Hospital admissions from a pediatric HIV care and treatment program in Malawi.

BACKGROUND: The scale up of pediatric antiretroviral treatment programs across Sub-Saharan Africa over the last decade has brought increasing numbers of children into HIV care. This patient population requiring life-long care presents new challenges in the outpatient and inpatient settings. We sought to describe hospitalizations from a large pediatric HIV treatment facility to better understand the scope of the situation and identify areas for improved care delivery. METHODS: We conducted a retrospective case series of all HIV-infected and exposed patients <18 years enrolled at Baylor College of Medicine Children's Foundation Malawi, from October 2004-October 2010. Patients admitted to the hospital on or after the day of enrollment were included. Data were extracted from electronic clinic records. Analysis was done at the patient and admission level, as some patients had multiple admissions. RESULTS: Of 5062 patients enrolled in care, 877 (17.3 %) had 1137 admissions at median age 24 months (IQR: 12-62). 191 (21.8 %) patients had multiple admissions. A high proportion of admissions occurred in patients under two years (49.4 %), those within one month of clinic enrollment (32.9 %), those with severe immune suppression (44.0 %), and those not on ART (48.5 %). The frequency of primary admission diagnoses varied across these same variables, with malnutrition, pneumonia, and malaria being the most common. CONCLUSIONS: Illness requiring hospitalization is common in HIV-infected and exposed children and these results reinforce the need for a comprehensive care package with special attention to nutrition. Strengthened programs for malaria prevention and expanded access to pneumococcal vaccine are also needed. The high burden of admissions in children under 24 months and those newly enrolled in care suggests a need for continued improvement of early infant diagnosis and provider-initiated testing programs to link patients to care before they are symptomatic. Similarly, the high proportion of admissions in those not yet started on ART emphasizes the importance of rapid initiation of ART for eligible pediatric patients.

Decreased pediatric hospital mortality after an intervention to improve emergency care in Lilongwe, Malawi.

BACKGROUND AND OBJECTIVE: Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in the developing world. This deficiency contributes to high inpatient mortality rates, particularly early during hospitalization. Our referral hospital in Lilongwe, Malawi, experiences high volume, acuity, and mortality rates. The entry point to our hospital for most children presenting with acute illness is the Under-5 Clinic. We hypothesized that early inpatient mortality and total inpatient mortality rates would decrease with an intervention to prioritize and improve pediatric emergency care at our hospital. METHODS: We implemented the following changes as part of our intervention: (1) reallocation of senior-level clinical support from other areas of the hospital to the Under-5 Clinic for supervision of emergency care, (2) institution of a formal triage process that improved patient flow, and (3) treatment and stabilization of patients before transfer to the inpatient ward. We compared early inpatient and total inpatient mortality rates before and after the intervention. RESULTS: After the intervention, early mortality decreased from 47.6 to 37.9 deaths per 1000 admissions (relative risk 0.80, 95% confidence interval 0.67-0.93). Total mortality also decreased from 80.5 to 70.5 deaths per 1000 admissions after the intervention (relative risk 0.88, 95% confidence interval 0.78-0.98). CONCLUSIONS: Simple, inexpensive interventions to improve pediatric emergency care at this underresourced hospital in sub-Saharan Africa were associated with decreased hospital mortality rates. The description of this process and the associated results may influence practice and resource allocation strategies in similar clinical environments.