The authors have declared that no competing interests exist.
Conceived and designed the experiments: GI ME. Performed the experiments: GI ME. Analyzed the data: GI ME JT DZ. Wrote the paper: GI ME DZ JT DG AG HK DM CM JM.
Implementation of WHO case management guidelines for serious common childhood illnesses remains a challenge in hospitals in low-income countries. The impact of locally adapted clinical practice guidelines (CPGs) on the quality-of-care of patients in tertiary hospitals has rarely been evaluated.
We conducted, in Kenyatta National Hospital, an uncontrolled before and after study with an attempt to explore intervention dose-effect relationships, as CPGs were disseminated and training was progressively implemented. The emergency triage, assessment and treatment plus admission care (ETAT+) training and locally adapted CPGs targeted common, serious childhood illnesses. We compared performance in the pre-intervention (2005) and post-intervention periods (2009) using quality indicators for three diseases: pneumonia, dehydration and severe malnutrition. The indicators spanned four domains in the continuum of care namely assessment, classification, treatment, and follow-up care in the initial 48 hours of admission. In the pre-intervention period patients' care was largely inconsistent with the guidelines, with nine of the 15 key indicators having performance of below 10%. The intervention produced a marked improvement in guideline adherence with an absolute effect size of over 20% observed in seven of the 15 key indicators; three of which had an effect size of over 50%. However, for all the five indicators that required sustained team effort performance continued to be poor, at less than 10%, in the post-intervention period. Data from the five-year period (2005–09) suggest some dose dependency though the adoption rate of the best-practices varied across diseases and over time.
Active dissemination of locally adapted clinical guidelines for common serious childhood illnesses can achieve a significant impact on documented clinical practices, particularly for tasks that rely on competence of individual clinicians. However, more attention must be given to broader implementation strategies that also target institutional and organisational aspects of service delivery to further enhance quality-of-care.
Despite availability of World Health Organization (WHO) case management guidelines, studies in low-income settings continue to identify poor health workers' compliance with evidence-based standards and poor follow-up care as some of the problems facing paediatric service delivery
In an effort to reduce childhood mortality in hospitals in Kenya, the Ministry of Health in collaboration with stakeholders developed ‘
Though the CPGs and ETAT+ were initially intended for district hospitals, they were in demand also at higher level hospitals
This was an uncontrolled before and after design that included an attempt to explore any intervention dose-effect relationship. We applied this design because of the absence of comparable tertiary hospitals in Kenya.
The study was conducted in KNH, a tertiary level hospital and a teaching hospital for the University of Nairobi (UoN) Medical School and other healthcare training institutions. KNH is the second largest hospital in Africa with a bed capacity of 1,800. The general paediatric wards have total capacity of 240 beds although the bed occupancy is often over 100%. There are 14,000 paediatric admissions annually. Sixty to seventy five trainee paediatricians who are enrolled in a three year postgraduate paediatric training programme in the UoN, provide most clinical in-patient care. They are normally supervised by 25 paediatricians. There are 126 qualified nurses who provide care on the four general paediatric wards – twelve to twenty nurses per shift. After initial emergency clerkship and initiation of life-saving treatments at the Paediatric Emergency Unit, all seriously sick patients are admitted to the wards and reviewed by a trainee paediatrician who provides the initial management plan.
