MANAGEMENT Practices for Children IN Sickle Cell Crisis in Selected Hospitals in Northern Malawi. 

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Maria Mtangwa Kumwenda, Ettah Chimbe Phiri, Dr. Ferestas Mpasa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4427084/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Sickle cell crisis is a common complication of Sickle Cell Disease (SCD) that is responsible for frequent hospitalizations among children. The condition carries a mortality rate of 50% − 90%. If appropriate care is not rendered, it can lead to early child mortality. The aim of the study was to assess the quality of care provided to hospitalized children in sickle cell crisis in selected hospitals in Northern Malawi. Methods A quantitative descriptive cross-sectional design was used to assess the quality of care provided to hospitalized children in sickle cell crisis at a tertiary, district and mission hospitals in the Northern Region of Malawi. Data was collected from files of 124 children admitted in sickle cell crisis from 2019 to 2021 using a checklist that was developed from WHO, National Heart, Lung, and Blood Institute (NHLBI), and Queens Paediatric Guidelines for the management of SCD while analysis was done using SPSS version 20. Results The results showed suboptimal quality of care as most children did not receive the recommended interventions such as oxygen therapy, intravenous fluids, the correct amount of intravenous fluids, and timely pain relief medication as stipulated by the guidelines for the management of SCD. Conclusions The study gave some insights regarding quality of care for children in sickle cell crisis in the Region. It can, therefore, be concluded that ensuring the availability and accessibility of SCD management guidelines, pain assessment tools in Paediatric care settings would improve clinical practice. Health sciences/Health care Health sciences/Medical research Quality Care Sickle Cell Disease Children Vaso-Occlusive Crisis Sickle Cell Crisis Figures Figure 1 Figure 2 INTRODUCTION Sickle cell disease (SCD) is a common genetic condition that occurs due to abnormal formation of hemoglobin S (HbS) as a result of mutations ( 1 ). Substitution of Glutamic for Valine Amino Acid in the 6th position of hemoglobin's chain changes the physical properties of the haemoglobin ( 2 ). This alteration in hemoglobin's physical structure results in functional challenges, especially with oxygen loading ( 3 ). Globally, 400 000 babies are born with the disease annually ( 4 ) with almost 75% of these newborn babies living in sub-Saharan ( 5 ). The disease is accompanied by acute and chronic complications. One of the most serious acute complication is sickle cell crisis (SCC) including vaso-occlusive crisis (VOC) ( 6 ). VOC is responsible for hospital visits and inpatient admissions ( 7 ), ( 8 ). The disease has a mortality of 50% − 90% among children born in low-resource countries like sub-Saharan Africa( 9 ). Without appropriate interventions, up to 90% of these children will not reach the age of 18 years ( 10 ). This entails that children presenting with SCC are at risk of serious morbidities and early mortality if appropriate care is not initiated promptly ( 11 ). Malawi has a significant burden of SCD. It is estimated that 2,000 infants are born with SCD every year ( 12 ). The disease contributes a significant proportion of pediatric hospitalizations (3.1%), with painful crises being the most common clinical feature ( 13 ). This indicates that SCD is a public health concern in Malawi, implying that effective interventions that includes high-quality care, is paramount for sick children. To address the high mortality rate associated with SCD, the World Health Organization (WHO) and the National Heart Lung and Blood Institute (NHLBI) developed guidelines for the management of complications resulting from SCD( 14 ). Malawi adopted some of these guidelines as reflected in the protocols for management of common childhood illnesses in Malawi ( 15 ). These guidelines include the provision of interventions such, as supplemental oxygen therapy, fluid therapy, pain management, antibiotics, folic acid supplementation, and transfusion of packed red blood cells. For sickle cell crisis, in particular, supplemental oxygen therapy, fluid therapy, and appropriate pain management are crucial. Adherence to these guidelines ensures the provision of high-quality care for children in SCC. Gaps in the provision of high-quality care for individuals with SCD have been documented ( 16 ). In Brazil, only 36.6% of children with SCD had their growth and development charts monitored and 28.6% had the minimum recommended follow-ups ( 17 ). In many resource-limited countries, this gap is directly related to the scarcity of resources for the delivery of high-quality care ( 5 );( 18 ). Gaps related to the structure, process, and outcome dimensions including inadequate knowledge of nurses on comprehensive care for SCD were reported in Ghana ( 19 ). Malawi is another resource-limited country. It is, therefore, possible that the situation might be the same. Data from Paediatric admission registers at a tertiary, district and mission hospitals, indicate that approximately 2.7%, 1.4%, and 0.5% of all pediatric admissions were due to SCC in the year 2020. This means that SCD is one of the causes of hospitalizations in children in the Northern Region. The government of Malawi through the Ministry of Health (MOH) has identified improving the quality of healthcare towards attainment of Universal Health Coverage as one of its priority areas of action in the Health Sector Strategic Plan 2023–2030. It is therefore envisaged that quality of care might improve by paying attention to improving the competencies and skills of health workers and provision of adequate medical equipment and supplies among others ( 20 ). Despite the government effort, inconsistent quality of care in Malawi remains a major challenge due to resource constraints ( 21 ). Providing comprehensive quality care for children with SCC would improve the quality of life for the children who are bound to live with the conditions for the rest of their lives. Although studies have reported gaps in quality of care for SCD, they focused on general routine care provided to children including follow-up care. There is scanty data on the quality of care provided to children hospitalized with SCC, especially in acute care. Therefore, this study was conducted to assess the quality of care provided to hospitalized children in SCC in selected hospitals in Northern Malawi. In particular to compare current practices for the provision of care for sickle cell crisis with the existing standard guidelines METHODS Study Design The study used the quantitative approach employing a cross-sectional design. A cross-sectional design enabled the researcher to obtain a snapshot description of the status of quality of care offered to children in SCC, and how it relates to inputs and processes for quality of healthcare adopted in the theoretical framework ( 22 ). The context in the study was the quality of care provided to children in the selected hospitals in Northern Malawi. Study Setting The study was conducted in three selected hospitals: a tertiary, district and mission hospital in Northern Malawi. A tertiary hospital is a facility that provides specialist health services, and offer referral services at reginal level; therefore, it was projected to see an influx of patients including those in SCC. The district hospital was chosen because of the prevalence of consanguine marriages within the district hence a significant number of SCD patients. A mission hospital is a faith-based hospital under the umbrella of Christian Health Association of Malawi (CHAM). In Malawi, CHAM provides approximately 30% of all health services to the population ( 20 ), therefore, it was necessary to include one facility managed by the organization in the study. Study Population Children who were hospitalized due to sickle cell crisis between 2019 and 2021 made up the study population. In the Malawian setting, the Paediatric ward admits children under 12 years of age. As such, their case files provided evidence of the quality of care provided during hospitalization for SCC. Data Collection Method The study employed systematic random sampling technique whereby each subject in the study population had an equal chance of being selected for the study ( 23 ). Therefore, all files of children admitted in Paediatric ward from the year 2019 to 2021 in sickle cell crisis for each hospital were collected. They were sorted to determine the sampling frame for each hospital. The sample size for the mean population was estimated using Yamane’s formula. Depending on the proportion of the population represented, a sample size of 87, 28, and 9 was met. The sampling interval was then calculated by dividing the population size for each hospital by the sample size. Then, every kth file from the list was included in the study after the first child's file was randomly selected from among all the sorted files. Inclusion and Exclusion Criteria The inclusion criteria was children up to 12 years, who were admitted with sickle cell crisis from the year 2019 to 2021. The exclusion criteria was children up to 12 years old who had SCD, but were admitted with other conditions, and those that were admitted with other conditions were not included in the study. Data Collection Tool Data from children’s files (chart review) was collected using a checklist developed by the researcher informed by the content from WHO guidelines on management of sickle cell crisis, NHLBI evidence-based management of sickle cell disease and protocols for management of common childhood illnesses in Malawi. The checklist was designed to collect management care practices documented in the patient's files. It included information on providers' performance concerning initial and supportive care for the management of sickle cell crisis. The initial care comprised patient assessment (history taking, physical examination, and appropriate laboratory investigations), then crucial care needed necessary for a child who is in crisis. This includes; administration of oxygen therapy, appropriate pain management, and administration of fluids. The supportive care included information on blood transfusion, administration of antibiotics, and patient monitoring. Each case file was reviewed and scored by ticking whether the care was done or not based on the documented evidence