N = 12,840), 679 (5.3%) children presented with shock using FEAST criteria and the mortality was 79/663 (11.9%). WHO-defined shock applied to 16/12,840 (0.1%) and the mortality was 9/15 (60.0%). Main diagnoses were viral/reactive airway diseases (40.4%), severe pneumonia (14.3%), gastroenteritis (11.3%) and presumed sepsis (5.7%). Children diagnosed with presumed sepsis and gastroenteritis had the highest odds of dying (OR 11.3; 95%-CI:4.9-25.8 and OR 4.4; 95%-CI:2.4-8.2). Considering the high mortality, prevalence of paediatric shock (FEAST and WHO definitions) in Malawi is high. Sepsis and gastroenteritis are diagnoses associated with poor outcome in these children. Consensus on a clinical meaningful definition for paediatric shock is essential to boost future studies.

Evaluating blood culture collection practice in children hospitalized with acute illness at a tertiary hospital in Malawi.

Blood culture collection practice in low-resource settings where routine blood culture collection is available has not been previously described. We conducted a secondary descriptive analysis of children aged 2-23 months enrolled in the Malawi Childhood Acute Illness and Nutrition (CHAIN) study, stratified by whether an admission blood culture had been undertaken and by nutritional status. Chi-square test was used to compare the differences between groups. A total of 347 children were included, of whom 161 (46%) had a blood culture collected. Children who had a blood culture collected, compared to those who did not, were more likely to present with sepsis (43% vs. 20%, p < 0.001), gastroenteritis (43% vs. 26%, p < 0.001), fever (86% vs. 73%, p = 0.004), and with poor feeding/weight loss (30% vs. 18%, p = 0.008). In addition, hospital stay in those who had a blood culture was, on average, 2 days longer (p = 0.019). No difference in mortality was observed between those who did and did not have a blood culture obtained. Blood culture collection was more frequent in children with sepsis and gastroenteritis, but was not associated with mortality. In low-resource settings, developing criteria for blood culture based on risk factors rather than clinician judgement may better utilize the existing resources.

Predictors of mortality following electrical and lightning injuries in Malawi: A decade of experience

IntroductionElectrical injuries can be devastating, and data is lacking in low-resource settings. We aimed to identify predictors of mortality following electrical and lightning injuries (ELI) in Malawi. MethodsWe performed a retrospective observational study of patients presenting with ELI and burn injuries at a tertiary hospital in Malawi from 2011 to 2020. Outcomes were compared and predictors of mortality were modeled. ResultsA total of 382 ELI and 6371 burn patients were included. The mean ages for ELI and burn groups were 24 ± 14 and 11 ± 14 years, respectively (p < 0.01). Most patients were injured at home (91% in the burn group versus 51% in the ELI group, p < 0.01). The crude mortality rate in the ELI group was 28%, compared to 12% in the burn group (p < 0.01). On multivariate logistic regression, predictors of mortality included ELI (odds ratio [OR] 13.3, 95% confidence interval [CI] 7.2–24.5) and total body surface area burned (OR 1.1, 95% CI 1.1–1.1). Predicted mortality for ELI has increased over time (p = 0.05). ConclusionsELI confers more than 13 times higher odds of mortality than burn injuries in Malawi, with mortality risk increasing over time. More efforts are needed to prevent electrical hazards and implement timely interventions for patients with ELI.

Family members’ perception of their needs in critical care units at a tertiary hospital in Malawi: A qualitative study

BackgroundFamily members experience an emotional crisis when their loved one is critically ill and admitted to a critical care unit (CCU). An extensive literature has explored optimal ways to interact with families in the critical care setting, including intervention studies. What is less explored are perceptions of family members in low-income settings including Malawi. In such settings, perceptions may differ as a consequence of different cultural practices and resource limitations (personnel and technology). Therefore, this study explored family members’ perceptions of their needs in CCUs at a tertiary hospital in Malawi.Study designs and methodsThe study used a qualitative descriptive design. Data were gathered through interviews with 12 participants who were purposively selected from immediate family members of patients hospitalized for 48 h or more in adult intensive care unit (ICU) and high dependency unit (HDU). The interviews were audio recorded and transcribed verbatim. Data analysis followed the steps of content analysis.FindingsThe following four themes were identified: perceived information, physical, and psychosocial needs, and coping mechanisms of the family members. The family members needed information about their patient’s progress frequently and viewed this as a priority compared to other needs such as comfort and food.ConclusionThis study suggests that there should be a collaborative relationship between the CCU team and family members in order to meet their needs. Findings affirm the need for health professionals to develop guidelines or standards that promote frequent discussions with CCU family members as a means to provide support and lessen anxiety.

