Audit of the current standard of care For children admitted to Mbagathi District hospital with severe Malnutrition
BACKGROUND: Inappropriate case management of severe malnutrition is believed to be one of the main reasons why high case fatality rates (20-30%) persist worldwide. In 1999, the WHO developed guidelines for the management of severe malnutrition which have shown to reduce mortality rate of children .These guidelines have been adopted by the ministry of health in Kenya in the Basic Paediatric Protocols. OBJECTIVE: The objective of this study was to evaluate the use of the World Health Organization guidelines for the treatment of children with severe acute malnutrition at Mbagathi District Hospital. METHODOLOGY: A prospective audit of care given to 102 children aged 6-59 months admitted to Mbagathi District Hospital with severe malnutrition was carried out over a period of 4 months between June 2012 and September 2012. Consecutive sampling of study subjects was done until the desired sample size was achieved. Relevant information was extracted from medical records and entered in a structured data collection tool which allowed assessment of WHO steps 1-8 of management of severe acute malnutrition. Additional information was collected through daily observations in the ward and interviews with care givers and health workers. RESULTS A total of 102 children were recruited. The male: female ratio was 1:1 and the median age was 13 months. The majority (84.3%) of the children were aged below 24 months out of whom 47.5% were aged below 12 months. Overall, 77.5% of children had marasmus, 12.7% had kwashiorkor and 9.8% had marasmic kwashiorkor. The initial steps (steps 1,2 and 3) of stabilization, which were essential for the survival of these children, were poorly implemented and inappropriately provided. The least implementation was in step I where none of the children were fed within one hour and there was a delay in initiating feeds with a median time of 12.3 hours from the time of admission. Less than half of the children were appropriately managed as per Step 3 (48.3%, 95%CI42.7-65.1) and step 8 (40.8%, 95%CI 33.7-47.8).There was modest implementation of Step 2 (78.6%, 69.1-86.1) and Step 6 (68.8%, (95%CI 60.4-78.2). The highest implementation was in Step 4 (96.1%, (95%C1 90.3-98.9), Step 5 (92.2%, 950/oC185.1-95.6) and step 7 (92%, (95%C182.7-95.2). Overall essential supplies were mostly available. CONCLUSIONS The management of children with severe malnutrition at Mbagathi District Hospital is inadequate and WHO guidelines are not adequately followed. Essential supplies needed for the management of these children are mostly available. RECOMMENDATIONS Continued training of health care workers in the use of the WHO guidelines and further studies to assess barriers to utilization of the WHO protocol which will help identify gaps which can be addressed.