Lessons laernt from Mortality Reviews -...

Lessons Learnt from Mortality Reviews

Dr Wong See Chang Dr Lee Phaik Ngan

Dr Chieng Chae Hee Dr Benjamin Ng Wei Liang

Paediatric Refresher Course 8-9 April 2017 Hospital Sibu

MDG 4 2015

• Malaysia tidak berjaya mencapai sasaran kadar kematian kanak-kanak di bawah 5 tahun seperti yang di tetapkan oleh MDG namun keturunan kadar sebanyak 50% daripada tahun 1990 daripada 16.8/1000 livebirths kepada 8.4/1000 livebirth adalah selaras dengan kebanyakan negara pembangun ( Data Jabatan Perangkaran Malaysia 2015)

MDG 4 2015

• Indikator lain bagi pencapaian MDG 4 adalah liputan immunasai MMR yang mana pada tahun 2015 telah menunjukan penurunan daripada tahun sebelumnya iaitu dari 93.4% kepada 93.1% dan tidak berjaya mencapai sasaran yang di tetapkan (95%)

Sustainable Development Goals(SDG)

• Target for Malaysia: To end all preventable under 5 deaths

• MGD 4 data: 23% of under 5 deaths are classified as preventable deaths, but interpretation of preventable deaths varies across the country.

2016

• • GUIDELINE ON CLASSIFICATION

OF UNDER 5 DEATHS INTO • PREVENTABLE AND NON

PREVENTABLE DEATHS • • • • • • PREPARED BY: • FAMILY HEALTH SECTION • MINISTRY OF HEALTH •

PREVENTABLE DEATHS

PREVENTABLE (MEDICALLY TREATABLE)

Conditions in which modifiable factors may have contributed to the death

These factors by means of nationally or locally achievable medical interventions , can reduce the risk of death

e.g. Delay referrals, diagnosis & treatment, poor resuscitations

PREVENTABLE (PUBLIC HEALTH/ OTHERS)

Conditions potentially preventable by public health care policies/interventions, social/patient factors

e.g. Drowning, choking, pneumococcal vaccination, teenage pregnancies, NAI

STRATEGIES TO REDUCE PREVENTABLE UNDER 5 DEATHS

PUBLIC HEALTH/OTHERS

• Sociopolitical factors

• Patient & family factors • Environmental factors • Legislatives

MEDICALLY TREATABLE

• Health system - Facilities - Equipment - Medical transport (retrieval) - Human resources & expertise - Quality of care - Communication - Timely diagnosis

Illegal immigrants Poverty/malnutrition Transport/logistics Infrastructures Clean water source Proper sanitation Smoking Teenage pregnancies

Non-preventable Deaths & Undetermined Deaths

• Definition of non-preventable deaths

• Non preventable deaths refer to deaths due to life limiting diseases such as lethal congenital malformation (eg Edward syndrome, hypoplastic left heart, pulmonary hypoplasia, Patau syndrome, multiple congenital anomalies,holoproencephalyetc), inborn error of metabolism, severe inoperable congenital heart disease etc.

• Undetermined deaths • These deaths are situations

where the committee cannot accurately determine the appropriate classification of death into preventable or non-preventable.

Paediatric Mortality in Sibu Hospital

Year 2011 2012 2013 2014 2015 2016 % Deaths

Birth -28days

48 23 59 49 45 34 258 58.90%

29 Days-1 year

18 18 18 13 6 17 90 20.55%

1-5 years

9 10 15 9 6 4 53 12.10%

> 5 years

6 4 8 6 8 5 37 8.45%

Total 81 55 100 77 65 60 438 100%

Causes of Perinatal and Neonatal Mortality 2014-2016

Causes of Perinatal and Neonatal Mortality according to the Birth Weight 2014-2016

Birth Weight (gram)

Classification

Prematurity Malformation Asphyxia Others

2014 2015 2016 2014 2015 2016 2014 2015 2016 2014 2015 2016

≤500 6 4 1 0 1 0 0 0 0 0 0 0

501-1000

14 13 12 4 3 0 0 0 0 0 0 0

1001-1500

2 5 3 5 2 3 0 0 0 0 1 0

1501-2500

1 0 2 12 3 5 1 2 0 1 5 2

>2500

0 0 0 5 5 3 2 3 1 3 1 3

Total 23 22 18 (51%)

26 14 11 (31%)

3 5 1 (3%)

4 7 5 (14%)

Total number of death : 2014(N=56); 2015(N=48); 2016 (N=35)

Potentially Preventable Deaths No. Cause of death Caretaker/

Parents Primary care

Hospital level

1. Pseudomonas Septicemia shock √

2. Chronic lung disease of prematurity with aspiration pneumonia

√

3. Prematurity with Pseudomonas sepsis (x3) √

4. Tension pneumothorax with pneumopericardium

√

5. Severe Hypoxic Ischaemic Encephalopathy √

6. Severe Hypoxic Ischaemic Encephalopathy √

7. E coli Sepsis with underlying Beckwith Wiedemann Syndrome

√

8. Cardiac tamponade √

9. Septicemia √ √

2016 Statistics

0

5

10

15

20

25

Home death BID* PC/DH** Hospital

Deaths (n=36)

Deaths (n=36)

23

6 3

* BID: Brought in dead ** PC/DH: Primary Care/District Hospital

4

Age classification

75% n=27

25% n=9

Paediatric Mortality - Age

<5 years

>5 years

Classification based on disease

• Respiratory disease: Pneumonia, Severe exacerbation of bronchial asthma, acute bronchiolitis

• Infection/Parasites: Acute gastroenteritis, sepsis

• Central nervous system: Intracranial bleed, cerebral palsy, autoimmune encephalitis

• Metabolic/genetics: Primary immunodeficiency, chromosomal anomaly, in born error of metabolism

Immediate cause of death

Cause of death Number of deaths Percentage

Hospital death Outside Sibu Hosp.

