AimsA prospective descriptive study was carried out to determine the causes and associated risk factors for childhood death,in a large government hospital in Malawi, Africa.Method: A proforma was written based on the South African Child Healthcare Problem Identifier form, a form devised to audit deaths in order to reduce mortality. We completed the proforma for every death that occurred in the study hospital between December 2015 and August 2016, collecting data on age, sex, HIV status, nutritional status, cause of death, blood and CSF culture, underlying medical factors and any other modifiable factors that may have affected the outcome. Date was collected contemporaneously and from patient files.ResultsThere were 376 inpatient deaths out of 11 086 admissions, giving a mortality rate of 3.4%. There were an additional 58 children brought in dead. One third of deaths (128) occurred in the first 24 hours of admission.There were 186 male deaths and 188 female deaths (n=374). Thirteen percent of deaths (48) occurred in the neonatal period (under 28 days), with a large proportion in the under ones (43%, 159).The most common cause of death was sepsis (85, 23%, of which 28 were neonatal sepsis), followed by lower respiratory tract infection (50, 13%), gastroenteritis (32, 9%),meningitis (29, 8%) and malaria (27,7%). In those children who were brought in dead it was gastroenteritis (14, 24%) followed by malaria (8, 14%) and sepsis (6, 10%).Of the patients with a known HIV status, 106 (38%) were either HIV positive or exposed at birth, compared with 1%–2% of the paediatric population in Malawi. Seventy-six patients (20%) had evidence of malnutrition (marasmus, kwashiorkor or marasmus-kwashiorkor).ConclusionThis study highlights the ongoing burden of infectious disease in Malawi, with the top 5 causes of death all being infection related and a very high proportion of deaths in HIV infected or exposed patients. However, it does show a much lower hospital mortality rate then was seen in adults patients in Malawi in 2009 (14.6%) and is comparable to the paediatric South African death rate of 2.4%.
Retention of medical information is often poor, especially when patients or parents are anxious. Patients often focus on diagnosis-related information and fail to register instructions on treatment. Retention is improved with written information.Patient experience feedback was collected using visual aids to engage patients. Communication was highlighted as an area for improvement.We present the use of bedside patient-led Communication (Comms) charts to improve communication between patients, parents and staff. This tool was implemented on a district general hospital Paediatric Ward with 15 inpatient beds. (See Figure 1).Abstract G548(P) Figure 1The ‘Comms Charts’ were ‘co-designed’ by patients, medical professionals, play therapists and a hospital schoolteacher. ‘Co-design’ is a process where health-care professionals work in partnership with service-users. Evidence suggests this can produce sustainable, cost-effective improvements.The ‘Comms Charts’ incorporated patient and parent-prioritised information. The tools were designed in a gender-neutral and child friendly layout. Information included: ‘I want to be called’, ‘facts about me’, ‘today I’m going to (goals)’, ‘I’m aiming to go home’, and ‘questions I want to ask’.Staff received training regarding the use of this tool. All members of the multidisciplinary team were responsible for updating and reviewing the ‘Comms Charts.’ Staff were encouraged to incorporate this process into daily routine. Champions were identified to improve sustainability of this tool. Patients were provided with whiteboard pens and the laminated sheets could be re-used.The ‘Comms Charts’ were implemented over a 3 month period. The intervention was assessed via quantitative and qualitative feedback to assess acceptability and feasibility. Staff were surveyed pre and post-intervention using a questionnaire. 11 of 15 healthcare professionals surveyed (73%) believed communication needed to be improved pre-intervention. Following intervention, 14 of 21 surveyed (67%) believed communication had improved. 18 of 21 surveyed (86%) stated it was an effective tool to aid communication, and 1 of 21 (5%) thought it led to excessive work. 18 of 21 surveyed (86%) believed it served as a useful prompt for on-going evaluation of patient’s healthcare.Qualitative data was collected from parents, patients and staff via semi-structured interviews. Staff included Doctors, Nurses, Physiotherapists, Play therapists and a School Teacher. Informed consent was obtained. Recurring themes highlighted on thematic analysis included: Improvements to information sharing and communication, and breaking down of barriers.Improved communication“It was very useful, I was able to mention my concerns and worries. We discussed and wrote the questions which were in my mind. Excellent idea” (Parent)“it can be a very useful tool for communication with all team members and family” (Physiotherapist)“Patients have appreciated them” (Teacher)Breaking down barriers“They make me feel welcome and at ease. I have gained more information...
