Holy Innocents Children's Hospital

Background: Many children under five die post hospital discharge in low-and middle–income countries (LMICs), particularly after treatment for severe infections. While some models exist, evidence on risk prediction for post-discharge mortality remains limited, with most relying solely on admission characteristics, overlooking in–hospital disease progression and discharge features. Methods: We used secondary data from prospective cohort studies in six Ugandan hospitals (2012–2021) to update models at discharge. Of 8,810 children included, 3,665 were aged <6 months and 5,145 were aged 6-60 months. Models were developed utilizing an elastic net regression approach, with admission variables selected a priori and discharge variables selected based on variable importance ranking. Performance was evaluated by applying 10–fold cross–validation, area under the receiver operating characteristic curve (AUROC), Brier score, and Net Reclassification Index (NRI). Results: Models augmented with discharge characteristics outperformed admission-only models. For children aged <6 months, the model AUROC improved by 5.1% (95% CI 3.0 – 7.3, P<0.001), achieving an AUROC of 0.81 and a Brier score of 0.06. In the 6–60m cohort, the model AUROC increased by 4.4% (95% CI 2.0 – 6.9, P<0.001), with an AUROC of 0.79 and a Brier score of 0.04. The NRI was 10.41% for children <6 months and 14.51% for those 6-60m and was achieved primarily through a reduction of false positive rates. Conclusion: Adding only three discharge characteristics to the post-discharge mortality model based on admission characteristics enhanced prediction accuracy, including model calibration, discrimination and risk stratification compared to admission–only models. Keywords: Post-discharge mortality, Risk prediction model, Elastic Net regression, Low-and middle-income countries, Child mortality, Critical illness. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by Mitacs through the Mitacs Accelerate Fellowship to T.A. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study involved a secondary analysis of a deidentified dataset. The parent study (Smart discharges to improve post-discharge health outcomes in children: A prospective before after study with staggered implementation) was approved by the Mbarara University of Science and Technology (MUST) Research Ethics Committee (REC) (15/10-16, approved November 28, 2017), the Uganda National Council for Science and Technology (HS 2207, approved April 12, 2017), and the University of British Columbia/Children & Women's Health Centre of British Columbia (UBC/C&W) Research Ethics Board (REB) (H16-02679, approved May 9, 2017). Written informed consent was obtained from parents or guardians of participating children in the parent study, and verbal assent was obtained from children where appropriate. As part of the consent process, participants were informed that their data would be deidentified and may be used for future research studies. The dataset used in this analysis was fully deidentified prior to secondary use. All procedures were conducted in accordance with the ethical standards of the MUST REC and UBC/C&W REB and with the Helsinki Declaration of 1975. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data underlying this article are available from the Smart Discharge Dataverse within the Borealis Dataverse repository. Access to the data can be granted upon request to the study investigators, in accordance with institutional data-sharing polices. [https://borealisdata.ca/dataverse/SD\_Processed\_Data][1] [1]: https://borealisdata.ca/dataverse/SD_Processed_Data

OBJECTIVE:Unplanned discharges are an important risk factor for adverse outcomes in children. We aimed to assess the impact of unplanned discharge on postdischarge outcomes and to identify key clinical and socioeconomic risk factors. METHODS:We conducted a secondary analysis of a multisite observational study in six Ugandan hospitals. Children aged 0-60 months admitted with suspected sepsis were enrolled (July 2017-April 2020) and followed for 6 months after discharge. Multivariable logistic regression adjusted for demographic, clinical and socioeconomic factors (including age, sex and site) identified risk factors for unplanned discharge and Cox proportional hazards regression similarly adjusted for demographic, clinical and socioeconomic factors assessed its impact on readmission and mortality. RESULTS:Of 6189 children who survived to discharge, 5403 (87.2%) had a planned discharge and 786 (12.8%) had an unplanned discharge with no unascertained cases. Among children with planned discharge, 271 (5.1%) of 5312 died within 6 months of discharge, compared with 105 (13.4%) of 760 among children with unplanned discharge. Unplanned discharge was associated with higher mortality (HR=2.6, 95% CI 1.9 to 3.5) and readmission (HR=2.4, 95% CI 1.4 to 4.2). In analyses identifying factors associated with unplanned discharge, risk factors included malnutrition, HIV and anaemia, as well as lower maternal education, greater distance from hospital and father-led presentation. CONCLUSIONS:Unplanned discharges are common and strongly associated with postdischarge mortality and readmission. Interventions targeting children at high risk of unplanned discharge, including those facing clinical, socioeconomic and structural barriers to care, are urgently needed to improve outcomes.

