Implementing WHO hospital guidelines improves quality of paediatric care in central hospitals in Lao PDR

Abstract

Abstractobjectives To evaluate the impact of implementing a multifaceted intervention based on the WHO Pocketbook of Hospital Care for Children on the quality of case management of common childhood illnesses in hospitals in Lao PDR.methods The quality of case management of four sentinel conditions was assessed in three central hospitals before and after the implementation of the WHO Pocketbook as part of a broader mixedmethods study. Data on performance of key steps in case management in more than 600 admissions were collected by medical record abstraction pre-and post-intervention, and change was measured according to the proportion of cases which key steps were performed as well as an overall score of case management for each condition.results Improvements in mean case management scores were observed post-intervention for three of the four conditions, with the greatest change in pneumonia (53-91%), followed by diarrhoea and low birthweight. Rational drug prescribing, appropriate use of IV fluids and appropriate monitoring all occurred more frequently post-intervention. Non-recommended practices such as prescription of antitussives became less frequent.conclusions A multifaceted intervention based on the WHO Pocketbook of Hospital Care for children led to better paediatric care in central Lao hospitals. The degree of improvement was dependent on the condition assessed.keywords clinical guidelines, quality of care, paediatric, Lao PDR

A Qualitative Study of Provider Perceptions of Influences on Uptake of Pediatric Hospital Guidelines in Lao PDR

“…14,24,25,27,32 The facilitators and barriers identified in this study are important influences on our intervention overall. Greater value comes from triangulating them with our quantitative findings, which showed greatest improvement in pneumonia case management, with less change in diarrhea and other diseases 7 (Figure 2). Changes in pneumonia management were facilitated by an absence of existing agreed hospital guidelines for pneumonia, by the guidelines implemented being simple and algorithmic to follow and compatible with existing provider practice of prescribing antibiotics and patient expectations ( Figure 2A).…”

“…Perceptions of change correlate well with the previously reported quantitative findings from the evaluation of guideline implementation which demonstrated improved quality of case management, both overall and in specific areas including rational drug and fluid prescribing. 7 This research primarily highlights facilitators of change in contrast to much of the literature, which focuses on barriers. 8,20,[24][25][26][27][28] A key guideline factor was physical accessibility.…”

“…We used driver diagrams to triangulate our findings with our previously reported quantitative outcomes. 7 Driver diagrams are a quality improvement tool used to visualize how barriers and facilitators of improving care interact within a health system. 22 They have been proposed as a potential tool for considering why or how an intervention works, and to highlight variation in contextual factors between sites of implementation.…”

“…Although significant resources have been invested in the development of the guidelines, their implementation has not been systematic and the impact on quality of care is not well understood. 6,7 At the heart of interventions to improve care is the need to change clinical behavior and extensive literature, from developed and developing countries, attests that this is difficult. Interventions, such as guidelines, often have modest and variable impact on clinical practices.…”

“…There was, however, variation in the degree of change for different diseases-large change seen for pneumonia, and moderate change for diarrhea. 7 In this qualitative study, we aimed to identify contextual factors that influenced uptake of clinical guidelines and their impact on practice.…”