Fred Were

A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial

Philip Ayieko and colleagues report the outcomes of a cluster-randomized trial carried out in eight Kenyan district hospitals evaluating the effects of a complex intervention involving improved training and supervision for clinicians. They found a higher performance of hospitals assigned to the complex intervention on a variety of process of care measures, as compared to those receiving the control intervention.

Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya

Kenya, in common with many developing countries, has committed itself to Millennium Development Goal (MDG)-4, which calls for a two-third reduction in 1990 mortality levels in under 5-year-old children by 2015.1 Improving the management of common severe childhood illnesses is one of many strategies likely to be needed to achieve this goal since hospital mortality rates as high as 15% are reported.2 3 Two further points also suggest the potential value of improved basic care to improve outcomes. First, the majority of deaths are attributable to a handful of illnesses and second, assessments demonstrate that the quality of care provided to children in low-income countries is often poor and has considerable scope for improvement.3 4 Clinical practice guidelines (CPGs) are intended to assist the health provider in evidence-based decision making and promote the provision of optimal care. Previous studies have shown that adherence to such evidence-based guidelines is associated with improved health outcomes.5–7 For some conditions such as pneumonia8 and diarrhoea,9 10 the World Health Organization has made CPGs available for many years. In 2000 evidence and expert opinion were used to provide comprehensive advice on the care of sick children in hospital with common conditions.11 However, few hospitals or health workers in Kenya have access to either the WHO recommendations or modern local practice guidelines3 and it is known that a wide range of factors affect the actual ability to improve care and outcomes.12–15 We therefore aimed to develop simple CPGs for conditions commonly associated with mortality in Kenyan hospitals and an in-service training package to facilitate their implementation. The effect on quality of hospital care of a multifaceted intervention project (including these CPGs and training) is the subject of ongoing research. Here we report the …

Are hospitals prepared to support newborn survival? – an evaluation of eight first-referral level hospitals in Kenya

Objective  To assess the availability of resources that support the provision of basic neonatal care in eight first‐referral level (district) hospitals in Kenya.

Health systems research in a low-income country: easier said than done.

Small hospitals sit at the apex of the pyramid of primary care in the health systems of many low-income countries. If the Millennium Development Goal for child survival is to be achieved, hospital care for referred severely ill children will need to be improved considerably in parallel with primary care in many countries. Yet little is known about how to achieve this. This article describes the evolution and final design of an intervention study that is attempting to improve hospital care for children in Kenyan district hospitals. It illustrates many of the difficulties involved in reconciling epidemiological rigour and feasibility in studies at a health system, rather than an individual, level and the importance of the depth and breadth of analysis when trying to provide a plausible answer to the question: does it work? Although there are increasing calls for more health systems research in low-income countries, the importance of strong, broadly based local partnerships and long-term commitment even to initiate projects is not always appreciated.

Assessment of neonatal care in clinical training facilities in Kenya

Objective An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya. Design Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data. Setting Neonatal units of 22 public hospitals. Patients Neonates aged <7 days. Main outcome measures Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission. Results All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0–3) and a median score of 6 out of 8 for signs of severe illness (IQR 4–7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively. Conclusions Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.

Quality of hospital care for sick newborns and severely malnourished children in Kenya: A two-year descriptive study in 8 hospitals

BackgroundGiven 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.MethodsAs 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.ResultsClinical documentation for neonatal and malnutrition admissions was often very poor at baseline with case records often entirely missing. Introducing a standard newborn admission record (NAR) form was associated with an increase in median assessment (IQR) score to 25/28 (22-27) from 2/28 (1-4) at baseline. Inadequate and incorrect prescribing of penicillin and gentamicin were common at baseline. For newborns considerable improvements in prescribing in the post baseline period were seen for penicillin but potentially serious errors persisted when prescribing gentamicin, particularly to low-birth weight newborns in the first week of life. Prescribing essential feeds appeared almost universally inadequate at baseline and showed limited improvement after guideline dissemination.ConclusionRoutine records are inadequate to assess newborn care and thus for monitoring newborn survival interventions. Quality of documented inpatient care for neonates and severely malnourished children is poor with limited improvement after the dissemination of clinical practice guidelines. Further research evaluating approaches to improving care for these vulnerable groups is urgently needed. We also suggest pre-service training curricula should be better aligned to help improve newborn survival particularly.

