A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial (original) (raw)
BMC Health Services Research, 2014
Background: In assessing quality of care in developing countries, retrospectively collected data are usually used given their availability. Retrospective data however suffer from such biases as recall bias and non-response bias. Comparing results obtained using prospectively and retrospectively collected data will help validate the use of the easily available retrospective data in assessing quality of care in past and future studies. Methods: Prospective and retrospective datasets were obtained from a cluster randomized trial of a multifaceted intervention aimed at improving paediatric inpatient care conducted in eight rural Kenyan district hospitals by improving management of children admitted with pneumonia, malaria and diarrhea and/or dehydration. Four hospitals received a full intervention and four a partial intervention. Data were collected through 3 two weeks surveys conducted at baseline, after 6 and 18 months. Retrospective data was sampled from paediatric medical records of patients discharged in the preceding six months of the survey while prospective data was collected from patients discharged during the two week period of each survey. Risk Differences during post-intervention period of16 quality of care indicators were analyzed separately for prospective and retrospective datasets and later plotted side by side for comparison. Results: For the prospective data there was strong evidence of an intervention effect for 8 of the indicators and weaker evidence of an effect for one indicator, with magnitude of effect sizes varying from 23% to 60% difference. For the retrospective data, 10 process (these include the 8 indicators found to be statistically significant in prospective data analysis) indicators had statistically significant differences with magnitude of effects varying from 10% to 42%. The bar-graph comparing results from the prospective and retrospective datasets showed similarity in terms of magnitude of effects and statistical significance for all except two indicators. Conclusion: Multifaceted interventions can help improve adoption of clinical guidelines and hence improve the quality of care. The similar inference reached after analyses based on prospective assessment of case management is a useful finding as it supports the utility of work based on examination of retrospectively assembled case records allowing longer time periods to be studied while constraining costs.
Assessment of inpatient paediatric care in first referral level hospitals in 13 districts in Kenya
The Lancet, 2004
Background The district hospital is considered essential for delivering basic, cost-effective health care to children in resource poor countries. We aimed to investigate the performance of these facilities in Kenya. Methods Government hospitals providing first referral level care were prospectively sampled from 13 Kenyan districts. Workload statistics and data documenting the management and care of admitted children were obtained by specially trained health workers. Findings Data from 14 hospitals were surveyed with routine statistics showing considerable variation in inpatient paediatric mortality (range 4-15%) and specific case fatality rates (eg, anaemia 3-46%). The value of these routine data is seriously undermined by missing data, apparent avoidance of a diagnosis of HIV/AIDS, and absence of standard definitions. Case management practices are often not in line with national or international guidelines. For malaria, signs defining severity such as the level of consciousness and degree of respiratory distress are often not documented (range per hospital 0-100% and 9-77%, respectively), loading doses of quinine are rarely given (3% of cases) and dose errors are not uncommon. Resource constraints such as a lack of nutritional supplements for malnourished children also restrict the provision of basic, effective care. Interpretation Even crude performance measures suggest there is a great need to improve care and data quality, and to identify and tackle key health system constraints at the first referral level in Kenya. Appropriate intervention might lead to more effective use of health workers' efforts in such hospitals.
Implementation Science, 2009
Background: It is increasingly appreciated that the interpretation of health systems research studies is greatly facilitated by detailed descriptions of study context and the process of intervention. We have undertaken an 18-month hospital-based intervention study in Kenya aiming to improve care for admitted children and newborn infants. Here we describe the baseline characteristics of the eight hospitals as environments receiving the intervention, as well as the general and local health system context and its evolution over the 18 months.
BMJ Public Health, 2023
Introduction Data on the pattern of admissions and causes of child death are crucial in informing priorities for improving child survival. In many health facilities in sub-Saharan Africa, understanding the pattern of paediatric admissions and their outcomes is constrained by poor documentation of these important features. Methods We developed and piloted a simple paper-based tool for documentation of basic, standardised patient-level information on causes of admissions, diagnoses, treatments and outcomes in children admitted to a rural hospital in Sierra Leone. The tool contained sections covering basic sociodemographic information about a patient, chief medical complaints, findings from clinical examinations and tests conducted at admission, results from subsequent clinical and laboratory investigations, working/definitive diagnoses, management and treatment outcomes. Results From 1 August 2019 to 31 July 2021, we used this tool to document the admissions, treatments and clinical outcomes of 1663 children admitted to Kambia district hospital in northern Sierra Leone. The majority of the children (1015, 62%) were aged 12-59 months, were boys (942, 57%), were wasted (516, 31%), stunted (238, 14%) or underweight (537, 32%). Above a half of the children lived more than 1 km distance from the hospital (876/1410, 62%). The highest number of admissions occurred in November 2019 and the lowest in April 2020. Severe malaria was the leading cause of admission. More than 80% of the children were successfully treated and discharged home (1356/1663, 81.5%) while 122/1663 (7.3%) died. Children aged under 5 years who were underweight, and those who presented with danger signs (eg, signs of breathing difficulty, dehydration, head injury or severe infections) had a higher risk of death than children without these features (p<0.01; p=0.03; p=0.011 and p=0.009, respectively). Conclusion Lack of systematic documentation of medical histories and poor record keeping of hospital admissions and outcomes can be overcome by using a simple tool. Continuous use of the tool with regular audits could improve delivery of paediatric care in resource-limited settings. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY ⇒ Developing a simple tool for documentation of basic, standardised patient-level information and demonstrating its usefulness in a rural hospital in Sierra Leone could help other hospitals with limited resources in finding a way to collect more reliable data on paediatric hospital admissions and their outcomes.
Delivery of paediatric care at the first-referral level in Kenya
Lancet, 2004
We aimed to investigate provision of paediatric care in government district hospitals in Kenya. We surveyed 14 firstreferral level hospitals from seven of Kenya's eight provinces and obtained data for workload, outcome of admission, infrastructure, and resources and the views of hospital staff and caretakers of admitted children. Paediatric admission rates varied almost ten-fold. Basic anti-infective drugs, clinical supplies, and laboratory tests were available in at least 12 hospitals, although these might be charged for on discharge. In at least 11 hospitals, antistaphylococcal drugs, appropriate treatment for malnutrition, newborn feeds, and measurement of bilirubin were rarely or never available. Staff highlighted infrastructure and human and consumable resources as problems. However, a strong sense of commitment, support for the work of the hospital, and a desire for improvement were expressed. Caretakers' views were generally positive, although dissatisfaction with the physical environment in which care took place was common. The capacity of the district hospital in Kenya needs strengthening by comprehensive policies that address real needs if current or new interventions and services at this level of care are to enhance child survival.
BMC health services research, 2011
Given the high mortality associated with neonatal illnesses and severe malnutrition and the development of packages of interventions that provide similar challenges for service delivery mechanisms we set out to explore how well such services are provided in Kenya. As a sub-component of a larger study we evaluated care during surveys conducted in 8 rural district hospitals using convenience samples of case records. After baseline hospitals received either a full multifaceted intervention (intervention hospitals) or a partial intervention (control hospitals) aimed largely at improving inpatient paediatric care for malaria, pneumonia and diarrhea/dehydration. Additional data were collected to: i) examine the availability of routine information at baseline and their value for morbidity, mortality and quality of care reporting, and ii) compare the care received against national guidelines disseminated to all hospitals. Clinical documentation for neonatal and malnutrition admissions was o...