Hidar Audit (2)

MORBIDITY AND MORTALITY REPORT OF PEOPD,
PROPD, Clinics, Ward, PICU AND NICU

From Tikimt 21 to Hidar 20 , 2017
Moderator : Dr. Abenezer

(Assoc. Prof of Pediatrics &child health)
PRESENTERS : Mulugeta
Mulunesh
nov/21/2024 SPHMMC Clinical audit

Outline
 Objectives and Methods

 Clinical audit of month of Tikimt 21 to Hidar 20 at Out patient
Department
 Clinical audit of month of Tikimt 21 to Hidar 20 of Inpatient activity
 IPPS, Supervision and quality improvement
 Culture Positivity
 Death summary
 Suggestions

Objectives
 To determine the number of patient visits and admissions
 To identify common causes of admission ,OPD visits and deaths
 To assess quality of clinical services and to identify areas to be improved
 To select major problems and to improve them till next session

cont
 To acknowledge the efforts of all staff members working in the hospital

 To discuss selected cases
 To use data for future planning
 To identify and Improve the gaps on Clinical services

Methods
 Audit period - from Tikimt 21 to Hidar 20,2017 E.C
 Data Sources-HMIS, Patient charts, Treating Physicians & Nurses
IPPS Quality, Supervision and Mentoring Report
 Data analysis was done manually
 Method of presentation of results-sentences, charts, graphs and tables.

Out Patient Department
 PEOPD
 PROPD
 Follow up Clinics
 ART clinic
 ID clinic

Clinical Audit of PEOPD Activity
 Total number of patients seen 490
Male - 274
Female-216
 PICT done=12 ,All are NR
 Patient triaged within 5 minutes of arrival = 98%

Sales
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Source of referral in PEOPD
350
300 156
250
200
150 119
100
28
50 25
18
2
0
self H/center Hospital(govt) Private(clinic) PROPD Undocumented

Common cases kept at EOPD
No LIST OF CASES Number of cases PERCENTAGE
1 SEVERE PNEUMONIA 87 17.7%
2 AGE with some and severe dehydration 57 11.6%
3 Seizure disorder 34 6.9%
4 Late onset sepsis 28 5.7%
5 Acute abdomen 4.4%

22
6 Asthma 17 3.4%
7 Bronchiolitis 15 3%
8 malaria 14 2.8%
9 Type I DM with DKA 12 2.4%

10 Underlying disease- SAM 23 4.6%
Length of stay
350 358
300
250
200
150
78
100 47
50
4
0
<24hr 24hr-2days 3-7days >1week

Reason for >24 hrs stay
25
24
20
15
18
10
5 4
2
0
lack of bed unaffordability waiting referral To be discharge
3 tmw 4

Outcome at PEOPD
No pt %
Admission 147 30 %
Refer out 7 0.14%
Discharge 182 37.1 %
Death 3 0.6%

Death pattern of PEOPD
Chart Title
6
5
5
4 4
4
3 3 3
3
2 2 2
2
1
1
0
Hidar Tahsas Tir Miyaziya Ginbot Sene Hamle Meskerem Tikimt Hidar
Series1

S.N Assesed area
1 Admission note completeness 95%
2 Progress note completeness 52%
3 Order sheet completeness 90%
Total physician score 79%
4 Clinical pharmacy completeness N/A
5 V/S monitoring &recording 88%
completeness
6 Medication administration 95%
completeness
7 Pain assesment &mgt 100%
8 Shift hand over conducted 86%
9 Input &out put monitoring and 100%

recording
SPHMMC Clinical audit nov/21/20214
Strength of PEOPD
 Patienttriaged with in 5 min of arrival
 organized Resucitation teams
 rounds are being done twice daily
 Case based discussion
 Availability of 2 warmer
 EMR being started

 Availability of bedside U/S
 Porters are available most of the time
 Most patients are not staying more than 24 hrs
 Emergency and critical care and anaesthesia department
physicians are available
 Critical patients being followed continuously on monitor

Identified problems
PROBLEMS Responsible body Proposed Pattern of
solution Problem
No mechanical Hospital Resource Cont from previous

ventilation at ER management mobilization month
Biomedical team
Feedbacks is not Residents Sensitization Cont from previous

being given to ER case managers month
referring units
Difficulty of Resident & Nurses To have order Cont from previous
replacing ER crash medications at month
chart hand
No utilisation of HIV Nurse To sensitive Same
risk assessment ER case manager residents & nurses
tools
Nonfunctional Biomedical Resource allocation Cont from previous

CPAPS ER case manager month
Problems, Responsible body Proposed solution Pattern of problem
Identified problems
 Accepting pt with out
 Hospital
communication management
 Timely document the no
free bed daily and
 Continuation from the
previous months
 Liaison office handover it
 Timely
Communication b/n the
catchment health
sectors
 Scarcity of desktop  Hospital  Cont from the previous

and poor connection management month
 IT professional

Clinical Audit of ROPD Activity
 Total number of patients seen --- 527
Male -277
Female- 250
Eligible for PICT -12
1-reactive
PICT Coverage=100%

ROPD patient visit pattern six month
700
657
600
574
560
545 536 527
500 502
490 481
476
400 406
300
200
100
0
JAN FEB MARCH APRIL MAY JUNE July August September October November

Age distribution of patients seen at PROPD
200
200
180
160
167
140
120
100
80
77
60
57
40
26
20
0
<28 D 29 D -1 Yr 1Yr - 5 yr 6Yr-11 yr >11 Yr

