Kathleen’s comments in Blue below:
Checklists:
1. Safe surgery outcome measures
a. Correct spelling for cardiac arrest. Can Shun please correct on my behalf in updated
tools.
b. Correct spelling for arrhythmia. Can Shun please correct on my behalf in updated tools.
c. There is nothing about OR organization and surgical practices
Rianna, this concern may need to be addressed by someone with more expertise than I
in the area of OR organization and best practices. I did make some recommendations
to the structural checklists for the OR inputs and best practices, but I am not sure if this
addresses adequately the concern expressed here.
I would think this component would be best integrated into one of the Management
and structural checklists. Perhaps one of the academic partner institutions (for the
residency training) can assist with this piece.
2. No comment on the Pediatric Outcome measures
3. Pediatric ETAT Chart Review Guide
a. Shock: what will be the indication for transfusion in a normally nourished child if they do
not show improvement after 3rd IV infusion? If signs of shock persist after 3 IV
infusions in a normally nourished child such as rapid heart rate and respiratory rate,
altered consciousness, low blood pressure, then WHO guidelines recommend blood
transfusion. However, I agree with the reviewer’s comment below, that a blood
transfusion is not necessarily justified. Please see my comment below recommending
deletion of this step in the ETAT chart review guide. I think, anyway, this is quite a
small detail that would be difficult to audit in practice so it is not worth retaining for
the purposes of this quality checklists.
b. COMA: the dosage for D50 should be a range of 1-5ml/kg. This is fine. Please amend to
state D-50 bolus (1-5 cc/kg)/
4. Pediatric Quality Process Measure ETAT and Malaria
a. What is considered relevant laboratory investigations? This could be subjective if not
clearly specified.
I am not clear on this question. The latest version of the pediatric ETAT and Malaria chart
review guide checklists clearly spell out laboratory investigations indicated in the
presence of specific urgency signs for ETAT and for Malaria. If I recall, however, the
malaria chart review table may need to be revised in line with the latest guide table
content. This should be very easy for Shun to do in line with other table review checklists
based on chart review guides.
Please see my comment in latest version of malaria checklist guide about checking on
which laboratory investigations to retain during the pre-testing of the tools (current
version includes national guidelines recommendations but there may be questions of
feasibility).
5. Newborn Sepsis Hospital Case Management Chart Review Guide
a. Admission to Maternity: there should be sterile maternity gloves not the ordinary sterile
gloves. Kathleen: o.k. I am assuming this has a specific meaning for Liberia hospital
context.
6. Newborn Sepsis Chart Review Table
Denominator: please check the possible total elements. Instead of 26, I believe it should be 19
Thanks for catching this error. I just re-counted and updated review table and I believe the
total # of elements in the denominator should be 20 (I have attached updated table).
7. Newborn Asphyxia Hospital Case Management Chart Review Guide
 For now, the APGAR scores should be recorded at 1 and 5 minutes since the consensus
is still growing. Kathleen: Allright. This addresses my question in the original
tool..
8. Newborn Asphyxia Chart Review Table
 include a space for APGAR 1 and 5 minutes. Can Shun please add this into
the revised version of the newborn asphyxia tool
9. Malaria Hospitalization Chart Review Guide
Labs :stick to HCT/HGB and Malaria microscopic testing while in hospital.
Other tests that are not specified should be removed. Kathleen : Thank
you, noted. Can Shun please remove all laboratory options except
HCT/HGB and Malaria microscopic testing from the malaria chart review
guide and chart review table checklist (the tool has a comment about this
which now can be removed).
2nd option: Quinine 600mg: 10mg/kg 1st, 2nd, 3rd, dose @8 hr interval then give
AS+AQ for 3days or Quinine PO 30mg/kg for 6 days(According to Liberia
Standards)
The standards did not give a third option. Perhaps I was not reviewing the
latest version of the national guidelines. Please remove the third option if not
applicable per latest version of national guidelines.
10. Liberia Hospital Service-delivery Quality Framework (no comments)
11. Pediatric ETAT Chart Review Guide
 Pulse oximeters must be provided. Therefore, we should remove the “if available and
functioning” quality improvement does not only entail services, it requires certain level
of advanced equipment regardless of how simple they are. Agreed!! Can Shun or an
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assistant please remove the reference to “if available and functioning” for
pulsoximeter in ETAT guide. Thank you.
Laboratory Investigations should read:
o Hct/Hgb, malaria (microscopic) (must be done for all cases of suspected malaria)
o If Respiratory Distress do a Chest X-ray
o If Coma/Convulsions do glucose and lumbar puncture
o If dehydration with lethargy and altered mental status do blood sugar
SHOCK: If a child is normally nourished I do not see the need for blood transfusion after
the 3rd IV bolus. Perhaps you can explain the rationale. I agree with this reviewer.
Since both myself and the reviewer agree on this point, can Shun please remove the
“blood transfusion” from the management of shock in the normally nourished child in
the ETAT chart review guide.
Take note that some portions of the document are written in both French and English.