Doctors’ experiences of referring and admitting patients to the intensive care unit: a qualitative study of doctors’ practices at two tertiary hospitals in Malawi

ObjectiveTo explore doctors’ experiences of referring and admitting patients to the intensive care unit (ICU) at two tertiary hospitals in Malawi.DesignThis was a qualitative study that used face-to-face interviews. The...

Healthcare workers' experiences in caring for critically ill COVID-19 patients at a tertiary hospital in Malawi.

The coronavirus pandemic overwhelmed the healthcare landscape, placing a strain on healthcare workers worldwide. In addition to directly causing the deaths of people, the COVID-19 pandemic disrupted critical health services in developing countries. The study aimed to explore the experiences of healthcare workers who cared for critically ill COVID-19 patients at a tertiary hospital in Malawi. A qualitative descriptive design was used. Data were gathered through in-depth interviews with doctors, clinical officers, nurses, and allied staff (n=25) who were involved in the care of critically ill COVID-19 patients at the hospital's COVID-19 treatment centres during the first and second waves of the pandemic in Malawi. The interviews were conducted in English, audiotaped, and later transcribed verbatim. Conventional content analysis was used to analyse the data following the steps proposed by Hsieh and Shannon1. The overall experience of the health workers was negative. However, delivering care to critically ill COVID-19 patients was associated with positive and negative experiences. The positive experience was a result of teamwork among staff and support from hospital authorities and the community. Negative experiences, on the other hand, were attributed to a lack of knowledge and skills in managing critically ill COVID-19 patients, a lack of resources, and abuse by some patients and members of the community. Furthermore, there was fear of contracting the virus from patients and fellow health workers while providing care. The findings point to the need for adequate preparedness within the health sector to support and protect the healthcare workers and individuals they look after. There is a need for disease awareness strategies for health workers and the general public for future pandemics.

Dyslipidaemia Patterns and Risk Factors Among Patients with Diabetes, Hypertension, and Both Diabetes and Hypertension at a Tertiary Hospital in Malawi

BackgroundDyslipidaemia is a significant risk factor for cardiovascular events but is often neglected in most resource-poor settings. AimWe aimed to investigate the prevalence, biochemical characteristics, screening and management practice for dyslipidaemia among patients with DM, hypertension, and both DM and hypertension at a tertiary teaching hospital in Southern Malawi, Africa. MethodsA total of 256 adult participants (DM=100; hypertension =100; both condition = 56) were included in the cross-sectional study in 2021. Medical data and anthropometric measurements were recorded. Blood samples were analysed for HbA1C and serum lipids. Associated risk factors for dyslipidaemia were assessed. ResultsDyslipidaemia was prevalent in 73.5%, 71.8%, and 76.7% of participants with DM, hypertension, and both conditions. High low-density lipoprotein cholesterol (LDL-C) was the most common dyslipidaemia type in all participant groups. Participants with both diabetes and hypertension had 2.4 times (95% CI 1.2 - 4.6) increased risk of LDL-C dyslipidaemia than those with diabetes alone (p=0.02). Overweight or obesity, and age over 30 years were risks for dyslipidaemia in patients with DM alone (RR 1.3 (95% CI 1.1 – 1.6), p=0.04, and RR 2.2 (95% CI 1.2 – 4.7) (p<0.01) respectively. Overweight and obesity predicted LDL-C dyslipidaemia in hypertensive patients (RR 3.492 (95% CI 1.234 - 9.884) p <0.001). Poorly controlled hypertension was associated with a 1.8 times risk (95% CI 1.06 – 2.7) of dyslipidaemia in patients with both DM and hypertension (p<0.01). Only 1% of the participants ever had a lipogram performed before the study and were on lipid-lowering therapy. ConclusionDyslipidaemia was highly prevalent, especially in individuals with both DM and hypertension. Screening and managing dyslipidaemia should be reinforced to reduce the risk of major cardiovascular events in this population at high risk.