10 Top Cases of PROPD
Cases Number of Percentage
Cases
URTI+Tonsillitis 93 17.6%
2. CAP 55 10.4
3. Epilepsy 33 6.26%
4. AGE 32 6.07%
5. UTI 18 3.4%
6. Rickets 16 3.03%
7.NHB 14 2.6%
8.Asthma 11 2.08%
9. CHD 10 1.8%
10. Umblical hernia 10 1.8%
TOP 5 surgical cases at RPOD
No Cases Number of cases Percentage
1 Umblical hernia 10 2.5%
2 Hypospadia 8 2.39%
3 Undescended testis 8 2.7%
4 Hydrocele 5 0.99%
5 Others 14 2.7%

Follow up clinics
Neurology 353
ped.surgery 153
Endocrine 200
Chest 136
Series1
DM 159
Renal 134
Miscellaneous 76
PHO 98
0 100 200 300 400 500 600 700 800 900

Pattern of patients seen at follow
up clinics
4000
3500
3350
3118 3110
3000 2997 2953 2953
2939 2941
2542
2500
2000
1500
1000
500
0
yekatit megabit miaziya Ginbot sene hamle nehase meskerem tikimt

ART Clinics
 Total on follow up-163  Stop –0
 Total this month visit- 74  TI-0
 Newly initiated-0  TO-1
 Lost-2
 Drop- 0
 Restart -0

ID clinic
 Total cases seen-7
 TB-4
 TB +RVI-0
 Viral hep-2
 Malaria-1
 PEP-0

Strength of OPD
 Allpatients seen on the same day of visit
 Senior & sub-specialists available for follow up clinics
 Computerized documentation
 Improved Computer Connection Problem
 Active utilization of HIV risk assessment tool
 Lunch time being covered in ROPD

RPOD identified problems
PROBLEMS RESPONSIBLE PROPOSED PATTERN OF
BODY SOLUTION PROBLEMS
1.TB screening is not • Allocated • Active • Similar to all
being done for all as physician & nurses sensitization months
protocol physician &nurses
with each rotation
2.No utilization of • Department • Trainings Similar to all months
National Health Data • Hospital quality
Dictionary at committee
all(NHDD),ICD • Opd case managers
3.appointment is not • OPD case sensitization • Similar to previous
equally distributed in managers months
different days of • Residents
follow up clinics

Inpatient clinical Services
 Hemato Oncology Ward

 Pediatrics Ward 4th Floor
 Pediatrics Ward 5th Floor
 Pediatric Surgical ward
 PICU

Activity of pediatrics Hematology and Oncology ward
 Total Cases Admitted= 68
General Pediatrics ward = 20
PHO ward =48

Male = 32
Female = 16

30
25
20
15
Series1
10
0
29 days-1 year 1-5 year 6-11 year >11 year

Length of stay at PHO ward
30 25(36.7%)
25
20
15
10
10(14.7%) 6(8.8%))
24-72hr 3-7d 7-14d

PHO: Disease Pattern
Disease No of Percentag
Admission e
ALL 13 19.1%
NHL 10 14.7%
Retinoblastoma 8 11.7%
Wilms TUMOR 7 10.9%

RMS 7 10.9%
HL 6 8.8%

Outcome--- PHO Ward
 Discharged Improved—40
 Transferred to the next month---8
 Transfer to PICU-0
 Death---0
 LAMA -- 0
 Undocumented--0

S.N Assesed area Average result Remark
1 Admission note completeness 90 Not proper paper
and time
2 Progress note completeness 56.6
3 Order sheet completeness 80 Time not written
Total physician score 75.46
4 Clinical pharmacy completeness NA
5 V/S monitoring &recording 100
completeness
6 Medication administration 100
completeness
7 Proactive patient round 86.6
8 Pain assesment &mgt 100
9 Shift hand over conducted 100
10 Input &out put monitoring and 100
recording nov/21/2024 SPHMMC Clinical audit
Strength
 Good team sprit
 Nurse and physician interaction with the patient is very good
 The nurses are well know the activities done in the ward
And they are willing to educate the others.

Pediatric Ward - 4th Floor
 Total no of admission- 94
M-53
F-41
PICT Done = 83
 all NR

Age Distribution---Pediatric Ward 4thfloor
35 30(44.1%)
30
25 20(29.4%)
16(23.5%)
20
12(17.6%)
15
9(9.5%)
10
0
7-28 days 29days-1year 1-5year 6-11 year >11 year

Length of Stay– Pedi Ward 4th floor
Length of stay Number of patients
1-5 days 30(44.1 %)
6 -10 days 26(38.2%)
> 10 days 16 (23.8)

Top cases admitted at Pedi Ward, 4th Floor
List of Cases Number of cases Percentage
Severe Pneumonia 20 29.4 %

LONS 11 16.1%
Meningities 9 13.2%
CHD 10 14.7%
Epilepsy 5 7.3%
Down syndrome 5 7.3%
DM 5 7.3%
Nephrotic syndrome 3 2.85%
Underlying disease - SAM 10 4.4 %

4th Floor Pedi Ward Outcome
No. Outcome Number of cases Percentage
1 Discharged Improved 60 62.85%
2 Transferred to PICU 2 1.9%

