Performance of Health Workers in the Management of Seriously Sick Children at a Kenyan Tertiary Hospital: Before and after a Training Intervention

Abstract

BackgroundImplementation 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.Methods and FindingsWe 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.ConclusionActive 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.

Designing a theory-informed, contextually appropriate intervention strategy to improve delivery of paediatric services in Kenyan hospitals

“…The overarching approach to developing the intervention was based on four main strategies: an iterative and reflective process aiming to draw lessons from the author’s prior research [10,17,34,37,39,40,42-44] in Kenya, accompanying observations of the Kenyan health system over a period of many years, and multiple informal discussions with other researchers, policy makers, senior professionals and district hospital practitioners with the aim to distill root causes for the problems with service delivery observed; developing a broad set of intervention options to address these problems identified from literature, discussions, and experience; a search of literature for theory that provided the most appropriate basis for intervention (and evaluation) design; and repeatedly moving backwards and forwards between identified causes, proposed interventions, identified theory, and knowledge of the existing context to develop an overarching intervention that seemed the ‘best fit’ and was deemed feasible, likely to be acceptable, and potentially sustainable. Throughout this process, the following questions guided thinking: Why is widely available practice guidance not reliably being used in district hospitals?…”

Sepsis guidelines: Suggestions to improve adherence

“…Courses that are sanctioned by the World Health Organization such as the Emergency Triage Assessment and Treatment and the Integrated Management of Adolescent and Adult Illness are useful in resource poor areas and addresses critical illness as well as sepsis. 5,15 In some areas procedural skills such as obtaining vascular access and methods to deliver supplemental oxygen are lacking and need to be taught. Large visual displays of the guideline as a constant reminder with easily accessible checklists in the patient care areas are also useful to improve adherence.…”

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

“…Importantly WHO and national guidelines for management of the seriously ill child with common diseases have been available since 2000 in aggregated form and earlier in disease-specific programme guidance and provide common, basic standards for assessments across this period. In Kenya specific efforts to develop and promote these guidelines in a simple, cheap format began in 20069 with distribution of 10 000 copies in 2007/2008 and 12 000 copies in 2010/2011 10. During this period, a training programme to support use of guidelines also reached over 1500 clinicians and nurses (less than 10% of the public sector health workforce) and was integrated into undergraduate and postgraduate teaching in the largest medical school from 2008 10.…”