KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
PLoS Med. 2011 Apr;8(4):e1001018. doi: 10.1371/journal.pmed.1001018. Epub 2011 Apr 5.
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.
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%]).
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.
在发展中国家，将重病儿童从初级保健机构转诊到区医院是很常见的，但医院的护理质量往往很差。然而，很少有策略来改变农村医院的多种儿科护理实践。
这是一项在肯尼亚 8 家农村地区医院进行的集群随机试验，其中 4 家被随机分配到旨在改善临床护理质量的全面干预组（基于证据的指南、培训、工作辅助工具、当地促进、监督和面对面反馈；n = 4），其余 4 家分配到对照组（指南、教学培训、工作辅助工具和书面反馈；n = 4）。在对照组和干预组的医院，分别在基线时和三个和五个每 6 个月的调查中测量预先指定的结构、过程和结果指标。主要结果是在基线后 18 个月评估的护理过程措施。在两组中，从基线开始，绩效都有所提高。在干预组中，入院评估任务的完成情况在 18 个月时更高（平均值= 0.94 比 0.65，调整后的差异为 0.54 [95%置信区间 0.05-0.29]）。在干预医院中，指南推荐的治疗实践的采用率也更高：采用每日一次庆大霉素（89.2%比 74.4%；17.1%[8.04%-26.1%]）；负荷剂量奎宁（91.9%比 66.7%，26.3%[-3.66%至 56.3%]）；以及严重脱水时静脉输液的适当处方（67.2%比 40.6%；29.9%[10.9%-48.9%]）。接受干预医院不适当剂量药物的儿童比例较低（奎宁剂量>40 mg/kg/天；1.0%比 7.5%；-6.5%[-12.9%至 0.20%]），以及庆大霉素剂量不足（2.2%比 9.0%；-6.8%[-11.9%至-1.6%]）。
需要采取具体措施来改善发展中国家的医院护理。与部分干预相比，全面、多方面的干预与农村肯尼亚医院多种高死亡率疾病的实践变化更大，为弥合证据与实践之间的差距和改善类似环境下的入院护理提供了一种模式。
