UNIVERSITY CONCLUSIONS.. 17 10.1. AREAS OF GOOD PRACTICE..

UNIVERSITY
OF GONDAR

COLLEGE
OF MEDICINE AND HEALTH SCIENCES

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SCHOOL
OF NURSING

DEPARTMENT
OF PEDIATRIC NURSING

 

 

Clinical
Audit Report

STANDARD OF GROWTH MONITORING AND PROMOTION IN PEDIATRIC WARD OF
GONDAR UNIVERSITY REFERRAL HOSPITAL, 2018

 

Submitted By: GAMECHU ATOMSA

          ID. No:  GUR
11377/10

        E-mail: [email protected]

 

Submitted To: Mr.
AMARE HAILEKIROS (BSc, MSc)

 

                                                                         
Gondar, Ethiopia

                                                                                  
Jan. 2018

ACKNOWLEDGEMENT

 

I have great full
acknowledgement to instructor Mr. Amare Hailekiros for his relevant guidance
and encouraging support to conduct this clinical audit.

   And I extended my acknowledgement to Mr.
Workye Mulugeta for his cooperation during data collection process.

  Finally I would like to express my gratitude
to the Nursing department for their supportive letter.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIST OF ABBREVIATIONS

 

GM   ————————— Growth
Monitoring

GMP
————————— Growth Monitoring and Promotion

GURH ————————-
Gondar University Referral Hospital

JSI   —————————

NA    ————————— Not Applicable

NNP ————————–
National Nutritional Program

OPD—————————-
Out Patient Department

U-5
—————————- Under-Five

WHO ————————-
World Health Organization

PHC ————————–
Primary Health-Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table of
contents

Contents
ACKNOWLEDGEMENT.. 2
LIST OF ABBREVIATIONS.. 3
Table of contents. 4
LIST OF TABLES AND
FIGURES.. 5
1.      AUDIT TITLE.. 6
2.      BACKGROUND.. 8
3.      JUSTIFICATION.. 9
4.      AIM AND OBJECTIVES.. 10
4.1.       AIM: 10
4.2.       OBJECTIVES.. 10
5.      STANDARDS OF PRACTICES
FOR GROWTH MONITORING AND PROMOTION.. 11
6.      AUDIT METHODOLOGY.. 12
6.1.       Audit population. 12
6.2.       Audit sample. 12
6.3.       Audit sample size and
sampling technique. 12
6.4.       Data collection. 12
6.5.       Data analysis. 12
7.      AUDIT PERFORMA.. 13
8.      RESULT.. 14
9.      DISCUSSION.. 16
10.        CONCLUSIONS.. 17
10.1.         AREAS OF GOOD PRACTICE.. 17
10.2.         AREAS OF IMPROVEMENT.. 17
11.        RECOMMENDATIONS.. 18
12.        ACTION
PLAN.. 19
13.        REFERENCES.. 20
 

 

 

LIST OF TABLES AND FIGURES

 

Table 1: standards
of practice for Growth Monitoring and promotion in U-5 children.

Table 2: Tally sheet
for the result of the audit data collected from the pediatric OPD and malnutrition
ward of GURH.

Table 3: Frequency distribution of
standards of practice of growth monitoring and promotion in GURH pediatric OPD
and Malnutrition ward.

Table 4: Action plan of the audit.

 

 

Figure 1: The frequency showing the
number of growth pattern correctly plotted on the WHO growth chart in the
pediatric OPD and Malnutrition ward GURH.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.  AUDIT
TITLE

 

Standard of growth monitoring and
promotion in pediatric ward of Gondar University Referral Hospital, 2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.  BACKGROUND

 

Growth monitoring (GM),
a process of regular weighing and measuring the height
and comparing the results with a standard for the identification of subgroups of the child
population that are at increased risk of faltered growth, impaired mental
development, and death.(1).

 

Growth
Monitoring and Promotion (GMP) is a public health intervention through frequent
growth assessment of children under five years which enable health workers to
early detect growth failure and takes
corrective actions through improvements in feeding and care practices(2).

 

So, growth monitoring consists of routine
measurements to detect abnormal growth, combined with some action when this is
detected. It is a standard component
of community pediatrics services throughout the world and is widely accepted
and strongly supported by health professionals(3).

 

Regular growth monitoring and promotion
is one of the basic activities of the under 5 clinics. Growth Monitoring must
start at an early age in the child’s life, right from birth. The suggested
monitoring intervals after birth are within one to two weeks of birth, at one,
two, four, six, nine, 12, 18 and 24 months, then once per year for children
over 2 years and for adolescents. Growth assessment should also occur at acute
care visits, keeping in mind that illnesses may affect weight(4).

