IMPROVING MALARIA CASE MANAGEMENT AT NTCHEU DISTRICT HOSPITAL, MALAWI'

1
IMPROVING MALARIA CASE MANAGEMENT AT NTCHEU
DISTRICT HOSPITAL, MALAWI. D. Mathanga¹, M.
Chaponda², I. Mofolo², J Ngoma³,, G. Malenga¹, S
Meshnick 4. 1. Malaria Alert Centre, College of
Medicine, 2. University of North Carolina/Malaria
Project, College of Medicine, 3. Ntcheu District
Hospital, 4. University of North Carolina, USA

• Summary
• Between April 2002 and September 2004, the
  Malaria Alert Centre (MAC), the University of
  North Carolina Malaria Project and Ntcheu
  district hospital collaborated in an effort to
  improve severe malaria case management by
  translating findings of extensive clinical
  malaria research at a tertiary institution into
  standard district hospital practice of care. Here
  we present the process and the impact of our
  intervention.
• Background
• Up to fifty percent of paediatric hospital deaths
  in many developing countries occur within first
  24 hours of hospital admission¹. Guardians and
  health institutions alike usually share reasons
  for this due to delayed or inadequate care
  respectively. Majority of these deaths in
  sub-Saharan Africa are contributed by malaria,
  and in Malawi malaria accounts for up to 40 of
  inpatient deaths among children under-fives². The
  WHO recommended assessment tool for standard of
  care guided our programme activities in
  Ntcheu³,4. The hospital has a capacity of 240
  beds, serves a population of 423,000 and admits
  on average, 20 patients per day in its 60-bedded
  paediatric ward, usually exceeding 100 bed
  occupancy, especially during the malaria season.
• Objectives
• To improve case management of severe malaria at a
  district hospital. Specifically, we aimed to
• Apply findings of research in malaria case
  management at a tertiary hospital into district
  hospital practice of care.
• Introduce locally adapted critical care
  pathways5,6 to standardize care and monitoring of
  a severely sick child, within the constraints of
  available district hospital resources.
• Methodology
• We targeted the whole healthcare and management
  teams in the hospital, assessing organizational
  and support structures on site. We assessed
  knowledge, attitudes and practices affecting
  malaria management, before and after the
  intervention, using questionnaires, interviews,
  and direct observational assessment of care
  practices, during and outside normal working
  hours, including time-in motion assessments. We
  organized structured visits for the whole health
  care team to the research wards in the tertiary
  institution in Blantyre, and promoted local
  consensus on areas deemed necessary for
  adaptation and adoption by the team. Over a
  period of two malaria seasons we conducted
  regular on-site training for malaria case
  management, including use of critical care
  pathways as a monitoring tool for and record of
  inpatient care.
• Results
• Fourty eight members of the health care team
  comprising of management, clinical, nursing and
  laboratory staff participated in the programme,
  and following were their team decisions
• Paediatric outpatient department was
  structurally and functionally reorganized to
  allow for
• Better patient flow, with identification of
  designated areas for instant microscopy and
  haemoglobin estimation for febrile and/or anaemic
  patients, and for administering first dose
  emergency treatment for in-patients before
  transfer to the ward, thereby significantly
  shortening patient waiting times, Fig 1,x² test
  plt 0.001.
• Establishment of a small pharmacy for majority of
  consultations in the unit with minor ailments,
  thus decongesting the main pharmacy.
• Triage training for first line healthcare workers
  in the unit, including support staff.
• Reorganization of existing nurses work shifts
  and reassigning clinical staff in less busy
  specialized areas for more rational hospital
  cover.
• Adaptation and adoption of critical care
  pathways as monitoring tool and record of
  in-patient care, fig 2.

Figure 2 Sample of Critical Care Pathways (CCP)
in use
Discussion and conclusion We found that working
with the whole health care team facilitated the
capacity building process. Visits to the tertiary
institution provided the mentorship that promoted
consensus among the team, resulting in the
implementation of some longstanding management
decisions that up to now had proven difficult to
implement, such as revision of nurses work
shifts. This then allowed management to come up
with innovative ways of managing their budget so
as to buy extra nurses time. Although we have
not presented comparative morbidity/mortality
data, we believe that processes for improved care
have been put in place in Ntcheu. We are aware
that in the public sector, permanent district
health care teams do not exist, as staff
continually gets transferred between
institutions. However, in the one year of
follow-up, the team in Ntcheu has maintained
structural changes in their outpatient
department, management decisions for better
hospital cover, and use critical care pathways as
standard practice of care in the paediatric
wards, orienting new staff in their use.
Availability of supplies for appropriate care
however remains a great challenge. The tertiary
hospital paediatric department has adopted
targeting of health care teams for its district
training programmes.
Acknowledgements The Gates Foundation, through
the Gates Malaria Partnership and CDC through the
University of North Carolina for funding the
project, INTRAH for support with questionnaire
development and administration and the Blantyre
Malaria Project for mentorship in the research
wards. References 1. Molyneux E, Paediatric
emergency care in developing countries,
commentary. Lancet 2001 35786-87. 2. Malawi
MOH Malaria Strategic plan 2005-2010 scaling up
malaria control interventions. 3. WHO. Improving
the paediatric care in small hospitals in
developing countries. Geneva. WHO/FCH/CAH. Jan
25, 2001. 4. Nolan T, Angos P. et al. Quality of
care for seriously ill children in less-developed
countries. Lancet 2001 357106-110. 5. Rogerson
S, Malenga G. Molyneux E M. Integrated care
pathways a tool to improve infant monitoring in
a neonatal unit. Annals of Trop. Paed. 2004
24171-174. 6. Molyneux E, Malenga G. Forms of
better care. World Health Forum 1998 19201-204