3 Death 3
4 Left Against Medical 4 0.95%
Advice
5 Transferred to Next month 24 33.33%
6 Transferred to oncology 1 0.95%

ward

 Death pattern at pediatrics ward
4.5
3.5
2.5
Series 1
Column2
2 Column1
1.5
0.5
0
hidar tahsas tir yekatit ginbot sene hamle meskerem tikimt hidar

Death pattern at pediatrics ward
8
7
7
5
5
4 4
4 Series1
2 2 2
2
1 1 1 1
1
0
0
meskerem tikimit hidar Tahasas Tir yekatit ginbot sene hamle Nehase Meskerem Tikimt

Pedi ward 4th Floor
 BOR= 96.9%
 ALOS= 8.2days
 MR =0%

Strength
 Daily health education
 Chart audits being done
 Good team sprit
 HIV test kit available most of the time
 Emergency drug available during resuscitation
 Psychotropic and narcotic prescriptions during night time and weekends are
available
 Portable oxygen timely filled most of the time

Identified problems
Identified Proposed solution Responsible body Pattern of
problems problem
1.No different age • To buy BP cuffs • Hospital • Continued from
APP. BP apparatus management last month
• department
2.No procedure • To have separate • Ward case • Continued from

room on 4th floor room for managers last month
procedures • department
3.No LP set • to buy procedure • hospital • same from

sets managements previous months
4.No avialable • to have separate • ward case • same from

ressucitation bed at bed with managers previous months
each room materials

Inpatient … Problems
problems Responsibl Proposed Pattern
e body solutions of
proble
m
 There is scarcity of To buy • Hospital Cont the
equipment(glucometry, equipment management previous
thermometer and • department
pulseoxymetry)
 No nebulizer To buy • Hospital Cont the

management previous
• department

S.N Assesed area
completeness
completeness
7 Proactive patient round 73%
recording
SPHMMC Clinical audit nov/21/2024
11 Instrument processing & 100%
Pediatric Ward- 5th Floor
 Total Admission = 46
M= 24
F= 22
 PICT=90%
 candidate-20
D0NE-18 , All NR

Age Distribution at 5th floor of Pedi
ward
15(32.6%)
25
20
8(17.3%
15 13(28.2%)
10
7(15.1)% 7(15.2)
0 7-28D 29D-1yr 1yr-5yr 6yr-11yr

Length of stay at 5th floor pedi ward
20 17
18
10
16
14
12
10
8
6 7
4
2
0
1-5days 6-10days >10days

Top cases admitted at 5th Floor Pedi Ward
List of Cases Number of cases Percentage
LONS 7 15.2
severe pneumonia 4 8.6%
Neutropenic fever 4 8.6%
ALL 4 8.6%
meningitis 3 6.5%
NHL 3 6.5%
CHD 2 4.3%
type I DM 2 4.3%

5th floor cont
No+ Outcome Number of Percentage
cases
1 Discharged 29 63.04%
2 Transferred to PICU 0 0
3 Transferred to Next 15 32.6%

month
4 Transferred to PHO 2 4.34%

 Bed Occupancy rate= 86%
 ALOS=7.68
 MR =0%

S.N Assesed area
completeness
completeness
7 Proactive patient round 90%
recording
11 Instrument processing & 100%
steralization nov/21/2024 SPHMMC Clinical audit
Strength of Pedi 5th Floor
 Good patient follow up
 No delay on discharge
 Isolation room available
 Perfuse, Bp apparatus, thermometer, available and
improved from the previous month
 Emergency drug available during resuscitation
 Psychotropic and narcotic prescription available

Weakness of 5th Floor pedi ward
 No permanently assigned physician for 5 th floor

 Round time delayed b/c the physician make a round
after 4th floor round complete

Major problems which can be corrected on the
coming month both ward
1. Late admission and Discharge
Responsible Body
- Residents and Interns
- Emergency nurses
- Ward nurses

Solution
 Whenever there is a decision of admission lets finish writing before the
lunch time
 The nurse will admit the patient within 1 hr of the finishing of the admission
 Availing adequate desktop to facilitate timely admission
 Strengthening the connection system

Pediatric Surgery Activity
 Total cases admitted = 116

 Male =81
 Female =35

Age Distribution at pediatrics surgical ward
<29 days Number of Percentage
cases
29 days - 1 yr 24 20.6%
1-5 yrs 43 37.06%
5-11yrs 35 30.1%
>11yrs 12 10.3 %

Common cases in pediatric surgical ward
s. no case no of cases percentage
1 Hypospadia 26 22.4%
2 Undescended testis 17 14.6%
3 cleft lip and palate 12 10.3%
4 acute appendicitis 11 8.8%
5 ARM 4 9.4%%

Pediatric surgery ward activity-length of stay
90
80 53(66%)
70
60
50
40
30
20
42(36.2%)
10 5(4.3%)
14(12.06%
0
1-2 days 3-4 days 5-6 days >7DAYS

Outcome
 Discharged =115
 Transfer to PICU -1
 Death –0

PICU Activity
male
 Total number of Admission—37
 Male - 17
 Female-14

Age Distribution - PICU
9 Chart Title 1
9(27.5%) 9(27.5%)
8 0.9
7 0.8
6 0.7
5(17.2%) 5(17.2%) 0.6
5
0.5
4
3(10.3%) 0.4
3 0.3
2 0.2
1 0.1
0 0
<28 days 29 days-1yr 1-5yr 6-11yr >12

