Quality of Care for Adult Inpatients with Malaria in a Tertiary Hospital in Uganda

Abstract Background: Prompt detection and appropriate treatment of malaria prevents severe disease and death. The quality of care for adult malaria inpatients is not well documented in sub-Saharan Africa, particularly in Uganda. We sought to describe the patterns of malaria diagnosis and treatment among adult inpatients admitted to the medical and gynaecological wards of Uganda’s 1790-bed Mulago National Referral Hospital from December 2013 to April 2014.Methods: A prospective cohort of 762 consented inpatients aged >18 years was assembled. Proportions of inpatients who received preadmission and in-hospital antimalarials, missed Day 1 dosing of hospital-initiated antimalarials and/or had malaria microscopy done were determined. Multivariable logistic regression was used to identify risk-factors for missed Day 1 dosing of antimalarials.Results: One in five (19%, 146/762) inpatients had an admitting or discharge malaria diagnosis or both; with median age of 29 years (IQR, 22 to 42 years). Microscopy was requested in 77% (108/141) of inpatients with an admitting malaria diagnosis; results were available for 46% (50/108), of whom 42% (21/50) tested positive for malaria parasitaemia. Only 13% (11/83) of inpatients who received in-hospital injectable artesunate (AS) or quinine (Q) received follow-up oral artemether-lumefantrine (AL); only 2 of 18 severe malaria cases received follow-up oral AL. Injectable AS only (47%, 47/100) was the most frequent hospital-initiated antimalarial followed by injectable Q only (23%, 23/100). A quarter (25%, 25/100; 95% CI: 17% to 35%) of inpatients missed Day 1 dosing of hospital-initiated antimalarials. Each additional admitting diagnosis was more than two-fold likely to increase the odds of missed Day 1 dosing of in-hospital antimalarials (aOR = 2.6, 95% CI: 1.52-4.56; P-value = 0.001).Conclusions: Half the malaria microscopy results were not available; yet, the rate of testing was high. The majority of inpatients initiated on injectable AS or Q did not receive the recommended follow-up treatment of oral AL. One in four inpatients delayed to initiate hospital antimalarials by at least one calendar day. The hospital should encourage prompt availability of malaria test-results to promote the timely initiation and completion of antimalarial treatment, thereby improving the quality of care for hospitalized malaria patients in Uganda.