We focussed on medical records of patients with any of the three discharge diagnoses: pneumonia, dehydration (due to diarrhoea) and severe malnutrition. These three diseases have a high disease burden, high case fatality and explicit WHO/Kenyan guidelines for their case management that have largely remained unchanged since 2000. The primary intervention consisted of provision and wide dissemination of CPG booklets linked to a 5 day ETAT+ training targeting clinical and nursing care providers. CPG booklets and training were provided at no charge to KNH. ETAT+ training was escalated in response to demand rather than as part of an overarching strategy. In this before and after intervention study, we define a pre-intervention period as from January to December 2005 – before any introduction of CPGs or ETAT+ training; and a post-intervention period as from January to December 2009 when all junior clinicians, 70% of consultants, and 60% of nurses were already trained in ETAT+ (
We aimed to study 280 randomly selected medical records per year per disease (70 records per disease per quarter). This would detect an increase in correct practice for each disease from 50% in the pre-intervention period to 65% in the post-intervention period, significant at the 5% level with 90% power (with no adjustment for multiple comparisons). We used a modified multistage random sampling of eligible medical records to select episodes of illness treatment for the three target diseases. It is possible that a re-admitted child or one diagnosed with both pneumonia and dehydration was randomly included in more than one diagnostic group but only one diagnostic episode was assessed per admission. Patients with co-morbidity or complications that rendered treatment in accordance with CPGs inappropriate were excluded. Details of the process of selection of the study population including a full description of the inclusion and exclusion criteria are provided elsewhere (
Data were collected from free text medical records for the period January 2005– December 2009 using a direct electronic data entry tool and detailed standard operating procedures. Data entry used a web scripting language (Hypertext Pre-processor, PHP) with a Structured Query Language database (MySQL) backend (
The primary effectiveness measures were 15 disease-specific process of care indicators. Performance indicators for this study were derived from the CPGs and ETAT+ programme after adaptation by the hospital staff in a consensus conference held in July 2008 using the modified nominal group technique
Domain of care | Criteria for considering the composite indicator achieved | Pneumonia | Dehydration | Severe malnutrition |
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Patient adequately assessed if all the following signs are assessed | Level of consciousness ability to drink |
Level of consciousness, pulse character |
Oedema, and weight for height Z-score or visual assessment of degree of severe wasting |
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Consistent with CPGs/ETAT+ if any the corresponding terms are used | Very severe pneumonia, severe pneumonia, | Shock, severe dehydration, some dehydration and no dehydration | Severe malnutrition, oedematous malnutrition, protein energy malnutrition, marasmic kwashiorkor, kwashiorkor marasmus |
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Consistent with CPGs if the following key treatment was prescribed at the correct dose and frequency (and duration for rehydration therapy) | Crystalline penicillin 50,000units/kg/dose X 4 per day (+/−20%) and/or Gentamicin 7.5 mg/kg/day X 1 per day (+/−20%) | Hartman's solution |
100–130 mls/kg/day (+/−20%) of F75 |
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Consistent with WHO/Kenya guidelines as adapted by the hospital staff | Evidence that doses of Crystalline penicillin were given as prescribed in the first 48 hrs of admission |
Evidence that intravenous fluid (IV) therapy for severe dehydration was monitored | Evidence that intake of feeds for severe malnutrition was monitored |
Patients documented to have altered consciousness were assumed that they are not able to drink if ability to drink is not documented while patients documented in the history as able to drink were assumed to have the sign ‘able to drink’.
Patients documented as able to drink or alert were assumed not to have a weak pulse if pulse character was not documented.
was either a manufactured product (depending on the availability) or milk-based solution prepared in the hospital that provided 75kcal and 0.9g of protein/100 ml.
If dextrose added, correct if given at 2.4–6.0 mg/kg/min (approximates dextrose requirement for a sick child 3–5 mg/kg/min; +/−20%).
Initial treatment is considered given on time if it is given within 12 hours of admission on the ward.
The definitions of the performance measures were based on KNH's adaptation of WHO/Kenya case management guidelines
All statistical analyses were carried out in STATA Version 11 (StataCorp, College Station, Texas). We present the results for each domain of care for each disease separately. However, as there were fewer critically sick patients, data for all diseases are combined for these analyses. Written consent was not obtained from the patients for their information to be stored in the hospital database and used for research as no such policy exists in the hospital. The data were thus analyzed anonymously.
Patient characteristics are summarized as percentages with 95% confidence intervals (95% CI) or medians with inter-quartile range, as appropriate. Chi-square tests were used to compare categorical variables, and parametric (ANOVA) or nonparametric (Kruskal Wallis) tests were used to compare continuous variables with a normal or skewed distribution respectively.
