Discussion
We developed and implemented a simple tool to improve the documentation of paediatric admissions and clinical outcomes in a resource-constrained, rural hospital in northern Sierra Leone. Under-5 male children constituted the majority of children admitted to the hospital during the period in which the toll was implemented. These demographic features are consistent with findings obtained from studies conducted in similar settings.24 25 Higher admission rates of boys to the hospitals in these studies were attributed to an increased vulnerability of male children to some illnesses and the prevalent African custom of placing a higher premium on care of a male child compared with a female child, because of the relatively higher social importance attached to a male child.26 Nevertheless, the gender disparity in the admission rate was not identified as a risk factor for death in our study population. This finding differs from previous studies conducted in similar settings where mortality in some studies was higher in females24 27 28 and higher in males in other studies.25 29
Although, severe acute malnutrition (SAM) was not a major primary cause of admission among the hospitalised children in our study, about one-third of the children were wasting and were underweight. This nutritional status is typical of the features commonly seen in similar African settings where low rates of exclusive breastfeeding and incorrect complementary feeding practices are prevalent.30 31 SAM might also be due to individual or combined effects of malaria and intestinal parasitic infections which were prevalent in the study areas.32
A majority of the children in our study lived more than 1 km from the hospital, although this did not translate to late presentation to the hospital. This might be because commercial motorcycles taxis, the most common means of transport in the study community, were readily available across the community and could be used to take a sick child to the hospital. More than 70% of the children presented at the hospital before 16:00 hours and during weekdays, nevertheless, improved clinical outcomes were significantly associated with patient admission after 16:00 hours. This finding is contrary to the findings of similar studies8 33 34 where poor quality care was associated with patient admission outside daytime work hour. Our study findings might be explained by the care provided by the hospital staff following their training on the ETAT guidelines, hands-on support and post-training mentorship provided by the Sierra Leone MoHS national ETAT+programme staff and the EBOVAC paediatric staff during and outside the work hours.
Outside COVID-19 pandemic, admissions into the paediatric ward followed the seasonal pattern that has been widely reported in many African settings.35–40 This is mainly because malaria still remains the leading cause of hospitalisations in these endemic countries, and given that malaria transmission is driven by environment factors such as rainfall, it is not surprising that a rise in admissions was observed during the rainy seasons.41
Owing to the rural location of the study hospital, which is not connected to the national electricity grid and depends largely on electricity supply from generators to power essential life-saving equipment, a point-of-care test was the major laboratory investigation deployed to confirm clinical suspicions of malaria. Similarly, because of the limited diagnostic facilities, the diagnosis of common childhood diseases such as pneumonia and meningitis depended on clinical symptoms and signs. This practice is consistent with the WHO guidelines recommendations in the integrated management of childhood illnesses that do not focus on a single diagnosis, but on selected signs and symptoms to guide rational treatment.42 These guidelines might have improved the case-management skills of health workers in settings such as Kambia.43
As expected, malaria was the leading cause of paediatric admissions during the course of the tool implementation. Manifestations of severe malaria and its complications which included cerebral malaria, prostration, severe malaria anaemia and complex febrile convulsions were consistent with findings of similar studies conducted in malaria endemic countries in sub-Saharan Africa,24 29 36–38 and lend credence to a WHO report that many African countries still carry a high burden of malaria, despite the considerable achievements recorded in the last two decades.44
We found an overall mortality of 7% among the children enrolled in this study. This finding is similar to that reported in a study which implemented ETAT+guidelines to strengthen paediatric care in similar settings.19 The ETAT+training programme offered by the staff of the Sierra Leone MoHS was complemented by the paediatric personnel employed to work in the hospital by the EBOVAC-Salone project to ensure appropriate clinical care for children enrolled in the Ebola vaccine trial and other sick children admitted to the ward. The high prevalence of anaemia recorded in the study was managed by an efficient blood transfusion service, which was supported by regular blood donation campaigns organised by community volunteers and a solar-powered fridge for optimal storage of the donated blood. Improved clinical care has been a major benefit of hosting clinical trials in African communities but sustainability of the quality of care beyond the lifespan of the projects is usually a challenge.45 46
The leading cause of death in our study was severe malaria. Being an under-5 child, wasted (ie, WFH <−2SD), and having at least one danger sign were risk factors for death in hospital. These factors resonate with findings of similar studies conducted in Africa24 28 29 and underscore the need for improved hospital care, improved nutritional support for children and better health-seeking behaviours of parents and caregivers of under-5 children.
Contrary to the findings of a nationwide survey on the impact of COVID-19 pandemic, which reported a slight reduction in the hospital utilisations but no significant changes in paediatric admissions across Sierra Leone,23 we observed a substantial reduction in paediatric admissions during the COVID-19 pandemic, especially during the period shortly after the first national lockdown in Sierra Leone. The reason for this disparity is not known, but it might be connected with the design of the national survey which focused on a specific time point during the early phase of the pandemic. Although, children have been reported to carry a low risk of morbidity and mortality from COVID-19, reduction in the hospital admissions during COVID-19 pandemic led to planned health service reconfigurations, with prioritisation of COVID-19 infection, and reduction of non-essential services, unplanned service disruption and changes in health-seeking behaviour.23
Our study had a few limitations. First, the clinical diagnoses were based almost entirely on clinical judgement with very limited laboratory support. Second, although it was documented that malaria was by far the most important cause of admission to the paediatric ward of Kambia hospital, clinical staff had not had enough experience, or had sufficient laboratory support, to allocate all hospital admissions with severe malaria to one of WHO recommended subgroups of this condition. Third, there were some missing data for anthropometric indices of the children. It is possible that these anthropometric measurements were taken by the ward staff, but were not recorded. Also, the proximity of the hospital to the homes of some children could not be estimated because their parents/caregivers did not provide a specific home address, making it difficult to estimate the distance between their homes and the hospital. Although the study was not designed to measure the impact of deployment of the tool on outcomes, it is possible that some of these factors, such as duration of hospital stay and mortality in hospital, were affected by the activities undertaken to introduce the tool into routine care.
Nevertheless, the overall response rate of about 80% of children admitted to the ward during this study enabled us to demonstrate that the challenges of lack of systematic documentation of medical histories and poor record keeping of hospital admissions and outcomes can be overcome with a simple tool. Following successful implementation, the tool was adopted by the management of the hospital as the standard method of record keeping for the paediatric ward and has been adapted for other wards in the hospital. Overall, despite the usefulness of hospital data in providing a rich source of information that can be used to inform quality health systems, its limitations should not be overlooked. Chronic conditions that rarely present in hospital are usually not captured in hospital data, thereby limiting the usefulness of hospital data as an indicator of disease burden in a community. More importantly, accuracy of hospital data is shaped by data quality checks, which depends on the primary purpose of the data.11
