Malada deaths in a rurd hospital

Original Research
Maladadeathsin a rurd hospital
Ptill'C, N{BBCh, DCH
Rrrntet'l1 N{edit'alOllicer', N{anglzi Hospit:rl
Currendl'Adrisor t<>Himalala Asha Kendra He:rlth C:ue PxrgLirmrrrc,Katlrnrandu,Nepal
CotLespotrclence:
C Pf-alT,PO Box 3t5(i5,SunningdaleClustel One, I)ur-banNorth,,1,05l
Tel: (0ilI) r;62-0U61,enrail:colin@g:rlacticomnr.org
Ke,rvorrls: nillaria deaths,clistricthospital
An audit of :rll nral:uia cleaths drat occurrecl at Manguzi Hospital betlrren I October 1998 to 30 Septemlrcr 1999
was periorrned. There n'ere 41 deaths fr-onr malaria in this time pedod, which was nlany lnore than firr the previons
three 1'ears.The most cornlnon causes of death n'ere cerebral malari:r, puhnonary oedema, anaemi:r and renill
firilur-e. 2l patients were assessedto have h:xl sub optinral medical or nursing rnanagelnent, lr,here altemative action
nra-n-have altered the outconre. A tot:rl of 28 areas of sub optimal nlallagement were found as some patients had
more thiur one. Reasous fcrr the increase in malaria cleathscompared were suggested.This stud1'highlights imporftnt
less<xrsin czring fbr patients r'l'ith severe and cornplicated malaria in a rural hospital setting.
SA Fun hact 200,?;4,i(7):2.?-28
30-50% of inpatient admissionsand up
to 50oh of outpatient (OPD) visitsr.
Malaria remainsone ofthe world's most During the years 1996to 2000therewas
serioustropical diseases,causingmore a marked increase in malaria transthan a million deathseachyear around mission in South Africa with the main
the world, of which 907o occur in
increase in the Kwa Zulu Natal
A f r i c a r . M a l a r i a h a s l o n g b e e n province2.Manguzi hospital is situated
recognisedasoneofthe major obstacles in the far North East corner of the Kwa
to socialand economicdevelopmentin
Zulu Natal province in the Ingwavuma
Africa and is estimated to cost the magisterial district and is 20 km from
continentmore than $12 billion every the Mozambique border. The hospital
year in lost gross domesticproduct.l servesa predominantlyrural population
Malaria is Africa's leading causeof
of 100 000 peopleand malaria forms a
underfive mortality (20%) and in areas significantproportion of the workload
of the hospital. Plasmodiumfalciparum
with high transmissioncan account for
INTRODUCTION
malaria incidence in this district has
been found to be 500 casesper 1000
people within I km of the border,
droppingto lessthan 5 per I 000 people
over 30 km from the border3. From I
October 1998 to 30 September1999,
m o r e m a l a r i a d e a t h sw e r e s e e n a t
Manguzi hospital than for the same
period in the previousthreeyears.(See
Table I) This was of great concern to
the staff. An audit was performed to try
and ascertainthe reasonfor this and to
look for areas where medical
managementof thesepatientsmay be
improved.
1 October1996to 1 October 1997to lOctober 1998to
1 October1995to
30 September1996 30 September1997 30 September1998 30 September 1999
Deaths from malaria in
Manguzi hospital
Admissionto Manguzi
hospital with malaria
Patientsseenin Manguzr
hospitalOPD with malaria
Total number of casesof
malariain lngwavumadistrict
SA Fanr Pract 200i1:4ri(7)
Figru'c l: \'Ionths o1'rleuthof' rnal:uiiryxrticntsat \l:urgrrzi
- I 1)!)1)
Irosyritallionr 1 Ockrbcr 11)l)8to i)0 Seyrtcrrrbcr
METHODS
All deathsat Manguzihospitaldue to
r n a l a r i af r o m I O c t o b e r 1 9 9 8 t o 3 0
Septernber1999were includedin this
to have
study.A patientwasconsidercd
died from malaria only if a rnalaria
s m e a ro r a r a p i dd i a g n o s t i ci r n u r u n o c h r o m a t o g r a p h i ca s s a y t c s t w a s
positivc.Stillbirthsfrom malariawere
excluded.The file numbersof patients
havingdiedfrom malariawereextracted
f r o r n t h e h o s p i t a lr n o r t u a r yr e g i s t e r .