We report performance of the composite indicators, dichotomised as achieved or not achieved, in pre-intervention (2005) and post-intervention (2009) periods with the primary effect being the absolute percentage change. We refer to an effect size of 50% or greater as very large, 20% to 49% as large, 10 to 19% as moderate, and below 10% as small based on previously used classifications
We used chi-squared tests for trend to explore performance of the disease specific composite indicators across the four study periods. We excluded indicators for follow-up care of the critically sick children in this analysis because of small sample size.
Ethical approval was provided by the Kenyatta National Hospital/University of Nairobi Ethics and Research Committee (reference number KNH-ERC/01/480). Although case records from which data were abstracted had names, data collected were de-identified and unique study patient identifiers created. Further, this study was classified as audit and therefore informed consent from the participants was not found necessary by the institutional ethics reviews committee.
The retrieval rate of the sampled medical records was over 80% and there was no major variation across the study quarters for the three target diseases (data not shown). Of the medical records retrieved, 31% (1429/4577) of those with a discharge diagnosis of pneumonia, 51% (1536/3012) with dehydration, and 58% (1119/1922) with severe malnutrition were eligible for the inclusion. Common reasons for exclusion were presence of a co-morbidity that prompted treatment not consistent with the CPGs: i) For pneumonia cases: co-morbidities such as wheezy conditions, possible meningitis and severe malnutrition; ii) For dehydration cases: persistent diarrhoea or severe malnutrition and, iii) For severe malnutrition cases: known HIV infection or possible meningitis.
There was a substantial improvement in the use of CPG (and WHO) suggested syndromic classification of illnesses and in the documentation of key clinical signs during the study period (
Target disease | Illness classification | 2005 n (%) | 2006 n (%) | 2007 n (%) | 2008 n (%) | 2009 n (%) |
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Very severe pneumonia | 3/265 (1.1%) | 4/283 (1.3%) | 15/259 (5.8%) | 26/312 (8.3%) | 53/293 (18.1%) | |
Severe pneumonia | 40/265 (15.1%) | 45/283 (15.0%) | 92/259 (35.5%) | 129/312 (41.4%) | 166/293 (56.7%) | |
Not classified |
222/265 (83.8%) | 251/283 (83.7%) | 152/259 (58.7%) | 157/312 (50.3%) | 74/293 (25.3%) | |
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Shock | 0/296 (0%) | 5/308 (1.6%) | 13/303 (4.3%) | 8/334 (2.4%) | 25/294 (8.5%) | |
Severe dehydration | 82/296 (27.6%) | 80/308 (26.0%) | 128/303 (42.2%) | 120/334 (36.0%) | 155/294 (52.7%) | |
Some dehydration | 139/296 (46.8%) | 121/308 (39.3%) | 116/303 (38.3%) | 144/334 (43.4%) | 79/294 (26.9%) | |
No dehydration | 1/296 (0.3%) | 4/308 (1.3%) | 9/303 (3.0%) | 26/334 (7.8%) | 7/294 (2.4%) | |
Not classified |
75/296 (25.3%) | 98/308 (31.8%) | 37/303 (12.2%) | 35/334 (10.5%) | 28/294 (9.5%) | |
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Severe malnutrition |
216/274 (78.8%) | 172/223 (77.1%) | 194/246 (78.9%) | 135/179 (75.4%) | 160/197 (81.2%) | |
Not classified |
58/274 (21.2%) | 51/223 (22.9%) | 52/246 (21.1%) | 44/179 (24.6%) | 37/197 (18.8%) |
Not classified' means a diagnostic label captured by the target disease inclusion criteria but not consistent with ETAT+ terms was used.
Includes pneumonia, bronchopneumonia and lobar pneumonia.
Includes gastroenteritis and dehydration.
Includes severe malnutrition, marasmus, marasmic kwashiorkor, kwashiorkor, oedematous malnutrition and protein energy malnutrition.