Quality of life among cancer patients at Queen Elizabeth and Kamuzu Central Hospitals in Malawi: a cross-sectional double-center study.

Many cancer patients experience psychosocial challenges that affect quality of life during the trajectory of their disease process. We aimed at estimating quality of life among cancer patients at two major tertiary hospitals in Malawi. The study was conducted among 398 cancer patients using semi-structured questionnaire. Quality of life was measured using EQ-5D-3L instrument. Mean age was 45 years ± 12.77. Pain (44%) was the most prevalent problem experienced by cancer patients. About 23% had worst imaginable health status on the subjective visual analogues scale. Attending cancer services at QECH (AOR= 0.29, 95% CI: 0.17-0.54, p<0.001) and having normal weight (AOR=0.25, 95% CI: 0.08-0.74, p = 0.012), were associated with improved quality of life. A history of ever taken alcohol (AOR= 2.36, 95% CI: 1.02-5.44, p = 0.045) and multiple disease comorbidities (AOR= 3.78, 95% CI: 1.08-13.12, p = 0.037) were associated with poor quality of life. Loss of earning, pain, marital strife, sexual dysfunction, were among the common psychosocial challenges experienced. History of ever taken alcohol and multiple comorbidities were associated with poor quality of life. There is need to integrate psychosocial solutions for cancer patients to improve their quality of life and outcomes.

Reallocation of Hospital Resources During COVID-19 Pandemic and Effect on Trauma Outcomes in a Resource-Limited Setting

INTRODUCTION: The COVID-19 pandemic has caused unprecedented disruption to surgical care worldwide, particularly in low-resource countries. We sought to characterize the association between pre- and intrapandemic trauma clinical outcomes at a busy tertiary hospital in Malawi. METHODS: We analyzed trauma patients who presented to Kamuzu Central Hospital in Lilongwe, Malawi, from 2011 through July 2021. Burn patients were excluded. We compared patients based on whether they presented before or during the pandemic, defined as March 11, 2020, the date of the official WHO designation. We used modified Poisson modeling to estimate the adjusted risk of death based on presentation. RESULTS: A total of 138,750 patients presented during the study period, with 13,901 patients during the pandemic. During the pandemic, patients were more likely to be older (mean 28 vs 25 years, p < 0.001), men (79 vs 74%, p < 0.001), and experience a traumatic brain injury (TBI) as their primary injury (9.7 vs 5.0%, p < 0.001). Crude trauma-associated mortality was higher during the pandemic at 3.7% vs 2.1% (p < 0.001). The risk ratio of mortality during the pandemic compared with prepandemic presentation was 1.17 (95% CI 1.09, 1.26) adjusted for age, sex, initial Alert, Voice, Pain, Unresponsive (AVPU) score, and injury type. Difference in the adjusted risk increased as age increased. (Figure).FigureCONCLUSION: During the pandemic, adjusted trauma-associated mortality significantly increased at a tertiary trauma center in a low-resource setting. Potential targets for improvement are addressing nursing shortage and reassignment along with shifts in intensive care use needed for COVID-19 patients. Further research is urgently needed to prepare for future pandemics.

Factors associated with in-hospital mortality of patients admitted to an intensive care unit in a tertiary hospital in Malawi.

To determine factors associated with in-hospital death among patients admitted to ICU and to evaluate the predictive values of single severely deranged vital signs and several severity scoring systems. A combined retrospective and prospective cohort study of patients admitted to the adult ICU in a tertiary hospital in Malawi was conducted between January 2017 and July 2019. Predefined potential risk factors for in-hospital death were studied with univariable and multivariable logistic regression models, and the performance of severity scores was assessed. The median age of the 822 participants was 31 years (IQR 21-43), and 50% were female. Several factors at admission were associated with in-hospital mortality: the presence of one or more severely deranged vital signs, adjusted odds ratio (aOR) 1.9 (1.4-2.6); treatment with vasopressor aOR 2.3 (1.6-3.4); received cardiopulmonary resuscitation aOR 1.7 (1.2-2.6) and treatment with mechanical ventilation aOR 1.5 (1.1-2.1). Having had surgery had a negative association with in-hospital mortality aOR 0.5 (0.4-0.7). The predictive accuracy of the severity scoring systems had varying sensitivities and specificities, but none were sufficiently accurate to be clinically useful. In conclusion, the presence of one or more severely deranged vital sign in patients admitted to ICU may be useful as a simple marker of an increased risk of in-hospital death.