Thesefiles were then retrievcdand the
courseof hospital stay noted by the
researcher.
From eachof the patient's
fileshaernoglobin,
urca,creatinineand
g l u c o s eb l o o d r e s u l t sa n d G l a s g o w
coma scale(GCS) were noted.(These
were the flrst resultsnoted in the file
thosefrom thc tirne
andnot nccessarily
The
tirne
fron,admission
of adrnission.)
to deathwas notedas was thc causeof
death and whether any alternate
managcmcntcould havepreventedthe
death.Thiswasa clinicaldecisionmade
by the rescarcherbut where thc exact
c a u s eo l d c a t ho r a l t c n r a t i v cI n a n a g e ment was uncertain,the decisionwas
madeby the whole rnedicaltealn at a
specialreviewmeetingof all thedeaths
wcre
of thatycar.Othcrrnalaria
statistics
collectedby the districtrnalariacontrol
pro-qramme
in Jozini.
10
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Oct- Nor Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep98
99 99 99
99 99
98 98 99 99 99 99
liigru'e 2: Agcs ol p:rticntsn'lro <lic<llirrur nralariairt N[:LngLrzi
hospital fionr I C)c'tober1!)!)Uto 30 Selrterrrbcllf)!)l)
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RESULTS
2\
Il ll
Illlll
2 1 1 1 , llllllllll
t
ZU
Forty onepaticntsdied during thc study
p e r i o d .A s o n e p a t i e n td i e d i n o u t patientsdeparlrnent,
no dctailedhospital
recordcould be traced.One additional
file couldnot be fourrd.The remaining
39 files were found and the clinical
informationanalysed.
Therewereconsiderablymoredeaths
thanfor the correspondingpcriodofthe
previonsthree years.While the total
numberof rnalariacasesin the district
increased.
thenurnberof admissionsdid
not.
Most deathsoccunedduringthepeak
transmission
uronthsof March to May
(24). (See Figure 1,) Most deaths
occurredin adult patientsbetwecn l2
and 65 yearsof age (27). (See Figure
il)
The rr.rostcolnrrrorlcause of death
was cerebralmalaria(21). followedby
(6),anaemia(5) and
pulmonaryoederna
renal failr,rre(4). (See TahleII)
ll
ll
r
tl
fl
II
tl
2
L__l n
tl
<5
5-12
tl
tt
tl
ll
II
II
13-30
tl
tl
tl
7
I n
tl tl
tl
6
L]t__lL_.1
31-50
51-65
>65
Yearsof age
Twenty one patientswere assessedto
havehadsuboptimalmedicalor nursing
l n a n a g e m e nwt .h e r ca l t e m a t i v ea c t i o n
may have alteredthe outcome.A total
of 28 areasof sub optimal management
were found as some patientshad rnore
than one. (See Tuble III)
DISCUSSION
Causesof death in patients
dying from malaria
Cerebralmalaria
The fact that nuurbersof adrnissionsor
OPD casesdid not change witlr
increasingnumbersof rnalariacasesin
t h e d i s t r i c tc a n b e e x p l a i n e db y t w o
t h c t o r sF. i r s t l yi n 1 9 9 9 .i n r e s p o n steo
l a r - q cn u m b e r s o f p a t i e n t s b e i n g
a d m i t t e d ,t h e a d m i s s i o nc r i l e r i a f o r
rnalariapatientswcre changed.Not all
c h i l d r e r ro r p r e g n a n tw o m e n w e r e
((,ottlitttrerl ott pqqe 2(t)
2l
Puhnonaryoedcrna
6
Anacrnia
5
Renalfailurc
4
A s s o c i a t eidl l n e s s
Electrolyteimbalance
Unknown
Total
3
4l
S , \ l l r u l ' ! r ' : L c2t( X ) i l ;1 . l ( 7 )
{ } r i,:i:t;r} 2X,','
nt':zr tlt
In one case pulmonary oedema was
worsenedby a suddeninfusion of fluid
given in an attempt to correct renal
failure. In two casesfrusemidewas not
given although signs of pulmonary
oedemawere present.
