A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial
Background:
In developing countries referral of severely ill children from primary care
to district hospitals is common, but hospital care is often of poor quality.
However, strategies to change multiple paediatric care practices in rural
hospitals have rarely been evaluated.
Methods and Findings:
This cluster randomized trial was conducted in eight rural Kenyan district
hospitals, four of which were randomly assigned to a full intervention aimed
at improving quality of clinical care (evidence-based guidelines, training,
job aides, local facilitation, supervision, and face-to-face feedback;
n = 4) and the remaining four to
control intervention (guidelines, didactic training, job aides, and written
feedback; n = 4). Prespecified
structure, process, and outcome indicators were measured at baseline and
during three and five 6-monthly surveys in control and intervention
hospitals, respectively. Primary outcomes were process of care measures,
assessed at 18 months postbaseline.
In both groups performance improved from baseline. Completion of admission
assessment tasks was higher in intervention sites at 18 months
(mean = 0.94 versus 0.65, adjusted difference 0.54
[95% confidence interval 0.05–0.29]). Uptake of
guideline recommended therapeutic practices was also higher within
intervention hospitals:
adoption of once daily gentamicin (89.2%
versus 74.4%; 17.1%
[8.04%–26.1%]); loading dose quinine
(91.9% versus 66.7%, 26.3% [−3.66% to
56.3%]); and adequate prescriptions of intravenous fluids for
severe dehydration (67.2% versus 40.6%; 29.9%
[10.9%–48.9%]). The proportion of children
receiving inappropriate doses of drugs in intervention hospitals was lower
(quinine dose >40 mg/kg/day; 1.0% versus 7.5%;
−6.5% [−12.9% to 0.20%]), and
inadequate gentamicin dose (2.2% versus 9.0%;
−6.8% [−11.9% to
−1.6%]).
Conclusions:
Specific efforts are needed to improve hospital care in developing countries.
A full, multifaceted intervention was associated with greater changes in
practice spanning multiple, high mortality conditions in rural Kenyan
hospitals than a partial intervention, providing one model for bridging the
evidence to practice gap and improving admission care in similar
settings.
Trial registration:
Current Controlled Trials ISRCTN42996612
: Please see later in the article for the Editors' Summary
Vyšlo v časopise:
A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial. PLoS Med 8(4): e32767. doi:10.1371/journal.pmed.1001018
Kategorie:
Research Article
prolekare.web.journal.doi_sk:
https://doi.org/10.1371/journal.pmed.1001018
Souhrn
Background:
In developing countries referral of severely ill children from primary care
to district hospitals is common, but hospital care is often of poor quality.
However, strategies to change multiple paediatric care practices in rural
hospitals have rarely been evaluated.
Methods and Findings:
This cluster randomized trial was conducted in eight rural Kenyan district
hospitals, four of which were randomly assigned to a full intervention aimed
at improving quality of clinical care (evidence-based guidelines, training,
job aides, local facilitation, supervision, and face-to-face feedback;
n = 4) and the remaining four to
control intervention (guidelines, didactic training, job aides, and written
feedback; n = 4). Prespecified
structure, process, and outcome indicators were measured at baseline and
during three and five 6-monthly surveys in control and intervention
hospitals, respectively. Primary outcomes were process of care measures,
assessed at 18 months postbaseline.
In both groups performance improved from baseline. Completion of admission
assessment tasks was higher in intervention sites at 18 months
(mean = 0.94 versus 0.65, adjusted difference 0.54
[95% confidence interval 0.05–0.29]). Uptake of
guideline recommended therapeutic practices was also higher within
intervention hospitals:
adoption of once daily gentamicin (89.2%
versus 74.4%; 17.1%
[8.04%–26.1%]); loading dose quinine
(91.9% versus 66.7%, 26.3% [−3.66% to
56.3%]); and adequate prescriptions of intravenous fluids for
severe dehydration (67.2% versus 40.6%; 29.9%
[10.9%–48.9%]). The proportion of children
receiving inappropriate doses of drugs in intervention hospitals was lower
(quinine dose >40 mg/kg/day; 1.0% versus 7.5%;
−6.5% [−12.9% to 0.20%]), and
inadequate gentamicin dose (2.2% versus 9.0%;
−6.8% [−11.9% to
−1.6%]).
Conclusions:
Specific efforts are needed to improve hospital care in developing countries.
A full, multifaceted intervention was associated with greater changes in
practice spanning multiple, high mortality conditions in rural Kenyan
hospitals than a partial intervention, providing one model for bridging the
evidence to practice gap and improving admission care in similar
settings.
Trial registration:
Current Controlled Trials ISRCTN42996612
: Please see later in the article for the Editors' Summary
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