Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
School of Mathematics, University of Nairobi College of Biological and Physical Sciences, Nairobi, Kenya.
Arch Dis Child. 2020 Jul;105(7):648-654. doi: 10.1136/archdischild-2019-317256. Epub 2020 Mar 12.
We explored who actually provides most admission care in hospitals offering supervised experiential training to graduating clinicians in a high mortality setting where practices deviate from guideline recommendations.
We used a large observational data set from 13 Kenyan county hospitals from November 2015 through November 2018 where patients were linked to admitting clinicians. We explored guideline adherence after creating a cumulative correctness of Paediatric Admission Quality of Care (cPAQC) score on a 5-point scale (0-4) in which points represent correct, sequential progress in providing care perfectly adherent to guidelines comprising admission assessment, diagnosis and treatment. At the point where guideline adherence declined the most we dichotomised the cPAQC score and used multilevel logistic regression models to explore whether clinician and patient-level factors influence adherence.
There were 1489 clinicians who could be linked to 53 003 patients over a period of 3 years. Patients were rarely admitted by fully qualified clinicians and predominantly by preregistration medical officer interns (MOI, 46%) and diploma level clinical officer interns (COI, 41%) with a median of 28 MOI (range 11-68) and 52 COI (range 5-160) offering care per study hospital. The cPAQC scores suggest that perfect guideline adherence is found in ≤12% of children with malaria, pneumonia or diarrhoea with dehydration. MOIs were more adherent to guidelines than COI (adjusted OR 1.19 (95% CI 1.07 to 1.34)) but multimorbidity was significantly associated with lower guideline adherence.
Over 85% of admissions to hospitals in high mortality settings that offer experiential training in Kenya are conducted by preregistration clinicians. Clinical assessment is good but classifying severity of illness in accordance with guideline recommendations is a challenge. Adherence by MOI with 6 years' training is better than COI with 3 years' training, performance does not seem to improve during their 3 months of paediatric rotations.
我们研究了在高死亡率环境下提供监督式体验式培训的医院中，哪些人实际上提供了大部分入院护理，而这些医院的实践与指南推荐存在偏差。
我们使用了 2015 年 11 月至 2018 年 11 月期间来自肯尼亚 13 个县医院的大型观察性数据集，将患者与入院临床医生联系起来。我们创建了儿科入院质量护理（cPAQC）评分的累积正确性（5 分制，0-4 分），在此基础上探索了指南的依从性，其中分数代表完全符合指南的护理提供情况，包括入院评估、诊断和治疗。在指南依从性下降最多的地方，我们将 cPAQC 评分二分为零和一，并使用多水平逻辑回归模型来探讨临床医生和患者层面的因素是否影响依从性。
在 3 年期间，有 1489 名临床医生可以与 53003 名患者联系起来。患者很少由完全合格的临床医生收治，主要由实习医生（MOI，46%）和临床助理医生（COI，41%）收治，每个研究医院平均有 28 名 MOI（范围 11-68）和 52 名 COI（范围 5-160）提供护理。cPAQC 评分表明，疟疾、肺炎或腹泻伴脱水的儿童中，完全符合指南的比例低于 12%。MOI 比 COI 更符合指南（调整后的 OR 1.19（95%CI 1.07-1.34）），但多病共存与较低的指南依从性显著相关。
在肯尼亚死亡率较高的提供体验式培训的医院中，超过 85%的入院患者由实习医生管理。临床评估良好，但根据指南建议对疾病严重程度进行分类是一个挑战。接受了 6 年培训的 MOI 的依从性优于接受了 3 年培训的 COI，但在他们 3 个月的儿科轮转期间，表现似乎没有提高。