The final caseof pulmonary oedema
was also the only pregnantpatient who
died in our series.Pulmonary oedema
Errors in management of
is said often to complicate malaria in
patients who died from
pregnancy.aThis lady presentedto a
malaria
remote clinic about 90 km from the
hospital at 30 weeks duration in her
pregnancy. She was tested for malaria
Delay in startingquinine
and once found to be positive was
treatedwith sulfadoxine-pyrimethamine
and askedto sleepover at the clinic that
night. This sherefusedto do and instead
went home. She returned the next day
in labour and acutely short of breath.
Shedelivereda I ,1 kg baby at the clinic
andwas urgentlyreferredto the hospital.
On arrival to the hospital the baby was
Delay in giving frusemide
resuscitated and whilst this was
No lumbar puncture performed
occurring the mother arrested and
subsequentlydied. The baby later died
2 8 errors in managementwerefound
too.
in 2I patients
Pulmonary oedema may be present
in pregnantwomen on admission,may
admitted as they had been previously.
develop several days later or, as in this
Also the openingof severalnew clinics
patient,may developimmediatelyafter
in late 1998meantthat many more cases
childbirth. In general malaria in
were being treated in the community
pregnancyis saidto be more severewith
rather than in hospital OPD.
a two to ten fold increasein mortality4
usually secondaryto pulmonaryoedema
CetebruI Malada
Pulmonary oedema
or hypoglycaemia.Malaria in pregnancy
Cerebralmalaria was the leading cause Pulmonary oedema was the second is alsoassociated
with an increasedrisk
of deathin this study.This is in keeping leading causeofdeath. This is a serious o f a b o r t i o n , s t i l l b i r t h , p r e m a t u r e
with the situation in many countries complication and has a fatality rate of
deliveries and low birth weightsa.In
where it can account for up to 80% of
above 50o/o.a
spite ofthis recordedgreaterrisk, there
all deaths.aCerebral malaria has a
Of the 6 patients who died from
was only one pregnancy related death
mortality of 20o/oeven with the best pulmonary oedema,in 4 casesan earlier i n o u r s e r i e s . A s i m i l a r s t u d y i n
medical care.s Cerebral malaria, for
transfer to a tertiary centre may have M p u m a l a n g a h a d o n l y t w o 6 . T h i s
researchpurposes,is defined as the altered the outcome. At Manguzi this
probably reflects the difference in
presenceof a non-rousable coma, for
usually means air transfer due to lack
patterns of malaria in endemic and
which no other cause is found. This
of paramedic support by road epidemic areas.In regions where
correspondsto a Glasgow coma scale ambulance and due to the distance malaria is endemic,resistancedevelops
of 4 or belowo.However for treatment involved (approximately 500 km) Air
in the general population so that it is
purposesany patient with an altered transferusually takesabout 3 to 4 hours mainly the young and pregnantthat are
level ofconsciousnessshouldbe treated to arrive at the hospital from the time
vulnerable. In areas where malaria is
ashaving cerebralmalaria. In our series when first contact is made with the
seasonal,such as in KwaZulu Natal, no
6 of the patients(40%) that were asses- emergency services and at the time of
such resistancedevelopsand so all are
sedof having died from cerebralmalaria the study the aircraft was only available vulnerableT.
had a GCS of 14 to 15 at the time of
to fly during daylight hours. On review
The averagetime from admission to
admission showing that death from
of these casesit would seem that all
death in patients with pulmonary
cerebral malaria cannot be predicted p a t i e n t s w i t h s i g n s o f p u l m o n a r y oedemawas 51,5 hours i.e. much later
from the mental state on admission. oedema should be referred as soon as than deaths from cerebral malaria.