There were more males than females with pneumonia in the pre-intervention period (59.6%) than in the post-intervention period (46.1%, p = 0.001). This pattern was consistent with that of the hospital data base of all pneumonia patients admitted in the corresponding periods. For dehydration, patients in the pre-intervention period were marginally younger (Kruskal-Wallis test, p = 0.003), of lower weight (Kruskal-Wallis test, p = 0.004) and had a longer duration of diarrhoea (Kruskal-Wallis test, p = 0.016) before seeking care in KNH than those in the post-intervention period. Patients with severe malnutrition in the pre-intervention period were older (p = 0.015) and marginally heavier (Kruskal-Wallis test, p = 0.056) than those in the post-intervention period (
Target disease | Patients characteristics | 2005 | 2006 | 2007 | 2008 | 2009 | |
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Male n (% ) | 158/265 (59.6%) | 174/300 (58.0%) | 144/259 (55.6%) | 172/312 (55.1%) | 135/293 (46.1%) | 0.001 |
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Median (IQR)age in months | 8 (4–14) | 8(5–14) | 8 (4–14) |
8 (5–15) | 7 (4–14) | 0.89 |
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Median(IQR weight)in kilograms | 7.0 (5.5–9.0) |
7.1 (5.7–9.0) |
7.2 (6.1–8.7) | 7.1 |
7.0 (5.7–9.0) | 0.69 |
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Median (IQR) duration of cough in days | 4 (3–7) | 4 (3–7) | 4 (3–7) | 4(3–7) | 4 (3–7) | 0.28 |
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Male n (% ) | 156/297 (52.5%) | 182/308 (59.1%) | 165/303 (54.5%) | 194/334 (58.1%) | 139/294 (47.3%) | 0.200 |
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Median age in months (IQR) | 7(5–11) | 8 (5–12) | 9(5–14) | 8(6–12) | 9(6–12) | 0.003 |
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Median weight in kilogram (IQR) |
7.0 (5.9–8.1) | 7.2 (6.0–8.4) | 7.2 (6.2–8.5) |
7.3 (6.1–8.5) |
7.4 (6.3–8.6) |
0.004 |
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Median duration (IQR) of diarrhoea in days | 4(3–6) | 3 (2–5) | 3 (2.5–5) | 3(3–5) | 3 (2–5) | 0.016 |
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Male n (% ) | 130/274 (47.5%) | 117/223 (52.5%) | 124/246 (50.4%) | 79/179 (44.1%) | 82/197 (41.6%) | 0.21 |
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Median (IQR) age in months | 14 (10–22) | 12 (9–18) | 12 (9–17) | 14 (9–20) | 13 (9–18) | 0.015 |
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Median (IQR) weight in kilogram |
6.5 (5.5–8.0) |
6.0 (5.2–7.0) | 6.0 (5.1–7.0) |
6.0 (5.2–7.3) | 6.3 (5.3–7.3) | 0.056 |
Chi square test.
Kruskal Wallis test.
Denominator does not include three patients with missing values.
Denominator does not include one patient with missing values.