Apologies. I was drawing on tools I had developed for ETAT improvement work in
Niger and Benin. Please correct latest version of tools so that all text is English (or I
will be glad to do so if needed).
12. ETAT Chart Review Checklist (no comments)
13. Eclampsia Chart Review Guide
a. Gestational age: what is considered best available evidence? I believe we must stick to
an ultrasound as the best evidence and provide the possibility at each of the
participating institutions if they do not already have.
Thank you for this clarification request. I agree that it is important to advocate for
ultrasound in every participating institution (and staff training to accurately interpret
obstetric ultrasounds).
I recommend amending the statement in the chart review guide to read:
“Gestational age (GA) recorded based on best available evidence : first
trimester ultrasound if available, followed by ultrasound at time of
presentation (If not first trimester result), followed by GA estimate based on
sure LMP (if known and no ultrasound available), followed by uterine fundal
height if no ultrasound and LMP is not known»
14. Eclampsia Chart Review Table
 Gestational age recorded by ultrasound I agree and would paste in sentence
from bullet above regarding recommended calculation of GA.
15. Pediatric Pneumonia Hospital Case Management Chart Review Guide
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Laboratory and Radiological examinations: Pulse oximetry must be
recorded. Therefore, the participating hospitals must be provided the
equipment. I agree! Let us hope that there will be functional pulsoximeters
and that this will be possible.
Liberia standards include ceftriaxone 50mg/kg/dy plus Gentamicin 35mg/kg/dy in three divided doses. Thank you. This may be an item to
review during pre-testing and with pediatric experts in Liberia. Can Shun
or an assistant please amend in the updated chart guide per final
consensus.
For most community-acquired post-neonatal pediatric pneumonia,
ceftriaxone plus gentamycin would be considered unnecessary for
inpatient treatment (as contrasted with ampicillin and gentamcyin usually
indicated for neonatal sepsis).
However, I am not an expert in the epidemiology of early childhood
pneumonia in Liberia so I would recommend verifying the date of the most
recent Liberia pneumonia standards revision and perhaps discuss with
Liberian experts during pre-testing of the tools. I will be glad to discuss
futher if necessary.
16. Pediatric Pneumonia Chart Review Table
 We continue to stress that Pulse oximetry is significant for the provision of
the quality of services to be provided. What will be the value of N/A on the
table and how does it affect the scoring ? I agree with the reviewer’s
comment. Please remove the NA option in this table (and adjust criteria
elements accordingly. Hopefully, the insistence on pulsoxmetry will
motivate hospital managers and providers to advocate for consistent
availabiltiy and maintenance of pulsoximeters in Ors, emergency
departments, maternities and pediatric wards.
17. Pediatric Diarrhea Hospital Case Management Chart Review Guide
Treatment/Liberia Standards :
If patient has severe dehydration without evidence of malnutrition:
• IV line in placed, Check glucose level, if <45 give 50% dextrose at 5ml/kg double diluted, Normal
saline or Ringers lactate (LR) given according to WHO guidelines for age and severe dehydration. If no
LR, use normal saline.
• If < 1 yr 30ml/kg over 1 hour then 70ml/kg over next 5 hrs
• If > 1 yr 30 ml/ kg over 30 minutes the 70 ml/kg over 2.5 hours
If unable to start IV and unable to drink administer ORS via NG tube
If patient assessed as moderate dehydration: ORS started 75ml/kg over 4 hours; repeat as needed
for severe continuing diarrhea. After 4 hours, need to evaluate condition again
maintenance ORS at 50 ml/kg over the next 24 to 72 hours
Encourage mother to breastfeed during rehydration and encourage eating when able for
non breastfeeding children.
If patient is assessed as malnourished and dehydrated but without shock−has strong pulse : Low
osmolarity ORS at 50 % strength (1 packet of ORS in 2 Liters of water) initiated at 5ml/kg for 2 hours
then 5- 10ml/kg/hr for next 4 hrs or more if still dehydrated
Treatment initiated according to stool exam
results: Giardia; metronidazole 5mg/kg for 5 days, Entameoba histolytica trophozytes seen,
10mg/kg for 5 days of metronidazole, Multivitamins started, Zinc started at 10–20 mg/kg/day
for 10 days, Vitamin A. If diarrhea continues despite treatment, consider other causes such as
HIV/AIDS
Thank you for these updates per national guidelines, I assume? Can Shun or an assistant
please insert above text into updated pediatric diarrhea chart review guide and chart review
table (where I noted need to update treatment guidelines per Liberia protocol). Please also
adjust criteria count as needed for denominator (on chart review table). I am glad to review
the revised tools if needed.
18. Maternal Sepsis Chart Review Guide
(no comment)
19. Maternal Sepsis Prevention & Treatment Chart Review Table(no comment)
20. PPH Chart Review Guide
 Monitoring for PPH
I would suggest we leave the Liberian Guidelines in place but modify the
monitoring to be 15 minutes during the first hour…………..
Noted. Please amend according to reviewer’s comnents and assess during
pre-testing of tools.
21. PPH Prevention & Treatment Chart Review checklist :
No comment.