Length of stay at PICU
12
10
4
6
6
4
3
2
2
0
<24hr 1-2days 3-6days 7-14days >14days

Top 5 cases admitted to PICU
No LIST OF CASES Number of PERCENTAGE
cases
1 septic shock 6 19.3 %
2 HF 5 16.1 %
3 Severe pneumonia 3 9.67 %
4 LONS 3 9.67%
5 AKI 3
333v//224 SPHMMC Clinical audit
9.67%
PICU out come
Number of patients percentage
Total admission 31
Transfer to ward 19 61.29%
LAMA 5 16.1%
Next month 1 3.2%
DEATH 4 12.9%

PICU …
 Average length of stay: 7.7 days

 Bed occupancy rate: 90%
 Mortality Rate: 12.9%

S.N Assesed area
1 Admission note completeness 88.8%
4 Clinical pharmacy completeness NA
completeness
completeness
7 Nursing care 100%

recording
SPHMMC Clinical audit
nov/21/2024
STRENGTH OF PICU
 Has policies ,protocols & treatment guide lines for running the PICU
 Availability of well trained staff
 Availability of nurses during rounds
 Rounds are done two times per day

 Full registration and Improved chart completeness
 Nurses handover pt every morning with head nurse making round
 Reading assignment being discussed
 Functional hand washing basin in each rooms
 Good team work spp. During resuscitations

Problems identified
Problems Proposed Responsible Pattern of
identified solutions body problem
No portable X- • To avail • Hospital • Same as
RAY, no LP & materilas management previous
intraosseous • department month
sets
No app. Consent • To print • Picu case • Same as
forms for formats manager previous
procedures like • department month
intubation
hosp. supplies • to cont the • PICU case • Same as
like dispo. glove hospital manager previous
& gucometer • hospital month
with strip
interruptions

 problems  Responsible  Proposed solutions  Pattern of
body problem
 Unavailable  Hospital  Resources  Continuous
equipment( intr management mobilization and from the
aossous needle,  All of us allocation previous
portable x-ray, month
ultrasound liner
probe,
Echocardiograp
hy)
 Scarcity of  Nurses and  Replace used  Continuous,
(emergency residents medication and ET from
drugs tube previous
(Fantanyl),  Hospital months
different size ET management  Avail pediatric size Et
tube(2.5),centr tube in the Hospital
al
lines,Trachseost nov/21/2024 SPHMMC Clinical audit
 Difficul 
ty of Hospital  Make the way to Continuou
transp manageme imaging comfortable s from the
orting nt  Avail portable previous
pt for imagings ( linear month
imagin probe,X-ray)
g

Culture Positivity:
sample total positive
Blood 84 6
Tracheal aspirate 1 0
CSF 48 0
Body fluid 12 0
urine 47 10
Stool 6 0
Abscess 2 0

Sputum 1 1
Undocumented 8
Rejected
4

Pattern of Culture Positivity
Organism Number of growth Outcome
CONS 13 2death, Others discharged
K. Pneumoniae 6 Discharged
K.Ozane 1 Discharged
S.aures 1 Discharged
enterococus 3 Discharged
E.coli 4 7Discharged,1LAMA
Pseudomonas 3 1discharged 1 transferred to next month
Enterobacter 1 discharged
acitnobacter 3 discharged
Organism Sensitivity Resistance Site Outcome
E.coli Amikacin.Ceftaz Pipe/Tazo urine discharged
idime,Levofloxa Cotrimoxazole
cin ampicilin
meropenum
tobramycin
E.coli Meropenum, Cotrimoxazole,c Peritoneal LAMA
Amikacin,augm iprofloxacin abscess
entin
CONS Cefotaxim , gentamycin, Blood dischaged

penicillin,
oxacillin
CONS CAF Cefoxitin blood dischaged

CONS CAF,Levofloxaci Pencilin blood death
n,vancomycin
k. Pneumonia Meropenem Ceftriaxon Blood Discharged
Augumentine ciprofloxacin
Vancomycin
Ceftazidim nov/21/2024 SPHMMC Clinical audit
Organism Sensitivity Resistance sample Outcome
k.ozane Amikacin, Ciprofloxacin,cot tracheal discharged

augmentin rimoxazole
k.ozane Meropenem Augmentin urine discharged

cephazoline cefixitine
Cefipime
piperacilin
CONS Clindamycin, Pencillin blood Discarged
ciprofloxacin,
erythromycin,
gentamycin,
tetracycline,TMP

Pseudomonas Ceftaazidime meropenem Blood Discharged

Ciprofloxacillin
Gentamycin
CONS gentamycin Penicillin, Blood discharged

cefoxitime
Pseudomonas None Ceftazidim TA dischaged

aeriginosa Ciprofloxacillin
gentamycin

Enterobacter Ampicillin Cefotaxime, Blood Discharged

ceftazidime,
Ciprofloxacin,
Gentamycin,
meropenem
K. Pneumonae cefotaxime, TMP Blood Discharged

ceftazidime,Ciprofl
oxacin,
gentamycin,
Meropenem

Tinsae Tegene
This is a 6 years old male child who was admitted
with the diagnosis of
 P1= Newly diagnosed stage IV RVI

