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UNIVERSITYOF GONDARCOLLEGEOF MEDICINE AND HEALTH SCIENCESSCHOOLOF NURSINGDEPARTMENTOF PEDIATRIC NURSING  ClinicalAudit ReportSTANDARD OF GROWTH MONITORING AND PROMOTION IN PEDIATRIC WARD OFGONDAR UNIVERSITY REFERRAL HOSPITAL, 2018   Submitted By: GAMECHU ATOMSA          ID. No:  GUR11377/10        E-mail: [email protected]  Submitted To: Mr.AMARE HAILEKIROS (BSc, MSc)                                                                          Gondar, Ethiopia                                                                                  Jan. 2018ACKNOWLEDGEMENT I have great fullacknowledgement to instructor Mr.

Amare Hailekiros for his relevant guidanceand 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 gratitudeto the Nursing department for their supportive letter.                     LIST OF ABBREVIATIONS GM   ————————— GrowthMonitoringGMP————————— Growth Monitoring and PromotionGURH ————————-Gondar University Referral HospitalJSI   ————————— NA    ————————— Not ApplicableNNP ————————–National Nutritional ProgramOPD—————————-Out Patient DepartmentU-5—————————- Under-FiveWHO ————————-World Health OrganizationPHC ————————–Primary Health-Care               Table ofcontents Contents ACKNOWLEDGEMENT.

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. 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: standardsof practice for Growth Monitoring and promotion in U-5 children.Table 2: Tally sheetfor the result of the audit data collected from the pediatric OPD and malnutritionward of GURH.Table 3: Frequency distribution ofstandards of practice of growth monitoring and promotion in GURH pediatric OPDand Malnutrition ward.Table 4: Action plan of the audit.  Figure 1: The frequency showing thenumber of growth pattern correctly plotted on the WHO growth chart in thepediatric OPD and Malnutrition ward GURH.                 1.

  AUDITTITLE  Standard of growth monitoring andpromotion in pediatric ward of Gondar University Referral Hospital, 2018                       2.  BACKGROUND  Growth monitoring (GM),a process of regular weighing and measuring the heightand comparing the results with a standard for the identification of subgroups of the childpopulation that are at increased risk of faltered growth, impaired mentaldevelopment, and death.(1).   GrowthMonitoring and Promotion (GMP) is a public health intervention through frequentgrowth assessment of children under five years which enable health workers toearly detect growth failure and takescorrective actions through improvements in feeding and care practices(2).  So, growth monitoring consists of routinemeasurements to detect abnormal growth, combined with some action when this isdetected. It is a standard componentof community pediatrics services throughout the world and is widely acceptedand strongly supported by health professionals(3). Regular growth monitoring and promotionis one of the basic activities of the under 5 clinics. Growth Monitoring muststart at an early age in the child’s life, right from birth.

The suggestedmonitoring 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 childrenover 2 years and for adolescents. Growth assessment should also occur at acutecare visits, keeping in mind that illnesses may affect weight(4).  According to guideline for assessing andmanaging children at PHC facilities to prevent overweight and obesity, allinfants and children aged less than 5 years should have both weight andlength/height measured, in order to determine weight-for-length/height and toclassify nutritional status according to WHO child growth standards. Theguideline also suggests that caregivers and families of infants and children agedless than 5 years presenting to PHC should receive general nutrition counselling(5).

 According to 2017 WHO report on AfricanRegion undernutrition is still persistent in the Africa, while the prevalenceof overweight among U-5 children is also rising, whereas the target is to haltits increase. This can be achieved through frequent and regular growthmonitoring of the children including community based growth monitoring andpromotion services(6).   Government of Ethiopia developed the NationalNutrition Strategy and the National Nutrition Programmes (NNP) in an effort toaccelerate 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 theachievement of this goal(7). There is lowutilization of growth monitoring and promotion services in Ethiopia. Accordingto research done in Southern Nations and Nationalities of Ethiopia, the overall utilization of GMPservices is 16.

9%. The study found that the health professionals focus onweighing and identifying children’s nutritional status instead of discussing withmothers and communities(8).        3.  JUSTIFICATIONThe first 1000 days of child’s life areextremely important in the child’s physical and emotional development. Appropriateand regular growth monitoring and promotion has the potential for significantimpact on mortality even in the absence of nutrition supplementation oreducation. It enables the care provider in early identification of childrenwith growth deviation i.e., undernutrition and over nutrition and toidentify diseases and conditions that manifest through abnormal growth.

So thisaudit is aimed at identifying whether the growth monitoring and promotionservices given in the Gondar University Hospital is being delivered as per thestandardized and updated guideline.          4.  AIM ANDOBJECTIVES   4.1.

      AIM: To improve nutritional assessment of under-five children by proper application of WHOgrowth monitoring and promotion charts in GURH, 2018.      4.2.      OBJECTIVES  1.

    To assess the current growth monitoringand promotion standards in Gondar University referral Hospital, 2018 2.    To compare the current growthmonitoring and promotion practices of GURH with the standards.3.    To inform the findings of the audit withthe relevant clinicians in the hospital.                5.

  STANDARDSOF PRACTICES FOR GROWTH MONITORING AND PROMOTIONTable 1: standardsof 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.  AUDITMETHODOLOGY 6.1.      Audit population The numberof growth monitoring sessions given for all under-fivechildren in GURH6.2.

      Audit sampleThe number of growth assessment sessionsgiven for under five children who were at pediatric OPD and malnutrition wardat the time of data collection.6.3.      Audit sample size and sampling techniqueThirtycare providers have been observed while giving care for childrenunder five-years. Consecutive nonprobability sampling technique has been used untilthe required sample is attained.6.

