Strengthening the Diagnosis and Treatment of Malnutrition Through Increased Nurse Involvement: A Quality Improvement Project From Pediatric Wards in Mozambique

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FIGURE 1
Timeline of the Quality Improvement Project to Improve Nutritional Outcomes on Pediatric Wards in 2 Referral Hospitals, Mozambique
Abbreviations: HCM, Hospital Central de Maputo; PDSA, Plan-Do-Study-Act; QI, quality improvement.
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FIGURE 2
Key Drivers Influencing Process Measures and Outcome Measures of the Plan-Do-Study-Act Cycles in 2 Referral Hospitals, Mozambique
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FIGURE 3
Evolution of Process Measures During Quality Improvement Project Phases in 2 Referral Hospitals, Mozambique
^a Defined as weight, length/height, mid-upper arm circumference, and either weight for length/height or body mass index z-scores, documented within 24 hours after admission during workdays, and within 72 hours for weekend admissions.
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FIGURE 4
Evolution of Outcome Measures During Quality Improvement Project Phases in 2 Referral Hospitals, Mozambique

TABLE 1.

Sociodemographic Patient Characteristics and Ward Distribution by Quality Improvement Project Phase, 2 Referral Hospitals, Mozambique

Indicator	Pre-Intervention Phase, No (%) n=426	Intervention Phase, No. (%) n=1,254	Post-Intervention Phase, No. (%) n=528	Total, No. (%) n=2,208
Median age (IQR), months	24 (10–72)	36 (13–86)	36 (11–84)	36 (11–84)
Age group, years
<1	117 (27.5)	292 (23.3)	143 (27.1)	552 (25.0)
1–4	165 (38.7)	468 (37.3)	184 (34.8)	817 (37.0)
5–9	82 (19.2)	276 (22.0)	125 (23.7)	483 (21.9)
10–14	61 (14.3)	213 (17.0)	76 (14.4)	350 (15.9)
Not recorded	1 (0.2)	5 (0.4)	0 (0.0)	6 (0.3)
Sex
Female	186 (43.7)	514 (41.0)	210 (39.8)	910 (41.2)
Male	240 (56.3)	740 (59.0)	318 (60.2)	1,298 (58.8)
HIV status
Positive	31 (7.3)	123 (9.8)	31 (5.9)	185 (8.4)
Exposed	21 (4.9)	22 (1.8)	6 (1.1)	49 (2.2)
Negative	258 (60.6)	793 (63.2)	334 (63.3)	1,385 (62.7)
Not recorded	116 (77.2)	316 (25.2)	157 (29.7)	589 (26.7)
Ward distribution
Infant ward	112 (26.3)	285 (22.7)	137 (25.9)	534 (24.2)
General pediatrics	114 (26.8)	295 (23.5)	100 (18.9)	509 (23.1)
Infectious diseases	115 (27.0)	408 (32.5)	162 (30.7)	685 (31.0)
Respiratory diseases	31 (7.3)	128 (10.2)	56 (10.6)	215 (9.7)
Pediatric oncology	12 (2.8)	65 (5.2)	42 (8.0)	119 (5.4)
Pediatric surgery	42 (9.9)	73 (5.8)	31 (5.9)	146 (6.6)

TABLE 2.

Evolution of Project Measures During Quality Improvement Project Phase, 2 Referral Hospitals, Mozambique

Measure	Pre-Intervention Phase, No. (%)	Intervention Phase, No. (%)	P Value^{^a}	Post-Intervention Phase, No. (%)	P Value^{^a}
Complete anthropometric evaluation^{^b} documented at admission	104/426 (24.4)	1,005/1,254 (80.1)	<.001	397/528 (75.2)	<.001
Documentation of admission weight	421/426 (98.8)	1,244/1,254 (99.2)	.8962	526/528 (99.6)	.6468
Documentation of discharge weight	232/426 (54.5)	1,135/1,254 (90.5)	<.001	276/303 (91.1)^{^c}	<.001
Documentation of height (or length)	135/426 (31.7)	1,057/1,254 (84.3)	<.001	436/528 (82.6)	<.001
Documentation of MUAC	100/361 (27.7)	748/1,068 (70.0)	<.001	268/463 (57.9)	<.001
Average number of weight measurements per hospitalization week (SD)	2.72 (2.37)	6.4 (4.29)	<.001	5.78 (4.19)	<.001
Proportion of patients with ≥3 weight measurements per hospitalization week^{^d}	85/381 (22.3)	771/931 (82.8)	<.001	303/404 (75.0)	<.001
Documentation of nutritional therapy for eligible patients	20/34 (58.8)	55/82 (67.1)	.8684	24/34 (70.6)	.5392
Documentation of referral for outpatient nutritional rehabilitation after discharge for eligible patients	19/34 (55.9)	45/82 (54.9)	.1338	24/34 (70.6)	<.001

Abbreviations: MUAC, mid-upper arm circumference; SD, standard deviation.
↵a P values refer to comparison with the pre-intervention phase.
↵b Defined as weight, length/height, MUAC, and either weight for length/height or body mass index z-scores, documented within 24 hours after admission during workdays and within 72 hours for weekend admissions.
↵c Adjusted for missing values.
↵d Includes only patients that were admitted ≥4 days.