Reduced in-hospital mortality after improved management of children under 5 years admitted to hospital with malaria: randomised trial

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Abstract
Objective To test whether strict implementation of a standardised protocol for the management of malaria and provision of a financial incentive for health workers reduced mortality.Design Randomised controlled intervention trial.Setting Paediatric ward at the national hospital in Guinea-Bissau. All children admitted to hospital with severe malaria received free drug kits.Participants 951 children aged 3 months to 5 years admitted to hospital with a diagnosis of malaria randomised to normal or intervention wards.Interventions Before the start of the study, all personnel were trained in the use of the standardised guidelines for the management of malaria, including strict follow-up procedures. Nurses and doctors were randomised to work on intervention or control wards. Personnel in the intervention ward received a small financial incentive ($50 (£25; €35)/month for nurses and $160 for doctors) and their compliance with standard case management was closely monitored.Main outcome measures In-hospital mortality and cumulative mortality within 4 weeks of hospital admission.Results In-hospital mortality was 5% for the intervention group and 10% in the control group (risk ratio 0.48, 95% confidence interval 0.29 to 0.79). The effect may have been stronger in patients with positive malaria slides (0.36, 0.16 to 0.80). Cumulative mortality 4 weeks after discharge was also lower in the intervention group (0.61, 0.40 to 0.95).Conclusions Supervising healthcare workers to adhere to a standardised treatment protocol was associated with greatly reduced in-hospital mortality. Financial incentives may be important for the dedication and compliance of staff members.Trial registration Clinical Trials NCT00465777.