Adil N. Ahmad & Hammad Shaikh Final Year Medical Students UCL

 Infectious – Lower Respiratory Tract Infection  Leading cause of death of children (<5) worldwide  Accounts for 17% of under 5 deaths in Uganda

 Most common causative organisms are Streptococcus Pneumoniae and Haemophilus Influenzae  Less common organisms include Staphylococcus Aureus, Neisseria Meningitis, Klebsiella, Cryptococcus, Pseudomonas  Pneumonia is treatable with antibiotics and these deaths are preventable

 Fever  Cough  Difficulty in Breathing/Tachypnoea

 Subcostal/Intercostal recession/Tracheal Tug  Chest Indrawing/Use of accessory muscles  Areas dull to percussion  Crackles on Auscultation  Cyanosis/Low Oxygen Saturations

 Sputum Culture – Antibiotic sensitivities  CBC/CRP  CXR

 60 bpm  2 months – 1 year = > 50 bpm  1-5 years = > 40 bpm

 ABC Approach  Oxygen  Antibiotics as early as possible!  Consider Nasogastric (NG) tube if patient is not feeding well  Correct Dehydration – ORS/IV Maintenance Fluids

 Dry Mucous Membranes  Sunken Eyes/Fontanelle  Reduced Skin Turgor  Irritability/Lethargy (GCS < 15/ BCS < 5)  Cold Peripheries (consider shock)

 Pneumonia  Severe Pneumonia ◦ Chest Wall Indrawing  Very Severe Pneumonia ◦ Airway – grunting ◦ Cyanosis/Low Oxygen Saturations/Reduced GCS ◦ Poor feeding/drinking ◦ Poor Clinical Picture

 Benzylpenecillin ◦ 50,000 IU/kg qds  Gentamicin ◦ 5 mg/kg OD  Vitamin A ◦ 6-11 months – 100,000 IU ◦ months – 200,000 IU

 Ceftriaxone 100 mg/kg OD ◦ If patient fails to improve after 48 hours OR ◦ If patient beings to deteriorate at any point

 Appropriate prescribing ◦ Good Clinical Outcome ◦ Short stay in Hospital (prevent Iatrogenic infection) ◦ Efficient use of resources  Poor Prescribing ◦ Poor Clinical Outcome – including death ◦ Longer Stay in Hospital (further infections) ◦ Poor use of hospital resources ◦ Antibiotic Resistance

 Audit is a review of prescribing in accordance with clinical guidelines  It attempts to improve clinical practice and therefore patient outcomes  It is NOT a blame game

 To review patient notes to assess whether: ◦ Patients had been correctly diagnosed according to signs and symptoms ◦ Whether prescribing was appropriate ◦ Whether doses were given on time  To come up with recommendations

 Patient files were reviewed of: ◦ Patients admitted between Friday 15 th November, 2013 to Friday 22 nd November 2013 ◦ Diagnosed with Pneumonia, Severe Pneumonia or Very Severe Pneumonia ◦ Many had concurrent diagnoses (eg. Malaria) ◦ Some gaps due to personal injury – Thank you to Dr. Rippon for collecting a significant amount of data

 Sample size = 14 patients

 Prescribing Ceftriaxone immediately when there is no indication before trying Penicillin and Gentamicin

 Dose of Gentamicin and Penicillin IV not being done according to weight.

 First dose usually given on time, but the follow up doses are sporadic  In these cases: ◦ 1 dose delay of less than 6 hours ◦ 2 doses delayed by hours ◦ 2 doses delayed by more than 24 hours

 Prescribing to children below 6 months or over 5 years  Dosage not done by weight

 Weighing scale not available in Emergency  No WHO Growth Charts available

 Poor Legibility – we are all guilty!  Drugs written up in Management Plans but not on Drug Chart – drugs not given.  Poor communication between Nursing Staff and Doctors about stocks of drugs  No signatures on drugs (accountability)

 Revise Guidelines  Write in BLOCK CAPITALS on drug chart  Ensure all drugs from clerking management plans are copied out  Nursing staff to communicate when drug unavailable

 Have printed WHO Weight for Age Growth Charts in Emergency and Wards  Have Weighing scales in Emergency and Wards  Nurse-patient allocation  Ward Organisation

 Early recognition of signs and symptoms  Early Health seeking behaviour  Good Hygiene – Handwashing to reduce spread of infection  Immunisations  Exclusive breastfeeding for 6 months

 Limited Medication  Limited Oxygen Supply  Only one saturation probe  Clinical Officers often don’t stay at night leading to increased risk to patient care  Low staffing levels

 Patient Admission times and dosage given  Time of deaths ◦ Mortality much greater at night

 Dr. Vanessa Rippon  Dr. Tenywa  The Interns ◦ Dr. Acleo ◦ Dr. Paul ◦ Dr. James  Nursing Staff