حسابرسی مرگ کودکان در یک بیمارستان بزرگ مالاوی A pediatric death audit in a large referral hospital in Malawi

Background The path to pediatric mortality in the developing world is complex, with myriad modifiable factors that can serve as public health intervention points. Programs directed at reducing child mortality have traditionally focused on the areas of prevention and improving access to care. More recently, the impact that acute and inpatient hospital care has on child mortality has been recognized, and opportunities for improvement have been described [1–5]. To successfully implement care improvement plans, existing systems must be objectively assessed and components amenable to intervention identified. However, accurate record keeping is often a challenge in low-resource settings. The paucity of reliable information about in-hospital care leads to further challenges in evaluating barriers to treatment, and in creating and assessing quality improvement interventions. The lack of valid vital statistics in the developing world often leaves many deaths unaccounted for, and the lack of accurate information regarding patient’s cause of death complicates the ability to plan for, fund, and assess interventions [6, 7]. Audits of deceased pediatric patient files have been shown to be a useful tool in creating sustainable hospital Quality Improvement initiatives in lowresource settings [8–10]. Malawi is a resource-poor, malaria-endemic country in sub-Saharan Africa, consistently ranked among the least developed in the world. Approximately 62% of its 16.7 million inhabitants live below the international poverty line of $1.25 USD (US Dollar) per day. Despite its challenges, great strides have been made in improving the health of children in Malawi in the last few decades. Malawi has reached its fourth Millennium Development Goal, a two-thirds reduction in childhood mortality, before the target date of 2015 [11]. The World Health Organization (WHO) reports that Under-five mortality was 71/1000 in 2013, compared to 245/1000 in 1990. However, although Malawian pediatric patients are accessing clinical care at an increasing rate, the clinical standards set forth by the WHO for some common illnesses are being inconsistently adhered to in hospitals nationwide [11]. Kamuzu Central Hospital (KCH) is a tertiary referral hospital in Lilongwe, Malawi, which serves the central region of the country and a population of approximately 5 million people. The pediatric ward of the hospital admits between 40 and 120 patients per day, with significant seasonal variation related to malaria burden and food insecurity. Medical record keeping has traditionally been inconsistent; charts are hand-written when paper is available and held by the pediatric patient’s caregiver. There is no electronic medical record. Deaths are recorded in a ledger by an administrative layperson, with a presumed cause of death as diagnosed by the evaluating clinician. To date, no comprehensive effort has been made at investigating modifiable factors that may contribute to pediatric mortality at KCH. We report the results of the first known audit of pediatric death files conducted at this hospital. In the absence of reliable record-keeping, the objective of this study was to describe the patients who died in the hospital, evaluate the emergency and inpatient care provided to them, and identify gaps in their care that may have contributed to their mortality.