AUDIT LEAD: DR LINDSAY FORD RCPCH Global Links Paediatrician

Transcription

1 AUDIT OF THE MANAGEMENT OF CHILDREN WITH GASTROENTERITIS IN MAMA LUCY KIBAKI HOSPITAL AUDIT LEAD: DR LINDSAY FORD RCPCH Global Links Paediatrician June

2 INTRODUCTION Gastroenteritis (GE) is a common diagnosis. There is often variability in choice of fluids prescribed with regard the degree of dehydration in the patient. Children with GE are commonly seen and discharged from our emergency department and some may be subsequently admitted to the ward. There is clear guidance from the Kenyan Paediatric Association and WHO regarding management of GE in children. This audit looks at the management of GE as specified in the 2013 KPA Basic Protocols Book (see appendix 1). AIM To audit the management of gastroenteritis for children aged > one month admitted to Mama Lucy Kibaki Hospital during November 2013 to ascertain compliance with National Guidelines on management of GE. OBJECTIVES To ensure appropriate classification of dehydration was undertaken To ensure timely re-evaluation of patients with Shock and severe dehydration To ascertain whether appropriate fluids were prescribed as per classification To assess whether all children with GE had Zinc Sulphate prescribed METHODS The audit adopted a retrospective case note review methodology using a structured audit data collection sheet (appendix 2). The audit sample was derived from patients admitted to the ward. This report does not include patients seen in OPD or casualty and discharged. All files for children admitted to the Paediatric ward in November 2013 were examined. Those with a diagnosis of gastroenteritis were identified. In total we looked at 30 inpatient records. CRITERIA In total there were 11 audit criteria taken from the KPA guidelines. These are shown in appendix 3. RESULTS Demographics There were 30 cases reviewed, with 14 males and 16 females. The median age was 13months, with a range of 4 72 months. The median length of stay was 3 days, with a range from <1 day to 10 days. 2

3 27 (90%) of the patients were discharged alive. 1 patient (3%) was referred to Kenyatta National Hospital for ongoing management and 2 patients died (7%). Classification of dehydration 29/30 (97%) of patients had the severity of their dehydration classified. Of those classified with Shock, 100% (2/2 patients) were correctly classified. Of those diagnosed with severe dehydration (4/12) 25% were correctly classified. Of those diagnosed with some dehydration, 40% were correctly classified. There were no patients admitted to the ward with a diagnosis of GE with no dehydration. Of those incorrectly classified as having severe dehydration, in 5 of the 9 cases, the diagnosis should have been some dehydration, and in 4 cases, they should either have been some dehydration or no dehydration. From the documentation available, it was not possible to distinguish between some dehydration and no dehydration. Fluid management Both patients diagnosed with shock were correctly treated with 20mls/kg of Ringers Lactate over 15minutes. 3

4 Of those patients diagnosed with severe dehydration, 33% were correctly treated with Plan C (30mls/kg of Ringers Lactate over 30minutes if >1 year or over 60minutes if <1 year; then 70mls/kg of Ringers Lactate over 2.5 hours if > 1year or over 5 hours if < 1year. OR Nasogastric tube rehydration with 100mls/kg of Oral Rehydration Solution over 6 hours). Of those diagnosed with Severe dehydration, who were not given the correct treatment (77%), the following were prescribed: - Plan A in 3/8 - Plan B in 2/8 - Plan B and C together at the same time 1/8 - Maintenance fluid 1/8 - No fluids 1/8 Those diagnosed with some dehydration were given the correct fluid management in 73% of cases. Of those diagnosed with some dehydration who were not given the correct fluid management (27%), the following were prescribed: - Plan A 1/4 - Plan C 1/4 - No fluids 2/4 None of the children with Shock or Severe dehydration had a documented review after 30minutes. Zinc Sulphate 4

