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© 2018 Journal of Global Health. Background Measurement and correct interpretation of vital signs is part of routine clinical care. Repeated measurement enhances early recognition of deterioration, may help prevent morbidity and mortality and is a standard of care in most countries. Objective To examine documentation of vital signs by clinicians for admissions to paediatric wards in Kenyan hospitals, to describe monitoring frequency by nurses and explore factors influencing frequency. Methods Vital signs information (temperature, respiratory and pulse rate) for the first 48 hours of admission was collected from case records of children admitted with non-surgical conditions to 13 Kenyan county hospitals between September 2013 and April 2016. A mixed effect negative binomial regression model was used to explore whether the severity of illness (indicated by danger signs or severe diagnostic episodes) is associated with increased vital signs observation frequency. Results We examined 54 800 admission episodes with an overall mortality 6.1%. Nurse to bed ratios were very low (1:10 to 1:41 across hospitals). Admitting clinicians documented all or no vital signs in 57.0% and 8.4% cases respectively. For respiratory and pulse rates there was pronounced even end-digit preference (an indicator of incorrect information) and high frequency recording of specific values (P < 0.001) suggesting approximation. Monitoring frequency was explored in 41 738 children. Those with inpatient stays =48 hours were expected to have a vital signs count of 18, hospitals varied but most did not achieve this benchmark (median 9, range 2-30). There were clinically small but significant associations between vital signs count and presence of multiple severe illnesses or presence of severe pallor (adjusted relative risk ratio = 1.04, P < 0.01, 95% confidence interval CI = 1.02-1.06 and 1.05, P = 0.02, 95% CI = 1.01-1.09, respectively). Conclusions Data suggest accurate admission measures are sometimes missing especially for pulse and respiratory rates, possibly linked to manual measurement. Monitoring frequency is often low in the high risk population studied probably indicating how quality of nursing care is undermined by considerable human resource shortages.

Objective To share approaches and innovations adopted to deliver a relatively inexpensive clinical data management (CDM) framework within a low-income setting that aims to deliver quality pediatric data useful for supporting research, strengthening the information culture and informing improvement efforts in local clinical practice. Materials and methods The authors implemented a CDM framework to support a Clinical Information Network (CIN) using Research Electronic Data Capture (REDCap), a noncommercial software solution designed for rapid development and deployment of electronic data capture tools. It was used for collection of standardized data from case records of multiple hospitals’ pediatric wards. R, an open-source statistical language, was used for data quality enhancement, analysis, and report generation for the hospitals. Results In the first year of CIN, the authors have developed innovative solutions to support the implementation of a secure, rapid pediatric data collection system spanning 14 hospital sites with stringent data quality checks. Data have been collated on over 37 000 admission episodes, with considerable improvement in clinical documentation of admissions observed. Using meta-programming techniques in R, coupled with branching logic, randomization, data lookup, and Application Programming Interface (API) features offered by REDCap, CDM tasks were configured and automated to ensure quality data was delivered for clinical improvement and research use. Conclusion A low-cost clinically focused but geographically dispersed quality CDM (Clinical Data Management) in a long-term, multi-site, and real world context can be achieved and sustained and challenges can be overcome through thoughtful design and implementation of open-source tools for handling data and supporting research.

Summary Background Management of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital. Methods We did a retrospective cohort study of children aged 2–59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia). Findings We assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1–6·8), mild to moderate pallor (3·4, 3·0–3·8), and weight-for-age Z score (WAZ) less than −3 SD (3·8, 3·4–4·3). Additional factors that were independently associated with death were: WAZ less than −2 to −3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more. Interpretation In settings of high mortality, WAZ less than −3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making. Funding Wellcome Trust.

Severe anemia is a leading indication for blood transfusion and a major cause of hospital admission and mortality in African children. Failure to initiate blood transfusion rapidly enough contributes to anemia deaths in sub-Saharan Africa. This article examines delays in accessing blood and outcomes in transfused children in Kenyan hospitals. Children admitted with nonsurgical conditions in 10 Kenyan county hospitals participating in the Clinical Information Network who had blood transfusion ordered from September 2013 to March 2016 were studied. The delay in blood transfusion was calculated from the date when blood transfusion was prescribed to date of actual transfusion. Five percent (2,875/53,174) of admissions had blood transfusion ordered. Approximately half (45%, 1,295/2,875) of children who had blood transfusion ordered at admission had a documented hemoglobin < 5 g/dl and 36% (2,232/6,198) of all children admitted with a diagnosis of anemia were reported to have hemoglobin < 5 g/dL. Of all the ordered transfusions, 82% were administered and documented in clinical records, and three-quarters of these (75%, 1,760/2,352) were given on the same day as ordered but these proportions varied from 71% to 100% across the 10 hospitals. Children who had a transfusion ordered but did not receive the prescribed transfusion had a mortality of 20%, compared with 12% among those transfused. Malaria-associated anemia remains the leading indication for blood transfusion in acute childhood illness admissions. Delays in transfusion are common and associated with poor outcomes. Variance in delay across hospitals may be a useful indicator of health system performance.

BackgroundLack of detailed information about hospital activities, processes and outcomes hampers planning, performance monitoring and improvement in low-income countries (LIC). Clinical networks offer one means to advance methods for data collection and use, informing wider health system development in time, but are rare in LIC. We report baseline data from a new Clinical Information Network (CIN) in Kenya seeking to promote data-informed improvement and learning.MethodsData from 13 hospitals engaged in the Kenyan CIN between April 2014 and March 2015 were captured from medical and laboratory records. We use these data to characterise clinical care and outcomes of hospital admission.ResultsData were available for a total of 30 042 children aged between 2 months and 15 years. Malaria (in five hospitals), pneumonia and diarrhoea/dehydration (all hospitals) accounted for the majority of diagnoses and comorbidity was found in 17 710 (59%) patients. Overall, 1808 deaths (6%) occurred (range per hospital 2.5%–11.1%) with 1037 deaths (57.4%) occurring by day 2 of admission (range 41%–67.8%). While malaria investigations are commonly done, clinical health workers rarely investigate for other possible causes of fever, test for blood glucose in severe illness or ascertain HIV status of admissions. Adherence to clinical guideline-recommended treatment for malaria, pneumonia, meningitis and acute severe malnutrition varied widely across hospitals.ConclusionDeveloping clinical networks is feasible with appropriate support. Early data demonstrate that hospital mortality remains high in Kenya, that resources to investigate severe illness are limited, that care provided and outcomes vary widely and that adoption of effective interventions remains slow. Findings suggest considerable scope for improving care within and across sites.