 

According to guideline for assessing and
managing children at PHC facilities to prevent overweight and obesity, all
infants and children aged less than 5 years should have both weight and
length/height measured, in order to determine weight-for-length/height and to
classify nutritional status according to WHO child growth standards. The
guideline also suggests that caregivers and families of infants and children aged
less than 5 years presenting to PHC should receive general nutrition counselling(5).

 

According to 2017 WHO report on African
Region undernutrition is still persistent in the Africa, while the prevalence
of overweight among U-5 children is also rising, whereas the target is to halt
its increase. This can be achieved through frequent and regular growth
monitoring of the children including community based growth monitoring and
promotion services(6).

 

 

 

Government of Ethiopia developed the National
Nutrition Strategy and the National Nutrition Programmes (NNP) in an effort to
accelerate the reduction of undernutrition. The Seqota Declaration (2015-2030)
aims to eliminate all forms of malnutrition among children under age 2 by 2030.
Growth monitoring and promotion is the potential contributor towards the
achievement of this goal(7).

 

There is low
utilization of growth monitoring and promotion services in Ethiopia. According
to research done in Southern Nations and Nationalities of Ethiopia, the overall utilization of GMP
services is 16.9%. The study found that the health professionals focus on
weighing and identifying children’s nutritional status instead of discussing with
mothers and communities(8).

 

 

 

 

 

 

 

3.  JUSTIFICATION

The first 1000 days of child’s life are
extremely important in the child’s physical and emotional development. Appropriate
and regular growth monitoring and promotion has the potential for significant
impact on mortality even in the absence of nutrition supplementation or
education. It enables the care provider in early identification of children
with growth deviation i.e., undernutrition and over nutrition and to
identify diseases and conditions that manifest through abnormal growth. So this
audit is aimed at identifying whether the growth monitoring and promotion
services given in the Gondar University Hospital is being delivered as per the
standardized and updated guideline.

 

 

 

 

 

 

 

 

 

 

4.  AIM AND
OBJECTIVES

 

 

4.1.      
AIM:

 

To improve nutritional assessment of under-five children by proper application of WHO
growth monitoring and promotion charts in GURH, 2018.

 

 

 

 

 

4.2.      
OBJECTIVES

 

1.    To assess the current growth monitoring
and promotion standards in Gondar University referral Hospital, 2018

2.    To compare the current growth
monitoring and promotion practices of GURH with the standards.

3.    To inform the findings of the audit with
the relevant clinicians in the hospital.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.  STANDARDS
OF PRACTICES FOR GROWTH MONITORING AND PROMOTION

Table 1: standards
of practice for Growth Monitoring and promotion in U-5 children.

SN

            List of standards
 

Target

Exceptions

Source
of evidence

Source
of data

1

The child’s age – in months – is
correctly calculated and recorded in the correct place.

100%

No

JSI Research & Training Institute
2008

Observation during care delivery

2

The weight of the child is correctly
measured and recorded;

100%

No

 

3

The child’s length is correctly
measured and recorded to the nearest 1cm.

100%

No

4.

Weight and/or height measurements are
plotted on the growth monitoring chart.

100%

No

5

The health provider visually screens
the child for malnutrition & assesses the anthropometric readings on the
growth monitoring charts.

100%

No

6

Signs of anemia are checked (pallor)
and laboratory tests are requested when needed.

100%

No

7

The health provider provided the
caregiver with the needed supplementations (iron, vitamin A&D)

50%

Iron is given for child dxed with  anemia.

8

The health provider explains procedures
and feeds back to the care giver how the child is growing.

100%

No

9

The health provider responds to the
caregiver questions and provides inf. about the proper feeding practices.

100%

No

10

The health provider tells the caregiver
when to come for the next visit.

100%

No

11

The appointment is recorded on the
card.

100%

No

Chart review

 

6.  AUDIT
METHODOLOGY

 

6.1.      
Audit population

The number
of growth monitoring sessions given for all under-five
children in GURH

6.2.      
Audit sample

The number of growth assessment sessions
given for under five children who were at pediatric OPD and malnutrition ward
at the time of data collection.

6.3.      
Audit sample size and sampling technique

Thirty
care providers have been observed while giving care for children
under five-years. Consecutive nonprobability sampling technique has been used until
the required sample is attained.

