SHINSHICHO PRIMARY HOSPITAL

CLINICAL AUDIT REPORT ON PNEUMONIA

MAY, 2025
SHINSHICHO, ETHIOPIA
Abbreviations/Acronyms

AHN – Adult Health Nutrition

CCO – Chief Clinical Officer

CEO – Chief Executive Officer

CGQIU – Clinical Governance and Quality Improvement Unit

EC – Ethiopian Calendar

ED – Emergency Department

GC – Gregorian Calendar

GP – General Practitioner

IPD – Inpatient Department

MPH/RH – Masters of Public Health in Reproductive Health

OPD – Outpatient Department

Audit Topic: Severe and very severe pneumonia (pediatric patients)

Aim: To improve quality of clinical care for pediatric patients diagnosed with
severe and very severe pneumonia.

Objectives:

 To ensure pediatrics patients admitted to the ED and then ward with severe
pneumonia are appropriately evaluated.
 To ensure pediatrics patients admitted to the ED and then ward with severe
pneumonia are appropriately investigated.
 To ensure pediatrics patients admitted to the ED and then ward with severe
pneumonia are appropriately treated.
 To ensure pediatrics patients admitted to the ED and then ward with severe
pneumonia are appropriately monitored.
 To ensure pediatrics patients admitted to the ED and then ward with severe
pneumonia are appropriately referred.
 To ensure pediatrics patients admitted to the ED and then ward with severe
pneumonia receive appropriate discharge care.

Period of audit: 21/04/17 – 21/07/17 EC

Inclusions Criteria: Pediatric patients with the diagnosis of severe and very severe
pneumonia admitted to ED and then ward.

Exclusion criteria: Pediatric patients with the diagnosis of non-severe pneumonia

evaluated in the ED, Pediatric patients with the diagnosis of severe pneumonia
managed and discharged from the ED with in 48 hrs, Pediatric patients with the
diagnosis of severe and very severe pneumonia whose age is greater than 5 years
old (60 months).
 1. Background

Pneumonia is an inflammatory condition of the lung primarily affecting the small

air sacks known as alveoli. Severe pneumonia is a serious infection of the lungs
that can be life threatening. It is characterized by high morbidity and mortality and
requires immediate medical attention, often hospitalization. It can lead to
complications such as respiratory failure, sepsis, and lung abscesses.

Pneumonia is still a major public health problem for children, especially in

developing countries. It is the leading cause of death in under-five children in low
income countries. Ethiopia is one of the countries with high burden of pneumonia.
Among its people, under-five children are highly affected by pneumonia
particularly severe community acquired pneumonia.

Shinshicho primary hospital is one of the hospitals in Central Ethiopia region

which stands as a lifeline for its community. In the last 9 months (21/10/16 –
20/07/17 E.C), pneumonia is the 3 rd leading cause of morbidity in under-5 patients
who visited OPD of Shinshicho primary hospital. In the same period, it is the
leading cause of morbidity in under-5 patients admitted to the pediatric ward of the
hospital.
2. Selected quality standards and set Criteria

S.No Standard/Criteria Actual Target Rema

performance performance rk

1 Identification information is recorded for a

pediatric patient presenting with pneumonia 53.7% 100%
2 Appropriate history is taken for a pediatric 28.1% 100%
patient with pneumonia
3 Appropriate physical examination is 46.5% 100%
performed for a pediatric patient with
pneumonia
4 Relevant investigations are done at initial 57.9% 100%
evaluation for a pediatric patient with
pneumonia
5 Appropriate diagnosis is made for a 47.3% 100%
pediatric patient with pneumonia
6 Appropriate management is provided for a 80.8% 80%
pediatric patient with pneumonia
7 Appropriate monitoring is done for a 78.9% 100%
pediatric patient with pneumonia during
hospital stay
8 Appropriate discharge care is provided for a 42.1% 100%
pediatric patient with pneumonia
9 Identification of provider is documented for 67.4% 100%
a pediatric patient with pneumonia
10 Average total standard met per chart 55.8%
 Quality standards and set criteria

90

80

70

60

50

40
Quality standards and set criteria
30

20

10

0
3. Measuring performance against standard

3.1. Data collection methods

To ensure the representativeness of the sample, systematic random sampling is

used to collect the secondary information/retrospective/ from inpatient registration
book. The data were collected by quality officers of Shinshicho primary hospital (1
GP, 2 MPH/RH and 1 MSc in AHN) with involving a senior (internist) in the ward.

From the total of 82severe pneumonia pediatric patients who admitted to the ward
in the last 3 months period, 19 of them were included using systematic random
sampling i.e k=n/N=82/19=4, every 4th patient’s chart from the register was
selected and reviewed.

