AUDIT LEAD: DR LINDSAY FORD RCPCH Global Links Paediatrician

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1 AUDIT OF THE MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN MAMA LUCY KIBAKI HOSPITAL AUDIT LEAD: DR LINDSAY FORD RCPCH Global Links Paediatrician June

2 INTRODUCTION Malnutrition is a common cause of admission to the paediatric ward. It carries a high level of morbidity, and is one of the top 5 causes of mortality in the ward. The WHO published guidelines on malnutrition in 2010 with a recent update in 2012 these are adopted by the Kenyan Paediatric Society (see appendix 1). AIM To audit the management of acute malnutrition for children aged > one month admitted to the Mama Lucy Kibaki Hospital during November 2013 to ascertain compliance with National / International Guidance. OBJECTIVES Check appropriate measurements taken for children with malnutrition Check appropriate investigations are taken for children with malnutrition Check appropriate fluid administration Check appropriate use of blood transfusion Check appropriate use of antibiotics Establish if supportive measures are being used appropriately METHODS The audit adopted a retrospective case note review methodology using a structured audit data collection sheet (Appendix 2). The audit sample was derived by reviewing all files of children admitted to the paediatric ward in Mama Lucy Kibaki Hospital in November The inclusion criteria were all infants (> 1 month) and children presenting to Mama Lucy Kibaki Hospital with a clinical diagnosis of malnutrition during November We included only samples of children admitted to hospital. In total we looked at 7 inpatient records. A data input sheet was produced to collect appropriate data from the sources of information. The audit standards were taken from the 2010 WHO guideline and KPA Basic Paediatric Protocol recommendations for the assessment, investigations, management of malnutrition (appendix 1). CLINICAL AUDIT STANDARDS From the current evidence, 18 core clinical audit standards were developed and measured. These are seen in appendix 3. 2

RESULTS Demographics There were 7 admissions with severe acute malnutrition whose records were reviewed - 5 males and 2 females. The median age was 13 months, with a range of 6-33 months.

3 RESULTS Demographics There were 7 admissions with severe acute malnutrition whose records were reviewed - 5 males and 2 females. The median age was 13 months, with a range of 6-33 months. 5 children were discharged alive, and 2 were referred to Kenyatta National Hospital for further management. The median length of stay was 7 days, with a range of 1-11 days. The child staying only 1 day was one of the children who were referred. Diagnosis and initial management 100% of the children diagnosed with severe acute malnutrition had their weight recorded. 86% had a mid-upper arm circumference (MUAC) measured, and 86% also had a Z-score documented. In terms of initial investigations, 100% of children had their temperature, full haemogram and electrolytes. 71% had an RBS checked; 71% had PITC checked; while only 57% had a Chest x-ray. 3

4 There were no children admitted with hypothermia or hypoglycaemia with severe acute malnutrition during the period examined. Dehydration and malnutrition There no children admitted with malnutrition and shock during the period of November Of the children diagnosed as having severe dehydration or some dehydration, 75% were rehydrated using enteral fluids. 25% were given IV fluids, where enteral rehydration would have been more appropriate. Antibiotics 71% of the children with severe acute malnutrition had IV Benzylpenicillin (or Ampicillin) prescribed. Only 41% had oral metronidazole prescribed. Anaemia 1/7 children had a haemoglobin of 4-6/dl and received appropriate transfusion for this. Other supportive management Only 1 of 7 children received Vitamin A. The child who was given vitamin A was given it on day 1 of admission. There were no children with eye signs in whom repeated doses of vitamin would have been indicated. None of the children were prescribed mebendazole for de-worming. Iron and folic acid were not indicated in these children as they were all on F75/F100 or RUTF. DISCUSSION There are a number of positive messages from this audit. 86% of children diagnosed with severe acute malnutrition had a MUAC done. 100% of children had a documented weight in their notes. 86% of children also had a z-score done. We should strive to ensure that all children with malnutrition have both their MUAC and z-score documented in the notes. In terms of investigations, we did well with temperature, FHG and electrolytes, which were done in all children. In particular we need to improve on doing blood glucose in all children admitted with severe acute malnutrition, as hypoglycaemia is lifethreatening in these children, and is easily treated. We need to improve our management of dehydration in children with severe acute malnutrition. Careful fluid management is essential in our children with severe acute malnutrition. 4

