Table 3.

Plan-do-study-act (PDSA) cycle barriers and associated interventions during the quality improvement initiative.

Period	Barrier	Intervention
Cycle A 18 Sept to 24 Nov 2019	SAM not diagnosed	• A nutritionist manager was hired and made responsible for overseeing nutritional assessment of all admissions and coordinating SAM care • Task-shifted nutritional assessments from data clerks to nutritionist interns (continued in Cycle B)
	Understaffing/absenteeism	• Nutritionist manager tasked with oversight of NRU staff • Monthly NRU team schedule posted on WhatsApp group
	Missing/broken equipment	• MUAC tape, scale, length board, and glucometer procured
	Staff lacks knowledge of SAM management	• 2-day guideline-based training for clinicians and nurses in identifying and managing complicated SAM • Permanent staff nurses and clinicians given overview of baseline data and introduction to these interventions • Charts created for patient care areas that detail the guidelines for inpatient management of SAM
Cycle B 25 Nov to 15 Jan 2020	Although documentation of SAM improved, clinical team not documenting the diagnosis nor appropriately managing those with SAM Power dynamics prevent NRU team from informing/reminding clinicians when SAM is identified or gaps in care occur	• NRU team encouraged to continue engaging clinicians • NRU team and nurses given permission to bypass clinicians to implement SAM management • Initiation of NRU team WhatsApp group with twice-daily updates from the team, including real-time updates on stockouts, faulty equipment, number of patients screened and found to have SAM, and handover of tasks to be followed up by the oncoming shift • Nutritionist manager added to ward clinical WhatsApp group to facilitate NRU consults
Cycle C 16 Jan to 17 March 2020	With increasing patient census, resources strained Ongoing disconnect between clinicians and NRU team to implement coordinated SAM management, especially in the EZ	• Implementation of a register of SAM patients in the EZ that allows for central tracking of patients and detection of gaps in management of individual patients • Continued reminders to the staff of the initiative and the importance of SAM documentation and guidelines during morning meetings. • Nutritionist manager tasked with orientation of new NRU staff and clinicians to initiative and guidelines • Began staffing speciality follow-up clinics (cardiology, endocrine)
Future Interventions	High rate of post-discharge mortality and re-admission of SAM patients	• Home follow-up of recently discharged patients
	Poor clinician engagement	• Hire clinician dedicated to management of SAM and providing consistent training and mentorship to department clinicians
	Vitals signs not regularly assessed and missed doses of medications	• Dedicated nursing staff for management of SAM

EZ: Emergency Zone, an acute care ward; MUAC: mid-upper-arm circumference; NGO: non-government organisation; NRU: nutritional rehabilitation unit; SAM: severe acute malnutrition.