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Treating severe malnutrition: implementing clinical guidelines in South African hospitals
Ann Ashworth Hill
2005-02-11
According to the World Health Organization malnutrition is associated with about 60 percent of deaths in children under five years old in the developing world.
The WHO has developed guidelines to improve the quality of hospital
care for malnourished children in order to reduce deaths. The guidelines
suggest ten steps for routine management of severe malnourishment. These
will require most hospitals to make substantial changes.
The London School of Hygiene and Tropical Medicine, together with the
University of the Western Cape, and the Health Systems Trust, South Africa
conducted a study in two hospitals - Mary Theresa and Sipetu - in rural Eastern
Cape Province, South Africa. The study was designed to assess the extent to
which the guidelines have been implemented and whether they have reduced
fatality rates among children diagnosed with severe malnutrition.
In 1998, two day workshops for hospital staff were held to help them begin
implementing the guidelines. All 193 children with severe malnutrition
admitted to the pediatric wards of both hospitals between April 2000 and April
2001 were studied. Researchers compared fatality rates during this period
with those during a one year period before staff training.
Findings from the study include:
- Staff at both hospitals were able to make many of the changes needed to
implement the guidelines, despite limited resources. However tasks
were not always performed fully or well.
- The most difficult practice changes to achieve were the introduction of a
triage system and the provision of zinc and copper supplements for children.
Two of the guidelines the provision of structured play and community
follow-up - were not implemented.
- Fatality rates at Mary Theresa Hospital fell from 46 percent to 21 percent
after implementation of the guidelines.
- Fatality rates at Sipetu Hospital fell from 25 percent before
implementation to 18 percent after April 2000. They then rose to 38
percent in 2001 after new doctors who had not received the required training
were taken on.
- In the two hospitals, 46 severely malnourished children died during the
study period. Of these deaths, 37 were judged to be avoidable: half were
attributed to doctors' errors and 28 percent to nurses' errors. A common
error was failure to prescribe appropriate antibiotics.
- 43 percent of the deaths were caused by sepsis, 22 percent by dehydration
and 15 percent by electrolyte imbalance and over hydration.
The findings show that implementation of the guidelines, though imperfect, is
feasible and can reduce the number of children dying from severe malnutrition.
If the avoidable deaths had been prevented, the fatality rates at Sipetu and
Mary Theresa hospitals would have been five and four percent respectively. The
main failures were not because of problems with the guidelines but because of
clinical errors and health system weaknesses. Several clear policy lessons
emerge:
- Medical training should equip young doctors to treat the conditions they
will encounter. In Africa the guidelines should be part of the medical
and nursing curricula.
- Ways must also be found to prepare young doctors and nurses for working in
under-resourced and under-staffed hospitals.
- Developing and disseminating clinical guidelines is not enough. Efforts to
improve quality of care must be accompanied by efforts to strengthen the
health system and improve leadership at local and central levels.
- Interventions such as supervised practice, audit and feedback, and
reminder systems could provide better support and supervision for staff.
- In South Africa, even these interventions may have limited effectiveness,
because of rapid staff turnover, emigration, sickness and the death of
public health staff.
A clinical approach to improving the quality of care must be accompanied by
efforts to improve health systems and management. Such initiatives would
also benefit the quality of care of other patients, not only severely
malnourished children.
Source (s) and Links:
WHO guidelines for management of severe malnutrition in rural South African hospitals: effects on case fatality and the influence of operational factors, The Lancet 363 (9415): 1110-1115, by A Ashworth et al, 2004 http://www.thelancet.com/
'Management of severe malnutrition: a manual for physicians and other senior health workers', World Health Organisation: Geneva, 1999
http://www.who.int/nut/documents/manage_severe_malnutrition_eng.pdf
'Caring for severely malnourished children', Macmillan Education, by A. Ashworth and A. Burgess, 2003
http://www.talcuk.org/catalog/product_info.php?products_id=294&osCsid=ed1ad00889b3c5b47230c560131d7ad5
London School of Hygiene and Tropical Medicine, UK
http://www.lshtm.ac.uk/
University of Western Cape, South Africa
http://www.uwc.ac.za/
Health Systems Trust, South Africa
http://www.hst.org.za/uploads/files/kwiksk16.pdf
(Source: ID21 highlight, February 4, 2005)
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