476 TRANSACTIONS OF THE
ROYALSOCIETY OF TROPICAL MEDICINEAND HYGIENE(1992)86, 47&478
An audit of the management D. G. C. Emerton*’
of malaria
in a Tanzanian
district
hospital
Murgzvanza Hospital, Private Bag, P.O. Ngara, Tanzania
Abstract An audit of the management of falciparum malaria was carried out over a 12 month period in a north-west Tanzanian district hospital; 1494 patients were studied, 75% being children under 5 years. Chloroquine was effective in 1128 cases (79%), 68 patients died! of whom 64 were aged under 5 years; 30 of them died fewer than 2 d after admission; 14 had received qumine chemotherapy. Management can be improved by better diagnosis of anaemia and hypoglycaemia, changing the dose of injectable chloroquine, earlier use of quinine, and enabling doctors to see very ill patients earlier. Introduction Murgwanza Hospital is a 160 bedded district hospital serving the rural Ngara District in north-west Tanzania. Malaria is the most common diagnosis for in- and out-patients and the leading cause of death. The rising number of patients attending with malaria, and the growing problem of chloroquine resistance, are making their correct management an increasing challenge. An audit of the medical management of all patients admitted to the hospital due to falciparum malaria in a one-year period was carried out with the aims of reviewing: (i) the number of admissions for malaria, their sex and age distribution, their length of stay, the deaths and the results of blood slides and haemoglobin determinations on admission; (ii) the drugs used and the number of blood transfusions received; and (iii) how the management of in-patients with malaria could be improved in the light of these results. Methods All in-patient notes were collected during the period 15 April 1990 to 14 April 1991. The case notes of patients whose diagnosis was substantiated by a positive blood slide at Murgwanza were further studied. The following data were recorded: name, in-patient number and address of patient; sex and age of patient; length of stay; number of previous admissions for malaria; blood slide results at the time of admission and discharge; haemoglobin result; blood transfusion given and drugs used. Laboratory investigations Thick blood films were examined by microscopy after Field’s staining and classified as follows: + + + + + , lOO1000 parasites in 1 microscope field; ++ + +, 10-100 parasites in 1 field; ++ +, l-10 parasites in 1 field; ++, I-10 parasites in 10 fields; f, 4-10 parasites in 100 fields; occasional, l-3 parasites in 100 fields. Haemoglobin was measured using the haemocyathin method (accuracy of -t lgidl). Drug treatment Each chloroquine course was a total of 25 mgikg body weight (WHO, 1986). Normally, oral chloroquine phosphate was given and the nurses were instructed to repeat the dose if the patient vomited within 30 min and if he or she vomited again to give 5 mgikg intramuscularly and repeat the injection after 6-8 h. Some children were also given 2 doses of intramuscular chloroquine if they had a heavy parasite count. Quinine was given as quinine sulphate tablets, 10 mgikg body weight 8 hourly for 34 d. If a child were vomiting or particularly sick, the first 3 doses were given as quinine dihydrochloride, diluted to 30 mgiml, by deep intramuscular injection. Adults and older children with cerebral malaria were given quinine infusions of 10 mgikg body weight over 4 h 3 times a day until they were able to take oral quinine. Pyrimethamine (25 mg) and sulfadoxine tablets (one tablet per 25 kg body weight) were given as single doses a few hours after the last dose of quinine (HALL et al., 1975). *Ad$ess for correspondence: c/o Accident and Emergency gaygs MUof;lston Hospital, Mornston, Swansea, SA6 6NL, > .