The intervention produced large improvement of the composite indicators for assessment of pneumonia (+27.1%, 95% CI: +21.7 to +32.6%) and dehydration (+23.5%, 95% CI: +18.6 to +28.3%). There was also a large improvement in classification of severity of pneumonia syndromes (+58.5%, 95% CI: +51.9 to +65.2) and a modest improvement for dehydration (+15.7%, 95% CI: +9.8 to +21.7). Nevertheless, the signs used in classification were not always consistent with CPGs recommendation. For example, 18/40 (45.0%) and 35/166 (21.1%) of patients classified as severe pneumonia in pre-intervention period and post-intervention periods respectively had one or more features of very severe pneumonia (altered consciousness, inability to drink or cyanosis). The intervention did not result in significant changes in the assessment or classification of patients with severe malnutrition (
Domain of care | Composite and individual indicators | Patients who achieved the indicator in the pre-intervention period n (%,95% CI) | Patients who achieved the indicator in the post-intervention period n (%,95% CI) | Effect size – absolute difference in percentage %; (95% CI) | |
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Level of consciousness | 58/265 (21.9%; 17.1–27.4) | 218/293 (74.4%; 69.0–79.3) | |||
Ability to drink | 100/265 (37.7%; 31.9–43.9) | 155/293 (52.9; 47.0–58.7) | |||
Cyanosis | 164/265 (61.9%; 55.7–67.8) | 220/293 (75.1%; 69.7–79.9) | |||
Lower chest wall indrawing | 49/265 (18.5%; 14.0–23.7) | 238/293 (81.2%; 76.3–85.5) | |||
Respiratory rate | 206/265 (77.7%; 72.2–82.6) | 255/293 (87.0%; 82.6–90.7) | |||
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Level of consciousness | 169/297 (56.9%; 51.1–62.6) | 247/294 (84.0%; 79.3–88.0) | |||
Ability to drinkb | 88/297 (29.6%; 24.5–35.2) | 136/294 (46.3%; 40.5–52.1) | |||
Pulse character | 74/297 (24.9%; 20.1–30.2) | 250/294 (85.0%; 80.4–88.9) | |||
Sunken eyes | 86/297 (29.0%; 23.8–34.5) | 206/294 (70.1%; 64.5–75.2) | |||
Skin turgor | 19/297 (6.4%; 3.9–9.8) | 211/294 (71.8%; 66.3–76.8) | |||
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Oedema | 193/274 (70.4%; 64.7–75.8) | 126/197 (64.0%; 56.8–70.7) | |||
Visible severe wasting | 161/274 (58.8%; 52.7–64.7) | 103/197 (52.3%; 45.1–59.4) | |||
Height | 0/274 (0%; N/A) | 51/197 (25.9%; 19.9–23.6) | |||
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Among children with pneumonia, prescription of correct dosages of crystalline penicillin improved from 51.7% in 2005 to 90% in 2009 (
Composite and corresponding individual tasks indicators | Patients whose treatment was consistent with CPGs in the pre-intervention period n(%; 95% CI) | Patients whose treatment was consistent with CPGs in the post-intervention period n (%; 95% CI) | Effect size – difference in percentage % (95% CI) | ||
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Patients who received less that 80% of the recommended dose of crystalline penicillin | 104/265 (39.2%, 33.3–45.4) | 6/287 (2.1%; 0.7–4.4) | |||
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Frequency of gentamicin consistent with ETAT+ guidelines | 46/191 (24.1%; 18.2–30.8) | 138/140 (98.6%; 94.9–99.8) | |||
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Type of IVF consistent with CPGs | 219/265 (82.6%; 77.5–87.0) | 251/286 (87.8%; 83.4–91.3) | |||
Volume of IVF consistent with CPGs | 160/265 (60.4%;54.2–66.3) | 205/286 (71.7%; 66.1–76.8) | |||
Duration of IVF consistent with CPGs | 147/265 (55.5%; 49.3–61.6%) | 213/286 (74.5%; 69.0–79.4) | |||
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Patients with feeds prescribed | 233/274 (85.0%; 80.3–89.0) | 176/197(89.3%; 84.2–93.3) | |||
Type of feed consistent with CPGs | 31/233 (13.3%; 9.2–18.4) | 142/176 (80.7%; 74.1–86.2) | |||
Volume of consistent with CPGs | 124/233 (53.2%; 47.0–60.2) | 158/176 (89.8%; 84.3–93.8) |
Chi square test.
Composite indicator; achieved if dose and frequency of crystalline penicillin is consistent with CPGs.
Composite indicator; achieved if dose and frequency of gentamicin is consistent with CPGs.
Composite indicator; achieved if type, volume and duration of IVF is consistent with CPGs.
22 records for 2005 and 3 for 2009 were excluded in the analysis for treatment due to serum sodium >145 or <135 mmol/l. In addition 11 and 5 records in 2005 and 2009 respectively were excluded because there was no evidence that IVF was continued on the ward and diagnosis of either some dehydration or no dehydration was made.
Composite indicator; achieved if type and volume of feeds for severe malnutrition is consistent with CPGs.