ContextWe present the development and evaluation of WhatsApp messaging to improve engagement adolescents with Type 1 Diabetes Mellitus at a District General Hospital in West London District.ProblemAdolescence is a particularly challenging time where metabolic control often deteriorates. Many adolescents find diabetes socially isolating. Engagement and compliance are challenging issues and traditional healthcare models don’t always seem relevant to this population. This issue was highlighted when a patient was admitted to resus with severe diabetic keto-acidosis who was text-messaging on her mobile phone and disclosed she missed her last clinic appointment.The way patients are accessing health information is changing. Social media is a rapidly expanding and under-utilised resource. Now more people world-wide have access to mobile phones than tooth-brushes.Intervention and assessment of problemThe concept of a WhatsApp broadcast was developed. This virtual community allows information to be disseminated quickly to a large group of patients without individuals feeling singled out. The group allows patients to share information and expertise in self-management, ask questions and form relationships with peers, with the aim of bridging gaps between appointments and improving motivation and self-management.Patients participated in the design process through a co-production session using a graphic facilitator to stimulate strategic dialogue. Co-production is where health-care providers and service users work together to identify problems and solutions to improve their care. The session was attended by 6 patients and 4 staff members. Patients believed this concept would improve patient motivation.DesignAll children with type 1 diabetes aged 11 years or greater were invited to participate in the WhatsApp group from March 2015. Twenty patients and 4 staff are now members. Informed consent was obtained from children and parents. Patient safety is maintained as the group is a ‘broadcast’ rather than an ‘open group,’ therefore replies are directed to the diabetic team phone, who have to approve messages sent ensuring quality control.Measurement of improvement and outcomesQualitative and quantitative data was collected to assess patient experience. Feedback was overwhelmingly positive.Patients send messages to the group, such as ‘snack advice.’ They write questions and send pictures for their peers. ‘Patient user’ sent messages increased from 7 messages in April to 88 messages in August 2015 demonstrating increasing user engagement.Qualitative data was obtained from patients and parents using questionnaires and semi-structured interviews. Recurring themes highlighted on thematic analysis included improved access to information and the benefits of talking to others with diabetes.One mother quoted ‘This is what my son needs, he knows no one with diabetes and often feels he is the only one who has to inject then acts out.’A patient quoted ‘I find it easier to ask questions on the WhatsApp group [compared to clinic].’All (100%) of s...
The incidence of Type 1 diabetes (T1DM) in Malawian children is unknown, however as healthcare improves the burden of non-communicable diseases such as diabetes is rapidly increasing. It has been widely believed that diabetic-ketoacidosis (DKA) is an overlooked cause of child mortality due to misdiagnosis and death prior to hospital. The Glycaemic control of Malawian children and adolescents with T1DM has never been evaluated. To improve services for diabetic patients, it is important to audit current practice and outcomes to support quality improvement.This audit aims to assess care processes, access to insulin and current regime, glycaemic control, complications of diabetes, patient factors and socio-economic status. These were audited against the IDF resource limited setting guidelines.A retrospective review of patient notes and diabetic register of the 57 registered patients from 2015–2016. There were 34 males and 23 females ranging from 4–20 years. The median age of diagnosis was 10 years..Ninety five percent of patients had a HBAlc in the last year. Seventy four percent had had a urine dipstick. Thirty five percent had had an ophthalmology review. Twenty eight percent had had a blood pressure. The median HbA1c for the study population was 11.4%. Overall only 16% of patients had reasonable control. One out of 20 5% had evidence of eye changes related to diabetes. Fifty one percent had microalbuminuria on urine dipstick, 28% had macroalbuminuria. Two patients had neurological complications. The median BMI was 17.6. There were 11 hospital admissions with DKA, four of these were new diagnoses. There was one 1 death due to DKA thought to be due to out of date insulin. There was no significant difference in HBA1c related to economic status. Surprisingly those with higher parental education had worse HBAlc (12 vs 10.9). Patients with access to a fridge also had worse glycaemic control (12 vs 10.6). Children living in rural areas had better HBAlc than those living in urban areas. Glycaemic control was better in children who had the diagnosis of diabetes longer.ConclusionThe management of T1DM can be challenging in resource-limited settings. The median HbAlc is comparable to other studies in low resource settings.
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