Grace Irimu

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.

Implementing locally appropriate guidelines and training to improve care of serious illness in Kenyan hospitals: a story of scaling-up (and down and left and right)

Inadequate health systems are now widely recognised as major barriers to improved newborn and child survival and achieving Millennium Development Goal 4 that calls for a two-thirds reduction in under 5 mortality in low-income settings.1 A key challenge of the coming decade is thus to strengthen health systems and ‘scale-up’ delivery of safe, accessible and high quality care.2,–,4 The required interventions are often divided up into ‘essential packages’, each with their own training materials and dedicated training courses. Examples include essential neonatal care, essential obstetric care, malaria case management, case management of severe malnutrition and management of the HIV infected child. Reported examples of successful scaling-up of such packages are usually drawn from large, internationally well-funded programmes in fields such as HIV.5 In contrast, support for widespread implementation of cross-cutting interventions such as WHO/UNICEFs Integrated Management of Childhood Illnesses can be half-hearted even if the approach is formally adopted at policy level.6 7 For care of the seriously ill child, in theory concentrated in rural hospitals as a result of referral, a holistic approach, identifying and managing all needs given the available resources, is intuitively sensible rather than focusing thinking and training on only malaria, or only HIV or only severe malnutrition.8 Such thinking prompted development of WHOs Emergency Triage Assessment and Treatment (ETAT) training programme,9 designed with a similar philosophy to emergency care courses aimed at higher income settings (eg, European Paediatric Life Support, EPLS). However, work indicating outdated, poor quality of case management of serious illness10 11 revealed a need for knowledge …

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.

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.

Audit of care for children aged 6 to 59 months admitted with severe malnutrition at kenyatta national hospital, kenya.

We conducted a prospective audit of 101 children with severe malnutrition aged 6 to 59 months admitted to Kenyatta National Hospital, Kenyas largest tertiary level health facility, from February-April 2008. A structured tool was prepared to capture data to allow assessment of implementation of the WHO guidelines steps 1-8. Overall, 58% of children had marasmus and 47% of children were younger than one year old. Common co-morbidities at admission were diarrhoea (70.3%) and pneumonia (51.4%). The highest degree of implementation was observed for Step 5, treatment of potentially severe infections (90%, (95% CI 85.1-96.9)). Only 55% of the patients had F75 prescribed although this starter formula was available in this hospital. There was a delay in initiating feeds with a median time of 14.7 hours from the time of admission. There was modest implementation of Step 2, ensuring warmth (46.5%, 36.8-56.2), Step 3, treat dehydration (54.9%, 43.3-66.5) and Step 4, correct electrolyte imbalance, (45.5%, 35.6-55.8%). There was least implementation of Step 8, transition to catch-up feeding (23.8%, 13.6-34.0). We conclude that quality of care for children admitted with severe malnutrition at KNH is inadequate and often does not follow the WHO guidelines. Improving care will require a holistic and not simply medical approach.

Effect of a multi-faceted quality improvement intervention on inappropriate antibiotic use in children with non-bloody diarrhoea admitted to district hospitals in Kenya

BackgroundThere are few reports of interventions to reduce the common but irrational use of antibiotics for acute non-bloody diarrhoea amongst hospitalised children in low-income settings. We undertook a secondary analysis of data from an intervention comprising training of health workers, facilitation, supervision and face-to-face feedback, to assess whether it reduced inappropriate use of antibiotics in children with non-bloody diarrhoea and no co-morbidities requiring antibiotics, compared to a partial intervention comprising didactic training and written feedback only. This outcome was not a pre-specified end-point of the main trial.MethodsRepeated cross-sectional survey data from a cluster-randomised controlled trial of an intervention to improve management of common childhood illnesses in Kenya were used to describe the prevalence of inappropriate antibiotic use in a 7-day period in children aged 2-59 months with acute non-bloody diarrhoea. Logistic regression models with random effects for hospital were then used to identify patient and clinician level factors associated with inappropriate antibiotic use and to assess the effect of the intervention.Results9, 459 admission records of children were reviewed for this outcome. Of these, 4, 232 (44.7%) were diagnosed with diarrhoea, with 130 of these being bloody (dysentery) therefore requiring antibiotics. 1, 160 children had non-bloody diarrhoea and no co-morbidities requiring antibiotics-these were the focus of the analysis. 750 (64.7%) of them received antibiotics inappropriately, 313 of these being in the intervention hospitals vs. 437 in the controls. The adjusted logistic regression model showed the baseline-adjusted odds of inappropriate antibiotic prescription to children admitted to the intervention hospitals was 0.30 times that in the control hospitals (95%CI 0.09-1.02).ConclusionWe found some evidence that the multi-faceted, sustained intervention described in this paper led to a reduction in the inappropriate use of antibiotics in treating children with non-bloody diarrhoea.Trial registrationInternational Standard Randomised Controlled Trial Number Register ISRCTN42996612