London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
School of Population Health & Environmental Sciences, King's College London, London, SE1 1UL, UK.
BMC Infect Dis. 2019 Jan 11;19(1):45. doi: 10.1186/s12879-019-3680-5.
Malaysia has rising dengue incidence. World Health Organization clinical practice guidelines for managing dengue have been adapted by the Ministry of Health in Malaysia, with evidence of good awareness by clinicians. However, dengue mortality has not reduced. This study aimed to explore the challenges of dengue management for Medical Officers, with a particular focus on use of clinical practice guidelines.
Qualitative study using six focus groups and 14 semi-structured interviews with doctors responsible for dengue management at a large tertiary hospital in Malaysia.
Dengue was recognised as difficult to diagnose and manage. Wide awareness and use of both WHO and Ministry of Health guidelines was reported, but several limitations noted in their coverage of particular patient groups. However, the phrase 'guidelines' also referred to local algorithms for fluid management, which were less clinically evidence-based. Where Medical Officers were well trained in the appropriate use of evidence-based guidelines, barriers to use included: the potential for 'following the algorithm' to undermine junior clinicians' claims to clinical expertise; inability to recognise the pattern of clinical progress; and lack of clinical experience. Other reported barriers to improved case management were resource constraints, poor referral practices, and insufficient awareness of the need for timely help seeking.
Awareness of clinical practice guidelines is a necessary, but not sufficient, condition for optimal dengue management. In high prevalence settings, all clinical staff would benefit from regular dengue management training which should include diagnosis, practice in monitoring disease progression and the use of clinical practice guidelines in a range of clinical contexts.
马来西亚登革热发病率上升。马来西亚卫生部已对世界卫生组织的登革热临床实践指南进行了改编，临床医生对此有很好的认识。然而，登革热死亡率并没有降低。本研究旨在探讨马来西亚医疗官员在登革热管理方面面临的挑战，特别关注临床实践指南的使用。
采用定性研究方法，在马来西亚一家大型三级医院对负责登革热管理的医生进行了 6 个焦点小组和 14 次半结构化访谈。
登革热的诊断和管理具有难度，医生报告说广泛了解并使用了世卫组织和卫生部的指南，但也注意到这些指南在涵盖特定患者群体方面存在一些局限性。然而，“指南”一词也指用于液体管理的本地算法，这些算法的临床证据基础较差。如果医疗官员接受过适当使用循证指南的培训，那么使用指南的障碍包括：“遵循算法”可能会削弱初级临床医生对临床专业知识的主张；无法识别临床进展模式；以及缺乏临床经验。其他报告的病例管理改进障碍包括资源限制、转诊实践不佳以及对及时寻求帮助的必要性认识不足。
了解临床实践指南是优化登革热管理的必要条件，但不是充分条件。在高流行地区，所有临床工作人员都将受益于定期的登革热管理培训，培训内容应包括诊断、监测疾病进展的实践以及在各种临床情况下使用临床实践指南。