benchmarked with the guideline. This then depicted the retrospective element since the researcher was reviewing the data that was collected sometime back from 2019 to 2021. While other studies argue that in low and middle-income countries, medical records are often poorly maintained and may not reflect actual practice ( 24 ), other studies recommend medical records as essential tools to measure and evaluate care and have proven useful for quality improvement ( 25 ). Therefore, this study used medical records to evaluate care practices provided to children in sickle cell crisis. Validity The checklist was vetted by the research supervisors and specialists in pediatric care to assess the appropriateness and relevance of each item to ensure content validity. In addition, the tools have been developed from WHO guidelines, NHLBI evidence-based management of sickle cell disease and Open Guidelines protocols for the management of common childhood illnesses in Malawi. Ethical consideration The study was approved by Mzuzu University Research Ethics Committee (MZUNIREC) (reference number MZUNIREC/DOR/23/14). Permission to conduct the study was sought from relevant authorities in all the three hospitals, and written authorization was granted. To ensure anonymity, children’s files were assigned codes and names were not used in the study. Data Collection and Management The required sample size for children’s case files of; 9, 28 and 87 files from the mission, district and tertiary hospitals respectively was obtained from the records storage area. In each hospital, the researcher was provided with a separate room to avoid disturbances during the review process. File code numbers were used instead of the child’s real name to maintain confidentiality. Each file and all the necessary records attached, thus the admission notes, medical and nursing progress notes, treatment charts, laboratory investigations and results records and vital sign monitoring charts, if attached, were reviewed by the researcher. The records were benchmarked with the checklist, ticking whether the care was provided basing on the documented evidence. Patients’ case files during the data collection process were stored in a safe place under lock and key only accessible to the researcher to maintain confidentiality. After data collection, all the children’s case files were returned to the records storage area. Thereafter, the data collected through the checklists were stored in envelopes, whereas electronic data was stored in a file protected by a password by the researcher. Data Analysis The data collected was checked for completeness and consistence, then variables were cleaned in an Excel spreadsheet package before analysis. The Statistical Package for the Social Science (SPSS) software version 20 was used to analyze the data. In SPSS, variables like patient assessment, physical examination, laboratory investigations and general care were coded after being entered. Descriptive statistics were used to summarize the data, making it easier to comprehend the specifics of the samples. RESULTS Results for Patient Assessment The results relating to patient assessment on admission indicated that the majority of the children had the recommended history collected in all the hospitals. History of infections and triggering events was more collected in all hospitals 97.7% (n = 85) for a central hospital, 89.3% (n = 25) for a district and 100% (n = 9) for a mission hospital, followed by history of painful crisis at a central and district hospitals. The following history was least collected; history of previous blood transfusion 57.1% (n = 16), and 66.7% (n = 6) for a district and mission hospitals respectively, and history of painful crises 66.7% (n = 6) for a mission hospital. The majority of the children had physical examinations performed in most important areas such as pallor, jaundice, chest and lungs and splenomegaly in all hospitals. The most neglected area on assessment was frontal bossing 97.7% (n = 85), 89.3% (n = 25) at a central and district hospitals respectively and at a mission hospital it was not assessed at all. Bone tenderness was not assessed in 27.6% (n = 24), 39.3% (n = 11) and 22.2% (n = 2) at a central, district and a mission hospital respectively. For more details on other findings refer to Table 1 . Table 1 Patient Assessment on Admission Patient assessment Variable Finding Central Hospital District Hospital Mission Hospital N % N % N % History Taking Blood Transfusions Yes 85 97.7 16 57.1 6 66.7 No 2 2.3 12 42.9 3 33.3 Painful crises Yes 83 95.4 26 92.9 6 66.7 No 4 4.6 2 7.1 3 33.3 Infections and triggering events Yes 85 97.7 25 89.3 9 100.0 No 2 2.3 3 10.7 0 0.0 Physical Examination Pallor Yes 86 98.9 26 92.9 9 100.0 No 1 1.1 2 7.1 0 0.0 Jaundice Yes 84 96.6 14 50.0 8 88.9 No 3 3.4 14 50.0 1 11.1 Chest and Lungs Yes 87 100.0 28 100.0 9 100.0 No 0 0.0 0 0.0 0 0.0 Splenomegaly Yes 86 98.9 27 96.4 6 66.7 No 1 1.1 1 3.6 3 33.3 Bone tenderness Yes 63 72.4 17 60.7 7 77.8 No 24 27.6 11 39.3 2 22.2 Frontal Bossing Yes 2 2.3 3 10.7 0 0.0 No 85 97.7 25 89.3 9 100.0 The results of data on the laboratory investigations indicated that the majority of the children in all the hospitals had PCV, full blood count (FBC) malaria test (MPS/MRDT) checked indicating compliance with the recommended investigations. For more details on other findings refer to Fig. 1 . Results based on patient management Regarding patient management, the researcher was interested in finding out acute care that was provided to children hospitalized using the evidence-based guidelines. The Paediatric guidelines in acute care recommend administration of supplemental oxygen therapy, intravenous fluids and prompt and effective pain management using appropriate analgesics. The findings showed that the majority of the children did not receive oxygen therapy as part of management, 82.1% (n = 23) and 56.3% (n = 49) for a district and central hospitals. Furthermore, at a mission hospital all children did not receive oxygen therapy. On fluid management 70.1% (n = 61), 42.9% (n = 12) and 33, 3% (n = 3) received intravenous fluids for a central, district and mission hospitals respectively. Out of those who received intravenous fluids, the majority did not receive the correct amount based on fluid calculation. The majority of children did not have regular assessment of vital signs and work of breathing. For more details on other findings refer to Tables 2 and 3 Table 2 Patient Management Variable Response Central Hospital District Hospital Mission Hospital N % N % N % Received Oxygen Yes 38 43.7 5 17.9 0 0.0 No 49 56.3 23 82.1 9 100.0 Received intravenous fluids Yes 61 70.1 12 42.9 3 33.3 No 26 29.9 16 57.1 6 66.7 Received proper maintenance fluid Yes 26 41.9 4 33.3 0 0.0 No 36 58.1 8 66.7 3 100.0 Encouraged on oral fluids Yes 29 33.3 4 14.3 1 11.1 No 58 66.7 24 85.7 8 88.9 Regular assessment of vital signs, work of breathing, and oxygen saturation Yes 14 16.1 1 3.6 1 11.1 No 73 83.9 27 96.4 8 88.9 Subsequent reviews by clinician Yes 87 100.0 26 92.9 9 100.0 No 0 0.0 2 7.1 0 0.0 Table 3 Medications Received Variable Type of Medication Central Hospital District Hospital Mission Hospital N % N % N % Appropriate pain relief medication received Morphine 22 25.3 6 21.4 1 11.1 Diclofenac 14 16.1 3 10.7 0 0.0 Paracetamol/Ibuprofen 51 58.6 19 67.9 8 88.9 Appropriate parenteral antibiotics received Ceftriaxone 62 71.3 8 28.6 6 66.7 Benzyl Penicillin and Gentamycin 24 27.6 17 60.7 3 33.3 Benzyl Penicillin 0 0.0 2 7.1 0 0.0 None 1 1.1 1 3.6 0 0.0 Regarding pain management, 32.2% (n = 28), 32.1% (n = 9) and 33.3% (n = 3) for a central, district and mission hospitals received medication on pain relief within 15–30 minutes of admission to the hospital. For the majority of children, the time for administration of the first medication on pain relief was not indicated in the patient’s files. This indicates that delay in administering medication on pain relief and deficiency in documentation. Refer to Fig. 2 for the findings on the timing for administration of medication of pain relief. DISCUSSION The findings revealed that on admission, majority of the children were properly assessed based on the admission form of the sick child. There was compliance for standard laboratory investigations to be carried out for children with SCD such as PCV, FBC, and Malaria tests. These investigations are not diagnostic but assist in the management of SCD( 26 ). Donabedian asserts that one of the important approaches to assessment of quality of care is to examine the process of care ( 27 ). The results showed good practice because of comprehensive patient assessment results reflected in the correct diagnosis and management which is a constituent of quality care. However, the admission form did not contain parameters on clinic reviews and treatment compliance as indicated on the guidelines for the management of SCD, as such, it was regarded that those areas were not assessed. This is in agreement with a study done in Ethiopia which revealed low quality assessment of sick children when comparing with the Integrated Management of Childhood Illnesses (IMCI) guidelines ( 28 ). This means that the admission form may need to be revised to include parameters that were missed or using a specific admission sheet for SCD patients. This is in agreement with some studies that revealed that despite comprehensive patient assessment on admission completion of documentation of patient assessments is often sub-optimal ( 29 ). The Malawi Paediatric Guidelines recommend the use of supplemental oxygen therapy for all children with painful VOC despite normal oxygen saturation ( 15 ). Oxygen therapy reverses the sickling process which is responsible for acute pain ( 30 ). Additionally, individuals with SCD have low haemoglobin levels due to chronic haemolysis of sickled red blood cells (RBS’s) ( 31 ).This, consequently, leads to the reduction of the amount of oxygen carrying capacity. Hence, administration of supplemental oxygen therapy maximises oxygen delivery to tissues ( 32 ). Studies have also supported use of oxygen therapy in reduction of pain. A study that was done in a tertiary hospital in London to determine optimum use of fluid and oxygen therapy in children presenting with VOE, indicated that oxygen therapy was associated with a higher reduction in pain score points at discharge ( 33 ). Conversely, the findings of this study revealed that most of the children did not receive oxygen therapy as part of their management. This was worse at