4.       Data collection Standardizedchecklist adopted from JSI Research and Training Institute 2008 has been usedto assess the care delivery of the healthcareproviders in the Hospital. The data has been collected by the directobservation during each care delivery sessions and review of the charts hasbeen done to check appropriate recording of thedatas.

 Starting date: –   16/01/2018 GC Completion date: – 26/01/2018GCPresentation date: – 15/02/2018GC 6.5.      Data analysisData would be checked for itscompleteness & reliability. The data was analyzed manually by tally &data are presented by using tables, graph &pie chart.6.

6.       Operationaldefinition  Good practice:  compliance rate of 60% and above  Poor practice:   compliance rate below 60%   7.  RESULT Table 2: Tally sheetfor the result of the audit data collected from the pediatric OPD andmalnutrition 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 330maximum indicated = 63.3%The total compliance rate of standardsof growth monitoring of under fivechildren in pediatric OPD and malnutrition ward was  = 63.

3% & the noncompliance rate(gap) was 36.7%. Table 3: Frequency distribution of standards ofpractice of growth monitoring and promotion in GURH pediatric OPD andMalnutrition 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 11standards of growth monitoring and promotion services delivered to 30 under-five children in pediatric OPD andmalnutrition ward of GURH, about 63.3% of the services are delivered accordingto the standards of the practice.   Figure 1: The frequency showing thenumber of growth pattern correctly plotted on the WHO growth chart in thepediatric OPD and Malnutrition ward GURH.    8.  DISCUSSION  The compliance rate of growth monitoringand promotion service given at pediatric OPD and malnutrition ward of GURH withthe standards of the practice is found to be around 63.3%.

This means the healthcare provider’s compliance with standardsduring care delivery was 63.3% and 36.7% care are delivered doesn’t comply withthe standard of growth monitoring and promotion. There was a good compliance observed withregard to completing the identification data of the children including childfull name, appropriate recording of the child’s age in months, and birth dateof the children in both units observed.

In addition the weight of most of thechildren who came to the pediatric OPD and malnutrition ward has been measuredwith appropriately calibrated instrument. Health care providers fairly measures theheight of the under-five children in acute care units particularly in thepediatric OPD. There is no regular measurement of the height of the children atthe point of caregiving. This hinders probability of early detection of growthfaltering especially stunting which is common nutritional problem in Ethiopiawith high prevalence in Amhara Region. There is a low compliance with regard toplotting children’s weight and height onthe appropriate WHO growth monitoring and promotion charts.

This is due to thereason that the growth monitoring and promotion chart wasn’t attached to mostof the patient’s chart during the time of data collection.               9.  CONCLUSIONS 9.1.      AREAS OF GOOD PRACTICEv  Full identification data of thechildren’s were appropriately recorded.v   The children’s age calculated in months anddate of birth of the children’s are recorded.v  Appropriate measurement of the children’sweight.v  Routine screening of the children formalnutrition and anemia at every point of care.

v  The healthcare providers responds to thecaregivers questions with respect.v  Discussion with caregivers about thechild’s growth condition and feeding practices. 9.2.      AREAS OF IMPROVEMENTv  Correct measurement and recording height/lengthfor all U-5 children.v  Appropriate plotting of weight andheight/length on the appropriate WHO growth monitoring chart.v  Regular and frequent growth monitoring ofthe children according to the recommended intervals.

v  Appointing the children for the nextvisit to monitor his/her growth trend.                  10.             RECOMMENDATIONS  Basedgaps identified the following recommendations are given:For federal Ministry of Health and policymakers:ü  Integrating growth monitoring andpromotion services with immunization programmes so that there will becontinuous growth monitoring and promotion of the children simultaneously whenthey come for immunization.For Gondar University Referral Hospital administrations:ü  Establishing separate Child WelfareClinics in the hospital where thechildren can be monitored regularly.ü  Providing valid and appropriate growthchart cards for every under-five children so that growth their growth patternsare plotted on it.

ü  Provide necessary supplements likestandardized height measuring instruments, weight scales and other materialsneeded for growth monitoring and promotion.For the healthcare providers:ü  Performing growth assessment based on thestandards for all under-five children.ü  Encouraging the involvement of thecaregivers in the growth monitoring and promotion services.                    11.             ACTION PLAN Table4: 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 growthmonitoring and its possible role in community-based nutrition programs.

-PubMed – NCBI. 2.   SandraGyamph_Assessment of Clinic-Based Growth Monitoring and Promotion in the AccraMetropolitan Area of Ghana_2012.pdf Internet.

cited 2018 Jan 27. 3.   PanpanichR, Garner P.

Growth monitoring in children. Cochrane Database Syst Rev.2000;(2). 4.   Ahealth professional’s guide for using the new WHO growth charts. Paediatr ChildHealth. 2010 Feb;15(2):84–90.

5.   WHO |Assessing and managing children at primary health-care facilities to preventoverweight and obesity in the context of the double burden of malnutrition.WHO. 6.   Nutritionin the WHO African Region 2017_0.

pdf Internet. cited 2018 Jan 9. 7.   EthiopiaDHS 2016 KIR – Final 10-17-2016.pdf Internet. cited 2018 Jan 27. 8.

  FelekeFW, Adole AA, Bezabih AM. Utilization of growth monitoring and promotionservices and associated factors among under two years of age children inSouthern Ethiopia. PloS One. 2017;12(5).  

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