Data Collection period

April 29&30, 2025 G.C

Data Collection Setting

Shinshicho primary hospital

3.2. Data Analysis

A total of 19 patient folder/charts were assessed for nine standards. From the above
19 patient charts, average total standard met per chart was 55.8%. High
discrepancy is being seen inappropriate history taken for a pediatric patient with
pneumonia and appropriate discharge care provided for a pediatric patient with
pneumonia assessment which met only 28.1% and 42.1% of requirements
respectively.
3.4. Presentation of the Findings

A total of 19 traumapatientsfolders/charts were assessed for nine standards. From

these, 55.8% met the required standard on average.

4. Selected quality standards for the data collection:

 Identification information is recorded for a pediatric patient presenting with

pneumonia
 Appropriate history is taken for a pediatric patient with pneumonia
 Appropriate physical examination is performed for a pediatric patient with
pneumonia
 Relevant investigations are done at initial evaluation for a pediatric patient
with pneumonia
 Appropriate diagnosis is made for a pediatric patient with pneumonia
 Appropriate management is provided for a pediatric patient with pneumonia
 Appropriate monitoring is done for a pediatric patient with pneumonia
during hospital
 Appropriate discharge care is provided for a pediatric patient with
pneumonia
 Identification of provider is documented for a pediatric patient with
pneumonia
 5. Strength and weakness

Strengths

 Appropriate management is provided for a pediatric patient with pneumonia

 Appropriate monitoring is done for a pediatric patient with pneumonia
during hospital stay
 Proper antibiotics are given with proper dose

Weakness

 Patient history was not appropriately taken for a pediatric patient with
pneumonia
 Appropriate discharge care is not provided for a pediatric patient with
pneumonia and the discharge sheet is not complete.
 Physical examination was not appropriately performed for a pediatric patient
with pneumonia
 The diagnosis was not appropriately made for a pediatric patient with
pneumonia
 Some of the sheets like progress note and history sheet are not complete.
 Some identification information’s were not fully recorded.
 6. Conclusion and recommendation

Conclusion

In developing countries, Pneumonia is still a major public health problem for

children. This audit will help the hospital improve severe pneumonia management,
reduce mortality and align with WHO standards. Adequate concern should be
given and all the responsible bodies should do their best for the identified gaps and
strategy should be designed in order to bring improvement.

Recommendations

 History of the pediatric patient should be taken and recorded

properly
 Standardized discharging protocols should be developed
 Trainings should be given on proper documentation and
pneumonia assessment protocols
 Physical examination for the patient should be done properly
 Basic diagnostic tools like x-ray should be available
 Standardized patient chart should be organized with
mandatory sections like history sheet, order sheet,
medication sheet and the documentation in all sheets should
be complete.
7. The clinical audit was done by the following personnel

S.No Name Responsibility Position Remark

1 Mr. Mulatu Belete Member CGQIU
head
2 Mr. Sitota Tesema Member Quality
officer
3 Mr. Degefe Mugore Member Quality
officer
4 DR Desalegn Samuel Member CCO
5 Mr. Melese Tagese Member IPD
coordinator
5 DR Antonios Markos Pedi ward senior Pediatrician
 Action plan, on Clinical Audit Report of Pneumonia, Shinshicho, Ethiopia,
May, 2025
S.n Gap identified Action to done Responsible Time Rem
o body frame
ark
1 No standardized discharge protocol Create a discharge IPD, CGQIU 1 month

checklist

2 There is no standardized history & Avail standardized H&PE IPD 1 month

physical examination forms forms

3 Lack of proper documentation Train staff on proper CCO, CGQIU 3 months

documentation

4 Lack of proper diagnosis Training the staff and IPD, CCO, 2018 E.C

availing diagnostic tools. CGQIU

5 Incomplete patient identification -Mandate complete IPD, CCO, 2018 E.C

registration CGQIU, CEO,

-Digital patient records Finance

6 Lack of investigation tools like x-ray Avail diagnostic tools CCO, CEO, 1 month

Finance

7 Missing essential documentation Standardize patient charts Matron, IPD, 1 month

sheets with mandatory forms like Medical records

order sheet, history sheet, officer, CGQIU

medication sheet and likes

8 There is no regular peer review audits Have a regular peer CGQIU, CCO 2018 E.C

review audits

SHINSHICHO PRIMARY HOSPITAL MEDICAL RECORD

NUMBERS SELECTED FOR PNEUMONIA CLINICAL
AUDIT
Chart number MRN selected Remark
1 008959/17
2 010245/17
3 010532/17
4 011196/17
5 009438/17
6 009121/17
7 008498/17
8 008756/17
9 008887/17
10 011785/16
11 011480/17
12 011313/17
13 011594/17
14 0049421/16
15 008635/17
16 008128/17
17 017729/16
18 000988/17
19 002189/15