Pneumonia Audit

Adil N. Ahmad & Hammad ShaikhFinal 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

Background on Pneumonia (1)

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

Background on Pneumonia (2)

Fever

Cough

Difficulty in Breathing/Tachypnoea

Signs and Symptoms

Subcostal/Intercostal recession/Tracheal Tug

Chest Indrawing/Use of accessory muscles

Areas dull to percussion

Crackles on Auscultation

Cyanosis/Low Oxygen Saturations

Signs and Symptoms (2)

Sputum Culture – Antibiotic sensitivities

CBC/CRP

CXR

Investigations only when necessary

< 2 months = > 60 bpm

2 months – 1 year = > 50 bpm

1-5 years = > 40 bpm

Tachypnoea

ABC Approach

Oxygen

Antibiotics as early as possible!

Consider Nasogastric (NG) tube if patient is not feeding well

Correct Dehydration – ORS/IV Maintenance Fluids

Mainstay of Treatment

Dry Mucous Membranes

Sunken Eyes/Fontanelle

Reduced Skin Turgor

Irritability/Lethargy (GCS < 15/ BCS < 5)

Cold Peripheries (consider shock)

Recognising signs of Dehydration

Pneumonia

Severe Pneumonia◦ Chest Wall Indrawing

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

Classification of Pneumonia

Benzylpenecillin◦ 50,000 IU/kg qds

Gentamicin◦ 5 mg/kg OD

Vitamin A◦ 6-11 months – 100,000 IU◦ 12-59 months – 200,000 IU

Treatment (severe/very severe)

Ceftriaxone 100 mg/kg OD

◦ If patient fails to improve after 48 hoursOR◦ If patient beings to deteriorate at any point

Use of Ceftriaxone

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

Prescribing

The Audit

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

Why do an Audit?

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

Aims and Objectives

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

Methodology

Results

Sample size = 14 patients

Sample size

Patients Prescribed Correct AntibioticsPatients Prescribed Correct Antibiotics

857%

643%

Were Patients Prescribed the Correct Antibiotic?

Yes

No

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

Areas for Improvement

1286%

214%

Were Patients Prescribed Correct Antibiotic Dose?

Yes

No

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

Areas for Improvement

Antibiotics Given on Time

964%

536%

Were the Antibiotics Given on Time?

Yes

No

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

Areas for Improvement

750%

750%

Were Patients Prescribed Vitamin A when Appropriate?

YesNo

229%

571%

Of the 7 Inappropriate Occasions

Given to < 6 monthsNot given to 6-59 month old

343%

457%

Was the Correct Dose of Vitamin A Given?

Yes No

Prescribing to children below 6 months or over 5 years

Dosage not done by weight

Areas for Improvement

857%

643%

Child below 3rd Centile (Weight for Age)?

Yes

No

Weighing scale not available in Emergency

No WHO Growth Charts available

Areas for Improvement

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)

Other Areas of Improvement

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

Recommendations

Have printed WHO Weight for Age Growth Charts in Emergency and Wards

Have Weighing scales in Emergency and Wards

Nurse-patient allocation

Ward Organisation

Recommendations (2)

Early recognition of signs and symptoms

Early Health seeking behaviour

Good Hygiene – Handwashing to reduce spread of infection

Immunisations

Exclusive breastfeeding for 6 months

Patient Health Education – Our Collective Responsibility

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

Structural Issues

Patient Admission times and dosage given

Time of deaths◦ Mortality much greater at night

Further Work

Dr. Vanessa Rippon

Dr. Tenywa

The Interns◦ Dr. Acleo◦ Dr. Paul◦ Dr. James

Nursing Staff

Special Thank you

Any Questions?