ISQUA17-3128ASSESSMENT OF EARLY MORTALITY IN PATIENTS ADMITTED TO THE GENERAL MEDICAL WARD AT A DISTRICT HOSPITAL IN BOTSWANA

Abstract

Objectives: Botswana has made significant gains in providing widespread access to medical care since its independence.1 However, measuring quality of care in the inpatient setting has not been a focus of public health efforts. Based on a prior study at our district hospital in Botswana2 as well as our clinical experience, early mortality is common among patients admitted to the adult medical wards. We aimed to quantify and examine cases of patients who died within 48 hours of admission in order to identify opportunities for intervention that might reduce preventable early in-hospital mortality. Methods: Retrospective chart review was performed on all patients who died within 48 hours of hospital admission to the general adult medical wards of Scottish Livingstone Hospital (SLH), the secondary referral center for Kweneng East district, Botswana, from December 2015 through April 2016. Root cause analysis (RCA) on each case was performed by two independent investigators using a template for RCA based on the Vincent Framework3 adapted to the Botswana setting. Summaries, including presenting signs and symptoms, probable causes of death, care management problems, contributory factors and the likelihood of preventability of death were assembled for each case. Results: Of 514 admissions during the study period (December 2015-April 2016), 31 patients (6%) died within 48 hours of admission to the adult general medicine wards. Respiratory distress was the most common presentation (74% of cases), followed by encephalopathy (63%) and hypotension (41%). Septic shock was identified as the probable cause of death in 74% of cases. A delay in antibiotics, inappropriate fluid management, and breakdown in communication between care providers were the most frequent care management issues, all present in 56% of cases. A lack of knowledge and skills among providers was associated with these care management issues in 93% of cases. Of the 27 deaths, we estimated that 5 deaths (18%) were either likely or very likely preventable, and 11 deaths (41%) were either unlikely or very unlikely preventable. The preventability of 11 deaths (41%) was uncertain. Conclusion: In this study of inpatient mortality in a district hospital in Botswana, death within 48-hours of hospital admission was most commonly associated with clinical symptoms of septic shock. 18% of deaths were estimated to be preventable, and in 40% of deaths preventability was uncertain. We identified associated care management issues that are now being used to create a quality improvement intervention at SLH targeting the early identification and management of sepsis in an effort to reduce preventable early mortality among hospitalized patients.