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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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Štítky
Interné lekárstvo

Článok vyšiel v časopise

PLOS Medicine


2011 Číslo 4
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