a mission hospital where all the children admitted in crisis (n = 9) did not receive oxygen therapy, followed by a district hospital 82.1% (n = 23) and central hospital 56.3% (n = 49). On the contrary, many health care workers indicated high levels of ability to manage children in SCC. Again, there was high availability of resources for management of SCD in all the hospitals with the highest scores recorded in oxygen concentrators, nasal prongs among others. This shows that resource constraints were not a problem in the provision of oxygen therapy as part of management. This finding was supported by those made in a Ghanaian study on the structure dimension of quality care for children with SCD that found that a high availability of resuscitation equipment among others ( 34 ). However, this finding contradicts the chart review finding on administration of oxygen therapy that clearly indicated a significant gap in quality of care that was delivered. This could be related to the provider's knowledge gap on current practice on treatment which is directly related to lack of guidelines. A study done to assess the knowledge and practices of Congolese physicians in treating sickle SCD in the Democratic Republic of Congo revealed insufficient knowledge of healthcare providers. The findings indicated that 44% of physicians followed recommendations for the management of VOC and prescribed analgesics and hydration while treating SCD patients ( 35 ). Findings in this study also indicated low availability of guidelines for the management of SCD. From the literature, it clearly indicates that the guidelines are there. As they were a basis for formulation of the data collection tool. This might mean that the guidelines were not accessible at the point of care. In this case, the chart review finding concur with this finding. This is a huge gap in patient management that would consequently lead to the provision of substandard care since high-quality care is achieved through the use of evidence-based guidelines ( 36 ). Again, clinical practice guidelines decrease variations in the delivery of care among healthcare providers ( 37 ). These findings are similar to several other studies done globally that showed that providers were unaware of the 2014 NHLBI SCD care guidelines ( 38 ), and some are not adherent to guideline use when providing care ( 39 ). In Malawi, similar findings were made that showed that hospitals had low availability for emergency guidelines at 33.3% ( 40 ). Timely pain management is central in quality care as it improves the quality of life in children ( 41 ). In this study, despite that all children received medication on pain relief of various types in all hospitals, only a few of them received it in time. NHLBI evidence-based guidelines recommend the use of medication on pain relief within 15–30 minutes of admission. This means that there was a delay in relieving pain which compromised the quality of life in these children. These findings are consistent with ( 42 ) who found that patients with SCD experienced significant delays in seeking medication on pain relief. Unrelieved pain may prolong the stress response and adversely affect the recovery process ( 43 ). Furthermore, poorly controlled acute pain can predispose patients to chronic pain syndromes and affect a child’s ability to cope as an adolescent and adult. Administration of fluids is important in the management of SCC because it helps to stop the sickling process and reduces episodes of pain ( 44 ) as dehydration causes an increase in blood viscosity which eventually triggers SCC episodes ( 45 ). Again, studies have found that administration of fluid therapy in patients with SCD is associated with reduced hospitalization and prevents development of complications such as acute chest syndrome ( 32 ). The NHLBI evidence-based and Queens Pediatric guidelines recommend immediate correction of acidosis and dehydration with appropriate intravenous and oral fluids as principal in care for SCC. Although 70.1% of children at a central hospital received intravenous fluids, the findings indicated that children were not adequately hydrated as 66.7% and 57.1% for the mission and the district hospitals respectively did not receive fluids. In addition, most of the children who received intravenous fluids did not receive the correct amount based on fluid calculation for the management of SCD. This observation was worse at the mission and district hospitals. These findings are similar to those made in a study done in Ghana where nurses displayed inadequate knowledge concerning maintenance of fluid requirements for children in crisis, such that only 13.5% knew the correct level of fluid prescription ( 19 ). This means that the children were either under or overhydrated. Other studies have found fluid overload in patients with SCD, occurring in 21% of patients especially for the total volume given in the first 24 hours ( 46 ). Fluid overload has adverse effects on the child’s respiratory and kidney functioning delaying recovery process. It was also observed in this study that the majority of children were not encouraged to take oral fluids in all the hospitals. Patient monitoring is central to patient care as it helps to assess the progress of the condition and to follow the provided care. Children who are admitted in crisis are acutely ill and they need to be monitored regularly possibly every 4 to 6 hours until they are stable. Regular monitoring of vital signs and documentation have been shown to improve the early detection of at-risk patients ( 47 ). However, research has consistently found that patient monitoring including assessment of vital signs is often a neglected area in clinical practice ( 48 ),( 49 ). Findings of this study revealed that majority of children did not have regular assessments of vital signs (temperature, pulse rate, respiration, and blood pressure), work of breathing, and oxygen saturation during hospitalization. The chart review showed that 83.9%, 96.4%, and 88.9% of children for the central, district, and mission hospitals respectively were not monitored regularly. Most of the children were assessed once a day especially during ward rounds by the clinician or doctors although assessment of vital signs is an important responsibility of nursing. A Malawian research study also found that 49% of Paediatric case files during death audit did not have any recorded records of vital signs within the first twenty-four hours of hospitalization, and documentation deficiencies were noted in 58% of the charts reviewed ( 50 ). Similar findings were also made in Kenya and Ghana by ( 51 ); ( 52 ) that hospitalized patients were not adequately monitored. In the broader perspective, findings of this study indicated that compliance with patient monitoring was low in all hospitals. This could mean that patient assessment is a challenge in resource-limited countries compromising the quality of nursing care. The lack of consistent monitoring might be due to several factors including a shortage of human resources, unavailability of equipment for checking vital signs, and their proper functioning status, among others. Therefore, identifying interventions that might improve monitoring compliance would seem to be a crucial step in quality improvement with the potential to improve clinical outcomes. Again, nursing assessments and care/progress notes were not documented in the files for most of the children indicating deficiency in nursing care. Strengths and limitations The study is among the few that have assessed hospital-based quality of care provided to children in sickle cell crisis with specific focus on acute care in low-income countries. The main limitation of the study is that it was conducted in three hospitals only in Northern Malawi. As such, the quality of care provided might be different in other hospital settings, and generalizability of the findings to all hospitals in the Northern Region and Malawi as a whole may not be possible. In addition, the retrospective nature of the data collection method had an impact on the generation of consistent data as assumptions were based on what was not documented, and there was some missing information. There is a need to extend the study to all second and third level hospitals in Malawi. Conclusion The study findings revealed gaps in the delivery of quality care especially with process dimensions. Hospitalized children in sickle cell crisis received suboptimal care specifically in acute care with reference to the evidence-based guidelines. They did not receive recommended care such as oxygen therapy, adequate hydration and timely medication for pain relief. There was lack of regular patient monitoring of general conditions and vital signs. Documentation of nursing care records was also found to be problematic. The Results from the study will inform planning and advocacy strategies at the Malawian Ministry of Health (MOH) and within study facilities where gaps exist in care. We recommend that the hospital management and the ward in-charges should ensure the availability and accessibility of SCD management guidelines in Paediatric care points Emergency Triage Assessment and Treatment (ETAT, and Paediatric wards) to guide clinical practice. Again, intensify the supervision of HCW’s in care delivery as well as the documentation to improve performance. Abbreviations CHAM Christian Health Association of Malawi ETAT Emergency Triage Assessment and Treatment FBC Full Blood Count HbS Hemoglobin S HCP Health Care Providers HCW’s Health Care Workers HSSP Health Sector Strategic Plan IMCI Integrated Management of Childhood Illnesses MOH Ministry of Health MRDT Malaria Rapid Diagnostic Test MZUNIREC Mzuzu University Research Ethics Committee NHLBI National Heart Lung and Blood Institute PCV Packed Cell Volume RBC Red Blood Cells SCC Sickle Cell Crisis SCD Sickle Cell Disease VOC Vaso -Occlusive Crisis WHO World Health Organization Declarations Acknowledgements The authors would like to express their appreciation to the study facilities for their willingness to share data with us. The authors would also like to thank the nurses, doctors and clinicians working in the Paediatric ward at the various study sites for the assistance rendered throughout the study. The librarian Mzuzu university, Associate Professor Aubrey Chaputula for editing the document. Contributions M.K. collected data in all the hospitals and developed the manuscript. E.P. and F.M. provided oversight and supervision, assisted to ensure methodological rigor, M.K, E.P. and F.M. assisted with data analysis and interpretation. All the authors contributed to the completion of this manuscript and have read and approved it. Corresponding author Maria Mtangwa Kumwenda Competing interests The authors declare no competing interests. Data Availability All data generated for analysis during this study are included in the supplementary information file. Ethics approval and consent to participate All methods were performed in accordance with the relevant guidelines and regulations. For example, ethical approval for the study was obtained from Mzuzu university Research Ethics Committee (MZUNIREC) (reference number MZUNIREC/DOR/23/14). Permission to conduct the study was sought from relevant authorities in all hospitals and the written approval was granted. To ensure anonymity, children’s files were assigned codes and names were not used in the study. Consent to Participate Informed consent was obtained from all participants Supplementary Information Data from case file reviews has been provided. Funding The study received no funding. Consent for publication Not applicable References Hoban MD, Orkin SH, Bauer DE. Genetic treatment of a molecular disorder: gene therapy approaches to sickle cell disease. Blood. 