Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY, USA.
ImpactMatters, New York, NY, USA.
Implement Sci. 2017 Nov 6;12(1):126. doi: 10.1186/s13012-017-0654-0.
To improve management of severely ill hospitalized patients in low-income settings, the World Health Organization (WHO) established a triage tool called "Quick Check" to provide clinicians with a rapid, standardized approach to identify patients with severe illness based on recognition of abnormal vital signs. Despite the availability of these guidelines, recognition of severe illness remains challenged in low-income settings, largely as a result of infrequent vital sign monitoring.
We conducted a staggered, pre-post quasi-experimental study at four inpatient health facilities in western Uganda to assess the impact of a multi-modal intervention for improving quality of care following formal training on WHO "Quick Check" guidelines for diagnosis of severe illness in low-income settings. Intervention components were developed using the COM-B ("capability," "opportunity," and "motivation" determine "behavior") model and included clinical mentoring by an expert in severe illness care, collaborative improvement meetings with external support supervision, and continuous audits of clinical performance with structured feedback.
There were 5759 patients hospitalized from August 2014 to May 2015: 1633 were admitted before and 4126 during the intervention period. Designed to occur twice monthly, collaborative improvement meetings occurred every 2-4 weeks at each site. Clinical mentoring sessions, designed to occur monthly, occurred every 4-6 months at each site. Audit and feedback reports were implemented weekly as designed. During the intervention period, there were significant increases in the site-adjusted likelihood of initial assessment of temperature, heart rate, blood pressure, respiratory rate, mental status, and pulse oximetry. Patients admitted during the intervention period were significantly more likely to be diagnosed with sepsis (4.3 vs. 0.4%, risk ratio 10.1, 95% CI 3.0-31.0, p < 0.001) and severe respiratory distress (3.9 vs. 0.9%, risk ratio 4.5, 95% CI 1.8-10.9, p = 0.001).
Theory-informed quality improvement programs can improve vital sign collection and diagnosis of severe illness in low-income settings. Further implementation, evaluation, and scale-up of such interventions are needed to enhance hospital-based triage and severe illness management in these settings.
Severe illness management system (SIMS) intervention development, ISRCTN46976783.
为了改善低收入国家中重病住院患者的管理，世界卫生组织（WHO）制定了一种名为“快速检查”的分诊工具，为临床医生提供一种快速、标准化的方法，根据识别异常生命体征来识别患有重病的患者。尽管有这些指南，但在低收入国家，严重疾病的识别仍然具有挑战性，主要是因为生命体征监测不频繁。
我们在乌干达西部的四家住院医疗机构进行了分期、前后准实验研究，以评估一种多模式干预措施对改善在低收入国家根据世界卫生组织“快速检查”指南诊断严重疾病的正式培训后的护理质量的影响。干预措施的组成部分是使用 COM-B（“能力”、“机会”和“动机”决定“行为”）模型开发的，包括由严重疾病护理专家进行的临床指导、与外部支持监督的合作改进会议，以及通过结构化反馈进行的临床绩效持续审计。
2014 年 8 月至 2015 年 5 月期间有 5759 名患者住院：1633 名在干预前入院，4126 名在干预期间入院。协作改进会议计划每两个月举行一次，每次在每个地点举行 2-4 周。临床指导课程计划每月举行一次，每次在每个地点举行 4-6 个月。审计和反馈报告按计划每周实施。在干预期间，初始评估体温、心率、血压、呼吸频率、精神状态和脉搏血氧饱和度的可能性显著增加。在干预期间入院的患者被诊断为败血症的可能性显著增加（4.3%比 0.4%，风险比 10.1，95%CI 3.0-31.0，p<0.001）和严重呼吸窘迫（3.9%比 0.9%，风险比 4.5，95%CI 1.8-10.9，p=0.001）。
基于理论的质量改进计划可以提高低收入国家的生命体征采集和严重疾病的诊断。需要进一步实施、评估和扩大此类干预措施，以加强这些环境中的医院分诊和严重疾病管理。
严重疾病管理系统（SIMS）干预措施的发展，ISRCTN46976783。
