Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda.
Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda.
PLoS One. 2019 Jan 25;14(1):e0210982. doi: 10.1371/journal.pone.0210982. eCollection 2019.
In resource limited settings, there is variability in the level of adherence to clinical guidelines in the inpatient management of children with common conditions like severe anemia. However, there is limited data on the effect of adherence to clinical guidelines on inpatient mortality in children managed for severe anemia.
We analyzed data from an uncontrolled before and after in-service training intervention to improve quality of care in Lira and Jinja regional referral hospitals in Uganda. Inpatient records of children aged 0 to 5 years managed as cases of 'severe anemia (SA)' were reviewed to ascertain adherence to clinical guidelines and compare inpatient deaths in SA children managed versus those not managed according to clinical guidelines. Logistic regression analysis was conducted to evaluate the relationship between clinical care factors and inpatient deaths amongst patients managed for SA.
A total of 1,131 children were assigned a clinical diagnosis of 'severe anemia' in the two hospitals. There was improvement in the level of care after the in-service training intervention with more children being managed according to clinical guidelines compared to the period before, 218/510 (42.7%) vs 158/621 (25.4%) (p < 0.001). Overall, children managed according to clinical guidelines had reduced risk of inpatient mortality compared to those not managed according to clinical guidelines, [OR 0.28, (95%, CI 0.14, 0.55), p = 0.001]. Clinical care factors associated with decreased risk of inpatient death included, having pre-transfusion hemoglobin done to confirm diagnosis [OR 0.5; 95% CI 0.29, 0.87], a co-morbid diagnosis of severe malaria [OR 0.4; 95% CI 0.25, 0.76], and being reviewed after admission by a clinician [OR 0.3; 95% CI 0.18, 0.59], while a co-morbid diagnosis of severe acute malnutrition was associated with increased risk of inpatient death [OR 4.2; 95% CI 2.15, 8.22].
Children with suspected SA who are managed according to clinical guidelines have lower in-hospital mortality than those not managed according to the guidelines. Efforts to reduce inpatient mortality in SA children in resource-limited settings should focus on training and supporting health workers to adhere to clinical guidelines.
在资源有限的情况下，儿童常见疾病（如严重贫血）的住院管理中，临床指南的遵循程度存在差异。然而，关于遵循临床指南对儿童严重贫血住院死亡率的影响的数据有限。
我们分析了乌干达利拉和金贾地区转诊医院一项提高医疗质量的无对照前后服务培训干预措施的数据。对 0 至 5 岁儿童的住院记录进行了回顾，以确定他们是否符合临床指南，比较了根据临床指南管理的严重贫血（SA）儿童与未根据临床指南管理的 SA 儿童的住院死亡率。采用逻辑回归分析评估了 SA 患儿临床护理因素与住院死亡之间的关系。
两所医院共有 1131 例患儿被临床诊断为“严重贫血”。与服务培训前相比，服务培训后治疗水平有所提高，根据临床指南管理的患儿更多，分别为 218/510（42.7%）和 158/621（25.4%）（p<0.001）。总体而言，与未根据临床指南管理的患儿相比，根据临床指南管理的患儿住院死亡率降低，[OR 0.28，（95%CI 0.14，0.55），p=0.001]。与住院死亡率降低相关的临床护理因素包括，进行输血前血红蛋白检测以明确诊断[OR 0.5；95%CI 0.29，0.87]、合并严重疟疾诊断[OR 0.4；95%CI 0.25，0.76]、入院后由临床医生进行复查[OR 0.3；95%CI 0.18，0.59]，而合并严重急性营养不良诊断则与住院死亡率增加相关[OR 4.2；95%CI 2.15，8.22]。
根据临床指南管理的疑似 SA 患儿的院内死亡率低于未根据指南管理的患儿。在资源有限的情况下，减少 SA 患儿住院死亡率的工作应侧重于培训和支持卫生工作者遵循临床指南。