 P2= + ? Disseminated TB(pleura, peritoneum)
on anti TB
 P3=? PCP
 P4= ? Lymphoma
 P4= ? DIC
 P5= Superior Mediastinal syndrome
 after he presented with non-barking non whooping cough of 2 weeks
duration. Associated with this he also has a history of HGIF for this
complaint he initially visited near by clinic and he was given unspecified Iv
medications for three days for the diagnosis of pneumonia but not getting
improved.
 After 3 days of treatment he developed easy fatigability, and worsening of

fever and associated chills and rigors. He also has history left neck
swelling of 2 years duration. The swelling was first small and later
increased in size to attain its current size. he has also a history profuse
nasal bleeding 1 episode 20 days back.
 .For this complaints he went to Zewditu hospital and was diagnosed with
stage 4 RVI + MAM+ Hodgkin lymphoma+ r/o disseminated TB and was
started on Meropenem, vancomycin, cotrimoxazole , anti TB and also
started HAART but discontinued after 3 days due to diss TB suspected .
While at Zewditu hospital he developed abdominal
distention that later involved the leg and the face.
 otherwise he has no hx of diarrhea , vomiting
 ABM OR LOC. weight loss
 difficulty of swallowing or
 ulceration in mouth
 skin rash
 bleeding from the body.
 previous hx of recurrent infections or
hospital admission
He is born from PII mother who had no
regular ANC follow Up and mode of delivery
was via c\s for an indication of previous C\s
Scar and delivery was at Ghandi Hospital and
she didn't have baseline investigation. She is
also newly diagnosed RVI patient, and his
father died during the COVID era.
he is vaccinated and adequately exposed to
sun light
He has comparable growth with his peers.
UPON INTIAL PRESENTATION
General appearance ASL
HEENT= Pink conjunctiva, Non-icteric sclera
Abdominal Exam -The abdomen was
distended.
there is no ballotable organ
Musculoskeletal there is grade II NON PIITING
EDEMA
CNS The patient is awake, alert
 x= CD4=867
 CBC intial = WBC=3410 (N=33.4% and L=61.6%)
 Hgb=3.4 HCT=9.3 MCV= 75.9 MCH=27.5 MCHC=36.2
 PLT=4
 Updated = WBC=2630 (N=47.8% and L=43.6%)
 Hgb=3.8 HCT=10.5 MCV= 77.1 MCH=28.2 MCHC=36.6
 PLT=5
 ESR-23
 Abdominal ultrasound-mesenteric lymphadenopathy likely reactive otherwise unremarkable
 Serum Electrolytes= Na-135\ K-2.86\ Cl-98.8
 RFT= urea-19 Cr-0.5
 LFT= SGOT=56 SGPT=15 ALP=138
 uric acid-2.5 LDH-523
 peripheral morphology - anisocytic ,normochromic RBCS +Mild Thrombocytopenia
 abdominal xray -unremarkable
 LN BIOPSY= Hodgkins Lymphoma (done at Zewditu Hospital)

HOSPITAL COURSE
After he was admitted to the ward initially he started on
prednisolone and it was planned for repeat the LN biopsy
but due to low platelet count it was deferred.
He had episodes of epistaxis and tarry stool and he was
transfused with 3 units of platelet, 01 unit of FFP, and also
transfused 2 units of PRBC and 1 unit of whole blood, Abx
and anti TB continued
on his 3rd day of admission (25/02/17) he had increased in
puffiness of the face and had also increased work of
breathing for this he was put on CPAP and stat dose of
dexamethasone was given with 0.15mg/kg and
And Subsquently he was having increased
work of breathing ,severe sc/ic retractions
and despite on CPAP he was having
desaturation
and ICU transfer was decided and
communicated for possible mechanical
ventilator and in between he had respiratory
arrest and CPR was done ,and 3 doses od
adrenaline was given ,despite that death was
confirmed with possible cause of respiratory
failure 2ndary to severe sepsis +pulumonary
Bojinera Hailu
 2)this is a 34 days old male infant
 was admitted with diagnosis of
 known DS+ CHD ( AVSD secundum ASD sever PAH)+ SCAP R/O IE+
hypothyroidism(on tx)
 who presented with a history of bleeding following circumcision at a HC that was
done 1wk back, the mother reports that the bleeding was excessive, was eventually
arrested then then he bled again after 2 days, he was taken back to the health
centre then it was arrested with packing and after they went back for wound care, he
was noted to have severe anaemia and was referred here for further management,
at arrival was unconscious with pulses with unpalpable and CPR was started
immediately
 otherwise no history of fever, ABM, no known family history of bleeding or anaemia
from the maternal side
 no vomiting or diarhea, no feeding interruption
 he is born from a para 2 mother after 9months of ammenoria who negative baseline
investigations, delivered via SVD and it was uneventful, no NICU admission,
vaccinated for age and started sunlight exposure, he is on exclusive breastfeeding