Death from cerebral malaria is usually possible to a tertiary centre for
Pulmonaryoedemamay developseveral
within 6 to 96 hoursaand in our series Intensive Care Unit QCU) support. An
days after commencing chemotherapy
an averagetime from admission to death increased respiratory rate is a good and at a time when the patient's general
(Continaed
onpage28)
was 24.5 hours.
indicatorof early pulmonaryoedema.a
Meticulousmedicaland nursingcareis
necessaryto managethesepatients.The
World Health Organisation(WHO) has
published guidelines highlighting the
errors commonly made in managing
thesepatientsat a district hospital.4In
our series,8 patients errors were found
that might have altered outcome. Some
patientshad more than one error in their
management;theseincluded a delay in
staring quinine therapy, using sulfadoxine-pyrimethamineinsteadinitially (3)
or no treatmentat all (l). This was
probably becausethe admitting medical
officer underestimatedthe severity of
the disease.In 5 patients there was a
failure to respond to a low plasma
glucose level. As hypoglycemia is a
frequent problem in patients with
malaria especiallyafter startingquinine
therapy,it is hospital policy to measure
fingerprick glucose6 hourly. Often this
is diffrcult to achieve when the wards
are full and thereis a shortageof nursing
staff. This task may be delegatedto the
most junior of staff who then do not
realisethe urgencyof responding.Or the
finger prick may not be taken at all. In
two patients,Phenobarbitalsodium was
not given prophylactically to prevent
seizuresas per protocol at the time*. In
one patient where featuressuspiciousof
co existing meningitis existed,a lumber
puncture was not done.
26
SA Fam Pract 2003;45(7)
4.; t r:1;*;r1?{t'rr;.illl;
condition is improving and the parasite
loads are decreasinga.
Anaemia
The third most common causeof death
was anaemia.Ofthe 5 patientswho died
due to anemia,3 were babiesbelow l8
months.In fact, of the 6 children below
5 years who died of malaria, anaemia
was the causeof deathin 3 and possibly
associatedwith another one. In 2 of
thesepatientsanaemiawas not detected
early enough due to clinician error. In
these two patients no formal haemoglobin value was measuredalthoughthe
patients were noted to be pale. An
earlier checking of the haemoglobin
may have resulted in action that may
have altered the outcome. In one other
case anaemiawas recognised,with a
haemoglobinmeasurementof 2,2g/dl
but there was a delay in starting the
blood transfusiondue to nursingstaffing
problems.
Two adults died of anaemiain our
study. In one, who had in initial
haemoglobinof 10,lgldl, but was later
noted to be pale, an earlier transfusion
may have prevented death. In another,
a co existent haemolytic diseasewas
suspectedand earlier transfermay have
preventeddeath.This patient died with
a haemoglobinof 2,7 gldl.
Anaemia is a common presenting
feature of malaria in African children
and along with cerebral malaria makes
up the two most important complicationsof malariain children.aThe recommendation is to transfuse blood when
the haematocritdropsto below 20Yoand
to give this together with 20mg frusemide if the renal function is normala.
The rate and degree of anaemia
dependson the severity and duration of
the parasitaemia.It can either be due to
repeatedepisodesof malaria giving a
normocytic, normochromic picfure, or
from acute haemolysis with high
parasiteloads.Thesecasesoften present
with tachycardiaand dyspnoealeading
to cerebralsigns and cardio pulmonary
signsa.
Renal failute
The fourth leading causeof death was
renal failure. A study of malaria deaths
in Durbanshowedthatpatientswho died
from renalfailure had a meancrea-tinine
of476 micromol./L,comparedto a mean
creatinineof 246 micromoVl in those
who survived with renal failure.'In our
28
study the mean creatinine of patients
who died from renal failure was 497
micromol/L. The Durban study found
that cerebral malaria and renal failure
were the most common causesof death
and had a much lower incidence of
deathsfrom pulmonaryoedemathan our
study. This may be becausein Durban,
ICU facilities areimmediatelyavailable,
or may be due to the fact that Durban is
a referral centre away from the at risk
areas.Many malaria patients seen in
Durban are in fact referrals from
outlying rural hospitalssuchas Manguzi
and so it may be that patients with
pulmonary oedemadie at thesehospitals
before reaching Durban.