5 In terms of administration of antibiotics, 71% of the children received the appropriate medication. Infection is common in these children, and early administration of intravenous antibiotics is an important aspect of their management. Only 41% had oral metronidazole prescribed, although, as per the 2013 WHO book of hospital care for children, this is not an essential part of management, as there is no evidence base for its routine use. Only 1 of the 7 children received vitamin A. We should be ensuring all children with severe acute malnutrition are given vitamin A. KEY POINTS FOR IMPROVEMENT All children should have a weight, height, MUAC and z-score documented on the day of admission Glucose is an essential investigation in children with severe acute malnutrition and must be done at the time of admission All children should receive IV antibiotics All children should receive vitamin A Severe dehydration and some dehydration should be managed with Resomal via NGT/oral STRATEGY FOR IMPROVING PERFORMACE Ensure all staff are familiar with the KPA 2013 guideline for the management og severe acute malnutrition Medical clinicians and nutritionist must work together CME session on malnutrition Re-audit 5

6 APPENDIX 1 6

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9 APPENDIX 2 Severe Acute Malnutrition Audit Proforma Sheet Hospital number Age Gender M F Length of stay Outcome: Died/Alive at discharge/referred DIAGNOSIS (please circle): Marasmus Kwashiorkor Marasmic Kwashiorkor Underweight Eye disease Measurements taken: Z score/muac/weight/height/% weight for length Severity classified: Mild Moderate Severe INVESTIGATIONS ON ADMISSION AND ON WARD (please circle): Temperature If below 35 deg, action taken Y N FHG UEC MPS CXR PITC Stool microscopy Urinalysis Glucose Y/N If Glucose <3, early feed or IV glucose bolus given Y N HYDRATION STATUS ON ADMISSION (please circle): Not dehydrated Some dehydration Severe Shock If dehydrated, what fluid was given? Resomal/ORS/NS/HSD&5%/Ringers/Other/Not prescribed How was fluid given? IV/NGT/Oral Speed of administration (e.g.ml/kg/hr or bolus) If the patient was in shock and given a bolus, did the patient improve after the bolus was given? Improved/Did not improve/no review documented/not shocked If the child did not improve, did the child receive blood? Y N If the child did improve, did they receive another bolus of fluid? Y N 9

10 ANAEMIA: Hb < 4 Y N Hb 4-6 with respiratory distress Y N If yes to either, transfused blood Y N ANTIBIOTICS GIVEN (please circle): X Pen/Gentamicin/Metronidazole/Ceftriaxone/Amikacin/Amoxicillin PO/No ABx OTHER (please circle): Vitamin A given Y N Day of admission prescribed Dewormed? Y N Iron prescribed when gaining weight? Y N Prescribed folate? Y N 10

11 APPENDIX 3 Criteria Standards Exceptions 1 Diagnosis and initial management 1A All children admitted with malnutrition should have their anthropometric measurements taken and classified accordingly 1B All children admitted with malnutrition should have the following recorded: - Temperature - Blood glucose (RBS) - Full haemogram (FHG) - Rapid Electrolytes - PITC - Chest x-ray (CXR) 1C Patients with a temperature of 35degrees or below should have measures instigated to increase the temperature 1D Patients with a blood glucose of <3mmol/l should be treated with 5mls/kg 10% dextrose. Enteral feeds should be commenced as soon as possible 2 Dehydration and malnutrition 2A Only children in shock should receive IV fluids 2B If the child is shocked, they should receive 20mls/kg of Ringers lactate with 5% dextrose over 2 hours. This may be repeated once. 2C If severe anaemia is present with shock, commence an urgent blood transfusion 2D If the child remains in shock after 2 x 20mls/kg of ringers lactate with 5% Z-score 86% MUAC 86% Weight 100% %weight for height 0% Temperature 100% RBS 71% FHG 100% Electrolytes 100% PITC 71% CXR 57% 11

12 dextrose, then they should receive a blood transfusion at 10mls/kg of whole blood over 3 hours. 2E Those with either severe dehydration or some dehydration should be rehydrated with enteral Resomal either orally or via NGT 3 Antibiotics 3A All children with severe acute malnutrition should receive IV Benzylpenicillin (or Ampicillin) and Gentamicin 3B All children admitted with severe acute malnutrition should receive oral metronidazole for 7 days 4 Anaemia 4A All children with severe acute malnutrition with a Hb <4d/dl should be transfused with 10mls/kg of whole blood over 3 hours 4B All children with severe acute malnutrition with a Hb of 4-6g/dl should be transfused with 10mls/kg of whole blood over 3 hours. 5 Other management 75% 71% Allergy to either antibiotic 43% Allergy to metronidazole 100% 5A All children with malnutrition should have vitamin A on admission 14% Those who have already received it during this illness 5B All children with eye signs should have vitamin A on admission, on day 2 and day 14 5C Iron should be prescribed when once a child is gaining weight, if not using RUTF 5D Folic acid should be given to children with malnutrition if they are not taking F75/F100/RUTF 5E All children with malnutrition should be prescribed Mebendazole after 7 days treatment 0% 12

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