Correct intravenous fluid therapy for dehydrated patients was prescribed for 37.7% of children in 2005 and 61.8% of children in 2009 giving an effect size of +24.2% (95% CI: +16.0 to 32.3). Majority of patients (>85%) with severe malnutrition had feeds prescribed on admission in both the pre-intervention and post-intervention periods. However, the intervention resulted in a very large improvement (+59.5%, 95% CI: +52.1 to +66.7) in the correctness of these prescriptions (
Despite improvement in prescription practices, documentation that prescribed treatment was administered in the first 48 hours of admission remained poor in both pre-intervention and post intervention periods (
Task in administration of treatment | Patients who had the task achieved in pre-intervention period n (%; 95% CI) | Patients who had the task achieved in post-intervention period. n (%; 95% CI) | effect size – difference in percentage % (95% CI) | |
Evidence that 8 doses crystalline was given for children with pneumonia |
20/154 (13.0%; 7.6–18.4) | 31 (16.6%; 11.2–22.0) | +3.6% (−3.9 to +11.1) | 0.36 |
Median doses of crystalline penicillin (IQR) given for children with pneumonia |
5.5 (4.5–7.0) | 6.5 (5.5–7.5) | - | 0.54 |
Intravenous fluid therapy for severe dehydration monitored |
2/285 (0.7%; 0.9–2.5) | 16/285 (5.6%; 3.2–9.0) | +4.9% (+2.1 to +7.8) | 0.001 |
Patients with severe malnutrition that had feeds prescribed and whose feeds intake was documented in the feed chart |
3/223 (1.3%; −0.2 to 2.9) | 13/170 (7.6%; 3.6–11.7) | +6.3% (+2.0 to +10.6) | 0.002 |
Analysis restricted to patients alive after 2 days, crystalline penicillin prescribed as four times a day and not stopped during the first 2 days of admission.
Chi square test.
Kruskal Wallis test.
Analysis restricted to patients with evidence that intravenous fluid (IVF) was prescribed on the ward and were alive after one day of admission.
Analysis restricted to patients who had feed prescribed and were alive after 1 day of admission.
Eleven per cent (93/836) of all study patients in the pre-intervention period and 6% (45/784) of patients in the post-intervention period were critically sick. Documented review of the patients by both nurses and clinicians in the first 48hrs of admission was very poor in both pre-intervention and post-intervention periods (
Composite indicator | Individual task | Patients who had the task/indicator achieved in the pre-intervention period n (%; 95% CI) | Patients who had the task/indicator achieved in the post-intervention period n (%; 95% CI) | effect size – difference in percentage % (95% CI) | |
Nurses' review and documentation of vital signs |
6houly review of vital signs |
1/93 (1.1%; 0.0 to −5.8) | 3/45 (6.7%; 1.4–18.2) | +5.6% (−2.0 to +13.2) | 0.066 |
Temperature | 1/93 (1.1%; 0.0 to −5.8) | 3/45 (6.7%; 1.4–18.2) | |||
Respiratory rate | 1/93 (1.1%; 0.0 to −5.8) | 3/45 (6.7%; 1.4–18.2) | |||
Pulse rate | 1/93 (1.1%; 0.0 to −5.8) | 3/45 (6.7%; 1.4–18.2) | |||
Clinicians' review |
Review of the critically sick patients 12hrly | 4/93 (4.3%; 1.2–10.6) | 2/45 (4.4%; 0.5–15.1) | 0.1% (−7.2 to +7.4) | 0.96 |
Clinicians review 6hrs before death | 21/93 (22.6%; 14.6–32.4) | 17/45 (37.8%; 23.8–53.5) |
Analysis restricted to patients who died within 5 days of admission but were alive on the first day of admission.
All the three vital signs (temperature, pulse and respiratory rate) assessed.
Chi square test.
