Morris Ogero

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.

Blood Transfusion Delay and Outcome in County Hospitals in Kenya

Severe anemia is a leading indication for blood transfusion and a major cause of hospital admission and mortality in African children. Failure to initiate blood transfusion rapidly enough contributes to anemia deaths in sub-Saharan Africa. This article examines delays in accessing blood and outcomes in transfused children in Kenyan hospitals. Children admitted with nonsurgical conditions in 10 Kenyan county hospitals participating in the Clinical Information Network who had blood transfusion ordered from September 2013 to March 2016 were studied. The delay in blood transfusion was calculated from the date when blood transfusion was prescribed to date of actual transfusion. Five percent (2,875/53,174) of admissions had blood transfusion ordered. Approximately half (45%, 1,295/2,875) of children who had blood transfusion ordered at admission had a documented hemoglobin < 5 g/dl and 36% (2,232/6,198) of all children admitted with a diagnosis of anemia were reported to have hemoglobin < 5 g/dL. Of all the ordered transfusions, 82% were administered and documented in clinical records, and three-quarters of these (75%, 1,760/2,352) were given on the same day as ordered but these proportions varied from 71% to 100% across the 10 hospitals. Children who had a transfusion ordered but did not receive the prescribed transfusion had a mortality of 20%, compared with 12% among those transfused. Malaria-associated anemia remains the leading indication for blood transfusion in acute childhood illness admissions. Delays in transfusion are common and associated with poor outcomes. Variance in delay across hospitals may be a useful indicator of health system performance.

Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance: a multi-hospital, retrospective, cohort study

Summary Background Management of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital. Methods We did a retrospective cohort study of children aged 2–59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia). Findings We assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1–6·8), mild to moderate pallor (3·4, 3·0–3·8), and weight-for-age Z score (WAZ) less than −3 SD (3·8, 3·4–4·3). Additional factors that were independently associated with death were: WAZ less than −2 to −3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more. Interpretation In settings of high mortality, WAZ less than −3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making. Funding Wellcome Trust.

Does audit and feedback improve the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in Kenya

Background Audit and feedback (A&F) is widely used in healthcare but there are few examples of how to deploy it at scale in low-income countries. Establishing the Clinical Information Network (CIN) in Kenya provided an opportunity to examine the effect of A&F delivered as part of a wider set of activities to promote paediatric guideline adherence. Methods We analysed data collected from medical records on discharge for children aged 2–59 months from 14 Kenyan hospitals in the CIN. Hospitals joined CIN in phases and for each we analysed their initial 25 months of participation that occurred between December 2013 and March 2016. A total of 34 indicators of adherence to recommendations were selected for evaluation each classified by form of feedback (passive, active and none) and type of task (simple or difficult documentation and those requiring cognitive work). Performance change was explored graphically and using generalised linear mixed models with attention given to the effects of time and use of a standardised paediatric admission record (PAR) form. Results Data from 60 214 admissions were eligible for analysis. Adherence to recommendations across hospitals significantly improved for 24/34 indicators. Improvements were not obviously related to nature of feedback, may be related to task type and were related to PAR use in the case of documentation indicators. There was, however, marked variability in adoption and adherence to recommended practices across sites and indicators. Hospital-specific factors, low baseline performance and specific contextual changes appeared to influence the magnitude of change in specific cases. Conclusion Our observational data suggest some change in multiple indicators of adherence to recommendations (aspects of quality of care) can be achieved in low-resource hospitals using A&F and simple job aides in the context of a wider network approach.

Risk factors for mortality and effect of correct fluid prescription in children with diarrhoea and dehydration without severe acute malnutrition admitted to Kenyan hospitals: an observational, association study

Summary Background Diarrhoea causes many deaths in children younger than 5 years and identification of risk factors for death is considered a global priority. The effectiveness of currently recommended fluid management for dehydration in routine settings has also not been examined. Methods For this observational, association study, we analysed prospective clinical data on admission, immediate treatment, and discharge of children age 1–59 months with diarrhoea and dehydration, which were routinely collected from 13 Kenyan hospitals. We analysed participants with full datasets using multivariable mixed-effects logistic regression to assess risk factors for in-hospital death and effect of correct rehydration on early mortality (within 2 days). Findings Between Oct 1, 2013, and Dec 1, 2016, 8562 children with diarrhoea and dehydration were admitted to hospital and eligible for inclusion in this analysis. Overall mortality was 9% (759 of 8562 participants) and case fatality was directly correlated with severity. Most children (7184 [84%] of 8562) with diarrhoea and dehydration had at least one additional diagnosis (comorbidity). Age of 12 months or younger (adjusted odds ratio [AOR] 1·71, 95% CI 1·42–2·06), female sex (1·41, 1·19–1·66), diarrhoea duration of more than 14 days (2·10, 1·42–3·12), abnormal respiratory signs (3·62, 2·95–4·44), abnormal circulatory signs (2·29, 1·89–2·77), pallor (2·15, 1·76–2·62), use of intravenous fluid (proxy for severity; 1·68, 1·41–2·00), and abnormal neurological signs (3·07, 2·54–3·70) were independently associated with in-hospital mortality across hospitals. Signs of dehydration alone were not associated with in-hospital deaths (AOR 1·08, 0·87–1·35). Correct fluid prescription significantly reduced the risk of early mortality (within 2 days) in all subgroups: abnormal respiratory signs (AOR 1·23, 0·68–2·24), abnormal circulatory signs (0·95, 0·53–1·73), pallor (1·70, 0·95–3·02), dehydration signs only (1·50, 0·79–2·88), and abnormal neurological signs (0·86, 0·51–1·48). Interpretation Children at risk of in-hospital death are those with complex presentations rather than uncomplicated dehydration, and the prescription of recommended rehydration guidelines reduces risk of death. Strategies to optimise the delivery of recommended guidance should be accompanied by studies on the management of dehydration in children with comorbidities, the vulnerability of young girls, and the delivery of immediate care. Funding The Wellcome Trust.