6.4.       Data collection

Standardized
checklist adopted from JSI Research and Training Institute 2008 has been used
to assess the care delivery of the healthcare
providers in the Hospital. The data has been collected by the direct
observation during each care delivery sessions and review of the charts has
been done to check appropriate recording of the
datas.

 

Starting date: –   16/01/2018 GC

Completion date: – 26/01/2018
GC

Presentation date: – 15/02/2018
GC

 

6.5.      
Data analysis

Data would be checked for its
completeness & reliability. The data was analyzed manually by tally &
data are presented by using tables, graph &pie chart.

6.6.       Operational
definition

  Good practice:  compliance rate of 60% and above

  Poor practice:   compliance rate below 60%

 

 

 

7.  RESULT

Table 2: Tally sheet
for the result of the audit data collected from the pediatric OPD and
malnutrition ward of GURH.

 
SN

      
List
of standards
 

              Results per care delivery
sessions

 

Compliance
%

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

1

The child’s age correctly recorded in
months.

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

×

?

?

?

×

×

?

?

?

?

?

?

?

?

?

90%

2

The weight of the child is correctly
measured and recorded; to the nearest 100 grams.

?

?

×

?

×

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

×

×

×

?

?

?

?

?

?

?

83.3%

3

The child’s length is correctly
measured and recorded to the nearest 1cm.

 
?

 
×

 
?

?

×

?

?

×

×

×

?

×

×

?

?

?

?

×

?

?

?

?

?

×

×

×

×

?

×

×

53%

4

Plot wt and/or ht on growth monitoring
chart

×

×

×

?

×

×

×

?

×

×

×

×

×

×

?

×

×

?

×

×

×

×

×

×

?

×

×

×

×

×

17%

5

Check for sign of malnutrition &
assesses the anthropometric readings on the GM charts.

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

×

?

×

?

?

?

×

?

?

×

×

?

87%

6

Signs of anemia are checked (pallor)
and laboratory tests are requested when needed.

?

?

?

?

?

?

?

×

×

×

×

×

×

?

?

?

?

?

×

?

×

?

?

?

?

?

?

?

?

?

73%

7

Supplementation of Iron, Vit A&D

×

?

?

×

?

?

?

×

×

?

?

×

?

?

?

?

?

?

?

?

×

?

×

?

×

×

×

×

×

?

60%

8

The health provider explains procedures
and feeds back to the care giver how the child is growing.

?

?

?

×

×

×

?

?

?

×

?

?

?

×

×

×

?

?

×

×

×

?

?

?

?

?

×

?

?

?

63%

9

The health provider discuss with
caregiver about feeding practices

?

?

×

?

?

?

?

?

?

×

?

?

?

?

?

?

?

?

?

?

×

?

×

?

?

?

×

×

×

?

77%

10

The health provider tells the caregiver
when to come for the next visit.

×

×

?

?

×

×

×

?

?

?

×

?

?

×

×

?

×

?

?

×

×

×

?

?

?

?

?

×

?

?

57%

11

The appointment is recorded on the
card.

×

×

?

?

×

×

×

?

×

×

×

?

?

×

×

?

×

?

?

×

×

×

?

?

?

×

×

×

?

?

43%

 

 

              
Overall Compliance Rate

63.3%

 

Total score = 209 of 330
maximum indicated = 63.3%

The total compliance rate of standards
of growth monitoring of under five
children in pediatric OPD and malnutrition ward was

 

= 63.3% & the noncompliance rate
(gap) was 36.7%.

 

Table 3: Frequency distribution of standards of
practice of growth monitoring and promotion in GURH pediatric OPD and
Malnutrition ward.

 

Frequency

Percent

Cumulative

Yes

209

63.3 %

63.3 %

No

121

36.7 %

36.7 %

Total

330

100 %

100 %

 

This audit result find out that out 11
standards of growth monitoring and promotion services delivered to 30 under-five children in pediatric OPD and
malnutrition ward of GURH, about 63.3% of the services are delivered according
to the standards of the practice.

 

 

Figure 1: The frequency showing the
number of growth pattern correctly plotted on the WHO growth chart in the
pediatric OPD and Malnutrition ward GURH.

 

 

 

 

8.  DISCUSSION

 

The compliance rate of growth monitoring
and promotion service given at pediatric OPD and malnutrition ward of GURH with
the standards of the practice is found to be around 63.3%. This means the healthcare provider’s compliance with standards
during care delivery was 63.3% and 36.7% care are delivered doesn’t comply with
the standard of growth monitoring and promotion.