2016;127(7):839–48. McCance KL, Huether SE. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 8th Ed. Elsevier; 2016. Oron AP, Chao DL, Ezeanolue EE, Ezenwa LN, Piel FB, Ojogun OT, et al. Caring for Africa’s sickle cell children: will we rise to the challenge? BMC Medicine. 2020;18(1):92. Wonkam A, Makani J. Sickle cell disease in Africa: an urgent need for longitudinal cohort studies. 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Nursing Research: Reading, Using and Creating Evidence. 4 th ed. Colorado: Jones & Bartlett Publishers; 2016. Hanefeld J, Powell-Jackson T, Balabanova D. Understanding and measuring quality of care: dealing with complexity. Bull World Health Organ. 2017;95(5):368–74. Rios-Zertuche D, Zúñiga-Brenes P, Palmisano E, Hernández B, Schaefer A, Johanns CK, et al. Methods to measure quality of care and quality indicators through health facility surveys in low-and middle-income countries. International Journal for Quality in Health Care. 2019;31(3):183–90. Ahmed SG, Ibrahim UA. A compendium of pathophysiologic basis of etiologic risk factors for painful vaso-occlusive crisis in sickle cell disease. Nigerian Journal of Basic and Clinical Sciences. 2017;14(2):57–77. Ayanian JZ, Markel H. Donabedian’s lasting framework for health care quality. The New England journal of medicine. 2016;375(3):205–7. Getachew T, Abebe SM, Yitayal M, Persson LÅ, Berhanu D. Assessing the quality of care in sick child services at health facilities in Ethiopia. BMC health services research. 2020;20:1–12. Redley B, Raggatt M. Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: a mixed methods study. BMJ Quality & Safety. 2017;26(9):704–13. Omoigui S. Pain Crises in Sickle Cell Disease: A Clinical Guide to Prevention and Treatment: How to Manage an Acute Pain Crisis in Sickle Cell Disease: Practical Recommendations. 2021;21. Sundd P, Gladwin MT, Novelli EM. Pathophysiology of Sickle Cell Disease. Annu Rev Pathol. 2019;14:263–92. Choudhury R. Hypoxia and hyperbaric oxygen therapy: a review. International journal of general medicine. 2018;431–42. Butt Z, Chakravorty S. Use of Fluid and Oxygen Therapy in Normoaxaemic Paediatric Patients Presenting with Acute Sickle Vaso-Occlusive Episodes Requiring Hospital Admission and Analysis of Clinical Outcome. Blood. 2019;134:4844. Korkortsi REK. Assessment of Quality of Care for Children with Sickle Cell Disease in the South Tongu District of Ghana: Nurses’ Perspective. Asian Journal of Research in Nursing and Health. 2021;4(4):58–74. Mukinayi Mbiya B, Tumba Disashi G, Gulbis B. Sickle cell disease in the democratic republic of Congo: assessing physicians’ knowledge and practices. Tropical medicine and infectious disease. 2020;5(3):127. World Health Organization. WHO guideline: recommendations on digital interventions for health system strengthening: web supplement 2: summary of findings and GRADE tables. World Health Organization; 2019. Kredo T, Bernhardsson S, Machingaidze S, Young T, Louw Q, Ochodo E, et al. Guide to clinical practice guidelines: the current state of play. Int J Qual Health Care. 2016;28(1):122–8. Smeltzer MP, Howell KE, Treadwell M, Preiss L, King AA, Glassberg JA, et al. Identifying barriers to evidence-based care for sickle cell disease: results from the Sickle Cell Disease Implementation Consortium cross-sectional survey of healthcare providers in the USA. BMJ open. 2021;11(11):e050880. Martin OY, Thompson SM, Carroll AE, Jacob SA. Emergency Department Provider Survey Regarding Acute Sickle Cell Pain Management. Journal of Pediatric Hematology/Oncology. 2020;42(6):375–80. Kayambankadzanja R. Emergency and critical care services in Malawi: Findings from a nationwide survey of health facilities. Mal Med J. 2020;32(1):19–23. Ballas SK, Gupta K, Adams-Graves P. Sickle cell pain: a critical reappraisal. Blood. 2012;120(18):3647–56. Almuqamam M, Diaz – Frias J, Malik M, Suwaidan AA, Sedrak A. Emergency management of SCD pain crises: Current practices and playing variables. Pediatric Hematology Oncology Journal. 2018;3(2):37–41. Darbari DS, Sheehan VA, Ballas SK. The vaso-occlusive pain crisis in sickle cell disease: definition, pathophysiology, and management. European journal of haematology. 2020;105(3):237–46. Uwaezuoke SN, Ayuk AC, Ndu IK, Eneh CI, Mbanefo NR, Ezenwosu OU. Vaso-occlusive crisis in sickle cell disease: current paradigm on pain management. Journal of pain research. 2018;3141–50. Carden MA, Fay ME, Lu X, Mannino RG, Sakurai Y, Ciciliano JC, et al. Extracellular fluid tonicity impacts sickle red blood cell deformability and adhesion. Blood. 2017;130(24):2654–63. Gaartman AE, Sayedi AK, Gerritsma JJ, Back TR de, Tuijn CF van, Tang MW, et al. Fluid overload due to intravenous fluid therapy for vaso-occlusive crisis in sickle cell disease: incidence and risk factors. British Journal of Haematology. 2021;194(5):899–907. The primacy of vital signs – Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study. International Journal of Nursing Studies. 2015;52(5):951–62. Kamio T, Kajiwara A, Iizuka Y, Shiotsuka J, Sanui M. Frequency of vital sign measurement among intubated patients in the general ward and nurses’ attitudes toward vital sign measurement. Journal of Multidisciplinary Healthcare. 2018;11(null):575–81. Weenk M, Koeneman M, van de Belt TH, Engelen LJLPG, van Goor H, Bredie SJH. Wireless and continuous monitoring of vital signs in patients at the general ward. Resuscitation. 2019;136:47–53. Fitzgerald E, Mlotha-Mitole R, Ciccone EJ, Tilly AE, Montijo JM, Lang HJ, et al. A pediatric death audit in a large referral hospital in Malawi. BMC Pediatrics. 2018;18(1):75. Ogero M, Ayieko P, Makone B, Julius T, Malla L, Oliwa J, et al. An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care? Journal of Global Health [Internet]. 2018 Jun [cited 2023 Oct 30];8(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826085/ Mugyenyi GR, Ngonzi J, Wylie BJ, Haberer JE, Boatin AA. Quality of vital sign monitoring during obstetric hospitalizations at a regional referral and teaching hospital in Uganda: an opportunity for improvement. Pan African Medical Journal. 2021;38(1). Additional Declarations No competing interests reported. Supplementary Files CaseFileReviewData.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4427084","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":311513519,"identity":"606c6ada-967c-4c52-bbf2-0617511fae83","order_by":0,"name":"Maria Mtangwa Kumwenda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBACCQjFDKESGGzgQkRrSSNVCwPDYcJaJGdkp0l83GEtzyB2+NmHBzXnE/tnNx98wFBjE41Li7RE7jbJmWfSDRuk04xnJBy7nTjjzrFkA4ZjabkNOLTIAbXc5m07zNggnWDMkMB2O7HhRo6ZBGPDYfxa/rYdtm+QTv/MkPDvXOJ8QlpADrvN2HY4sUE6x5ghse1A4gZCWiR73m7/2duWntwmnVPMkNiXbLzxRlqyQQIev0gcz91s8LPN2rZfOn0z449vdrLzbiQffPChxganFjhgg9KOYJUJhJQjA3tSFI+CUTAKRsHIAACCIF0MAlPGtQAAAABJRU5ErkJggg==","orcid":"","institution":"Mzuzu University","correspondingAuthor":true,"prefix":"","firstName":"Maria","middleName":"Mtangwa","lastName":"Kumwenda","suffix":""},{"id":311513520,"identity":"620ae266-e47b-4d02-ad8f-23dabcfe612a","order_by":1,"name":"Ettah Chimbe Phiri","email":"","orcid":"","institution":"Mzuzu University","correspondingAuthor":false,"prefix":"","firstName":"Ettah","middleName":"Chimbe","lastName":"Phiri","suffix":""},{"id":311513521,"identity":"a17bcd41-791c-4dbc-9417-ba7190a75990","order_by":2,"name":"Dr. Ferestas Mpasa","email":"","orcid":"","institution":"Mzuzu University","correspondingAuthor":false,"prefix":"Dr.","firstName":"Ferestas","middleName":"","lastName":"Mpasa","suffix":""}],"badges":[],"createdAt":"2024-05-15 19:41:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4427084/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4427084/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58146369,"identity":"9aa75892-d9ac-401f-9bb2-c091c272d5d0","added_by":"auto","created_at":"2024-06-11 18:36:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":7452,"visible":true,"origin":"","legend":"\u003cp\u003eResults of patients’ data on laboratory Investigations\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4427084/v1/fb4c1bed5b98add4c55a839d.png"},{"id":58146372,"identity":"71565a78-fe6f-4b22-9c27-24460b5f03c1","added_by":"auto","created_at":"2024-06-11 18:36:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32732,"visible":true,"origin":"","legend":"\u003cp\u003eResults for the timing of administering medication on pain relief after admission to the hospital\u003c/p\u003e\n\u003ch3\u003e\u003cbr\u003e\u003c/h3\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4427084/v1/4f6d8459048edc59ca90d4e6.png"},{"id":61757811,"identity":"fc28f509-d88e-4db6-aa12-a50fe4708213","added_by":"auto","created_at":"2024-08-05 08:52:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":659613,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4427084/v1/0458b799-f283-4fe6-83da-be0d342b8ceb.pdf"},{"id":58146370,"identity":"dd42203b-a984-49e7-be53-2294c97a91d8","added_by":"auto","created_at":"2024-06-11 18:36:19","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22307,"visible":true,"origin":"","legend":"","description":"","filename":"CaseFileReviewData.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4427084/v1/96bdd43101e69c660a03b7d2.