Handling missing data in propensity score estimation in comparative effectiveness evaluations: A systematic review

Aim Even though systematic reviews have examined how aspects of propensity score methods are used, none has reviewed how the challenge of missing data is addressed with these methods. This review there-fore describes how missing data are addressed with propensity score methods in observational comparative effectiveness studies. Methods Published articles on observational comparative effectiveness studies were extracted from MEDLINE and EMBASE databases. Results Our search yielded 167 eligible articles. Majority of these studies (114; 68%) conducted complete case analysis with only 53 of them stating this in the methods. Only 16 articles reported use of multiple imputation. Conclusion Few researchers use correct methods for handling missing data or reported missing data methodology which may lead to reporting biased findings.

Inappropriate prescription of cough remedies among children hospitalised with respiratory illness over the period 2002-2015 in Kenya

To examine trends in prescription of cough medicines over the period 2002–2015 in children aged 1 month to 12 years admitted to Kenyan hospitals with cough, difficulty breathing or diagnosed with a respiratory tract infection.

An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care?

Background Measurement and correct interpretation of vital signs is part of routine clinical care. Repeated measurement enhances early recognition of deterioration, may help prevent morbidity and mortality and is a standard of care in most countries. Objective To examine documentation of vital signs by clinicians for admissions to paediatric wards in Kenyan hospitals, to describe monitoring frequency by nurses and explore factors influencing frequency. Methods Vital signs information (temperature, respiratory and pulse rate) for the first 48 hours of admission was collected from case records of children admitted with non-surgical conditions to 13 Kenyan county hospitals between September 2013 and April 2016. A mixed effect negative binomial regression model was used to explore whether the severity of illness (indicated by danger signs or severe diagnostic episodes) is associated with increased vital signs observation frequency. Results We examined 54 800 admission episodes with an overall mortality 6.1%. Nurse to bed ratios were very low (1:10 to 1:41 across hospitals). Admitting clinicians documented all or no vital signs in 57.0% and 8.4% cases respectively. For respiratory and pulse rates there was pronounced even end-digit preference (an indicator of incorrect information) and high frequency recording of specific values (P < 0.001) suggesting approximation. Monitoring frequency was explored in 41 738 children. Those with inpatient stays ≥48 hours were expected to have a vital signs count of 18, hospitals varied but most did not achieve this benchmark (median 9, range 2-30). There were clinically small but significant associations between vital signs count and presence of multiple severe illnesses or presence of severe pallor (adjusted relative risk ratio = 1.04, P < 0.01, 95% confidence interval CI = 1.02-1.06 and 1.05, P = 0.02, 95% CI = 1.01-1.09, respectively). Conclusions Data suggest accurate admission measures are sometimes missing especially for pulse and respiratory rates, possibly linked to manual measurement. Monitoring frequency is often low in the high risk population studied probably indicating how quality of nursing care is undermined by considerable human resource shortages.

A hidden burden of neonatal illness? A cross-sectional study of all admissions aged less than one month across twelve Kenyan County hospitals

© 2018 Murphy GAV et al. Background: Small and sick newborns need high quality specialised care within health facilities to address persistently high neonatal mortality in low-income settings, including Kenya. Methods: We examined neonatal admissions in 12 public-sector County (formerly District) hospitals in Kenya between November 2014 and November 2016. Using data abstracted from newborn unit (NBU) admission registers and paediatric ward (PW) medical records, we explore the magnitude and distribution of admissions. In addition, interviews with senior staff were conducted to understand admission policies for neonates in these facilities. Results: Of the total 80,666 paediatric admissions, 28,884 (35.8%) were aged ≤28 days old. 24,212 (83.8%) of neonates were admitted to organisationally distinct NBUs and 4,672 (16.2%) to general PWs, though the proportion admitted to NBUs varied substantially (range 59.9-99.0%) across hospitals, reflecting widely varying infrastructure and policies. Neonatal mortality was high in NBUs (12%) and PWs (11%), though varied widely across facilities, with documentation of outcomes poor for the NBUs. Conclusion: Improving quality of care on NBUs would affect almost a third of paediatric admissions in Kenya. However, comprehensive policies and strategies are needed to ensure sick neonates on general PWs also receive appropriate care.