Clinical and laboratory features associated with mortality in children with severe malnutrition in Papua New Guinea.

Background: The World Health Organization has a clinical and syndromic approach to the management of severe acute malnutrition which recognises that laboratory investigations are often not possible where children with severe malnutrition present. In low- and middle-income countries including Papua New Guinea, rates of death from severe malnutrition in many hospitals remain 10% or more.Aim: To evaluate the clinical predictors of death and the association between disturbances of electrolytes and haematological investigations in children with severe malnutrition and the risk of mortality.Methods: The clinical and laboratory predictors of death in a prospective cohort of 150 children with severe malnutrition admitted to a provincial hospital in Papua New Guinea were analysed. The clinical signs and electrolytes, complete blood count and liver function tests at presentation and on Days 3 and 5 were recorded.Results: The strongest independent predictors of mortality at assessment on admission were a low child Glasgow coma scale (≤12), hypoxaemia (SpO2 <90%), prolonged capillary refill (>3 seconds) and dysnatraemia (<130 or >150 mmol/L). The area under the receiver operating characteristics curve for these four variables was 0.93.Conclusions: That three of these four criteria correspond closely to the WHO Emergency Clinical Signs reinforces the value of a system of triage and risk assessment in children with severe malnutrition. If a child has emergency signs they should be managed in an area on the ward where close monitoring and supportive care can be provided, the WHO guidelines for severe malnutrition followed, and other specific care provided. Measurements of serum sodium, particularly in children with diarrhoea and dehydration, is also important in risk assessment and management.

Solar-powered oxygen, quality improvement and child pneumonia deaths: a large-scale effectiveness study.

BACKGROUND: Pneumonia is the largest cause of child deaths in low-income countries. Lack of availability of oxygen in small rural hospitals results in avoidable deaths and unnecessary and unsafe referrals. METHOD: We evaluated a programme for improving reliable oxygen therapy using oxygen concentrators, pulse oximeters and sustainable solar power in 38 remote health facilities in nine provinces in Papua New Guinea. The programme included a quality improvement approach with training, identification of gaps, problem solving and corrective measures. Admissions and deaths from pneumonia and overall paediatric admissions, deaths and referrals were recorded using routine health information data for 2-4 years prior to the intervention and 2-4 years after. Using Poisson regression we calculated incidence rates (IRs) preintervention and postintervention, and incidence rate ratios (IRR). RESULTS: There were 18 933 pneumonia admissions and 530 pneumonia deaths. Pneumonia admission numbers were significantly lower in the postintervention era than in the preintervention era. The IRs for pneumonia deaths preintervention and postintervention were 2.83 (1.98-4.06) and 1.17 (0.48-1.86) per 100 pneumonia admissions: the IRR for pneumonia deaths was 0.41 (0.24-0.71, p<0.005). There were 58 324 paediatric admissions and 2259 paediatric deaths. The IR for child deaths preintervention and postintervention were 3.22 (2.42-4.28) and 1.94 (1.23-2.65) per 100 paediatric admissions: IRR 0.60 (0.45-0.81, p<0.005). In the years postintervention period, an estimated 348 lives were saved, at a cost of US$6435 per life saved and over 1500 referrals were avoided. CONCLUSIONS: Solar-powered oxygen systems supported by continuous quality improvement can be achieved at large scale in rural and remote hospitals and health care facilities, and was associated with reduced child deaths and reduced referrals. Variability of effectiveness in different contexts calls for strengthening of quality improvement in rural health facilities. TRIAL REGISTRATION NUMBER: ACTRN12616001469404.

Solar powered oxygen systems in remote health centers in Papua New Guinea: a large scale implementation effectiveness trial.

BACKGROUND: Pneumonia is the largest cause of child deaths in Papua New Guinea (PNG), and hypoxaemia is the major complication causing death in childhood pneumonia, and hypoxaemia is a major factor in deaths from many other common conditions, including bronchiolitis, asthma, sepsis, malaria, trauma, perinatal problems, and obstetric emergencies. A reliable source of oxygen therapy can reduce mortality from pneumonia by up to 35%. However, in low and middle income countries throughout the world, improved oxygen systems have not been implemented at large scale in remote, difficult to access health care settings, and oxygen is often unavailable at smaller rural hospitals or district health centers which serve as the first point of referral for childhood illnesses. These hospitals are hampered by lack of reliable power, staff training and other basic services. METHODS: We report the methodology of a large implementation effectiveness trial involving sustainable and renewable oxygen and power systems in 36 health facilities in remote rural areas of PNG. The methodology is a before-and after evaluation involving continuous quality improvement, and a health systems approach. We describe this model of implementation as the considerations and steps involved have wider implications in health systems in other countries. RESULTS: The implementation steps include: defining the criteria for where such an intervention is appropriate, assessment of power supplies and power requirements, the optimal design of a solar power system, specifications for oxygen concentrators and other oxygen equipment that will function in remote environments, installation logistics in remote settings, the role of oxygen analyzers in monitoring oxygen concentrator performance, the engineering capacity required to sustain a program at scale, clinical guidelines and training on oxygen equipment and the treatment of children with severe respiratory infection and other critical illnesses, program costs, and measurement of processes and outcomes to support continuous quality improvement. CONCLUSIONS: This study will evaluate the feasibility and sustainability issues in improving oxygen systems and providing reliable power on a large scale in remote rural settings in PNG, and the impact of this on child mortality from pneumonia over 3 years post-intervention. Taking a continuous quality improvement approach can be transformational for remote health services.