Quality Assurance Could Save Malnourished Children in Africa
Adamson Sinjani Muula, Division of Community Health, University of Malawi
29 March 2006
The recent report by Bachou et al [1] adds to the literature that quality assurance is still an important, but as yet unrealised aspect of health care delivery in Africa. Why should blood transfusion and fluid (other than blood) infusion result in death when these fluids should have been life-saving? The authors report that of 180 children with HB equal to or greater than 5, 44 (24%) were transfused i.e. against the Uganda guidelines.
While the authors have not reported on the quality of nursing care and monitoring during and after transfusions, in wards with high case loads, and minimal staffing, this aspect of care can be problematic. It may be usual therefore not be possible to monitor urine output and pulmonary signs as transfusion occurs. The 'brain drain' of nursing staff and the increasing work load as a result of AIDS are some of the culprits.
It would have been interesting also if the authors had reported on the type of fluids given for dehydration. In resource-poor settings, it is sometimes tempting to give any electrolyte and fluid therapy regardless of contraindications in particular clinical situations.
Although we may never know, some of the 52 children who were discharged against medical advice may have been 'saved' from our inappropriate transfusions that may have resulted in their mortality.
The authors have done an excellent job in pointing towards areas in medical management of malnutrition that need our attention. Ensuring that guidelines are followed, and improved where necessary will be our responsibility to honur those children who died at Mulago because of inappropriate transfusion and failures to observe them judiciously during and after transfusions and infusions.
Bachou H, Tumwine JK, Mwadime RKN, Tylleskar T. risk factors in hospital deaths in severely malnourished children in Kampala, Uganda. BMC Pediatrics 2006, 6:7 doi:10.1186/1471-2431-6-7
Quality Assurance Could Save Malnourished Children in Africa
29 March 2006
The recent report by Bachou et al [1] adds to the literature that quality assurance is still an important, but as yet unrealised aspect of health care delivery in Africa. Why should blood transfusion and fluid (other than blood) infusion result in death when these fluids should have been life-saving? The authors report that of 180 children with HB equal to or greater than 5, 44 (24%) were transfused i.e. against the Uganda guidelines.
While the authors have not reported on the quality of nursing care and monitoring during and after transfusions, in wards with high case loads, and minimal staffing, this aspect of care can be problematic. It may be usual therefore not be possible to monitor urine output and pulmonary signs as transfusion occurs. The 'brain drain' of nursing staff and the increasing work load as a result of AIDS are some of the culprits.
It would have been interesting also if the authors had reported on the type of fluids given for dehydration. In resource-poor settings, it is sometimes tempting to give any electrolyte and fluid therapy regardless of contraindications in particular clinical situations.
Although we may never know, some of the 52 children who were discharged against medical advice may have been 'saved' from our inappropriate transfusions that may have resulted in their mortality.
The authors have done an excellent job in pointing towards areas in medical management of malnutrition that need our attention. Ensuring that guidelines are followed, and improved where necessary will be our responsibility to honur those children who died at Mulago because of inappropriate transfusion and failures to observe them judiciously during and after transfusions and infusions.
Bachou H, Tumwine JK, Mwadime RKN, Tylleskar T. risk factors in hospital deaths in severely malnourished children in Kampala, Uganda. BMC Pediatrics 2006, 6:7 doi:10.1186/1471-2431-6-7
Competing interests
None declared