General appearance-ASL, unconscious
HEENT-paper white conjunctiva, NIS, no dysmorphism
Respiratoryno respiratory effort, cyanosed,
Cardiac-cold extremities, peripheral pulses -not
palpable, bradycardic, s1, s2 heard and normal, no
murmur
Abdominal Exam-no hepatomegaly, soft
Musculoskeletal-no deformities , no swelling, no
oedema
CNS-unconscious
Other pertinent physical finding-no jaundice
Immediately CPR was intiated ,and 3 doses of
adrenaline was given,bolous of N/S was
given ,meropeneum was intiated and despite
that death was confirmed with possible cause
of Hypovolemic shock 2ndary to ABL 2ndary
to circumsion site bleeding

 this is a 15month old female toddler who is a known DOWN SYNDROME pt on follow up
since the age of 10 month at Saudi and since age of 1 yr at our hospital taking
spironolactone 6.25mg PO daily, Lasix 10mg PO BID, levothyroxine 50microgram PO/day
 currently she presented with cough, nasal congestion and sneezing of 3 days duration
with associated fast breathing, grunting, LGIF , decreased feeding and excessive
sleepiness of 2 days duration.
 she has hx of contact with a person having URTI like symptoms
 no hx of LOC or ABBM
 she is born from PARA 2 mother after 9 month of amenorrhea via SVD at home in Saudi,
she didn't cry immediately after birth but had no NICU admission.
 her first hospital visit was at the ae of 10 month at Saudi where she presented with similar
compliant, stayed at hospital for 2 weeks and discharged.
 her 2nd admission was at the age of 1 yr at SPHMMC for measles.
 she was on EBF for 5 months then started on complementary feeding
 hospital course
 admitted and put on CPAP, antibiotics started, CBC,U/A, CXR, ESR, BC with 2 bottle was
sent
 GA ASL in RD, gross dysmorphic feature
 VS PR -156 , RR- 74 ,TO 37.7 ,SaO2 86-90% with CPAP
 W=7KG ,L=72CM
 WFA=AT -2 ,HFA=B/N 0 AND -2 ,WFL=AT -2
 HEENT -flat nasal bridge ,low setted ears,
 chest -nasal congestion and flaring
 mod SC/IC retraction
 transmitted sound all over the lung field bilaterally
 CVS -PP palpable ,CR- fast
 G3 holosystolic murmur best heard at LLSB
 ABD liver 2 cm BRCM
 MSK- no edema
 NS -irritable
WBC 17.42 N 68.5 L 28.1
hg/HCT/PLT 12.1/35.5/290
MCV 61.4 RDW 25.2
U/A protein +1 ketone +1
echo -complete 15 mm AVSD secundum ASD
severe PAH(done 2 month back)

Currently at ER
GA- ASL RD PR-165 RR- 64 T 37.9 Spo2 80%
Wt 7kg Ht 69cm Muac 11.5cm
Wfa <5th , s.underwt
Wfl b/n 5th & 10thC
Lfa <5th c, s. Stunted
Chest- severe retraction w diffuse wheezing
biphasic, coarse creps & transmitted sounds
bilaterally
Cvs- active precordium , grade 4 HSM, CR
fast PP palpable S1&s2 well heard
Abd- no distension , liver 4cm BRCM
CNS- conscious GCS 15/15
Inv ECHO- large Os ASD +SPAH w moderate
RV Systolic dysfunction
1st cbc wbc 7.3 N 35.4 L 47.6 Hb/hct/plt-
11.8/32.9/476
Stool-many pus cell , moderate RBC
2nd cbc Wbc 9.16 N 40 L22.8 Hb/hct/plt-
9.7/27.7/363 mcv 79.4
Hospital course- at ER put on Ino2, pneumonia
considered , ceftriaxone started, for wheeze
challenged w salbutamol, dexamethasone loaded ,
mgso4 given, there was mild improvement and was
admitted to ward. Since he was congested lasix Iv
2mg/kg/day started but later on hold for frequent
diarrhea. After 1 day ward stay resporatory
Distress worsened and nebulized,lasix
rechallenged , dexa reloaded , transferred to
Picu for impending respiratory failure
In picu- GA ASL( severe distress)
PR 170 full RR 80 T 36.8 Spo2 50% RBS
190mg/dl BP 88/31
On Ns- irritable, chest- severe distress full of
wheezing and crepitation , liver 6cm Brcm ,
for
Which IVC collapsed, fluid bolus 10ml/kg
given , written consent taken , difficult
intubation and became bradycardic &apnec
after taking Suxx 1 dose, immediately CPR
started chest compression and bag and mask
15min done, adrenaline given 3x, calcium
gluconate 1x, atropine 2x, after rosc achieved
reintubated with ETT 3 depth 12cm
And was put on post CPR adrenaline after
intubation despite maximum sedation with
ketofol and maximum mv parameters in the
absence of machine failure, obstruction or
pneumothorax, patient kept desaturating. For
the wheeze ? Pulmonary edema entertained
lasix infusion started and kept on 0.1mg/kg/hr
, HAI of chest
Focus entertained, meropenum and
vancomycin started. Salbutamol QID
continued.
Despite efforts after 12 hrs pt became
bradycardic again, CPR started , adrenaline
given. Pt couldn't be salvaged.
Cause of death - respiratory failure 2ry CHD+
pulmonary edema
Kena
Age 1 year and 4 months
P1. 3rd post intubation for coma 2ry
complicated menengitis w ?VME
P2. Sepsis w septic shock
P3. Bicytopenia 2ry severe sepsis
P4. MOF( limb ischemia, Resp, cvs, cns, renal,
liver)
P5. AKI
Presented with sidden loss of consciousness
of 1 day duration, preseeded by vomiting and
diarrhea of 3 day duration, watery and 10ep
per day , also had hx of URTI, went to LHC
treated with ORS , Zinc and unspecified po
syrup but no improvement. At the onset of
LOC, admitted to enchini hospital, menengitis
was considered
Ceftriaxone, vancomycin , dexamethasone
started and referred here.
At ER
GA- comatose BP 72/54 PR 138(feeble) RR 28
T 34.9 Spo2 99%ino2
Wt 11 ht 82cm anthropometry unaffected
Heent- dry mucosa
Chest - severe retractions, comparable air
entry bilaterally
Cvs- s1 and s2 well heard CR delayed PP
feeble
Ns- comatose GCS-6/15 M3 v1 E2 hypoyonic
P msrb
Hospital course- at ER put on facemask ,
20ml/kg bolus given 3x , intubated w ETT 3,
ceftra vanco dexa continued and admitted to
picu.
Investigations
1st wbc 53k N70 L11 Hb/hct/plt 7.9/26.4/663
2nd wbc 49.1 N 73.1 L 21.5 Plt 30
3rd wbc 32k N 84.4 L10.5 Hb10.5 Hct 29.8
Plt50
PM- AA anemia +left shift 68% toxic
granulation no blast no parasites seen
Na/k/CL- 153/3.5/138 ......159/3/139.2
Ica 1.15 AST/ALT/ALP- 261/64/204
Cr/ur- 2.4/117 .... 2.4/119
Ldh/ uric- 1938/10.2
Hospital course at picu
Shock persisted adrenaline and noradrenaline
reached max, hydrocortisone started ,
meropenum and vanco renal adjusted
started, acyclovir too for ? Viral
menengioencephalitis, had focal sz for which
phenytoin loaded and continued
maintainance
After 24hr progressively developed limb
ischemia of bilateral foot , coag profile wasn't
Since was anemic, PRBC was transfused,
progressively Aki w oligouria worsened and
liver enzyme elevated
Despite all efforts patient continued to
detirorate and bradycardic, CPR done for
20min , adrenaline given. Despite which pt
couldn't be salvaged.
Possible cause of death- MOF 2ry
overwhelming sepsis
A 1 years old female patient on her 38th day of admission to picu
with assessment
 P1. SAM(E)
 P2. 35th post extubation date (intubated 16 days for RF 2ry to
rachitic lung
 With RT upper and middle lung collapse
 P3.HAI(3x tx)
 P4.fungal sepsis(tx)
 P5. Disseminated TB (lung,liver)
 P6. Clinical malaria (tx)
 P7. HTN 2ry ?
 P8. MDD 2ry rickets
 P9. ?opioid withdrawal syndrome