Though this study was not designed to evaluate change in mortality rate, the mortality rate for children admitted with pneumonia dropped from 15.1% (40/265) in the pre-intervention period to 6.5% (19/293) in the post-intervention period. Mortality for children admitted with dehydration dropped from 17.9% (53/297) to 8.8% (26/294). Mortality rate for severe malnutrition dropped from 29.9% (82/284) to 22.3% (44/197). However, as explained above, inadequate case data precluded attempts to explore whether changing case-severity contributed to these reductions. Overall, deaths amongst children admitted with the target diseases that occurred in the first 48 hours of admission accounted for 45.1% (79/175) 49.4% (44/89) deaths in the pre-intervention and post-intervention periods respectively.
There was consistent improvement of performance for 10/13 of the composite indicators assessed over the four sequential periods (
Target disease | Composite indicator | Period 0 Proportion (%, 95% CI) | Period 1 Proportion (%, 95% CI) | Period 2 Proportion (%, 95% CI) | Period 3 Proportion (%, 95% CI) | P-value of chi squared for trend |
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Adequately assessed | 5/265 (1.9%; 0.6–4.3%) | 5/300 (1.7%; 0.5–3.8%) | 62/403 (15.4%;12.0–19.2%) | 107/461 (23.2%;19.4–27.3%) | <0.001 | |
correctly classified | 43/265 (16.2%; 12.0–21.2%) | 49/300 (16.3%;12.3–21.0) | 178/403 (44.2%; 39.3–49.1%) | 303/461 (65.7%; 61.2–70.1%) | <0.001 | |
Dose of crystalline penicillin consistent with CPGs | 137/265 (51.7%; 45.5–57.9%) | 209/300 (69.7%; 64.1–74.8%) | 343/399 (86.0%; 82.2–89.2) | 409/452 (90.5%; 87.4–93.0%) | <0.001 | |
Dose of gentamicin consistent with CPGs | 38/191(19.9%;14.5–26.3%) | 167/243(68.7%; 62.5–74.5%) | 175/242 (72.3%; 66.2–77.9%) | 221/244 (90.6%; 86.2–93.9%) | <0.001 | |
Administration of crystalline penicillin | 20/154 (13.0%; 8.1–19.3%) | 20/163 (12.3%; 7.7–18.3%) | 19/216 (8.8%; 5.4–13.4%) | 43/275 (15.6%; 11.6–20.5%) | 0.463 | |
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Adequately assessed | 0/297 | 1/308 (0.3%; 0.0–1.8%) | 45/490 (9.2%; 6.8–12.1%) | 108/441 (24.5%;20.5–28.9% | <0.001 | |
correctly classified | 222/297 (74.5%; 69.4–79.6%) | 210/308 (68.2%; 62.7–73.3%) | 429/490 (87.5%; 84.3–90.3%) | 402/441 (91.2; 88.1–93.6%) | <0.001 | |
IVF therapy consistent with CPGs | 100/265 (37.5%; 31.9–43.9%) | 118/290 (40.7%; 35.0–46.6%) | 249/473 (52.6%; 48.0–57.2%) | 260/422 (61.2%; 56.8–66.3%) | <0.001 | |
IVF monitored | 2/297 (0.1%; 0.1–2.4%) | 1/308 (0.3%; 0.0–1.8%) | 7/490 (1.4%; 0.58–2.92%) | 18/441 (4.1%; 2.4–6.4%) | <0.001 | |
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Adequately assessed | 120/274 (43.8; 37.8–49.9%) | 93/223 (41.7; 39.2–48.5%) | 125/335 (37.3; 32.1–42.7%) | 114/287 (39.7; 34.0–45.6%) | 0.20 | |
correctly classified | 216/274 (78.8; 73.5–83.5%) | 172/223 (77.1; 71.1–82.5%) | 264/335 (78.8%; 74.0–83.1%) | 225/287 (78.4%; 73.2–83.0%) | 0.98 | |
Feeds therapy consistent with CPGs | 25/274 (9.1; 0.6–13.2%) | 108/223 (48.4; 41.7–55.2%) | 185/335 (55.2; 49.7–60.6%) | 209/287 (72.8; 67.2–77.9%) | <0.001 | |
Feeds monitored | 3/223 (1.3; 0.2–3.9%) | 1/198 (0.5%; 0–2.7%) | 13/271 (4.8%; 2.6–8.1%) | 20/247 (8.1%; 5.0–12.2%) | <0.001 |
Before CPGs/ETAT+ training, care for common serious childhood illnesses in KNH, a university teaching hospital, was largely inconsistent with best-practice recommendations as defined by WHO and endorsed within Kenya. Only 2/15 indicators had baseline performance of over 70%, while 8/15 indicators had performance below 10%, suggesting little impact of any previous efforts to disseminate WHO and local guidelines. This poor uptake of international recommendations for care is consistent with findings in district hospitals in this country
Examination of the individual tasks aggregated into composite indicators (data not shown) allowed us to identify suboptimal health workers' practices and gave us insight into specific clinical decision-making processes. There was generally marked improvement in patient assessment. However, for assessment of pneumonia and diarrhoea, the sign ‘ability to drink’ achieved the lowest performance. This sign has not been emphasised in mainstream academic paediatric teaching, despite it being a predictor of death in seriously ill children
