WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors

Summary

Background

WHO case-management guidelines for severe malnutrition aim to improve the quality of hospital care and reduce mortality. We aimed to assess whether these guidelines are feasible and effective in under-resourced hospitals.

Methods

All children admitted with a diagnosis of severe malnutrition to two rural hospitals in Eastern Cape Province from April, 2000 to April, 2001, were studied and their case-fatality rates were compared with the rates in a period before guidelines were implemented (March, 1997 to February, 1998). Quality of care was assessed by observation of medical and nursing practices, review of medical records, and interviews with carers and staff. A mortality audit was used to identify cause of death and avoidable contributory factors.

Findings

At Mary Theresa Hospital, case-fatality rates fell from 46% before implementation to 21% after implementation. At Sipetu Hospital, the rates fell from 25% preimplementation to 18% during 2000, but then rose to 38% during 2001, when inexperienced doctors who were not trained in the treatment of malnutrition were deployed. This rise coincided with less frequent prescribing of potassium (13% vs 77%, p<0·0001), antibiotics with gram-negative cover (15% vs 46%, p=0·0003), and vitamin A (76% vs 91%, p=0·018). Most deaths were attributed to sepsis. For the two hospitals combined, 50% of deaths in 2000–01 were due to doctor error and 28% to nurse error. Weaknesses within the health system—especially doctor training, and nurse supervision and support—compromised quality of care.

Interpretation

Quality of care improved with implementation of the WHO guidelines and case-fatality rates fell. Although major changes in medical and nursing practice were achieved in these under-resourced hospitals, not all tasks were done with adequate care and errors led to unnecessary deaths.

Introduction

About 11 million children aged 0–4 years die worldwide every year and 99% are in the developing world.¹ Malnutrition is associated with more than 60% of these deaths¹ and poor hospital care of severely malnourished children contributes to case-fatality rates as high as 50%.2, 3 Guidelines have been developed to help improve the quality of hospital care for malnourished children4, 5 and implementation of these guidelines is one of the goals of the WHO strategy of Integrated Management of Childhood Illness (IMCI). The guidelines highlight ten steps for routine management of children with malnutrition (panel).

This study assessed the feasibility of implementing WHO guidelines for management of severe malnutrition, and their effectiveness in lowering case fatality in two rural district hospitals in South Africa. Before the study, treatment of severe malnutrition in these hospitals was inappropriate and none of the ten steps was adequately practised.⁶ Triage was absent and there were long delays (typically 8 h) in admission of children. Oedematous children were wrongly prescribed diuretics; children with diarrhoea received intravenous fluids indiscriminately, thereby greatly increasing their risk of heart failure; antibiotics were not given routinely; and electrolyte and micronutrient deficiencies were not corrected. Special feeds were not prepared and malnourished children simply received smaller portions of the general adult ward diet. Children went 11 h or more without food at night, placing them at risk of death from hypoglycaemia. Play and stimulation were not provided and there was no continuity of care after discharge. Hospitals lacked many basic resources including nasogastric tubes, vitamin A capsules, multivitamins, and scales (both paediatric and dietary). Furthermore, wards were often cold because of an irregular electricity supply. Hospital staff reported caring for severely malnourished children to be unrewarding and there was no provision for mothers or carers to stay at night. Hygiene was poor. Thus, major changes (nursing, medical, and administrative) were needed to implement the WHO guidelines.

This study was initiated because of concern by the WHO Working Group on Referral Care that the changes required to implement the WHO guidelines for severe malnutrition may be so radical as to be unachievable in rural district hospitals, especially in Africa where resources are often inadequate. Here, we report case-fatality rates before and after a training intervention to implement the guidelines. We also assessed the clinical causes of death and underlying avoidable factors that may have contributed to death. A more detailed account of the feasibility of each component of the guidelines is to be published separately.