Manifestations, Quality of Emergency Care and Outcome of Severe Malaria in Mulago Hospital, Uganda

Background: About 100,000 children die annually from severe malaria in Uganda and more than 75% of health unit based deaths occur within 24 hours of admission. Most of these deaths are associated with poor resuscitation systems, delays within the units by health workers and lack of essential drugs and supplies.
Objective: To describe the manifestations and quality of care children with severe malaria receive in Mulago Hospital Paediatric emergency unit and evaluate its impact on outcome.
Methods: A cohort of 784 children with severe malaria was recruited at admission and followed up. Selected measures of quality were the exposure factor and death, the outcome measure.
Results: Only 22.5% of the children were brought at night. The commonest defining manifestations were severe anaemia (39.4%), respiratory distress (17.1%), multiple generalized convulsions (13.3%), hypoglycaemia (11.4%) and cerebral malaria (7.2%). Over 50% lacked an essential drug or supply needed for resuscitation and 23.4% were seen within 1 hour of arrival. Commonly lacking items were intravenous cannulae (53.1%) syringes (23.3%) and blood transfusion sets (15.0%). Children brought at night took a shorter time before being seen by a doctor (1.9 SD 2.4 vs 2.5 SD 2.0 hours, p=0.002), received the first dose of quinine earlier (4.1 SD 3.2 vs 5.2 SD 3.2 hours, p<0.0001), fewer lacked essential drugs and supplies (45% vs 57.9%, p=0.003) and fewer died (0.6% vs 3.8%, p=0.028). Children who lacked an item for resuscitation took 30 minutes longer to receive the first dose of quinine. Caretaker satisfaction was predictive of mortality in the unit.
Conclusions: Quality of care for severe malaria in Mulago paediatric emergency unit is still poor although nighttime services are comparatively better. Caretakers buy at least one resuscitation item in over 50% of cases and their level of satisfaction is predictive of mortality.
Recommendations: The unit should set targets for quality improvement to include increased staffing and supplies, a time limit within which children should be seen and measures of decongestion. Determination of blood sugar in patients with severe malaria should be made a basic requirement.