 

There was a good compliance observed with
regard to completing the identification data of the children including child
full name, appropriate recording of the child’s age in months, and birth date
of the children in both units observed. In addition the weight of most of the
children who came to the pediatric OPD and malnutrition ward has been measured
with appropriately calibrated instrument.

 

Health care providers fairly measures the
height of the under-five children in acute care units particularly in the
pediatric OPD. There is no regular measurement of the height of the children at
the point of caregiving. This hinders probability of early detection of growth
faltering especially stunting which is common nutritional problem in Ethiopia
with high prevalence in Amhara Region.

 

There is a low compliance with regard to
plotting children’s weight and height on
the appropriate WHO growth monitoring and promotion charts. This is due to the
reason that the growth monitoring and promotion chart wasn’t attached to most
of the patient’s chart during the time of data collection.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.  CONCLUSIONS

 

9.1.      
AREAS OF GOOD PRACTICE

v  Full identification data of the
children’s were appropriately recorded.

v   The children’s age calculated in months and
date of birth of the children’s are recorded.

v  Appropriate measurement of the children’s
weight.

v  Routine screening of the children for
malnutrition and anemia at every point of care.

v  The healthcare providers responds to the
caregivers questions with respect.

v  Discussion with caregivers about the
child’s growth condition and feeding practices.

 

9.2.      
AREAS OF IMPROVEMENT

v  Correct measurement and recording height/length
for all U-5 children.

v  Appropriate plotting of weight and
height/length on the appropriate WHO growth monitoring chart.

v  Regular and frequent growth monitoring of
the children according to the recommended intervals.

v  Appointing the children for the next
visit to monitor his/her growth trend.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.             
RECOMMENDATIONS

 

 Based
gaps identified the following recommendations are given:

For federal Ministry of Health and policy
makers:

ü  Integrating growth monitoring and
promotion services with immunization programmes so that there will be
continuous growth monitoring and promotion of the children simultaneously when
they come for immunization.

For Gondar University Referral Hospital administrations:

ü  Establishing separate Child Welfare
Clinics in the hospital where the
children can be monitored regularly.

ü  Providing valid and appropriate growth
chart cards for every under-five children so that growth their growth patterns
are plotted on it.

ü  Provide necessary supplements like
standardized height measuring instruments, weight scales and other materials
needed for growth monitoring and promotion.

For the healthcare providers:

ü  Performing growth assessment based on the
standards for all under-five children.

ü  Encouraging the involvement of the
caregivers in the growth monitoring and promotion services.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.             
ACTION PLAN

 Table
4: action plan of the audit.

 
S.N

 
Actions to be implemented

 
Responsible person
 

 
Timescale

1.     

Discuss the result with the concerned
bodies.

Ø  Ato Amsalu GURH
Quality Assurance head
Ø  Mr. workye
Mulugeta ( pediatric unit team leader)
Ø  Gamechu Atomsa (Audit
leader)
 

February 15, 2018

2.     

Prepare sensitization training.

Ø  Audit leader(Gamechu
Atomsa )
Ø  Hospital
administration
Ø  Ato Amsalu

February 25. 2018

3.     

Allocate necessary equipments

Ø  Hospital
administration

February 30.2018

4.     

Re-audit

Ø  Audit leader(Gamechu
Atomsa)

May 10, 2018

5.     

Presentation of re-auditing result

Ø  Audit leader

May 15, 2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.             
REFERENCES

1.
  Revisiting the concept of growth
monitoring and its possible role in community-based nutrition programs. –
PubMed – NCBI.

2.   Sandra
Gyamph_Assessment of Clinic-Based Growth Monitoring and Promotion in the Accra
Metropolitan Area of Ghana_2012.pdf Internet. cited 2018 Jan 27.

3.   Panpanich
R, Garner P. Growth monitoring in children. Cochrane Database Syst Rev.
2000;(2).

4.   A
health professional’s guide for using the new WHO growth charts. Paediatr Child
Health. 2010 Feb;15(2):84–90.

5.   WHO |
Assessing and managing children at primary health-care facilities to prevent
overweight and obesity in the context of the double burden of malnutrition.
WHO.

6.   Nutrition
in the WHO African Region 2017_0.pdf Internet. cited 2018 Jan 9.

7.   Ethiopia
DHS 2016 KIR – Final 10-17-2016.pdf Internet. cited 2018 Jan 27.

8.   Feleke
FW, Adole AA, Bezabih AM. Utilization of growth monitoring and promotion
services and associated factors among under two years of age children in
Southern Ethiopia. PloS One. 2017;12(5).

 

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