5 77% of the patients admitted with gastroenteritis were prescribed zinc sulphate. Symptoms The median number of days of symptoms before admission to hospital was 4 days, with a range of 2-14 days. 2/30 children were reported to have bloody diarrhoea. Neither of these children received antibiotic therapy for dysentery 21/30 (70%) children had a history of fever. In 2 cases it was not documented whether there was fever or not. 22/30 (73%) of children had a history of vomiting prior to admission. DISCUSSION Nearly all children are having a classification documented in relation the severity of their dehydration. Shock was correctly diagnosed. However both severe dehydration and some dehydration are being regularly mis-classified. This means that they are unlikely to receive the appropriate fluid therapy for their clinical condition. Of the 2 children who died, one was classified correctly as being in shock and given the initial correct treatment. The other child who died had been correctly classified as having severe dehydration, but only received plan A. Most of the cases incorrectly diagnosed as severe dehydration should have been classified as some or no dehydration. This means a number of children may have received IV fluids, when oral rehydration solution would have been appropriate. There is a higher risk of morbidity with intravenous fluids, and enteral fluids should be used whenever it is possible and appropriate. The initial fluid management in shock was correct in both patients. The fluid management in severe dehydration is done less well. 77% of children with severe dehydration diagnosed did not receive the correct fluid management. It is also worth noting that all children given plan C were given IV Ringers lactate. 25% of the children classified as severe dehydration did not have vomiting, and therefore in these children it is likely that NG rehydration as per plan C would have been appropriate. 4 children (27%) of children with some dehydration did not receive the correct fluid. In 2 cases there was no fluid prescribed, and no plan to give fluid (oral rehydration solution) documented. It may be that clinicians are giving the advice regarding oral rehydration solution to parents, but not documenting it. None of the children with Shock or severe dehydration had a review documented at 30 minutes. It is unclear if the reviews are happening and not being documented, or if the reviews are not being done. This is an area which we must improve on, reassessment and documentation of that reassessment is essential in the management of these patients. 5

6 77% of patients were given zinc sulphate. This can be improved upon. Again, it may be that a lack of good documentation is contributing to this figure. KEY POINTS FOR IMPROVEMENT All patients with gastroenteritis must be prescribed Zinc sulphate on the treatment sheet IV fluids should only be used when indicated. Those patients with some dehydration do not require IV fluid All children with Shock and Severe dehydration require a review at 30minutes. STRATEGY FOR IMPROVING PERFORMANCE Ensure all staff aware of KPA protocol CME session on the management of gastroenteritis Re-audit 6

7 APPENDIX 1 7

8 APPENDIX 2 Gastroenteritis audit tool HOSPITAL NO: SEX:M/F LOS OUTCOME: DISCHARGED/DIED/REFERRED AGE AT ADMISSION.. CATEGORY OF GE: SHOCK SEVERE DEHYDRATION SOME DEHYDRATION NO DEHYDRATION CATEGORISED APPROPRIATELY: Y..N.. PRESCRIBED FLUIDS: Y N PRESCRIBED PLAN A PLAN B PLAN C BOLUS FOR SHOCK PRESCRIBED FLUIDS APPROPRIATELY: Y N REASSESED AFTER 30MINUTES IF IN SHOCK/ SEVERE DEHYDRATION: Y N PRESCRIBED ZINC SULPHATE ON ADMISSION: Y.N. IF DYSENTRY PRESCRIBED ANTIBIOTICS: Y.N.N/A STOOL ANALYSIS DONE: Y.N.N/A. WATERY DIARRHOEA BLOODY DIARRHOEA VOMITING FEVER LENGTH OF SYMPTOMS 8

9 APPENDIX 3 Criteria Standards Exceptions 1 Classification of dehydration 1A Patients should be classified as Shock, Severe dehydration, Some dehydration or no 97% dehydration 1B Patients classified as having Shock should have all 4 of: 100% AVPU less than A Weak/absent pulse Cold hands + temperature gradient Capillary refill > 3 seconds + sunken eyes and slow skin pinch 1C Patients classified as having Severe dehydration should have: 25% Unable to drink OR AVPU > A with: Sunken eyes Return of skin pinch >2seconds 1D Patients classified as having Some dehydration should have: Ability to drink and 2 or more of: Sunken eyes Skin pinch 1-2seconds Restlessness/irritability 1E Patients classified as No dehydration should have: Diarrhoea/GE with fewer than 2 of the above signs of dehydration 2 Fluid Management 2A Patients classified as having shock with GE should receive Ringers Lactate 20mls/kg over 15minutes. This may be repeated a 2 nd time if required 40% n/a 100% Severe acute malnutrition 2B Patients classified as having severe dehydration should receive Plan C. Either: 50% Severe acute malnutrition 9

10 30mls/kg of Ringers Lactate over 30minutes if >1 year or over 60minutes if <1 year. Then 70mls/kg of Ringers Lactate over 2.5 hours if > 1year or over 5 hours if < 1year OR Nasogastric tube rehydration with 100mls/kg of Oral Rehydration Solution over 6 hours 2C Patients classified as having some dehydration should receive Plan B 73% Severe acute malnutrition 75mls/kg of Oral rehydration solution over 4 hours Plus continued breast feeding as tolerated 2D Patients classified as having no dehydration should receive Plan A n/a Severe acute malnutrition 10mls/kg of Oral rehydration solution after every loose stool Plus continued breast feeding and encourage feeding if > 6months 3 Zinc Sulphate 3A All children with gastroenteritis should be prescribed Zinc sulphate 77% 4 Reviews 4A All patients with shock or severe dehydration should be reviewed after 30 minutes 0% 10