Cardiovascular disease 2 1 8.3%

Respiratory disease 2 3 13.9%

Infection/Parasites 8 2 27.8%

Dengue 1 - 2.8%

Malignancy 2 1 8.3%

Injury/Poisoning/MVA - 2 5.5%

Metabolic/Genetics 4 2 16.7%

Central Nervous System

4 2 16.7%

Total 23 13 100.0%

*N/B: Severe AGE accounts for 40% (n=4) of cases of infection/parasites.

Outside Hospital Sibu Deaths No. Mortality cases Place of mortality

Home BID PC/DH

1. Congenital Heart √

2. Bronchial Asthma √

3. Severe Pneumonia √

4. Acute Bronchiolitis √

5. Severe AGE √

6. AGE/Malnutrition √

7. Medulloblastoma √

8. MVA/Trauma √

9. Polytrauma (Selangau) √

10. SCID √

11. Pompe Disease √

12. CP/HIE √

13. Intracranial Haemorrhage √

Total 3 6 4

BID cases

No Cause of death Age (Year)

1. Severe asthma >5

2. Aspiration pneumonia <5

3. Cerebral Palsy - Hypoxic Ischaemic Encephalopathy (Acquired during perinatal period)

<5

4. Acute Gastroenteritis with severe dehydration <5

5. Severe Combined Immunodeficiency (SCID) <5

6. Motor Vehicle Accident (MVA) <5

*Brought in dead cases – those cases that showed no signs of life when arrived at Sibu Hospital

Preventable/Not Preventable

42% (n=15)

58% n=21

Deaths

Preventable

Not Preventable

*Preventable – also include those classified as ‘potentially preventable’

Preventable causes No. Cause of death Caretaker/Parents Primary care Hospital level

1. Severe AGE √

2. Severe AGE √

3. Severe Sepsis √

4. Severe Asthma √

5. Polytrauma √

6. Strep. Pyogenes √

7. Aspiration pneu. √ √

8. Dengue √

9. Severe AGE √ √

10. Cong. Heart dis. √ √

11. Acute Bronchiolitis √

12. HIE √ √

13. MVA/Trauma √

14. Strep. Sepsis √ √

15. AGE/Malnutrition √ √

General Conclusions

• For preventable causes, as categorized in the previous chart – caretakers/parents, primary care level or hospital level, the following are the general conclusions for each category: – Caretakers/parents: late to recognize an ill child/danger signs;

lack of education on child safety (e.g. car seats); delay in seeking treatment

– Primary care: Education to patients is still suboptimal, inadequately trained staff to perform effective paediatric resuscitation, delayed referral, failure to recognize an ill child and urgency to refer.

– Hospital level: Delay in diagnosis and intervention, failure of junior staffs to recognize an ill child, missed cardiac lesions during newborn checks (also failure at the MCH level).

PREVENTABLE CAUSES OF DEATHS

PUBLIC HEALTH/OTHERS

• Injuries RTA/Fall

• Drowning

• Immunisation: Severe Invasive pneumococcal Disease

• Malnutrition: Kwashiorkor

• NAI

• Teenage pregnancies (premature births)

• BID cases

MEDICALLY TREATABLE

• Acute gastroenteritis

• Severe infections eg melioidosis:

(Delayed diagnosis and/or treatment)

• Treatable congenital heart disease

Question (1) - Is the child sick?

History: Useful questions • Is the child able to drink or eat? • Does he have recurrent vomiting after food or drink? • How is the child’s urine output? • Is the child getting worse since the onset of illness? • Has the child been less playful or less active? • Is the child irritable or inconsolable? • Has the child been more sleepy or drowsy or less alert? • Has the child had any convulsion during this illness?

Question 1 - Is the child sick? General assessment: Appearance

•Optimal observation is important •Assess the child’s interaction with his / her environment •Assess the child’s age appropriate response to multiple stimuli

Alertness - the use of child’s eye (looking at observer or the pen being offered and looking around the room): look vs gaze or speech vs cry

Motor Ability - the child’s sitting, moving arms and legs on table or lap, lying on table and not moving in mother’s arm: activity, movement & muscle tone

Playfulness - vocalizing spontaneously, playing with objects, reaching out for objects, smiling and crying with noxious stimuli

Consolability - Response of a crying child to being held by parents - Normal response: child stops crying when held by parents - Severe impairment: continual cry despite being held or comforted

Question 1 - Is the child sick?

General assessment: Breathing – Work of Breathing

increased (nasal flare, retractions) , decreased or absent respiratory effort, abnormal sounds (grunting, stridor, wheezing)

General Assessment: Circulation

abnormal skin color ( pallor or mottling) or bleeding

Question (2) – Does the child have any risk factor for severe illness?

Some of the risk factors are:

– Temperature

– Age

– Immunodeficiency or other predisposing condition

– Risk of specific infectious diseases based on local epidemiology and overseas travel

– NICU graduates

– Congenital Heart Disease

The safety net

The safety net should be one or more of the following:

– verbal and/or written information on warning symptoms and how further healthcare can be accessed

– arranging further follow-up

– liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if required.

Information leaflet(3) When to come back to see your doctor

• Looks more sick than before

• Does not get better in 48 hours.

• Drinks poorly or has repeated vomiting

• Has persistent high fever > 38.5 C

• Looks weak & not keen to play or move around

• Is more sleepy than usual.

• Has a fit or increased startles during sleep or awake.

• Has problems with breathing

• Develops a rash

• Is in pain

Gaining more knowledge (Many unanswered questions!)