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":" MANAGEMENT Practices for Children IN Sickle Cell Crisis in Selected Hospitals in Northern Malawi. ","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSickle cell disease (SCD) is a common genetic condition that occurs due to abnormal formation of hemoglobin S (HbS) as a result of mutations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Substitution of Glutamic for Valine Amino Acid in the 6th position of hemoglobin's chain changes the physical properties of the haemoglobin (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This alteration in hemoglobin's physical structure results in functional challenges, especially with oxygen loading (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Globally, 400 000 babies are born with the disease annually (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) with almost 75% of these newborn babies living in sub-Saharan (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The disease is accompanied by acute and chronic complications. One of the most serious acute complication is sickle cell crisis (SCC) including vaso-occlusive crisis (VOC) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). VOC is responsible for hospital visits and inpatient admissions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The disease has a mortality of 50% \u0026minus;\u0026thinsp;90% among children born in low-resource countries like sub-Saharan Africa(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Without appropriate interventions, up to 90% of these children will not reach the age of 18 years (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This entails that children presenting with SCC are at risk of serious morbidities and early mortality if appropriate care is not initiated promptly (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMalawi has a significant burden of SCD. It is estimated that 2,000 infants are born with SCD every year (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The disease contributes a significant proportion of pediatric hospitalizations (3.1%), with painful crises being the most common clinical feature (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This indicates that SCD is a public health concern in Malawi, implying that effective interventions that includes high-quality care, is paramount for sick children. To address the high mortality rate associated with SCD, the World Health Organization (WHO) and the National Heart Lung and Blood Institute (NHLBI) developed guidelines for the management of complications resulting from SCD(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Malawi adopted some of these guidelines as reflected in the protocols for management of common childhood illnesses in Malawi (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These guidelines include the provision of interventions such, as supplemental oxygen therapy, fluid therapy, pain management, antibiotics, folic acid supplementation, and transfusion of packed red blood cells. For sickle cell crisis, in particular, supplemental oxygen therapy, fluid therapy, and appropriate pain management are crucial. Adherence to these guidelines ensures the provision of high-quality care for children in SCC.\u003c/p\u003e \u003cp\u003eGaps in the provision of high-quality care for individuals with SCD have been documented (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In Brazil, only 36.6% of children with SCD had their growth and development charts monitored and 28.6% had the minimum recommended follow-ups (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In many resource-limited countries, this gap is directly related to the scarcity of resources for the delivery of high-quality care (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e);(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Gaps related to the structure, process, and outcome dimensions including inadequate knowledge of nurses on comprehensive care for SCD were reported in Ghana (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Malawi is another resource-limited country. It is, therefore, possible that the situation might be the same.\u003c/p\u003e \u003cp\u003eData from Paediatric admission registers at a tertiary, district and mission hospitals, indicate that approximately 2.7%, 1.4%, and 0.5% of all pediatric admissions were due to SCC in the year 2020. This means that SCD is one of the causes of hospitalizations in children in the Northern Region.\u003c/p\u003e \u003cp\u003eThe government of Malawi through the Ministry of Health (MOH) has identified improving the quality of healthcare towards attainment of Universal Health Coverage as one of its priority areas of action in the Health Sector Strategic Plan 2023\u0026ndash;2030. It is therefore envisaged that quality of care might improve by paying attention to improving the competencies and skills of health workers and provision of adequate medical equipment and supplies among others (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Despite the government effort, inconsistent quality of care in Malawi remains a major challenge due to resource constraints (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Providing comprehensive quality care for children with SCC would improve the quality of life for the children who are bound to live with the conditions for the rest of their lives.\u003c/p\u003e \u003cp\u003eAlthough studies have reported gaps in quality of care for SCD, they focused on general routine care provided to children including follow-up care. There is scanty data on the quality of care provided to children hospitalized with SCC, especially in acute care. Therefore, this study was conducted to assess the quality of care provided to hospitalized children in SCC in selected hospitals in Northern Malawi. In particular to compare current practices for the provision of care for sickle cell crisis with the existing standard guidelines\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThe study used the quantitative approach employing a cross-sectional design. A cross-sectional design enabled the researcher to obtain a snapshot description of the status of quality of care offered to children in SCC, and how it relates to inputs and processes for quality of healthcare adopted in the theoretical framework (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The context in the study was the quality of care provided to children in the selected hospitals in Northern Malawi.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eThe study was conducted in three selected hospitals: a tertiary, district and mission hospital in Northern Malawi. A tertiary hospital is a facility that provides specialist health services, and offer referral services at reginal level; therefore, it was projected to see an influx of patients including those in SCC. The district hospital was chosen because of the prevalence of consanguine marriages within the district hence a significant number of SCD patients. A mission hospital is a faith-based hospital under the umbrella of Christian Health Association of Malawi (CHAM). In Malawi, CHAM provides approximately 30% of all health services to the population (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), therefore, it was necessary to include one facility managed by the organization in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eChildren who were hospitalized due to sickle cell crisis between 2019 and 2021 made up the study population. In the Malawian setting, the Paediatric ward admits children under 12 years of age. As such, their case files provided evidence of the quality of care provided during hospitalization for SCC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Method\u003c/h2\u003e \u003cp\u003eThe study employed systematic random sampling technique whereby each subject in the study population had an equal chance of being selected for the study (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Therefore, all files of children admitted in Paediatric ward from the year 2019 to 2021 in sickle cell crisis for each hospital were collected. They were sorted to determine the sampling frame for each hospital. The sample size for the mean population was estimated using Yamane\u0026rsquo;s formula. Depending on the proportion of the population represented, a sample size of 87, 28, and 9 was met. The sampling interval was then calculated by dividing the population size for each hospital by the sample size. Then, every kth file from the list was included in the study after the first child's file was randomly selected from among all the sorted files.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eThe inclusion criteria was children up to 12 years, who were admitted with sickle cell crisis from the year 2019 to 2021. The exclusion criteria was children up to 12 years old who had SCD, but were admitted with other conditions, and those that were admitted with other conditions were not included in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Tool\u003c/h2\u003e \u003cp\u003e Data from children\u0026rsquo;s files (chart review) was collected using a checklist developed by the researcher informed by the content from WHO guidelines on management of sickle cell crisis, NHLBI evidence-based management of sickle cell disease and protocols for management of common childhood illnesses in Malawi. The checklist was designed to collect management care practices documented in the patient's files. It included information on providers' performance concerning initial and supportive care for the management of sickle cell crisis. The initial care comprised patient assessment (history taking, physical examination, and appropriate laboratory investigations), then crucial care needed necessary for a child who is in crisis. This includes; administration of oxygen therapy, appropriate pain management, and administration of fluids. The supportive care included information on blood transfusion, administration of antibiotics, and patient monitoring. Each case file was reviewed and scored by ticking whether the care was done or not based on the documented evidence benchmarked with the guideline. This then depicted the retrospective element since the researcher was reviewing the data that was collected sometime back from 2019 to 2021.