Implementation of a structured paediatric admission record for district hospitals in Kenya – results of a pilot study

BackgroundThe structured admission form is an apparently simple measure to improve data quality. Poor motivation, lack of supervision, lack of resources and other factors are conceivably major barriers to their successful use in a Kenyan public hospital setting. Here we have examined the feasibility and acceptability of a structured paediatric admission record (PAR) for district hospitals as a means of improving documentation of illness.MethodsThe PAR was primarily based on symptoms and signs included in the Integrated Management of Childhood Illness (IMCI) diagnostic algorithms. It was introduced with a three-hour training session, repeated subsequently for those absent, aiming for complete coverage of admitting clinical staff. Data from consecutive records before (n = 163) and from a 60% random sample of dates after intervention (n = 705) were then collected to evaluate record quality. The post-intervention period was further divided into four 2-month blocks by open, feedback meetings for hospital staff on the uptake and completeness of the PAR.ResultsThe frequency of use of the PAR increased from 50% in the first 2 months to 84% in the final 2 months, although there was significant variation in use among clinicians. The quality of documentation also improved considerably over time. For example documentation of skin turgor in cases of diarrhoea improved from 2% pre-intervention to 83% in the final 2 months of observation. Even in the area of preventive care documentation of immunization status improved from 1% of children before intervention to 21% in the final 2 months.ConclusionThe PAR was well accepted by most clinicians and greatly improved documentation of features recommended by IMCI for identifying and classifying severity of common diseases. The PAR could provide a useful platform for implementing standard referral care treatment guidelines.

Adoption of recommended practices and basic technologies in a low-income setting

Objective In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent. Design and setting We used data collected on a consistent panel of indicators during four separate cross-sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002–2012). Main outcome measures Basic resource availability, use of diagnostics and uptake of recommended practices. Results There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines. Conclusions Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low-income settings and to those developing novel therapeutic or diagnostic interventions.

Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network

Background Lack of detailed information about hospital activities, processes and outcomes hampers planning, performance monitoring and improvement in low-income countries (LIC). Clinical networks offer one means to advance methods for data collection and use, informing wider health system development in time, but are rare in LIC. We report baseline data from a new Clinical Information Network (CIN) in Kenya seeking to promote data-informed improvement and learning. Methods Data from 13 hospitals engaged in the Kenyan CIN between April 2014 and March 2015 were captured from medical and laboratory records. We use these data to characterise clinical care and outcomes of hospital admission. Results Data were available for a total of 30 042 children aged between 2 months and 15 years. Malaria (in five hospitals), pneumonia and diarrhoea/dehydration (all hospitals) accounted for the majority of diagnoses and comorbidity was found in 17 710 (59%) patients. Overall, 1808 deaths (6%) occurred (range per hospital 2.5%–11.1%) with 1037 deaths (57.4%) occurring by day 2 of admission (range 41%–67.8%). While malaria investigations are commonly done, clinical health workers rarely investigate for other possible causes of fever, test for blood glucose in severe illness or ascertain HIV status of admissions. Adherence to clinical guideline-recommended treatment for malaria, pneumonia, meningitis and acute severe malnutrition varied widely across hospitals. Conclusion Developing clinical networks is feasible with appropriate support. Early data demonstrate that hospital mortality remains high in Kenya, that resources to investigate severe illness are limited, that care provided and outcomes vary widely and that adoption of effective interventions remains slow. Findings suggest considerable scope for improving care within and across sites.

Moving towards Routine Evaluation of Quality of Inpatient Pediatric Care in Kenya

Background Regular assessment of quality of care allows monitoring of progress towards system goals and identifies gaps that need to be addressed to promote better outcomes. We report efforts to initiate routine assessments in a low-income country in partnership with government. Methods A cross-sectional survey undertaken in 22 ‘internship training’ hospitals across Kenya that examined availability of essential resources and process of care based on review of 60 case-records per site focusing on the common childhood illnesses (pneumonia, malaria, diarrhea/dehydration, malnutrition and meningitis). Results Availability of essential resources was 75% (45/61 items) or more in 8/22 hospitals. A total of 1298 (range 54–61) case records were reviewed. HIV testing remained suboptimal at 12% (95% CI 7–19). A routinely introduced structured pediatric admission record form improved documentation of core admission symptoms and signs (median score for signs 22/22 and 8/22 when form used and not used respectively). Correctness of penicillin and gentamicin dosing was above 85% but correctness of prescribed intravenous fluid or oral feed volumes for severe dehydration and malnutrition were 54% and 25% respectively. Introduction of Zinc for diarrhea has been relatively successful (66% cases) but use of artesunate for malaria remained rare. Exploratory analysis suggests considerable variability of the quality of care across hospitals. Conclusion Quality of pediatric care in Kenya has improved but can improve further. The approach to monitoring described in this survey seems feasible and provides an opportunity for routine assessments across a large number of hospitals as part of national efforts to sustain improvement. Understanding variability across hospitals may help target improvement efforts.