 Currently on - machine cpap for 22 days with high parameters, Antibiotics and pyridoxine
(34th day),
 Calcedenk 75mg/kg/day , Stoss VitD given, meropenum vancomycin clindamycin
completed,
 Fluconazole completed, on chest Physio, budesonide nebulization, hypersonic saline,
salbutamol Qid,
 PCM Qid, fentanyl PRN , nifedipine po 3mg/kg/day, enalapril po 0.2mg/kg/day,
 Presentation- relatively healthy 3 months before admission when she developed watery
diarrheaof 3-4 ep per day of 4 day duration , visited local health center, given po syrup and
ORS , improved. After 1 week developed fast breathing,LGIF,grunting and decreased
feeding , admitted to hospital for 2 weeks , was on unspecified IV antibiotics for pneumonia
but referred here for no improvement. Went to private hospital kept there for 12 days, took
meropenum and vancomycin and after CT Chest showed multifocal pneumonia with ddx TB
, clinically Anti TB was started and referred. Has hx of consanguity ( mother and father are
cousins). Not sunlight exposed at all. Born from para 4 mom at 9month. No nicu admission.
BW unknown. Was on EBF for 6 month then started complementary feeding. Has had good
appetite till current illness. Is vaccinated for age. Started head support at 6months, sit with
support at 10months, said mama and baba at 9month, still can't sit with out support, can't
crawl , can't stand
On initial presentation- GA ASL in RD
PR 160 RR 68 T 36.8 Spo2 49-52off o2 RBS 146mg/dl
Wt 5.5kg Lt 60cm Muac 12cm HC 45cm, Wfa <-3SD, Lfa <-
3SD wfl (-1,-2)
Pertinent Chest- severe IC and SC retraction, bilateral coarse
creps with scattered wheeze all over the Chest, severe
chest deformity, architecture rosary , costochondral
beadings
Abd- flat, not distended, liver 4cm below with TVLS 7cm
Mssk- wrist widening , double malleable, hyperpigmented
rash over neck and diaper area
Cns- lethargic Pupil- MSRB, hypotonic

 Hospital course- at ER initially put on bottle cpap, dexamethasone given, nebulizer w adrenaline
and hypersonic saline, salbutamol challenged, mgso4 given but for increased work of breathing
admitted to picu where she was intubated with ETT 3.5 depth 12cm , meropenum vancomycin
continued, vitD was 22 for which stoss dose vitD given and calcedenk po continued. CXR was
repeated showing rachitic lung with multiform pneumonia with Rt upper &middle lobe collapse .
After 15 days of antibiotics meropenum and vancomycin was DC. Still was shooting fever for
which AntiTB continued,chloramphenicol started for staph coverage and took 10days. And DC .
For persistent fever since she was from malaria endemic area and emperic artesunate given and
completed. Later on began to have thick trachea aspirated for which TA culture sent which grew
Ecoli, sensitive to meropenum, gentamycin, amikacin where by VAP considered, gentamycin
started took 7day then DC. Later on extubated after 16 days , still had high machine cpap
requirement, prolonged antibiotic use, persistent thrombocytopenia for which clinical fungal
sepsis entertained, fluconazole started and completed 10days and DC. After 2nd week of PICU
admission BP was persistently stage 2 which wasn't explained so Hydralazine PRN , nifedipine
started with current dose 3mg/kg/day and enalapril also added with 0.2mg/kg/day after which it's
decreasing to elevated and normal BP ranges. She was on morphine and pcm standing dose for
pain control but later was giving significant sweating tachypnea tachycardia irritability which was
attributed to opioid withdrawal, morphine hold, pcm continued , fentanyl PRN added. Currently
still on high CPAP parameters, azithromycin 3x weekly added, budesonide nebulization being
done and on chest PT. Despite which still tachypnec (>80) tachycardic (>160) and spo2 88-92 on
machine cpap. Methadone was planned but not available.