\u003c/p\u003e \u003cp\u003eWhile other studies argue that in low and middle-income countries, medical records are often poorly maintained and may not reflect actual practice (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), other studies recommend medical records as essential tools to measure and evaluate care and have proven useful for quality improvement (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Therefore, this study used medical records to evaluate care practices provided to children in sickle cell crisis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eValidity\u003c/h2\u003e \u003cp\u003eThe checklist was vetted by the research supervisors and specialists in pediatric care to assess the appropriateness and relevance of each item to ensure content validity. In addition, the tools have been developed from WHO guidelines, NHLBI evidence-based management of sickle cell disease and Open Guidelines protocols for the management of common childhood illnesses in Malawi.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEthical consideration\u003c/h2\u003e \u003cp\u003e The study was approved by Mzuzu University Research Ethics Committee (MZUNIREC) (reference number MZUNIREC/DOR/23/14). Permission to conduct the study was sought from relevant authorities in all the three hospitals, and written authorization was granted. To ensure anonymity, children\u0026rsquo;s files were assigned codes and names were not used in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Collection and Management\u003c/h2\u003e \u003cp\u003eThe required sample size for children\u0026rsquo;s case files of; 9, 28 and 87 files from the mission, district and tertiary hospitals respectively was obtained from the records storage area. In each hospital, the researcher was provided with a separate room to avoid disturbances during the review process. File code numbers were used instead of the child\u0026rsquo;s real name to maintain confidentiality. Each file and all the necessary records attached, thus the admission notes, medical and nursing progress notes, treatment charts, laboratory investigations and results records and vital sign monitoring charts, if attached, were reviewed by the researcher. The records were benchmarked with the checklist, ticking whether the care was provided basing on the documented evidence. Patients\u0026rsquo; case files during the data collection process were stored in a safe place under lock and key only accessible to the researcher to maintain confidentiality. After data collection, all the children\u0026rsquo;s case files were returned to the records storage area. Thereafter, the data collected through the checklists were stored in envelopes, whereas electronic data was stored in a file protected by a password by the researcher.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data collected was checked for completeness and consistence, then variables were cleaned in an Excel spreadsheet package before analysis. The Statistical Package for the Social Science (SPSS) software version 20 was used to analyze the data. In SPSS, variables like patient assessment, physical examination, laboratory investigations and general care were coded after being entered. Descriptive statistics were used to summarize the data, making it easier to comprehend the specifics of the samples.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eResults for Patient Assessment\u003c/h2\u003e \u003cp\u003eThe results relating to patient assessment on admission indicated that the majority of the children had the recommended history collected in all the hospitals. History of infections and triggering events was more collected in all hospitals 97.7% (n\u0026thinsp;=\u0026thinsp;85) for a central hospital, 89.3% (n\u0026thinsp;=\u0026thinsp;25) for a district and 100% (n\u0026thinsp;=\u0026thinsp;9) for a mission hospital, followed by history of painful crisis at a central and district hospitals. The following history was least collected; history of previous blood transfusion 57.1% (n\u0026thinsp;=\u0026thinsp;16), and 66.7% (n\u0026thinsp;=\u0026thinsp;6) for a district and mission hospitals respectively, and history of painful crises 66.7% (n\u0026thinsp;=\u0026thinsp;6) for a mission hospital.\u003c/p\u003e \u003cp\u003eThe majority of the children had physical examinations performed in most important areas such as pallor, jaundice, chest and lungs and splenomegaly in all hospitals. The most neglected area on assessment was frontal bossing 97.7% (n\u0026thinsp;=\u0026thinsp;85), 89.3% (n\u0026thinsp;=\u0026thinsp;25) at a central and district hospitals respectively and at a mission hospital it was not assessed at all. Bone tenderness was not assessed in 27.6% (n\u0026thinsp;=\u0026thinsp;24), 39.3% (n\u0026thinsp;=\u0026thinsp;11) and 22.2% (n\u0026thinsp;=\u0026thinsp;2) at a central, district and a mission hospital respectively. For more details on other findings refer to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Assessment on Admission\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePatient assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFinding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eCentral Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eDistrict Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eMission\u003c/p\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eHistory Taking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood Transfusions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePainful crises\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInfections and triggering events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e89.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003ePhysical Examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePallor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eJaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChest and Lungs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSplenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e96.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBone tenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFrontal Bossing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e89.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of data on the laboratory investigations indicated that the majority of the children in all the hospitals had PCV, full blood count (FBC) malaria test (MPS/MRDT) checked indicating compliance with the recommended investigations. For more details on other findings refer to Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResults based on patient management\u003c/h2\u003e \u003cp\u003e Regarding patient management, the researcher was interested in finding out acute care that was provided to children hospitalized using the evidence-based guidelines. The Paediatric guidelines in acute care recommend administration of supplemental oxygen therapy, intravenous fluids and prompt and effective pain management using appropriate analgesics. The findings showed that the majority of the children did not receive oxygen therapy as part of management, 82.1% (n\u0026thinsp;=\u0026thinsp;23) and 56.3% (n\u0026thinsp;=\u0026thinsp;49) for a district and central hospitals. Furthermore, at a mission hospital all children did not receive oxygen therapy. On fluid management 70.1% (n\u0026thinsp;=\u0026thinsp;61), 42.9% (n\u0026thinsp;=\u0026thinsp;12) and 33, 3% (n\u0026thinsp;=\u0026thinsp;3) received intravenous fluids for a central, district and mission hospitals respectively. Out of those who received intravenous fluids, the majority did not receive the correct amount based on fluid calculation. The majority of children did not have regular assessment of vital signs and work of breathing. For more details on other findings refer to Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Management\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCentral Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eDistrict Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eMission Hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReceived Oxygen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReceived intravenous fluids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReceived proper maintenance fluid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEncouraged on oral fluids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRegular assessment of vital signs, work of breathing, and oxygen saturation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSubsequent reviews by clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedications Received\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of Medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCentral Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eDistrict Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eMission Hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAppropriate pain relief medication received\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMorphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiclofenac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParacetamol/Ibuprofen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAppropriate parenteral antibiotics received\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCeftriaxone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenzyl Penicillin and Gentamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenzyl Penicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding pain management, 32.2% (n\u0026thinsp;=\u0026thinsp;28), 32.1% (n\u0026thinsp;=\u0026thinsp;9) and 33.3% (n\u0026thinsp;=\u0026thinsp;3) for a central, district and mission hospitals received medication on pain relief within 15\u0026ndash;30 minutes of admission to the hospital. For the majority of children, the time for administration of the first medication on pain relief was not indicated in the patient\u0026rsquo;s files. This indicates that delay in administering medication on pain relief and deficiency in documentation. Refer to Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for the findings on the timing for administration of medication of pain relief.