Research Article: A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial

Date Published: April 5, 2011

Publisher: Public Library of Science

Author(s): Philip Ayieko, Stephen Ntoburi, John Wagai, Charles Opondo, Newton Opiyo, Santau Migiro, Annah Wamae, Wycliffe Mogoa, Fred Were, Aggrey Wasunna, Greg Fegan, Grace Irimu, Mike English, Igor Rudan

Abstract: Philip Ayieko and colleagues report the outcomes of a cluster-randomized trial carried out in eight Kenyan district hospitals evaluating the effects of a complex intervention involving improved training and supervision for clinicians. They found a higher performance of hospitals assigned to the complex intervention on a variety of process of care measures, as compared to those receiving the control intervention.

Partial Text: Common illnesses including pneumonia, malaria, and diarrhea remain major contributors
to child mortality in low-income countries [1]. Hospital care of severe
illnesses may help improve survival, and disease-specific clinical guidelines have
been provided by the World Health Organization (WHO) for more than 15 y [2], and as collated
texts since 2000 [3],[4]. These guidelines form part of the Integrated Management
of Childhood Illnesses (IMCI) approach adopted by over 100 countries. However, in
contrast to its primary care aspects [5],[6], implementation
of IMCI at district hospitals has not been evaluated. Paediatric hospital care is
often inadequate in our setting and also in other low-income countries both in
Africa and Asia [7]–[10], with most inpatient deaths occurring within 48 h of
admission [11].

All hospitals participated in each survey as planned (Figure 2). The intervention’s implementation
is summarized in Table 1 and
showed that intended training for at least 32 workers (the majority were nurses) was
attained in three of the four intervention sites. No hospital received additional,
nonstudy paediatric training during the study period. Staff turnover, which was of a
like-for-like nature, was high in both intervention and control hospitals,
especially in the larger hospitals (H3 and H7). At 18 mo only, 5% (2/35) to
13% (3/23) and 0 to 26% (6/23) of frontline clinical staff in the
intervention and control hospitals, respectively, had received initial training
(Table 1). As part of
supervisory activities, the implementation team conducted an additional
10–12-h training session in two intervention hospitals and two to three small
group sessions of 2–4 h in all four intervention hospitals over the 18 mo
intervention period.

We tested an approach to implementing clinical guidelines for management of illnesses
that cause most deaths in children admitted to district hospitals in Kenya. Despite
their modest success in developed countries [15], we used a multifaceted
approach reasoning that deficiencies in knowledge, skills, motivation, resources,
and organization of care would all need to be addressed. The intervention design was
guided by experience in the setting [7],[8] and theories of change and
culture of practice [13],[15],[27]–[29]. Our baseline data and other reports [7]–[10] suggest that
the simple availability of authoritative WHO and national guidelines—for
periods of more than 15 y—are currently having little impact on hospital care
for children. So what did our interventions achieve?

Source:

http://doi.org/10.1371/journal.pmed.1001018

 

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