Molecular Epidemiological Characterisation of ESBL- and Plasmid-Mediated AmpC-Producing Escherichia coli and Klebsiella pneumoniae at Kamuzu Central Hospital, Lilongwe, Malawi.

The global rise in infections caused by multidrug resistant (MDR) Enterobacterales poses a public health problem. We have performed a molecular epidemiological characterisation of representative plasmid-mediated AmpC (pAmpC) and ESBL-positive clinical isolates of Escherichia coli (n = 38) and Klebsiella pneumoniae (n = 17) from a tertiary hospital in Malawi collected in 2017. BlaCTX-M-15 was the most prevalent ESBL-determinant in E. coli (n = 30/38) and K. pneumoniae (n = 17/17), whereas blaCMY-2 was detected in nearly all AmpC-phenotype E. coli (n = 15/17). Whole genome sequencing revealed dominant globally disseminated E. coli sequence types (STs); ST410 (n = 16), ST131 (n = 7), and ST617 (n = 6). The ST distribution in K. pneumoniae was more diverse but included ST101 (n = 2), ST14 (n = 2), and ST340 (n = 2), all considered high-risk MDR clones. The isolates expressed an MDR profile, including resistance against commonly used antibiotics, such as fluoroquinolones, aminoglycosides, and/or trimethoprim-sulfamethoxazole, and harboured corresponding resistance determinants. Clonal analyses of the major STs of E. coli revealed closely related genetic clusters within ST410, ST131, and ST617 supporting within-hospital transmission between patients and/or via a common reservoir. The overall findings add to the limited knowledge on the molecular epidemiology of MDR E. coli and K. pneumoniae in Malawi and may help health policy makers to identify areas to target when addressing this major threat of antibiotic resistance.

The effect of COVID-19 on burn management and outcomes in a resource-limited setting

IntroductionOptimal burn care includes fluid resuscitation and early excision and grafting. During the COVID-19 pandemic, resource-constrained environments were susceptible to interruptions in burn care. We sought to characterize pre- and intra-pandemic burn-associated outcomes at a busy tertiary hospital in Malawi. MethodsThis is a retrospective analysis of burn patients that presented to Kamuzu Central Hospital Lilongwe from 2011 through December 2021. We compared patients based on whether they presented pre- or intra-pandemic, starting on March 11, 2020, the date of official WHO designation. Comparing these cohorts, we used modified Poisson modeling to estimate the adjusted risk of undergoing an operation and the risk of death. ResultsWe included 2969 patients, with 390 presenting during the pandemic. Patient factors were similar between the cohorts. More patients underwent surgery pre-pandemic (21.1 vs 10.3 %, p < 0.001) but crude mortality was similar at 17.3 % vs. 21.2 % (p = 0.08). The RR of undergoing surgery during the pandemic was 0.45 (95 % CI 0.32, 0.64) adjusted for age, sex, % TBSA, flame burns, and time to presentation. During the pandemic, the risk ratio for in-hospital mortality was 1.23 (95 % CI 1.01, 1.50) adjusted for age, sex, % TBSA, surgical intervention, flame burns, and time to presentation. ConclusionsDuring the pandemic, the probability of undergoing burn excision or grafting was significantly lower for patients, independent of the severity. Consequently, the adjusted risk of mortality was higher. To improve patient outcomes, efforts to preserve operative capacity for burn patients during periods of severe resource constraint are imperative.

High prevalence, low identification and screening tools of hospital malnutrition in critically- ill patients in Malawi.

