Improving adherence to severe malaria treatment guidelines in children at a Ugandan regional hospital: assessment of a quality improvement initiative.

BACKGROUND: Malaria is the leading cause of hospitalizations and death in Uganda, particularly in children under the age of five. Studies have shown that adherence to the World Health Organization (WHO) guidelines for the management of severe malaria reduces mortality in hospitalized children. This study aimed to determine the impact of targeted interventions on adherence to the WHO severe malaria treatment guidelines in children at a Ugandan hospital as part of a quality improvement initiative. METHODS: Interventions included workflow changes, such as obtaining patient blood samples for diagnostic testing by the admitting healthcare provider as well as utilizing patient caregivers to assist nursing staff in timing medications. An additional intervention was the use of an admission checklist sticker. The post-intervention sample was compared to the baseline assessment. The primary outcome was the proportion of patients receiving care consistent with all aspects of the WHO guidelines. Secondary outcomes included the proportion of patients receiving malaria diagnostic testing, those receiving at least 3 doses of artesunate, the timely administration of artesunate, and adherence to other guideline components. Statistical analyses were conducted using GraphPad PRISM 9.0. Comparisons between groups were analysed using Chi-square or Fisher's exact test for categorical variables and Mann-Whitney test for continuous variables. RESULTS: The post-intervention group included 230 patients with a median age of 5 years [4-8], and 58% of patients were male. Adherence to all aspects of the WHO guidelines was achieved in 10% of patients in the post-intervention group compared to 3% of patients in the baseline (P = 0.007). Appropriate malaria diagnostic testing was performed in 85% of patients post-intervention compared to 66% of patients in the baseline (P < 0.0001). Patients in the post-intervention group were more likely to receive the minimum 3 doses of artesunate (86%) than in the baseline (74%) (P = 0.008). Patients in the post-intervention group were more likely to receive artesunate doses on time than in the baseline (dose 2 P = 0.02, dose 3 P = 0.003). CONCLUSIONS: Targeted, low-cost interventions led to improvement in adherence to severe malaria treatment guidelines. The most notable changes were in malaria diagnostic testing and antimalarial administration.

Resurgence of blackwater fever among children in sub-Saharan Africa: a scoping review protocol.

INTRODUCTION: Blackwater fever (BWF), a complication of malaria, has in the past been considered as a rare complication of malaria in children living in high transmission settings. More recently, however, a growing number of paediatric clusters of BWF cases have been reported predominantly in sub-Saharan Africa (SSA). The aim of this study is to map evidence on BWF among children in SSA from 1 January 1960 to 31 December 2021. METHODS AND ANALYSIS: This review will be guided by Arksey and O' Malley's methodological framework for scoping reviews with methodological refinements by Levac et al and will comply with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews' guidelines. Five electronic databases (MEDLINE via PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO) will be systematically searched using predefined keywords. In addition, reference lists of included articles will be searched. Our multidisciplinary team has formulated search strategies and two reviewers will independently complete study eligibility screening, final selection and data extraction. A third reviewer will adjudicate the final decision on disputed articles. Bibliographic data and abstract content will be collected and analysed using a data-charting tool developed iteratively by the research team. ETHICS AND DISSEMINATION: This scoping review being a secondary analysis does not require ethics approval. We anticipate results of this review will broaden understanding of paediatric BWF in SSA and identify its research gaps in SSA. We will be disseminating results through journals and conferences targeting primary care providers.

Alcohol-based hand rub and incidence of healthcare associated infections in a rural regional referral and teaching hospital in Uganda ('WardGel' study).

Background: Good hand hygiene (HH) practice is crucial to reducing healthcare associated infections (HAIs). Use of alcohol-based hand rub (ABHR) at health facilities is strongly recommended but it is limited in Uganda. Data on the practice of HH and the incidence of HAIs is sparse in resource-limited settings. We conducted a quasi-experimental study to evaluate HH practices of health care providers (HCPs) utilizing locally made ABHR and the incidence of HAIs. Methods: HH compliance among HCPs and the incidence of HAIs were assessed at Mbale Regional Referral Hospital, a teaching hospital in rural Uganda. Inpatients from the obstetrics/gynecology (OBGYN), pediatric and surgical departments were enrolled on their day of admission and followed up during their hospital stay. The baseline (pre-intervention) phase of 12-weeks was followed by a 12-week intervention phase where training for HH practice was provided to all HCPs present on the target wards and ABHR was supplied on the wards. Incidence of HAIs and or Systemic Inflammatory Response Syndrome (SIRS) was measured and compared between the baseline and intervention phases. Multivariate survival analysis was performed to identify associated variables with HAIs/SIRS. Results: A total of 3335 patients (26.3%) were enrolled into the study from a total of 12,665 admissions on the study wards over a 24-week period. HH compliance rate significantly improved from 9.2% at baseline to 56.4% during the intervention phase (p < 0.001). The incidence of HAIs/SIRS was not significantly changed between the baseline and intervention phases (incidence rate ratio (IRR) 1.07, 95% CI: 0.79 - 1.44). However, subgroup analyses showed significant reduction in HAIs/SIRS on the pediatric and surgical departments (IRR 0.21 (95% CI: 0.10 - 0.47) and IRR 0.39 (95% CI: 0.16 - 0.92), respectively) while a significant increase in HAIs/SIRS was found on the OBGYN department (IRR 2.99 (95% CI: 1.92 - 4.66)). Multivariate survival analysis showed a significant reduction in HAIs/SIRS with ABHR use on pediatric and surgical departments (adjusted hazard ratio 0.26 (95% CI: 0.15 - 0.45)). Conclusions: To our knowledge, this study is one of the largest studies that address HAIs in Africa. During the 24-week study period, significant improvement in HH compliance was observed by providing training and ABHR. The intervention was associated with a significant reduction in HAIs/SIRS on the pediatric and surgical departments. Further research is warranted to integrate HAIs surveillance into routine practice and to identify measures to further prevent HAIs in resource limited settings. Trial registration: ClinicalTrials.gov NCT02435719, registered on 20 April, 2015 (retrospectively registered).