Objectives Each year, 5.3 million children under 5 years of age die in low-resource settings, often due to delayed recognition of disease severity, inadequate treatment, or a lack of supplies. We describe the use of a comprehensive digital facility-readiness survey tool, recently developed by the Pediatric Sepsis Data CoLaboratory, which aims to identify target areas for quality improvement related to pediatric emergency and critical care. Methods Facility-readiness surveys were conducted at six sub-Saharan African hospitals providing pediatric emergency and critical care in Uganda (n = 4) and Cameroon (n = 2). The tool is a 2-phase survey to assess readiness to provide pediatric essential emergency and critical care: (1) an “environmental scan,” focusing on infrastructure, availability, and functionality of resources, and (2) an “observational scan” assessing the quality and safety of care through direct observation of patients receiving treatment for common diseases. Data were captured in a mobile application and the findings analyzed descriptively. Results Varying levels of facility readiness to provide pediatric emergency care were observed. Only 1 of 6 facilities had a qualified staff member to assess children for danger signs upon arrival, and only 2 of 6 had staff with skills to manage emergency conditions. Only 21% of essential medicines required for pediatric emergency and critical care were available at all six facilities. Most facilities had clean running water and soap or disinfectants, but most also experienced interruptions to their electricity supply. Less than half of patients received an appropriate discharge note and fewer received counseling on postdischarge care; follow-up was arranged in less than a quarter of cases. Conclusions These pilot findings indicate that facilities are partially equipped and ready to provide pediatric emergency and critical care. This facility-readiness tool can be utilized in low-resource settings to assist hospital administrators and policymakers to determine priority areas to improve quality of care for the critically ill child.

In low-resource settings, limited laboratory capacity adds to the burden of central nervous system (CNS) infections in children and spurs overuse of antibiotics. The commercially available BioFire® FilmArray® Meningitis/Encephalitis Panel (FA-ME) with its capability to simultaneously detect 14 pathogens in cerebrospinal fluid (CSF), could potentially narrow such a diagnostic gap. In Mbarara, Uganda, we compared clinical utility (clinical turnaround time [cTAT], microbial yield, and influence on patient outcome and antibiotic exposure) of FA-ME with bacterial culture, in children 0–12 years with suspected CNS infection. Of 212 enrolled children, CSF was sampled from 194. All samples underwent bacterial culture, of which 193 also underwent FA-ME analyses. FA-ME analyses prospectively influenced care for 169 of the 193 patients, and they constituted an 'Index group'. The remaining 43/212 patients constituted a 'Reference group'. Of all 194 CSF-sampled patients, 87% (168) had received antibiotics before lumbar puncture. Median cTAT for FA-ME was 4.2 h, vs. two days for culture. Bacterial yield was 12% (24/193) and 1.5% (3/194) for FA-ME and culture, respectively. FA-ME viral yield was 12% (23/193). Fatality rate was 14% in the Index group vs. 19% in the Reference group (P = 0.20). From clinician receival of FA-ME results, median antibiotic exposure was 6 days for bacteria-negative vs. 13 days for bacteria-positive patients (P = 0.03). Median hospitalization duration was 7 vs. 12 days for FA-ME negative and positive patients, respectively (P < 0.01). In this setting, clinical FA-ME utility was found in a higher and faster microbial yield and shortened hospitalization and antibiotic exposure of patients without CSF pathology. More epidemiologically customized pathogen panels may increase FA-ME utility locally, although its use in similar settings would require major cost reductions. The trial was registered with clinicaltrials.gov (NCT03900091) in March 2019, and its protocol was published in November 2020.