Investigations-
Vit D recent 58.2 (normal)
Recent wbc 11.9 L 44 N 45 Plt 335 Hb 15.9
Hct 44
Sr albumin 2.9
Ica 0.9(low) po4 5.2(normal) mg 3.4(normal)
TFT normal
Echo unremarkable
VDRL- negative
Abdominal and Transfontanelle ultrasound- unremarkable
Chest CT- peribronchial thickening, rt upper lobe consolidation
with severe chest wall deformity
Brain CT- unremarkable
Electrolytes- normal , RDT negative, RFT normal,BF negative
Genexpert gastric aspirate- negative
Urine analysis- negative
Peripheral morphology- dimorphic anemia, hypochromic
anisocytosis
ESR-22mm/hr
CRP- negative
LFT- normal ALP 5715(high)

 New progress
 - on her 23rd post extubation date she developed new onset of HGIF , worsened respiratory
distress , desaturated to level of 72%, new onset HAI entertained and vancomycin and ceftazidime
initiated. While all other management with ambroxol,anti TB, chest physiotherapy, nebulization and
salbutamol continued. Reintubation was planned but family deferred
 - on 25th post extubation date was transfused with whole blood since still had high machine cpap
requirements and tachypnec, Hb at the time was 9.8 hct 29.4 plt 247k
 - on 27th post extubation date, she had sudden apnec episodes followed by severe retractions, RBS
at the time was normal, required bag and mask ventilation and stimulation for about 1 minute
 - endocrinologist was consulted for possibility of Vitamin D resistant rickets, where by Ica,PTH,MG,
1,25 vitD3 planned, ica 0.8(low), MG 1.4(borderline low), phosphorus 3.3(borderline low) but
couldn't find 1,25 vitD3 in the labs
 -after this calcium gluconate iv QID reinstated, stops dose vitD repeated 300,000iu Im Stat,
magnisium hydroxide initiated BID
 -updated CXR and wrist xray show worsening and show no improvement. Still has ratcheting
features.
 -after ID consultation PCP also considered and high dose cotrimoxazole bid initiated.
 -brain CT result= enlarged cranial vault w sutural diathesis2ry to rickets otherwise normal
 -recent VIT D 58.2
 - was having persistent congestion and hepatomegally , lasix initiated with 0.5mg/kg/dose BID

she developed new onset of HAI ( fever,
persistent desaturation on maximum ) for
which vancomycin and ceftazidime started
and on 12th day she deteriorated
desaturated and bradycardic, CPR done and
adrenaline given 3x but wasn't able to
salvage.
Possible cause of death - respiratory failure
2ry to chronic respiratory insufficiency 2ry
rachitic lung

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MORBIDITY AND MORTALITY REPORT OF PEOPD,

PROPD, Clinics, Ward, PICU AND NICU

Moderator : Dr. Abenezer

nov/21/2024 SPHMMC Clinical audit

 Objectives and Methods

nov/21/2024 SPHMMC Clinical audit

 To determine the number of patient visits and admissions

 To identify common causes of admission ,OPD visits and deaths

 To assess quality of clinical services and to identify areas to be improved

 To select major problems and to improve them till next session

nov/21/2024 SPHMMC Clinical audit

 To acknowledge the efforts of all staff members working in the hospital

nov/21/2024 SPHMMC Clinical audit

 Data Sources-HMIS, Patient charts, Treating Physicians & Nurses

IPPS Quality, Supervision and Mentoring Report

 Data analysis was done manually

 Method of presentation of results-sentences, charts, graphs and tables.

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

1 SEVERE PNEUMONIA 87 17.7%

2 AGE with some and severe dehydration 57 11.6%

3 Seizure disorder 34 6.9%

4 Late onset sepsis 28 5.7%

5 Acute abdomen 4.4%

9 Type I DM with DKA 12 2.4%

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

Refer out 7 0.14%

Discharge 182 37.1 %

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

8 Shift hand over conducted 86%

9 Input &out put monitoring and 100%

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

No mechanical Hospital Resource Cont from previous

Feedbacks is not Residents Sensitization Cont from previous

Nonfunctional Biomedical Resource allocation Cont from previous

 Scarcity of desktop  Hospital  Cont from the previous

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

1 Umblical hernia 10 2.5%

3 Undescended testis 8 2.7%

nov/21/2024 SPHMMC Clinical audit

0 100 200 300 400 500 600 700 800 900

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

 Lunch time being covered in ROPD

nov/21/2024 SPHMMC Clinical audit

nov/21/2024 SPHMMC Clinical audit

 Hemato Oncology Ward

nov/21/2024 SPHMMC Clinical audit