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings revealed that on admission, majority of the children were properly assessed based on the admission form of the sick child. There was compliance for standard laboratory investigations to be carried out for children with SCD such as PCV, FBC, and Malaria tests. These investigations are not diagnostic but assist in the management of SCD(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Donabedian asserts that one of the important approaches to assessment of quality of care is to examine the process of care (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The results showed good practice because of comprehensive patient assessment results reflected in the correct diagnosis and management which is a constituent of quality care. However, the admission form did not contain parameters on clinic reviews and treatment compliance as indicated on the guidelines for the management of SCD, as such, it was regarded that those areas were not assessed. This is in agreement with a study done in Ethiopia which revealed low quality assessment of sick children when comparing with the Integrated Management of Childhood Illnesses (IMCI) guidelines (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This means that the admission form may need to be revised to include parameters that were missed or using a specific admission sheet for SCD patients. This is in agreement with some studies that revealed that despite comprehensive patient assessment on admission completion of documentation of patient assessments is often sub-optimal (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Malawi Paediatric Guidelines recommend the use of supplemental oxygen therapy for all children with painful VOC despite normal oxygen saturation (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Oxygen therapy reverses the sickling process which is responsible for acute pain (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Additionally, individuals with SCD have low haemoglobin levels due to chronic haemolysis of sickled red blood cells (RBS\u0026rsquo;s) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).This, consequently, leads to the reduction of the amount of oxygen carrying capacity. Hence, administration of supplemental oxygen therapy maximises oxygen delivery to tissues (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Studies have also supported use of oxygen therapy in reduction of pain. A study that was done in a tertiary hospital in London to determine optimum use of fluid and oxygen therapy in children presenting with VOE, indicated that oxygen therapy was associated with a higher reduction in pain score points at discharge (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Conversely, the findings of this study revealed that most of the children did not receive oxygen therapy as part of their management. This was worse at a mission hospital where all the children admitted in crisis (n\u0026thinsp;=\u0026thinsp;9) did not receive oxygen therapy, followed by a district hospital 82.1% (n\u0026thinsp;=\u0026thinsp;23) and central hospital 56.3% (n\u0026thinsp;=\u0026thinsp;49). On the contrary, many health care workers indicated high levels of ability to manage children in SCC. Again, there was high availability of resources for management of SCD in all the hospitals with the highest scores recorded in oxygen concentrators, nasal prongs among others. This shows that resource constraints were not a problem in the provision of oxygen therapy as part of management. This finding was supported by those made in a Ghanaian study on the structure dimension of quality care for children with SCD that found that a high availability of resuscitation equipment among others (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, this finding contradicts the chart review finding on administration of oxygen therapy that clearly indicated a significant gap in quality of care that was delivered. This could be related to the provider's knowledge gap on current practice on treatment which is directly related to lack of guidelines.\u003c/p\u003e \u003cp\u003eA study done to assess the knowledge and practices of Congolese physicians in treating sickle SCD in the Democratic Republic of Congo revealed insufficient knowledge of healthcare providers. The findings indicated that 44% of physicians followed recommendations for the management of VOC and prescribed analgesics and hydration while treating SCD patients (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Findings in this study also indicated low availability of guidelines for the management of SCD. From the literature, it clearly indicates that the guidelines are there. As they were a basis for formulation of the data collection tool. This might mean that the guidelines were not accessible at the point of care. In this case, the chart review finding concur with this finding. This is a huge gap in patient management that would consequently lead to the provision of substandard care since high-quality care is achieved through the use of evidence-based guidelines (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Again, clinical practice guidelines decrease variations in the delivery of care among healthcare providers (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). These findings are similar to several other studies done globally that showed that providers were unaware of the 2014 NHLBI SCD care guidelines (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), and some are not adherent to guideline use when providing care (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In Malawi, similar findings were made that showed that hospitals had low availability for emergency guidelines at 33.3% (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTimely pain management is central in quality care as it improves the quality of life in children (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). In this study, despite that all children received medication on pain relief of various types in all hospitals, only a few of them received it in time. NHLBI evidence-based guidelines recommend the use of medication on pain relief within 15\u0026ndash;30 minutes of admission. This means that there was a delay in relieving pain which compromised the quality of life in these children. These findings are consistent with (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) who found that patients with SCD experienced significant delays in seeking medication on pain relief. Unrelieved pain may prolong the stress response and adversely affect the recovery process (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Furthermore, poorly controlled acute pain can predispose patients to chronic pain syndromes and affect a child\u0026rsquo;s ability to cope as an adolescent and adult.\u003c/p\u003e \u003cp\u003eAdministration of fluids is important in the management of SCC because it helps to stop the sickling process and reduces episodes of pain (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) as dehydration causes an increase in blood viscosity which eventually triggers SCC episodes (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Again, studies have found that administration of fluid therapy in patients with SCD is associated with reduced hospitalization and prevents development of complications such as acute chest syndrome (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The NHLBI evidence-based and Queens Pediatric guidelines recommend immediate correction of acidosis and dehydration with appropriate intravenous and oral fluids as principal in care for SCC. Although 70.1% of children at a central hospital received intravenous fluids, the findings indicated that children were not adequately hydrated as 66.7% and 57.1% for the mission and the district hospitals respectively did not receive fluids. In addition, most of the children who received intravenous fluids did not receive the correct amount based on fluid calculation for the management of SCD. This observation was worse at the mission and district hospitals. These findings are similar to those made in a study done in Ghana where nurses displayed inadequate knowledge concerning maintenance of fluid requirements for children in crisis, such that only 13.5% knew the correct level of fluid prescription (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This means that the children were either under or overhydrated. Other studies have found fluid overload in patients with SCD, occurring in 21% of patients especially for the total volume given in the first 24 hours (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Fluid overload has adverse effects on the child\u0026rsquo;s respiratory and kidney functioning delaying recovery process. It was also observed in this study that the majority of children were not encouraged to take oral fluids in all the hospitals.\u003c/p\u003e \u003cp\u003ePatient monitoring is central to patient care as it helps to assess the progress of the condition and to follow the provided care. Children who are admitted in crisis are acutely ill and they need to be monitored regularly possibly every 4 to 6 hours until they are stable. Regular monitoring of vital signs and documentation have been shown to improve the early detection of at-risk patients (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). However, research has consistently found that patient monitoring including assessment of vital signs is often a neglected area in clinical practice (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e),(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Findings of this study revealed that majority of children did not have regular assessments of vital signs (temperature, pulse rate, respiration, and blood pressure), work of breathing, and oxygen saturation during hospitalization. The chart review showed that 83.9%, 96.4%, and 88.9% of children for the central, district, and mission hospitals respectively were not monitored regularly. Most of the children were assessed once a day especially during ward rounds by the clinician or doctors although assessment of vital signs is an important responsibility of nursing. A Malawian research study also found that 49% of Paediatric case files during death audit did not have any recorded records of vital signs within the first twenty-four hours of hospitalization, and documentation deficiencies were noted in 58% of the charts reviewed (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Similar findings were also made in Kenya and Ghana by (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e); (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) that hospitalized patients were not adequately monitored. In the broader perspective, findings of this study indicated that compliance with patient monitoring was low in all hospitals. This could mean that patient assessment is a challenge in resource-limited countries compromising the quality of nursing care. The lack of consistent monitoring might be due to several factors including a shortage of human resources, unavailability of equipment for checking vital signs, and their proper functioning status, among others. Therefore, identifying interventions that might improve monitoring compliance would seem to be a crucial step in quality improvement with the potential to improve clinical outcomes. Again, nursing assessments and care/progress notes were not documented in the files for most of the children indicating deficiency in nursing care.