There was some evidence of improvements in recommended processes of care increasing with intensity (dose) of the interventions. However, the adoption rate of the best practices was variable across diseases and the study periods. Improvement in prescription practices began during piloting of the intervention. This was perhaps related to the attendance at a guidelines development workshop by some paediatric trainees where drug dose guidelines were discussed and endorsed followed by rapid informal dissemination of knowledge and CPGs amongst this clinical group
Contrary to our expectation, the composite indicator for severe malnutrition assessment, comprising only two individual tasks which we considered to be simple was not adopted and had poorer performance than those for assessment of diarrhoea and pneumonia which spanned five tasks each. This appears to defy the simple premise that the more steps in a pathway, the less likely there is to be success
It is hard to interpret the apparently large falls in case fatality rates especially as these cannot be appropriately adjusted for disease severity and there are no comparable control site data. Further, while we demonstrated improvements in domains of care studied independently the effect on patients' outcomes will likely reflect the way multiple domains of care are improved within one patient journey, something our data do not necessarily capture. Despite this our observations do raise the possibility that adherence to simple and low-cost recommendations, as stipulated in WHO case management guidelines, combined with perhaps other improvements in service provision, may reduce case fatality of common serious illnesses in tertiary care facilities, a finding consistent with other studies
Despite some improvements observed in this study, the overall frequency of errors in the management of common serious illnesses at a university teaching hospital expected to train manpower that is responsive to societal needs remains of concern. In particular, it should challenge academic staff and national professional bodies concerned with establishing and maintaining standards of expertise
Poor documentation of the care provided by the health professionals may explain, in part, the observed errors in the management. Simple approaches to improve documentation of illness that might support introduction and use of guidelines could include use of critical care pathways or standardised record forms that have proven valuable in other settings
The study had a number of limitations. First, we acknowledge that a before and after design without control data makes it difficult to infer causal relationships between the intervention and the outcomes
Secondly, when basing work on review of records we assume implicitly that the written records reflect actual practice, a potential limitation. This analysis, however, is based on indicators of practices that hospital staff felt should be documented to avoid compromising the ability of the clinical team to provide effective treatment and follow-up for patients. Further, several indicators were based on treatment prescriptions that were routinely well documented throughout the entire study period. Such prescriptions arguably provide the most robust link between a clinician's intentions and the treatment actually received.
Finally, the intervention used assumed the knowledge embodied in the CPGs is uncontested and that rationally, increased adherence to the guidelines merely requires an increase in dissemination. This model ignores the hidden or poorly illuminated values or needs that influence practitioner and organizational behaviour.
There are very few published studies evaluating the impact of dissemination of guidelines for multiple serious childhood illnesses in a large teaching hospital in a LIC. Our data complement that at outpatient level
The authors are grateful to the management and staff of Kenyatta National Hospitals, colleagues from the Department of Paediatrics (University Of Nairobi) and the KEMRI/Wellcome Trust Programme for their assistance in the conduct of this study. This work is published with the permission of the Director of KEMRI.