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INTRODUCTION: Half of Kenya’s high infant and under five mortality rates is due to malnutrition. Proper implementation of World Health Organization’s (WHO) Evidence Based Guidelines (EBG) in management of severe acute malnutrition can reduce mortality rates to less than 5%. The objectives were to establish the level of adherence to WHO guideline and the proportion of children appropriately managed for severe acute malnutrition (steps 1-8) as per the WHO protocol in the management of severe acute malnutrition. This was a short longitudinal study of 96 children, aged 6-59 months admitted to the pediatric ward with diagnosis of severe acute malnutrition.
The design was a short longitudinal study at Garissa Provincial General Hospital (GPGH) over a four month period (July to October 2012). The study sites included the pediatric ward (PW), the Maternal and Child Health Clinic (MCH) and the Outpatient department (OPD). Garissa PGH is a regional referral hospital for North Eastern Kenya (population of 2.23 million) and three other neighboring districts. It also serves a further 400,000 refugees from the refugee camps in Daadab. It is a 250 bed-capacity hospital with 297 technical and non-technical staff. Sample size was calculated using the Fisher’s formula, n = {t2 x p(1-p)}/m2, Where n = minimum sample size required, t = confidence level at 95% (standard value of 1.96), p = estimated prevalence of malnutrition in the project area (50% (0.5)) and m= margin of error at 10% (0.01), Our study population of 96 children aged 6-59 months whose guardians gave informed written consent were purposively sampled. Children with chronic conditions (cerebral palsy, cardiac disease and renal disease) that predispose them to severe malnutrition were excluded. Based on the information obtained from the medical records, the management for all children aged 6-59 months who were admitted from OPD and MCH and admitted to PW for severe malnutrition was reviewed using an audit tool so as to determine the proportion of children appropriately managed for the 1st 8 steps of the WHO guideline for the management of severe acute malnutrition. A self-administered questionnaire was also used to collect additional information from health workers on their awareness on availability and accessibility of WHO guidelines, trainings on management of malnourished children and inventory of essential supplies. The principle investigator (OW) with two research assistants visited the MCH, OPD and Pediatric Ward daily from7am to 10pm and purposively recruited eligible patients. Data extracted from medical file of patients was recorded into an audit tool to compare care provided with guideline recommendation for 1st 8 steps. A self-administered questionnaire was also used to collect additional information from health workers on their awareness on availability and accessibility of WHO guidelines, trainings on management of malnourished children and inventory of essential supplies. The researcher and the assistants audited purposively selected medical records/files for all admitted patients with severe malnutrition using a prepared audit tool. The records extracted included the following:-the clinician’s admission notes (to check if there was documentation of the following : Anthropometry measurements (weights and lengths (or height if aged 2 years or older) and weight/height ratio or Z-score and was compared with the median National Center for Health Statistics (NCHS) reference population), presence or absence of edema and wasting, correct classification of malnutrition, presence or absence of diarrhea/ dehydration/shock, conscious level, the treatment sheets(correct choice/dosages of antibiotics, micronutrients, electrolytes, correct choice/volume/route of administration of F75 and F100, and also check if “keep warm” was prescribed), observation charts & nursing cardex ( if temperature was monitored 6-hourly, correct monitoring of fluids and feeds), the laboratory request forms (results of random blood sugar, hemoglobin level and blood slide for malaria). The audit was conducted to check if the 1st 8 steps were correctly applied or not. Data were cross checked for completeness and accuracy before entering into the computer using Microsoft Access. It was analyzed using Stata Version 11. Categorical variables were summarized using proportions and measures of central tendencies (means, medians) and dispersions (standard deviations) used for continuous variables. The outcome was calculated as the percentage of children managed according to the guideline recommendations. The outcome was compared with other categorical variables using the chi square test. Appropriate correlation was applied to the chi square using the Yates or Fishers exact tests when expected cell counts were less than five. T-tests were used to compare means for continuous variables.
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