An investigation into the dramatic increase in deaths from gastroenteritis during the summer of 2007/08 at National District Hospital, Bloemfontein, Free State

Abstract

Introduction and background: Despite national guidelines and agreed upon admission and referral criteria for children in National District Hospital (NDH), Bloemfontein, the number of children admitted with gastroenteritis (GE) has increased dramatically since December 2007. From the previous year’s Child Healthcare Problem Identification Programme (Child PIP) data the increase in GE admissions was evident in NDH. During the preceding year, 123 children were admitted for GE and during the audit period 267. The number of deaths in NDH also increased from an average of 2.25 a month over the past 3 years to 10 a month during January and February 2008. Aim: The aims of the study were: to determine the causes of death of children in NDH; to determine the relationship between nutritional status, HIV disease, laboratory results, demographic data, time of admission, duration of admission and other diseases or conditions and GE child deaths in NDH; to determine whether doctors adhered to prescribed GE treatment protocols; to determine whether nursing personnel carried out doctors’ orders as prescribed; and to identify other factors that contributed to GE deaths. Methodology: A cross-sectional study design was used. All child deaths, as well as all children admitted with GE to Ward 3 in NDH from May 2007 to April 2008 were included in the study. The first author collected the information on a cause of death form, a data form and an audit tool. As part of the quality-improvement project, 10 items were assessed to determine whether doctors adhered to treatment protocols, and 10 items were assessed to determine whether nurses adhered to nursing orders and basic nursing care. Any other factors that contributed to poor care were also noted. Results: 1. Cause of death: During this period, 49 children died, 33 (67%) due to GE, 6 (12%) due to tuberculosis (TB), 5 (10%) due to septicaemia, 4 (8%) due to pneumonia and 1 (2%) due to congenital abnormalities. Only 4.1% of the children who died were considered as normal weight for age according to their Road to Health Chart (RTHC). Regarding HIV status, 82.5% of the children who died tested HIV positive. In total, 19.4% of all GE admissions died during this one-year period. 2. GE deaths: Demographic data such as gender and age did not influence the outcome of GE. As expected, severe malnutrition, HIV-positive status and severe dehydration all contributed statistically significantly to high mortality in GE. Severe abnormalities occurred in the laboratory results of most of the children who died and indicated the severity of their disease(s). No specific organisms were cultured from stool specimens and the quality of drinking water in Bloemfontein was declared safe for human consumption. 3. Other factors that contributed to GE deaths: Medical and nursing care were of a high standard and treatment protocols were followed. Pre-admission factors such as transport, non-availability of 24-hour medical services, non-initiation of emergency treatment before referral, and caregivers not realising the severity of the disease need urgent attention to prevent further deaths. Conclusion: GE contributed to 67% of deaths in the paediatric ward of NDH. Underlying poor nutritional status and/or HIV disease were present in 96% of the GE deaths. In more than nine out of ten cases the doctors and nurses in the hospital rendered medical care in accordance with standard guidelines. Pre-admission factors need to be addressed in order to prevent more deaths.