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1. Experience: developing an inpatient malnutrition checklist for children 6 to 59 months to improve WHO protocol adherence and facilitate quality improvement in a low-resource setting

Author

Kathryn Beck, Angelique Mukantaganda, Scheilla Bayitondere, Richard Ndikuriyo, Almaque Dushimirimana, Vianney Bihibindi, Souzane Nyiranganji, Michel Habiyaremye, and Jennifer Werdenberg

Subjects
Malnutrition, checklists, quality improvement, low-resource setting, under-5 mortality, Public aspects of medicine, RA1-1270
Abstract

In low-resource settings, inpatient case fatality for severe acute malnutrition (SAM) remains high despite evidenced-based protocols and resources to treat SAM. Key reasons include a combination of insufficiently trained staff, poor teamwork and inadequate compliance to WHO treatment guidelines which are proven to reduce mortality. Checklists have been used in surgery and obstetrics to ameliorate similarly complicated yet repetitive work processes and may be a key strategy to improving inpatient SAM protocol adherence and reducing unnecessary death. Here, we share our experience developing and piloting an inpatient malnutrition checklist (MLNC) for children 6 to 59 months and associated scoring system to coordinate care delivery, improve team documentation, strengthen WHO malnutrition protocol adherence and facilitate quality improvement in a district hospital in rural Rwanda. MLNC was developed after careful review of the 2009 Rwandan National Nutrition Protocol and 2013 WHO malnutrition guidelines. Critical steps were harmonized, extracted and designed into an initial MLNC with input from pediatric ward nurses, doctors, a locally based pediatrician and a registered dietitian. A scoring system was developed to facilitate quality improvement. Using the standard Plan-Do-Study-Act cycle, MLNC was modified and progress assessed on a monthly to bimonthly basis. Significant modifications occurred in the first 6 months of piloting including incorporation of treatment reminders and formatting improvements, as well as initiation of the MLNC from the emergency department. The MLNC is the first checklist to be developed that unifies WHO 10 steps of treatment of inpatient SAM with local standards. Anecdotally, MLNC was observed to identify gaps in key malnutrition care, promote protocol adherence and facilitate quality improvement. Data gathering on the MLNC local facility impact is underway. Collaborative international efforts are needed to create an inpatient malnutrition checklist for wider use to improve quality and reduce unnecessary, facility-based child mortality.

Published
2018
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2. Experience: developing an inpatient malnutrition checklist for children 6 to 59 months to improve WHO protocol adherence and facilitate quality improvement in a low-resource setting

Author

Richard Ndikuriyo, Scheilla Bayitondere, Angelique Mukantaganda, Almaque Dushimirimana, Souzane Nyiranganji, Vianney Bihibindi, Jennifer Werdenberg, Michel Habiyaremye, and Kathryn L. Beck

Subjects
Male, medicine.medical_specialty, Quality management, media_common.quotation_subject, Short Communication, Severe Acute Malnutrition, Nutritional Status, World Health Organization, Severity of Illness Index, quality improvement, 03 medical and health sciences, 0302 clinical medicine, Documentation, Pregnancy, 030225 pediatrics, Case fatality rate, medicine, Humans, 030212 general & internal medicine, Intensive care medicine, checklists, media_common, Protocol (science), Teamwork, Inpatients, under-5 mortality, business.industry, Health Policy, lcsh:Public aspects of medicine, Malnutrition, Public Health, Environmental and Occupational Health, Rwanda, Infant, lcsh:RA1-1270, medicine.disease, Checklist, Child, Preschool, Practice Guidelines as Topic, Female, low-resource setting, business, Delivery of Health Care, Diet Therapy
Abstract

In low-resource settings, inpatient case fatality for severe acute malnutrition (SAM) remains high despite evidenced-based protocols and resources to treat SAM. Key reasons include a combination of insufficiently trained staff, poor teamwork and inadequate compliance to WHO treatment guidelines which are proven to reduce mortality. Checklists have been used in surgery and obstetrics to ameliorate similarly complicated yet repetitive work processes and may be a key strategy to improving inpatient SAM protocol adherence and reducing unnecessary death. Here, we share our experience developing and piloting an inpatient malnutrition checklist (MLNC) for children 6 to 59 months and associated scoring system to coordinate care delivery, improve team documentation, strengthen WHO malnutrition protocol adherence and facilitate quality improvement in a district hospital in rural Rwanda. MLNC was developed after careful review of the 2009 Rwandan National Nutrition Protocol and 2013 WHO malnutrition guidelines. Critical steps were harmonized, extracted and designed into an initial MLNC with input from pediatric ward nurses, doctors, a locally based pediatrician and a registered dietitian. A scoring system was developed to facilitate quality improvement. Using the standard Plan-Do-Study-Act cycle, MLNC was modified and progress assessed on a monthly to bimonthly basis. Significant modifications occurred in the first 6 months of piloting including incorporation of treatment reminders and formatting improvements, as well as initiation of the MLNC from the emergency department. The MLNC is the first checklist to be developed that unifies WHO 10 steps of treatment of inpatient SAM with local standards. Anecdotally, MLNC was observed to identify gaps in key malnutrition care, promote protocol adherence and facilitate quality improvement. Data gathering on the MLNC local facility impact is underway. Collaborative international efforts are needed to create an inpatient malnutrition checklist for wider use to improve quality and reduce unnecessary, facility-based child mortality.

Published
2018

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