Transcript Pneumonia Audit

Adil N. Ahmad & Hammad Shaikh
Final Year Medical Students
UCL
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Infectious – Lower Respiratory Tract Infection
Leading cause of death of children (<5)
worldwide
Accounts for 17% of under 5 deaths in
Uganda
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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
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Fever
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Cough
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Difficulty in Breathing/Tachypnoea
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Subcostal/Intercostal recession/Tracheal Tug
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Chest Indrawing/Use of accessory muscles
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Areas dull to percussion
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Crackles on Auscultation
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Cyanosis/Low Oxygen Saturations
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Sputum Culture – Antibiotic sensitivities
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CBC/CRP
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CXR
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< 2 months
=
> 60 bpm
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2 months – 1 year
=
> 50 bpm
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1-5 years
=
> 40 bpm
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ABC Approach
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Oxygen
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Antibiotics as early as possible!
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Consider Nasogastric (NG) tube if patient is not
feeding well
Correct Dehydration – ORS/IV Maintenance Fluids
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Dry Mucous Membranes
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Sunken Eyes/Fontanelle
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Reduced Skin Turgor
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Irritability/Lethargy (GCS < 15/ BCS < 5)
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Cold Peripheries (consider shock)
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Pneumonia
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Severe Pneumonia
◦ Chest Wall Indrawing
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Very Severe Pneumonia
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Airway – grunting
Cyanosis/Low Oxygen Saturations/Reduced GCS
Poor feeding/drinking
Poor Clinical Picture
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Benzylpenecillin
◦ 50,000 IU/kg qds
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Gentamicin
◦ 5 mg/kg OD
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Vitamin A
◦ 6-11 months – 100,000 IU
◦ 12-59 months – 200,000 IU
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Ceftriaxone 100 mg/kg OD
◦ If patient fails to improve after 48 hours
OR
◦ If patient beings to deteriorate at any point
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Appropriate prescribing
◦ Good Clinical Outcome
◦ Short stay in Hospital (prevent Iatrogenic infection)
◦ Efficient use of resources
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Poor Prescribing
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Poor Clinical Outcome – including death
Longer Stay in Hospital (further infections)
Poor use of hospital resources
Antibiotic Resistance
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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
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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
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To come up with recommendations
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Patient files were reviewed of:
◦ Patients admitted between Friday 15th November, 2013
to Friday 22nd 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
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Sample size = 14 patients
Were Patients Prescribed the Correct
Antibiotic?
6
43%
Yes
8
57%
No
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Prescribing Ceftriaxone immediately when
there is no indication before trying Penicillin
and Gentamicin
Were Patients Prescribed Correct Antibiotic Dose?
2
14%
Yes
12
86%
No
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Dose of Gentamicin and Penicillin IV not
being done according to weight.
Were the Antibiotics Given on Time?
5
36%
Yes
9
64%
No
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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 12-24 hours
◦ 2 doses delayed by more than 24 hours
Were Patients Prescribed Vitamin A when
Appropriate?
7
7
50%
50%
Yes
No
Of the 7 Inappropriate Occasions
2
29%
5
71%
Given to < 6 months
Not given to 6-59
month old
Was the Correct Dose of Vitamin A Given?
3
4
57%
43%
Yes
No
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Prescribing to children below 6 months or
over 5 years
Dosage not done by weight
Child below 3rd Centile (Weight for Age)?
6
43%
8
57%
Yes
No
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Weighing scale not available in Emergency
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No WHO Growth Charts available
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Poor Legibility – we are all guilty!
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Drugs written up in Management Plans but
not on Drug Chart – drugs not given.
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Poor communication between Nursing Staff
and Doctors about stocks of drugs
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No signatures on drugs (accountability)
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Revise Guidelines
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Write in BLOCK CAPITALS on drug chart
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Ensure all drugs from clerking management
plans are copied out
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Nursing staff to communicate when drug
unavailable
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Have printed WHO Weight for Age Growth
Charts in Emergency and Wards
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Have Weighing scales in Emergency and
Wards
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Nurse-patient allocation
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Ward Organisation
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Early recognition of signs and symptoms
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Early Health seeking behaviour
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Good Hygiene – Handwashing to reduce spread
of infection
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Immunisations
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Exclusive breastfeeding for 6 months
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Limited Medication
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Limited Oxygen Supply
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Only one saturation probe
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Clinical Officers often don’t stay at night leading
to increased risk to patient care
Low staffing levels
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Patient Admission times and dosage given
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Time of deaths
◦ Mortality much greater at night
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Dr. Vanessa Rippon
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Dr. Tenywa
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The Interns
◦ Dr. Acleo
◦ Dr. Paul
◦ Dr. James
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Nursing Staff