Date Published: January 25, 2019
Publisher: Public Library of Science
Author(s): Robert O. Opoka, Andrew S. Ssemata, William Oyang, Harriet Nambuya, Chandy C. John, Charles Karamagi, James K. Tumwine, Ana Paula Arez.
In resource limited settings, there is variability in the level of adherence to clinical guidelines in the inpatient management of children with common conditions like severe anemia. However, there is limited data on the effect of adherence to clinical guidelines on inpatient mortality in children managed for severe anemia.
We analyzed data from an uncontrolled before and after in-service training intervention to improve quality of care in Lira and Jinja regional referral hospitals in Uganda. Inpatient records of children aged 0 to 5 years managed as cases of ‘severe anemia (SA)’ were reviewed to ascertain adherence to clinical guidelines and compare inpatient deaths in SA children managed versus those not managed according to clinical guidelines. Logistic regression analysis was conducted to evaluate the relationship between clinical care factors and inpatient deaths amongst patients managed for SA.
A total of 1,131 children were assigned a clinical diagnosis of ‘severe anemia’ in the two hospitals. There was improvement in the level of care after the in-service training intervention with more children being managed according to clinical guidelines compared to the period before, 218/510 (42.7%) vs 158/621 (25.4%) (p < 0.001). Overall, children managed according to clinical guidelines had reduced risk of inpatient mortality compared to those not managed according to clinical guidelines, [OR 0.28, (95%, CI 0.14, 0.55), p = 0.001]. Clinical care factors associated with decreased risk of inpatient death included, having pre-transfusion hemoglobin done to confirm diagnosis [OR 0.5; 95% CI 0.29, 0.87], a co-morbid diagnosis of severe malaria [OR 0.4; 95% CI 0.25, 0.76], and being reviewed after admission by a clinician [OR 0.3; 95% CI 0.18, 0.59], while a co-morbid diagnosis of severe acute malnutrition was associated with increased risk of inpatient death [OR 4.2; 95% CI 2.15, 8.22]. Children with suspected SA who are managed according to clinical guidelines have lower in-hospital mortality than those not managed according to the guidelines. Efforts to reduce inpatient mortality in SA children in resource-limited settings should focus on training and supporting health workers to adhere to clinical guidelines.
Severe anemia (SA) is a common cause of childhood morbidity and mortality in resource-limited settings. It accounts for 9–29% of total pediatric admissions and 8–17% of hospital deaths in sub-Saharan Africa [1–6]. According to clinical guidelines from the World Health Organization , the management of severe anemia (SA) involves: confirmation of the diagnosis via measurement of hemoglobin (Hb) level; investigation of the specific cause of anemia via appropriate diagnostic tests (such as absolute reticulocyte count, blood smear); and prompt provision of a blood transfusion (if indicated) to correct the severe anemia and additional treatment for the specific cause of the SA . However, in resource-limited settings, there are many challenges involved in the provision of care to critically ill children such as those with SA. In these settings, blood is often not available for transfusion and, when available, there is often considerable delay in receipt of blood [8, 9]. Other challenges include inadequate laboratory and clinical investigation to support/confirm the SA diagnosis and etiology, lack of essential supplies and medicines, and disregard of laboratory results by clinicians . The above challenges are compounded by human resource problems such as staff shortages and lack of skills required for resuscitation of critically ill children, including patients with SA .
A total of 1,131 cases were managed for SA in the two hospitals during the study period. The mean age was 2.1 (SD 1.3) years with a slight male preponderance of 654 (57.8%). The mean age, gender distribution, co-morbid diagnoses, blood transfusion rates and duration of hospitalization were similar between children managed and those not managed according to clinical guidelines (Table 2). Amongst children whose time of admission was available, a higher proportion of those managed according to clinical guidelines presented during the day shift, 123/223 (55.2%) vs 176/401(43.9%), while a higher proportion of children not managed according to clinical guideline presented during the night shift, 67/401 (16.7%) vs 22/223(9.9%) (Table 2).
We evaluated the effect of adherence to clinical guidelines on inpatient mortality among children managed for SA. Our study found that adherence to clinical guidelines reduced inpatient mortality in children with suspected SA by 72%. Similarly, for children with severe acute malnutrition, a recent meta-analysis also found that management according to WHO guidelines reduced inpatient deaths by 41% . Taken together these findings highlight the important role that adherence to clinical guidelines plays in determining inpatient outcomes for critically ill children in resource-limited settings.