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BACKGROUND: Anaemia is a significant cause of mortality in children in sub-Saharan Africa where blood transfusion is often available only at referral hospitals. Understanding the pattern of referrals by health facilities is essential to identify the delays which affect child survival. AIM: To determine if there was a correlation between change in haemoglobin (Hb) level and distance from referring facilities to Kamuzu Central Hospital (KCH) in Malawi, and whether distance affected mortality rates. METHODS: This was a retrospective cohort study of 2259 children referred to KCH whose Hb was measured at the referring facility or at KCH. Maps were created using ArcGIS® software. The relationship between distance from KCH and change in Hb was assessed by χ(2) analysis and multiple linear regression with SAS© software. RESULTS: The majority of children were referred by health facilities in the Lilongwe District. When categorised as Hb 6 g/dL, 87.0% of children remained in the same category during transfer. There was no significant relationship between a drop in Hb and distance from KCH. Distance from KCH was not a significant predictor of Hb level at KCH or Hb change. However, mortality rates were significantly higher in facilities which were 10–50 km from KCH than in those which were

BACKGROUND: Severe acute malnutrition (SAM) is common in low-income countries such as Malawi and is associated with high mortality in young children. OBJECTIVE: To improve recognition and management of SAM in a tertiary hospital in Malawi. METHODS: The impact of multifaceted quality improvement interventions in multiple process measures pertaining to identification and management of children with SAM using a before-after design was assessed. Interventions included focused training for clinical staff, reporting process measures to clinical staff, and mobile phone-based group messaging for enhanced communication. This initiative focused on children aged 6–36 months admitted to Kamuzu Central Hospital in Malawi from 18 September 2019 to 17 March 2020. Before-after comparisons were made with baseline data from the year prior, and process measures within this intervention period that included three plan-do-study-act (PDSA) cycles were compared. RESULTS: During the intervention period, 418 children had SAM and in-hospital mortality was 10.8%, which was not significantly different than the baseline period. Compared with the baseline period, there was significant improvement in the documentation of full anthropometrics on admission, blood glucose test within 24 hours of admission and HIV testing results by discharge. During the intervention period, amidst increasing patient census with each PDSA cycle, three process measures were maintained (documentation of full anthropometrics, determination of nutrition status and HIV testing results) and there was significant improvement in blood glucose documentation. CONCLUSIONS: Significant improvement in key quality measures represents early progress towards the larger goal of improving patient outcome, most notably mortality, in children admitted with SAM.

Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the 'WHO 10 Steps' and mortality in children with SAM is not fully understood.Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6-36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients' charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the 'WHO 10 Steps' were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression.Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1%HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.