Table 3 Top five indicators by domain†

Structure: drugs and equipment

1. The availability of intravenous fluids with physiological sodium concentrations (one or more of: Normal saline, Hartmann's solution, or Ringer's Lactate).

2. The availability of Epinephrine (Adrenaline) for injection.

3. The availability of the locally recommended first line oral antimalarial in settings where there is malaria.

4. The availability of Gentamicin.

5. The availability of vaccines including Pentavalent vaccine or DTP or DTP-HepB, BCG polio and measles vaccine in the hospital.

Structure: organisation of care

1. The presence of a system to prioritize severely ill children and group them together for observation in the ward.

2. The presence of a triage system in the outpatients department.

3. The presence of an area in the outpatients section of the hospital that is dedicated to provision of routine and walk-in services for children under 5 years only.

4. Proportion of all admitted children with documentation providing evidence that they were reassessed at least daily (during working days) by a doctor or clinical officer.

5. The availability of up to date hospital records describing paediatric admissions with diagnosis, age, sex and outcomes.

General care for severely ill children:

1. The proportion of children described as unable to feed/drink or with AVPU < V who are prescribed an appropriate fluid or feed regimen.

2. The proportion of children who have documentation that they were clinically assessed (wasting or oedema of Kwashiokor) or assessed with MUAC or WHZ for severe malnutrition.

3. The proportion of admitted children with documentation of assessment for 'danger signs' - these include convulsions, cyanosis, grunting, acidotic breathing, weak pulse, capillary refill, consciouness level (AVPU score) (in)ability to drink, neck stiffness or bulging fontanelle.

4. The proportion of Diazepam prescriptions for convulsions that are of the correct dose (iv or rectal doses according to national guidelines).

5. The proportion of prescriptions for injection Phenobarbitone that are the correct dose.

Cough/pneumoia/asthma:

1. The proportion of children with pneumonia prescribed antibiotics at correct doses (correct dose is defined as weight appropriate dose according to WHO or local guidelines with a ± 20% range of acceptability).

2. The proportion of children prescribed oxygen correctly (including route device and flow rate).

3. The proportion of children with severe or very severe asthma correctly prescribed a steroid (including route of administration dose and frequency).

4. The proportion of children with a diagnosis of pneumonia who are correctly classified as having pneumonia severe pneumonia or very severe pneumonia (The correctness of classification must be based on documentation of appropriate supporting signs).

5. The proportion of children requiring oxygen (i.e. children with cyanosis or other signs of very severe pneumonia/asthma including grunting/head nodding/inability to drink or breastfeed/AVPU < A) actually prescribed oxygen

Fever/malaria/meningitis:

1. The proportion of children with fever in a malaria endemic area who are investigated for malaria (with either a blood slide or rapid test).

2. The proportion of children with malaria prescribed treatment antimalarial that is appropriate to the clinician's classification of severity and local guidelines (correct drug choice dose and frequency)

3. The proportion of children with the presence or absence of fever recorded in their medical notes.

4. The proportion of children with a primary diagnosis of malaria in whom the diagnosis is supported by a positive blood slide/rapid test for malaria.

5. The proportion of children with a diagnosis of meningitis prescribed correct antibiotics (first line appropriate for context or second line if known to have failed prior treatment) in correct doses.

Diarrhoea and dehydration:

1. The proportion of children with dehydration prescribed treatment (including right fluid type volume and rate) that is appropriate to their classification (including shock/severe and some dehydration) and weight.

2. The proportion of children with bloody diarrhoea given correct antibiotic (as recommended by the national guidelines).

3. A composite indicator of the proportion of children assessed completely. This include skin turgor, sunken eyes level of consciousness, ability to drink/breastfeed or sit, capillary refill, peripheral skin temperature and temperature gradient, presence of weak (absent) peripheral pulses, presence of acidotic breathing, irritability, urine output, malnutrition

4. The proportion of diarrhoea cases prescribed Zinc (where this is national policy) at correct dose for age.

5. The proportion of children with diarrhoea who have documentation of whether or not there is blood in the stool.

Malnutrition:

1. The proportion of children in HIV endemic areas with a diagnosis of severe malnutrition who are tested for HIV as an inpatient.

2. The proportion of children with a diagnosis of severe malnutrition prescribed appropriate parenteral antibiotics.

3. The proportion of children with a diagnosis of severe malnutrition receiving Vitamin A on admission.

4. The proportion of children with a diagnosis of severe malnutrition and dehydration prescribed appropriate rehydration fluid (ReSoMal or other low Sodium fluid e.g. half strength Darrows with potassium supplementation).

5. The proportion of children with a diagnosis of severe malnutrition prescribed the correct feed in the recommended volume and frequency.

Neonates:

1. The proportion of sick neonates with a diagnosis of neonatal sepsis prescribed the appropriate antibiotics (including correct choice of drug correct dose for weight and age frequency and route of administration according to guideline).

2. The proportion of babies born in hospital to HIV+ mothers who receive PMTCT therapy in line with national policy.

3. The proportion of babies born in hospital whose mothers have their HIV status known before delivery.

4. The proportion of babies aged <14 days prescribed routine Vitamin K in countries where this is national policy.

5. The proportion of newborn babies who get eye prophylaxis (Tetracycline Eye Ointment).