In Africa, approximately two-thirds of patients are at risk of malnutrition on admission and the nutritional status of patients deteriorates during hospitalization, with associated increased morbidity, mortality, and hospital-related cost. This cross-sectional study aimed at estimating rates of malnutrition in critical care units and determining the extent to which malnutrition diagnoses are documented in medical records by physicians, at two public tertiary hospitals in Malawi. A total of 315 adult (n = 112) and paediatric (n = 203) participants from Queen Elizabeth Central Hospital and Kamuzu Central Hospital, were included in the analysis. Nutrition status was measured by Subjective Global Assessment (SGA) and Mid-Upper Arm circumference (MUAC) and medical notes were reviewed, in both adults and paediatrics. In adults, more than half were malnourished, with a higher proportion considered moderately-to-severely malnourished using SGA compared to MUAC (84.8%; 57.3%, respectively). Likewise, in paediatrics, a higher proportion was considered moderately-to-severely malnourished using SGA compared to MUAC (84.7%; 23.4%, respectively). Both adult and paediatric patients with cancer had the highest rates of malnutrition. Only 12.9% and 9.6% had documentation of malnutrition diagnosis in the medical record, for paediatrics and adult patients, respectively. The high rates of hospital malnutrition in critically ill patients in Malawi call for comprehensive screening practices and methods; complemented by documentation of the malnutrition diagnosis and use of nutrition interventions by dietitians. This includes enteral, parenteral and supplemental nutrition as a prerequisite for patient recovery in hospitals.

Effect of an educational programme on critical care nurses' competence at two tertiary hospitals in Malawi.

Critical care specialty deals with the complex needs of critically ill patients. Nurses who provide critical care are expected to possess the appropriate knowledge and skills required for the care of critically ill patients. The aim of this study was to assess the effect of an educational programme on the competence of critical care nurses at two tertiary hospitals in Lilongwe and Blantyre, Malawi. A quantitative pre- and post-test design was applied. The training programme was delivered to nurses (n = 41) who worked in intensive care and adult high dependency units at two tertiary hospitals. The effect of the training was assessed through participants' self-assessment of competence on the Intensive and Critical Care Nursing Competence Scale and a list of 10 additional competencies before and after the training. The participants' scores on the Intensive and Critical Care Nursing Competence Scale before the training, M = 608.2, SD = 59.6 increased significantly after the training, M = 684.7, SD = 29.7, p <.0001 (two-tailed). Similarly, there was a significant increase in the participants' scores on the additional competencies after the training, p <.0001 (two-tailed). The programme could be used for upskilling nurses in critical care settings in Malawi and other developing countries with a similar context.

Factors associated with stillbirths among women delivering at a resource limited tertiary hospital in Malawi

Background: Stillbirths remain a major public health issue worldwide with an estimated 3 million deaths per year globally. We investigated the factors associated with stillbirths in fetuses of at least 28 weeks’ gestation or 1000 grams at birth. Methods: We performed a hospital-based, cross-sectional study among women who delivered stillbirths at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from May-November 2017. Eligible women were enrolled after obtaining informed consent, and their demographic and reproductive health information was collected. Blood samples were collected for full blood count, malaria, blood glucose, syphilis, and HIV testing, and the probable risk factors associated with stillbirths were assessed. Results: A total of 1,687 deliveries with 126 stillbirths occurred during the 6-month period, representing a stillbirth rate of 79 per 1,000 births. Seventy percent of these stillbirths were diagnosed on admission at KCH, and about 49% were fresh stillbirths. Half of the stillbirths had a birthweight of at least 2,500g, and the majority of these stillbirths were fresh (60%). The following factors were associated with stillbirth: uterine rupture (15.1%), placental abruption (14.3%), Hypertension (10.3%), obstructed/prolonged labor (5.8%), syphilis (7.1%), malaria (2.4%), congenital anomalies (2.4%), and diabetes (1.5%). Conclusions: The stillbirth rate at KCH is high, and most fetal deaths occurred prior to arrival at KCH. Although most of the stillbirths were unexplained, uterine rupture and abruption placenta emerged as major factors associated with stillbirths and these are largely preventable even in resource limited settings.

Paediatric sickle cell disease at a tertiary hospital in Malawi: a retrospective cross-sectional study

IntroductionSickle cell disease (SCD) remains a major cause of childhood mortality and morbidity in Malawi. However, literature to comprehensively describe the disease in the paediatric population is lacking.MethodsA retrospective review...