Blood transfusion Blood was allowed to sediment and the red cell fraction transfused slowly, giving 20 ml/kg body weight. Frusemide, 1 mgikg body weight, was given parenterally at the start of transfusions and repeated after 68 h if there were signs of heart failure. Results The sex and age of patients admitted due to malaria are shown in Table 1. Admissions due to malaria totalled Table
1. Sex and age of patients
Age (years) lO Total
Males 250 ‘:z 112 744
admitted
due to malaria
Females
Subtotal
247 296
497 (33%)
1:: 750
y:, W] 266 (18;) 1494
8169 patient-days (average stay 5.5 d). Admissions reached a peak in June and November/December, just after the long and short rainy seasons. Two hundred and thirty-nine patients had been previously admitted a total of 408 times for malaria (range l-7 admissions). Blood slide examination for Plasmodium falciparum on admission gave the following results: + + + + +, 5 (0.3%); ++++, 171 (11.5%); fff, 452 (30.3%); ++, 468 (31.3%); f, 284 (19.0%); occasional, 112 (7.5%); and gametocytes 2 (0.1%). One hundred and ninety-six patients had a haemoglobin level
ROYALSOCIETY OF TROPICAL MEDICINEAND HYGIENE(1992)86, 47&478
An audit of the management D. G. C. Emerton*’
of malaria
in a Tanzanian
district
hospital
Murgzvanza Hospital, Private Bag, P.O. Ngara, Tanzania
Abstract An audit of the management of falciparum malaria was carried out over a 12 month period in a north-west Tanzanian district hospital; 1494 patients were studied, 75% being children under 5 years. Chloroquine was effective in 1128 cases (79%), 68 patients died! of whom 64 were aged under 5 years; 30 of them died fewer than 2 d after admission; 14 had received qumine chemotherapy. Management can be improved by better diagnosis of anaemia and hypoglycaemia, changing the dose of injectable chloroquine, earlier use of quinine, and enabling doctors to see very ill patients earlier. Introduction Murgwanza Hospital is a 160 bedded district hospital serving the rural Ngara District in north-west Tanzania. Malaria is the most common diagnosis for in- and out-patients and the leading cause of death. The rising number of patients attending with malaria, and the growing problem of chloroquine resistance, are making their correct management an increasing challenge. An audit of the medical management of all patients admitted to the hospital due to falciparum malaria in a one-year period was carried out with the aims of reviewing: (i) the number of admissions for malaria, their sex and age distribution, their length of stay, the deaths and the results of blood slides and haemoglobin determinations on admission; (ii) the drugs used and the number of blood transfusions received; and (iii) how the management of in-patients with malaria could be improved in the light of these results. Methods All in-patient notes were collected during the period 15 April 1990 to 14 April 1991. The case notes of patients whose diagnosis was substantiated by a positive blood slide at Murgwanza were further studied. The following data were recorded: name, in-patient number and address of patient; sex and age of patient; length of stay; number of previous admissions for malaria; blood slide results at the time of admission and discharge; haemoglobin result; blood transfusion given and drugs used. Laboratory investigations Thick blood films were examined by microscopy after Field’s staining and classified as follows: + + + + + , lOO1000 parasites in 1 microscope field; ++ + +, 10-100 parasites in 1 field; ++ +, l-10 parasites in 1 field; ++, I-10 parasites in 10 fields; f, 4-10 parasites in 100 fields; occasional, l-3 parasites in 100 fields. Haemoglobin was measured using the haemocyathin method (accuracy of -t lgidl). Drug treatment Each chloroquine course was a total of 25 mgikg body weight (WHO, 1986). Normally, oral chloroquine phosphate was given and the nurses were instructed to repeat the dose if the patient vomited within 30 min and if he or she vomited again to give 5 mgikg intramuscularly and repeat the injection after 6-8 h. Some children were also given 2 doses of intramuscular chloroquine if they had a heavy parasite count. Quinine was given as quinine sulphate tablets, 10 mgikg body weight 8 hourly for 34 d. If a child were vomiting or particularly sick, the first 3 doses were given as quinine dihydrochloride, diluted to 30 mgiml, by deep intramuscular injection. Adults and older children with cerebral malaria were given quinine infusions of 10 mgikg body weight over 4 h 3 times a day until they were able to take oral quinine. Pyrimethamine (25 mg) and sulfadoxine tablets (one tablet per 25 kg body weight) were given as single doses a few hours after the last dose of quinine (HALL et al., 1975). *Ad$ess for correspondence: c/o Accident and Emergency gaygs MUof;lston Hospital, Mornston, Swansea, SA6 6NL, > .
Blood transfusion Blood was allowed to sediment and the red cell fraction transfused slowly, giving 20 ml/kg body weight. Frusemide, 1 mgikg body weight, was given parenterally at the start of transfusions and repeated after 68 h if there were signs of heart failure. Results The sex and age of patients admitted due to malaria are shown in Table 1. Admissions due to malaria totalled Table
1. Sex and age of patients
Age (years) lO Total
Males 250 ‘:z 112 744
admitted
due to malaria
Females
Subtotal
247 296
497 (33%)
1:: 750
y:, W] 266 (18;) 1494
8169 patient-days (average stay 5.5 d). Admissions reached a peak in June and November/December, just after the long and short rainy seasons. Two hundred and thirty-nine patients had been previously admitted a total of 408 times for malaria (range l-7 admissions). Blood slide examination for Plasmodium falciparum on admission gave the following results: + + + + +, 5 (0.3%); ++++, 171 (11.5%); fff, 452 (30.3%); ++, 468 (31.3%); f, 284 (19.0%); occasional, 112 (7.5%); and gametocytes 2 (0.1%). One hundred and ninety-six patients had a haemoglobin level
