Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya.
PLoS One. 2012;7(7):e39964. doi: 10.1371/journal.pone.0039964. Epub 2012 Jul 31.
Implementation 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.
We 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.
Active 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.
在低收入国家的医院中，实施世界卫生组织（WHO）针对严重常见儿童疾病的病例管理指南仍然是一项挑战。针对三级医院患者，当地适应性临床实践指南（CPG）对医疗质量的影响很少得到评估。
我们在肯尼亚国家医院进行了一项无对照的前后研究，试图探索干预剂量-效应关系，因为 CPG 得到了传播，培训也在逐步实施。紧急分诊、评估和治疗加入院护理（ETAT+）培训和当地适应性 CPG 针对常见的严重儿童疾病。我们使用三种疾病的质量指标比较了干预前（2005 年）和干预后（2009 年）的表现：肺炎、脱水和严重营养不良。这些指标涵盖了入院后最初 48 小时护理连续体的四个领域，即评估、分类、治疗和随访护理。在干预前，患者的护理在很大程度上不符合指南，15 个关键指标中有 9 个的表现低于 10%。干预措施显著提高了指南的遵守率，在 15 个关键指标中有 7 个指标的绝对效应大小超过 20%；其中 3 个指标的效应大小超过 50%。然而，对于所有五个需要持续团队努力的指标，在干预后阶段，表现仍较差，低于 10%。在 2005-09 年的五年期间，数据表明存在一定的剂量依赖性，尽管最佳实践的采用率因疾病和时间而异。
积极传播针对常见严重儿童疾病的当地适应性临床指南可以对记录的临床实践产生重大影响，特别是对于依赖个体临床医生能力的任务。然而，必须更加关注更广泛的实施策略，这些策略也针对服务提供的机构和组织方面，以进一步提高医疗质量。