The Association of Low Blood Glucose and Low Serum Cortisol Levels in Severely Ill Children Admitted to Tertiary Referral Hospitals in Malawi: A Case-Control Study

ABSTRACT.Low blood glucose concentrations < 5 mmol/L in severely ill children presenting to hospitals in low-income countries are associated with mortality. Adrenal insufficiency with low cortisol levels may contribute to low blood glucose concentrations. Understanding the association between low cortisol and low blood glucose may assist in improving guidelines for management of severely ill children. The study aimed to determine the association between low serum cortisol and low blood glucose in severely ill children. A matched case-control study of children aged 1 month to 15 years was conducted at two tertiary hospitals in Malawi. Cases were children with blood glucose < 5 mmol/L. Two age-matched controls with blood glucose of ≥ 5–15 mmol/L were enrolled per case. Low cortisol was defined as serum cortisol of < 25 µg/dL (690 nmol/L) and adrenal insufficiency as serum cortisol of < 10 µg/dL (276 nmol/L). A total of 54 cases and 108 controls were enrolled with, median age of 2.8 years (interquartile range [IQR]: 1.7–4.4). The median cortisol level was 58.7 µg/dL (IQR: 42.3–61.8) in cases and 40.9 µg/dL (IQR: 33.7–51.2) in controls (P = 0.911). The proportion of low cortisol was 4/54 (7.4%) in cases and 9/108 (8.3%) in controls. Logistic regression shows no association between low cortisol and low blood glucose (adjusted odds ratio: 0.33; 95% confidence interval, 0.04–3.02). Results suggest that there is no association between low cortisol and low blood glucose among severely ill children presenting to hospitals in Malawi. The reason for low blood glucose needs further investigation.

Are Surgeons Enough? The Relationship between Increasing Surgical Demand and Access to Surgery in a Resource-Limited Environment

IntroductionThe relationship between increasing surgical demand and access to operative intervention remains unclear in delivering general surgical care in resource-limited settings, where demand often exceeds capacity. We sought to characterize the association between general surgery patient volume and operative intervention at a tertiary hospital in Malawi, which has an adequate surgical workforce. MethodsWe analyzed patients admitted to Kamuzu Central Hospital Lilongwe, Malawi, with a general surgery complaint from 2018-2020. We examined the relationship between the census at the time of admission, the use of operative intervention, and the time to operative intervention. The patient census was defined as low (≤30 patients), medium (31-49 patients), and high (≥50 patients), based on historical patterns. Results2,701 patients were included. The mean daily census was 46 patients (SD 10). For the medium and high census, the adjusted risk ratio of undergoing surgery was 0.86 (95% CI 0.78, 0.95) and 0.81 (95% CI 0.73, 0.90), respectively, adjusted for admission diagnosis. For patients requiring urgent abdominal exploration, at a census of 25, the adjusted mean time to operation was 0.8 days (95% CI 0.1, 1.5) compared to 2.8 days (95% CI 2.1, 3.5) at a census of 65 patients. ConclusionsDespite an adequate surgical workforce, an increasing mean daily census significantly reduced the use of operative intervention and increased time to operation for patients who needed urgent abdominal exploration. Additional improvements in the surgical ecosystem beyond surgeons are necessary to improve surgical access.

Improving recognition and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi: a quality improvement initiative

ABSTRACT Background Severe acute malnutrition (SAM) is common in low-income countries and is associated with high mortality in young children. Objective To improve recognition and management of SAM in a tertiary hospital in Malawi. Methods The impact of multifaceted quality improvement interventions in process measures pertaining to the identification and management of SAM was assessed. Interventions included focused training for clinical staff, reporting process measures to staff, and mobile phone-based group messaging for enhanced communication. This initiative focused on children aged 6–36 months admitted to Kamuzu Central Hospital in Malawi from September 2019 to March 2020. Before-after comparisons were made with baseline data from the year before, and process measures within this intervention period which included three plan-do-study-act (PDSA) cycles were compared. Results During the intervention period, 418 children had SAM and in-hospital mortality was 10.8%, which was not significantly different from the baseline period. Compared with the baseline period, there was significant improvement in the documentation of full anthropometrics on admission, blood glucose test within 24 hours of admission and HIV testing results by discharge. During the intervention period, amidst increasing patient census with each PDSA cycle, three process measures were maintained (documentation of full anthropometrics, determination of nutritional status and HIV testing results), and there was significant improvement in blood glucose documentation. Conclusion Significant improvement in key quality measures represents early progress towards the larger goal of improving patient outcomes, most notably mortality, in children admitted with SAM.