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe study is among the few that have assessed hospital-based quality of care provided to children in sickle cell crisis with specific focus on acute care in low-income countries. The main limitation of the study is that it was conducted in three hospitals only in Northern Malawi. As such, the quality of care provided might be different in other hospital settings, and generalizability of the findings to all hospitals in the Northern Region and Malawi as a whole may not be possible. In addition, the retrospective nature of the data collection method had an impact on the generation of consistent data as assumptions were based on what was not documented, and there was some missing information. There is a need to extend the study to all second and third level hospitals in Malawi.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study findings revealed gaps in the delivery of quality care especially with process dimensions. Hospitalized children in sickle cell crisis received suboptimal care specifically in acute care with reference to the evidence-based guidelines. They did not receive recommended care such as oxygen therapy, adequate hydration and timely medication for pain relief. There was lack of regular patient monitoring of general conditions and vital signs. Documentation of nursing care records was also found to be problematic. The Results from the study will inform planning and advocacy strategies at the Malawian Ministry of Health (MOH) and within study facilities where gaps exist in care. We recommend that the hospital management and the ward in-charges should ensure the availability and accessibility of SCD management guidelines in Paediatric care points Emergency Triage Assessment and Treatment (ETAT, and Paediatric wards) to guide clinical practice. Again, intensify the supervision of HCW\u0026rsquo;s in care delivery as well as the documentation to improve performance.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHAM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Christian Health Association of Malawi\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eETAT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Emergency Triage Assessment and Treatment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFBC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Full Blood Count\u003c/p\u003e\n\u003cp\u003eHbS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hemoglobin S\u003c/p\u003e\n\u003cp\u003eHCP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health Care Providers\u003c/p\u003e\n\u003cp\u003eHCW\u0026rsquo;s\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health Care Workers\u003c/p\u003e\n\u003cp\u003eHSSP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Health Sector Strategic Plan\u003c/p\u003e\n\u003cp\u003eIMCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Integrated Management of Childhood Illnesses\u003c/p\u003e\n\u003cp\u003eMOH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ministry of Health\u003c/p\u003e\n\u003cp\u003eMRDT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Malaria Rapid Diagnostic Test\u003c/p\u003e\n\u003cp\u003eMZUNIREC\u0026nbsp; \u0026nbsp;Mzuzu University Research Ethics Committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNHLBI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Heart Lung and Blood Institute\u003c/p\u003e\n\u003cp\u003ePCV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Packed Cell Volume \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRBC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Red Blood Cells\u003c/p\u003e\n\u003cp\u003eSCC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sickle Cell Crisis\u003c/p\u003e\n\u003cp\u003eSCD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sickle Cell Disease\u003c/p\u003e\n\u003cp\u003eVOC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Vaso -Occlusive Crisis\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their appreciation to the study facilities for their willingness to share data with us. The authors would also like to thank the nurses, doctors and clinicians working in the Paediatric ward at the various study sites for the assistance rendered throughout the study. The librarian Mzuzu university, Associate Professor Aubrey Chaputula for editing the document.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.K. collected data in all the hospitals and developed the manuscript. E.P. and F.M. provided oversight and supervision, assisted to ensure methodological rigor, M.K, E.P. and F.M. assisted with data analysis and interpretation. All the authors contributed to the completion of this manuscript and have read and approved it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaria Mtangwa Kumwenda\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated for analysis during this study are included in the supplementary information file.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll methods were performed in accordance with the relevant guidelines and regulations. For example, ethical approval for the study was obtained from Mzuzu university Research Ethics Committee (MZUNIREC) (reference number\u0026nbsp;MZUNIREC/DOR/23/14). Permission to conduct the study was sought from relevant authorities in all hospitals\u0026nbsp;and the written approval was granted. To ensure anonymity, children\u0026rsquo;s files were assigned codes and names were not used in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from case file reviews has been provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHoban MD, Orkin SH, Bauer DE. Genetic treatment of a molecular disorder: gene therapy approaches to sickle cell disease. 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Identifying barriers to evidence-based care for sickle cell disease: results from the Sickle Cell Disease Implementation Consortium cross-sectional survey of healthcare providers in the USA. BMJ open. 2021;11(11):e050880.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin OY, Thompson SM, Carroll AE, Jacob SA. Emergency Department Provider Survey Regarding Acute Sickle Cell Pain Management. Journal of Pediatric Hematology/Oncology. 2020;42(6):375\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKayambankadzanja R. Emergency and critical care services in Malawi: Findings from a nationwide survey of health facilities. Mal Med J. 2020;32(1):19\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBallas SK, Gupta K, Adams-Graves P. Sickle cell pain: a critical reappraisal. 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Frequency of vital sign measurement among intubated patients in the general ward and nurses\u0026rsquo; attitudes toward vital sign measurement. Journal of Multidisciplinary Healthcare. 2018;11(null):575\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeenk M, Koeneman M, van de Belt TH, Engelen LJLPG, van Goor H, Bredie SJH. Wireless and continuous monitoring of vital signs in patients at the general ward. Resuscitation. 2019;136:47\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzgerald E, Mlotha-Mitole R, Ciccone EJ, Tilly AE, Montijo JM, Lang HJ, et al. A pediatric death audit in a large referral hospital in Malawi. BMC Pediatrics. 2018;18(1):75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgero M, Ayieko P, Makone B, Julius T, Malla L, Oliwa J, et al. An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care? Journal of Global Health [Internet]. 2018 Jun [cited 2023 Oct 30];8(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826085/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826085/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMugyenyi GR, Ngonzi J, Wylie BJ, Haberer JE, Boatin AA. Quality of vital sign monitoring during obstetric hospitalizations at a regional referral and teaching hospital in Uganda: an opportunity for improvement. Pan African Medical Journal. 2021;38(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Quality Care, Sickle Cell Disease, Children, Vaso-Occlusive Crisis, Sickle Cell Crisis","lastPublishedDoi":"10.21203/rs.3.rs-4427084/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4427084/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSickle cell crisis is a common complication of Sickle Cell Disease (SCD) that is responsible for frequent hospitalizations among children. The condition carries a mortality rate of 50% \u0026minus;\u0026thinsp;90%. If appropriate care is not rendered, it can lead to early child mortality. The aim of the study was to assess the quality of care provided to hospitalized children in sickle cell crisis in selected hospitals in Northern Malawi.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA quantitative descriptive cross-sectional design was used to assess the quality of care provided to hospitalized children in sickle cell crisis at a tertiary, district and mission hospitals in the Northern Region of Malawi. Data was collected from files of 124 children admitted in sickle cell crisis from 2019 to 2021 using a checklist that was developed from WHO, National Heart, Lung, and Blood Institute (NHLBI), and Queens Paediatric Guidelines for the management of SCD while analysis was done using SPSS version 20.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e The results showed suboptimal quality of care as most children did not receive the recommended interventions such as oxygen therapy, intravenous fluids, the correct amount of intravenous fluids, and timely pain relief medication as stipulated by the guidelines for the management of SCD.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe study gave some insights regarding quality of care for children in sickle cell crisis in the Region. It can, therefore, be concluded that ensuring the availability and accessibility of SCD management guidelines, pain assessment tools in Paediatric care settings would improve clinical practice.\u003c/p\u003e","manuscriptTitle":" MANAGEMENT Practices for Children IN Sickle Cell Crisis in Selected Hospitals in Northern Malawi. 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