Renal failure from malaria usually
occurs only in adults. The progression
is from deranged renal function, to
anuria to acute fubular necrosisa.It is
important to distinguish between pre
renal and intra renal failure. In the
former, fluid for rehydration should be
given, but cautiously to prevent
overload.
If the patient is anuric after
rehydration, the patient will need
dialysis. If the patient passessmall
amounts of urine after rehydration it
may be possible to maintain fluid
balance without dialysis. Fluid given
should be restricted to urine output and
insensible losses. Indications for
dialysis included metabolic acidosis,
hyperkalaemia, fluid overload and
clinical evidenceof uraemiaa.Progressive renal failure may require dialysis
or may improve as malaria is treated.
Haemodialysis is preferable to
peritoneal dialysisa.This is because
patients with malaria have decreased
flow of blood to the peritoneal cavity.
Peritonealdialysis has also been associatedwith high ratesof complications
and mortality in peripheralhospitals4.
doctors were new or inexperienced.
2 . Crowdedwards led to problemswith
nursingcare.
The total casesin the district for the
year were more althoughadmissions
and casesseenin OPD were similar
in numbersto previousyears.
4 . Difficulty in transfer.
5 . Logistics such as the lack of available blood, high care facilities etc.
J.
CONCLUSION
Severalimportantlessonscanbe learned
from this study in how to better care for
critically ill patientswith malaria.These
include:
l. The importanceof startingquinine
early in patientswith severedisease.
2. The need to refer early to a tertiary
centre casesof pulmonary oedema
and worsening renal failure.
3. The importance of regularly
checking for anaemiaand the renal
function indicators.
4. The importanceof early blood transfusion in patients with a low
haemoglobin.
5. The importance of regularly
checking for hypoglycaemia in
patients on quinine therapy and in
taking the correct action when the
glucoseis low
Clinical audit such as this can help to
highlight these issues to hospital staff
in order to learn from their own
experience.D
Aclaowledgments
I am grateful to Prof. I Couper and the
staff of Manguzi hospital for their help
in this study.This articleis basedon an
assignmentthat was submitted for the
Mastersin Family Medicine degreeat
Medunsa.
*
OTHER
CAUSES OF DEATH
Other causesof death included multi
organ failure in an elderly man, and in
another patient, severe electrolyte
imbalance.In one patientco incidental
meningitis was suspectedbut a lumbar
puncturewas not done. In 3 patientsthe
causewas unknown.
In our study the increased number of
deaths seen during 1998/9 may be
relatedto severalfactors:
l. A rapid turnover of medical staff
meant that more than half of the
Current guidelines do not include
p henobarbito I prophy laxis.
Refetences
l.
2.
3.
/
6.
7.
d.
Roll Back Malaria, WHO internet site
www.who.int/int-fs/en/1infomation Sheet03.pdf
http://www.malaria.org.za/Malaria - Risk/
General Infomationfuodaie/uodate.html
www.malaria.ors. zallsdi/ovenlew/overview. html
Wanell DA, Moulyneux ME, Beales PF. Severe
and complicated malaria 2"0 edition. Tran R Soc
Trop Meil & Hyg 1990:84 (suppl2): I -65
wtiite NJ. Mdliria. ln: Coo[ GC.ed. Manson's
tropical diseases. 2Orh edition. London,
W.B.Saunders,
1996:I 087- I I 64
D u r r h e i m D N , F i e r e m a n sS . P r o f i l e o f p a t i e n t s
d v i n e w i t h P l a s m o d i u mf a l c i p a r u m m a l a r i a i n
Mpuhalanga. South Alr J Epideniol lnJecr
1999;14:24-5
Bell DR (ed) Lecture Notes in Tropical Medicine.
4'hedition. London, Blackwell Science,1995
Soni PN, Gouws E. Severeand complicated malaria
in KwaZulu-Natal. S Afr Med J 1996;86:653-6
SA Fa-rnPract 20011;45(7)