Sally Mugabe Children’s Hospital: A snapshot

This is a summary of a Field Exchange field article that was included in issue 67. The original article was authored by Svitlana Austin, Molifia Manyasha-Kuona, Elizabeth Ngarivhume and David Musorowegomo.  

Svitlana Austin is the Paediatrician in charge of the Malnutrition Unit (MU) at the Sally Mugabe Children’s Hospital (SMCH).

Molifia Manyasha-Kuona is a Dietitian at SMCH.

Elizabeth Ngarivhume is a Senior House Officer at the MU, SMCH.

David Musorowegomo is a Paediatrician at SMCH.

Wasting carries a significant health burden in Zimbabwe. At the Sally Mugabe Children’s Hospital (SMCH), increased cases of complicated severe wasting, and associated high mortality, led to its development into a Centre of Excellence for wasting management.

• A specialist multidisciplinary inpatient service was established with strong links to outpatient care which has reduced mortality and improved outcomes
• The SMCH Malnutrition Unit (MU) is now a centre for targeted teaching. and research in childhood wasting and, once finalised and approved by the Ministry of Health and Child Care, its standard operating procedures will be nationally distributed to streamline inpatient care.
• Continued efforts are being made to improve the quality of care for wasted patients and further reduce deaths, particularly for high-risk patients such as those with cerebral palsy.

Background

Zimbabwe faces a significant burden of child wasting, reaching a prevalence of 4.5% in 2020. At the Sally Mugabe Children’s Hospital (SMCH), the average monthly cases of complicated severe wasting increased from 34 to 86 per month between 2019 and 2020 and inpatient mortality reached 45.7%. This article describes the SMCH’s experience in becoming a National Centre of Excellence for wasting management and the progress made towards improved quality of care.

Wasting services at the SMCH

Role of the Paediatric Association of Zimbabwe (PAZ)

The PAZ is a group of paediatricians and other health professionals who have worked with UNICEF and the Ministry of Health and Child Care (MoHCC) to support capacity building and mentorship in wasting management across Zimbabwe. The first phase of the collaboration focused on capacity building in health facilities, training doctors, nurses and nutritionists in the integrated management of acute malnutrition (IMAM) and developing online IMAM training videos, providing clinical mentorship and supporting clinical audits.

Phase 2 of the collaboration aimed to scale up and implement a sustainable, quality of care improvement intervention for children presenting to inpatient care with complicated severe wasting. Project activities were planned over a nine-month period towards the following objectives:

• Quarter 1 (February – May 2021): Establishing a specialised national unit for wasting management. The SMCH was selected as a Centre of Excellence for wasting management and became the main site for training, protocol development and research. A comprehensive data collection system was established and plans were made to create a new High Dependency Unit within the Malnutrition Unit (MU) for critically ill children.
• Quarter 2 (May – August 2021): Completing training in other provinces and establishing a sustainable capacity-building system. This involved the development of a comprehensive IMAM e-learning package for nationwide training.
• Quarter 3 (August – November 2021): Training and dissemination of the Continuous Quality Improvement (CQI) approach. Guided by the MoHCC’s Quality Improvement Strategy, generic training of 100 healthcare workers was conducted across various institutions with additional training on the specific and practical application of CQI to the IMAM programme. This training capacitated staff at health facilities to identify priority quality improvement needs and to design strategies to track, monitor and achieve the priority quality improvement indicators.

Patient flow and staffing

Prior to the MU’s inception, care for patients with severe wasting was provided as a part of general paediatric services at the SMCH. There was no prioritisation of children with complicated severe wasting and these patients were often refused admission to the intensive care unit in favour of children perceived as having a ‘better chance of survival’. Patients were also not triaged according to the severity of malnutrition. The following changes have been made to address these issues:

• All children presenting to the SMCH casualty department are screened for wasting. Those identified as wasted are prioritised and managed according to newly introduced standard operating procedures (SOPs).
• Patients who meet the MU’s admission criteria are admitted as priority cases and managed by a multidisciplinary team of doctors, nurses, a nutritionist and a qualified counsellor specialising in disability counselling and child protection. Social workers also join ward rounds on a weekly basis and a family planning team provides educational sessions for mothers twice a week.
• All new admissions are placed into one of two Stabilisation Units (SUs). Once stabilised, patients are moved to Transition Units. This allows for the separation of patients according to the severity of their condition and the stage of their illness.
• Following discharge from the MU, patients are transferred to the outpatient treatment programme (OTP). The OTP is run by doctors and nutritionists following a holistic approach including medical and nutritional assessment, health education, counselling and emotional support.

Data collection and audit

The paucity of data on inpatients managed for wasting was one of the major challenges when the MU was established. Within the first quarter of the PAZ/UNICEF collaboration, a data collection system was set up in electronic and paper formats. The MU is the first facility in the country to conduct routine formal audits of paediatric deaths. The intention is to nationally disseminate this practice following MoHCC approval.

Key outcomes 

• During the first year, mortality of patients admitted to the MU with complicated wasting dropped from 45.7% to 14.2%.
• The unit acts as a centre for targeted teaching and research in childhood wasting, with SOPs developed by the team. Once finalised and approved by the MoHCC, the SOPs will be distributed to other SUs to streamline inpatient care.
• Through this collaboration, the majority of districts in Zimbabwe have been trained in IMAM. Ongoing mentorship visits are planned to support clinical staff and to further strengthen capacity in stabilisation centres (SCs) across the country. An IMAM e-learning training package is also being finalised and will allow free access to resources via the MoHCC platform.   
• Data collection at the MU has allowed for the identification of referral hotspots. This will inform the development of other interventions to improve wasting management in both inpatient and outpatient settings while strengthening linkages between them.
• Data has also identified a large burden of disability in children with wasting, particularly cerebral palsy. The average length of stay for children with associated neurological disability is 3.5 weeks compared to approximately two weeks for patients with wasting alone. There is a need to scale up wasting prevention and screening in this vulnerable group.

Successes and challenges

• The Centre of Excellence represents a hub for training and research as well as the development and implementation of care standards.
• Prior to this project, the nutrition and medical teams at the SMCH worked independently, preventing a holistic approach to patient care and creating conflict between the teams. In the newly established MU, patients are managed by a specialised multidisciplinary team that draws on different areas of expertise to improve patient outcomes.
• Restructuring of nursing staff allocations was needed during the MU’s inception to allow for continuity of training and care. Rather than being rotated on a daily basis, nurses are now allocated to the MU for two months at a time and the majority of SMCH nurses have been trained in IMAM.
• Having a dedicated MU with a specialised team provided an opportunity for targeted fundraising to support renovations. Fundraising efforts are ongoing to provide vulnerable families with food supplies upon discharge from the MU.
• Each death at the unit is audited to identify gaps and to improve practice. However, the number of deaths remains high and further efforts are being made to improve the quality of care including accelerating the development of SOPs, strengthening the links between SCs and OTPs, finalising the IMAM e-learning package for national use, lobbying for the provision of nutritional and social support for families of patients with poor socioeconomic circumstances or disabilities and engaging in the prevention of, and screening for, wasting in high-risk patients, particularly those with cerebral palsy.

Conclusion

The SMCH’s MU has achieved a significant reduction in mortality since its inception. While improvements are ongoing, this model can and should be replicated in other SCs across Zimbabwe. A key starting point would be identifying malnutrition champions such as doctors, nurses and nutritionists who are passionate about improving outcomes for wasted children admitted to their facilities. Their efforts should be supported by SOPs developed at the SMCH MU to standardise care for this vulnerable group of patients.