Published online December 1, 2004
PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1737-1738 (doi:10.1542/10.1542/peds.2004-1263)

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Mortality Among Kenyan Children Admitted to a Rural District Hospital on Weekends as Compared With Weekdays

James A. Berkley, MD
Andrew Brent, MRCP
Isaiah Mwangi, MTropPaeds
Mike English, MD
Kathryn Maitland, PhD
Kevin Marsh, FRCP
Norbert Peshu, MTropPaeds
Charles R. Newton, MD
Centre for Geographic Medicine Research (coast)
Kilifi, Kenya

To the Editor.—

Arias et al¹ and Bell and Redelmeier² recently identified associations between timing of admission and mortality rates in North America. Such studies highlight potential areas for improvement in health care delivery. Hospitals in less-developed countries are typically under-resourced and understaffed all of the time.³ However, similar to North America, there may be differences in health care delivery outside of office hours.

We previously conducted a prospective study of 12 893 consecutive admissions of children 90 days old to our own district hospital in Kenya and developed prognostic scores for inpatient deaths occurring <4 hours after admission (very early), 4 to 48 hours after admission (early), and >48 hours after admission (late).⁴ Prognostic characteristics were length of history, prostration, coma, seizures, subcostal indrawing, deep breathing, wasting, kwashiorkor, axillary temperature, and severe anemia. Using these data, we compared the risk-adjusted mortality among weekend (midnight Friday to midnight Sunday) versus weekday pediatric admissions.

During the weekends, there were 2754 (21%) admissions, although 29% (2 of 7 days) would be expected if they were distributed evenly throughout the week. Of those admitted during the weekend, 171 of 2754 (6.2%) died, compared with 487 of 10139 (4.8%) admitted on weekdays (crude odds ratio [OR]: 1.31; 95% confidence interval [CI]: 1.10–1.57). There was no evidence for differences in mortality between any of the weekdays. The majority of admissions were for a febrile illness (see Table 1). During the weekends, admitted patients were more likely to have unconsciousness or seizures and less likely to have a prolonged illness, malnutrition, or subcostal indrawing. There was no evidence for differences in the distributions of very early, early, and late prognostic scores between weekend and weekday admissions (Kruskall-Wallis tests: very early ² = 1.08, P = 0.30; early ² = 0.51, P = 0.47; late ² = 2.53, P = 0.11). When adjusted for prognostic score, age, bacteremia and Plasmodium falciparum parasitemia, admission during the weekend was associated with ORs for death of 2.05 (95% CI: 1.26–3.31) within 4 hours of admission, 1.54 (95% CI: 1.17–2.03) within 4 to 48 hours, and 1.09 (95% CI: 0.80–1.47) >48 hours after admission.

View this table: [in this window] [in a new window]   TABLE 1. Numbers and Characteristics of Admissions on Weekdays (10 139) and Weekends (2754)

 
There was a substantially higher risk of early inpatient death among weekend compared to weekday pediatric admissions. Because we adjusted for the presence or absence of the major clinical correlates of mortality, we cannot simply attribute the excess mortality on weekends to children being more severely ill on arrival on the ward. It could be argued that the prognostic scores were not sensitive enough to detect clinically important differences. Yet, the greatest mortality excess was in the first 4 hours, and the very early prognostic score had previously been shown to very accurately predict these deaths in this population.⁴

We recently reported that mortality among severely ill children with severe anemia is associated with delayed blood transfusion.⁵ Delays in identification and treatment of other common, severe complications such as hypoxemia, hypovolemia, metabolic acidosis, or hypoglycemia could be similarly associated with increased risk of early mortality. We think that these findings warrant a careful audit of the quality of care provided during the first few hours after admission. Since these data were collected, we have examined staffing levels and strengthened training in basic and advanced life support.

REFERENCES

1. Arias Y, Taylor DS, Marcin JP. Association between evening admissions and higher mortality rates in the pediatric intensive care unit. Pediatrics. 2004;113(6) . Available at: www.pediatrics.org/cgi/content/full/113/6/e530
2. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001;345 :663 –668[Abstract/Free Full Text]
3. Nolan T, Angos P, Cunha AJ, et al. Quality of hospital care for seriously ill children in less-developed countries. Lancet. 2001;357 :106 –110[CrossRef][Web of Science][Medline]
4. Berkley J, Ross A, Mwangi I, et al. Prognostic indicators of early and late death in children admitted to district hospital in Kenya: cohort study. BMJ. 2003;326 :361[Abstract/Free Full Text]
5. World Health Organization. Management of the Child With a Serious Infection or Severe Malnutrition. Guidelines at the First Referral Level in Developing Countries. Geneva, Switzerland: World Health Organization; 2000
6. English M, Ahmed M, Ngando M, Berkley J, Ross A. Blood transfusion for severe anaemia for children in a Kenyan hospital. Lancet. 2002;359 :494 –495[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Related articles in Pediatrics Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Berkley, J. A. Articles by Newton, C. R. Search for Related Content PubMed PubMed Citation Articles by Berkley, J. A. Articles by Newton, C. R. Related Collections Office Practice Social Bookmarking                         What's this?