Improving the quality of paediatric care in peripheral hospitals in developing countries

Effectiveness of bubble continuous positive airway pressure for treatment of children aged 1-59 months with severe pneumonia and hypoxaemia in Ethiopia: a pragmatic cluster-randomised controlled trial

BACKGROUND

The safety and efficacy of bubble continuous positive airway pressure (bCPAP) for treatment of childhood severe pneumonia outside tertiary care hospitals is uncertain. We did a cluster-randomised effectiveness trial of locally made bCPAP compared with WHO-recommended low-flow oxygen therapy in children with severe pneumonia and hypoxaemia in general hospitals in Ethiopia.

METHODS

This open, cluster-randomised trial was done in 12 general (secondary) hospitals in Ethiopia. We randomly assigned six hospitals to bCPAP as first-line respiratory support for children aged 1-59 months who presented with severe pneumonia and hypoxaemia and six hospitals to standard low-flow oxygen therapy. Cluster (hospital) randomisation was stratified by availability of mechanical ventilation. All children received treatment in paediatric wards (in a dedicated corner in front of a nursing station) with a similar level of facilities (equipment for oxygen therapy and medications) and staffing (overall, one nurse per six patients and one general practitioner per 18 patients) in all hospitals. All children received additional care according to WHO guidelines, supervised by paediatricians and general practitioners. The primary outcome was treatment failure (defined as any of the following: peripheral oxygen saturation <85% at any time after at least 1 h of intervention plus signs of respiratory distress; indication for mechanical ventilation; death during hospital stay or within 72 h of leaving hospital against medical advice; or leaving hospital against medical advice during intervention). The analysis included all children enrolled in the trial. We performed both unadjusted and adjusted analyses of the primary outcome, with the latter adjusted for the stratification variable and for the design effect of cluster randomisation, as well as selected potentially confounding variables, including age. We calculated effectiveness as the relative risk (RR) of the outcomes in the bCPAP group versus low-flow oxygen group. This trial is registered with ClinicalTrial.gov, NCT03870243, and is completed.

FINDINGS

From June 8, 2021, to July 27, 2022, 1240 children were enrolled (620 in hospitals allocated to bCPAP and 620 in hospitals allocated to low-flow oxygen). Cluster sizes ranged from 103 to 104 children. Five (0·8%) of 620 children in the bCPAP group had treatment failure compared with 21 (3·4%) of 620 children in the low-flow oxygen group (unadjusted RR 0·24, 95% CI 0·09-0·63, p=0·0015; adjusted RR 0·24, 0·07-0·87, p=0·030). Six children died during hospital stay, all of whom were in the low-flow oxygen group (p=0·031). No serious adverse events were attributable to bCPAP.

INTERPRETATION

In Ethiopian general hospitals, introduction of locally made bCPAP, supervised by general practitioners and paediatricians, was associated with reduced risk of treatment failure and in-hospital mortality in children with severe pneumonia and hypoxaemia compared with use of standard low-flow oxygen therapy. Implementation research is required in higher mortality settings to consolidate our findings.

FUNDING

SIDA Sweden and Grand Challenges Ethiopia.

Vaccination following the expanded programme on immunization schedule could help to reduce deaths in children under five hospitalized for pneumonia and severe pneumonia in a developing country

Background

Worldwide, pneumonia is the leading cause of mortality in children under the age of five. An expanded program on immunization (EPI) is one kind of evidence-based tool for controlling and even eradicating infectious diseases.

Objectives

This study aimed to explore the impact of EPI vaccination, including BCG, DPT-Hib-Hep B, OPV, IPV, and PCV-10, among children from the age of 4 to 59 months hospitalized for pneumonia and severe pneumonia. Additionally, we evaluated the role of 10 valent pneumococcal conjugate vaccines alone on clinical outcomes in such children.

Methods

In this retrospective chart review, children from the age of 4 to 59 months with WHO-defined pneumonia and severe pneumonia admitted to the Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) between August 2013 and December 2017 who had the information on immunization as per EPI schedule by 4 months of age were included in the analysis. A comparison was made between the children who were fully immunized (immunization with BCG, DPT-Hib-Hep B, OPV, and IPV from 2013 to 2015 and PCV-10 from 2015 to 2017) and who were not immunized (consisting of partial immunization and no immunization) during the study period.

Results

A total of 4,625 children had pneumonia and severe pneumonia during the study period. Among them, 2,605 (56.3%) had received the information on immunization; 2,195 (84.3%) were fully immunized by 4 months of age according to the EPI schedule and 410 were not immunized. In the log-linear binomial regression analysis, immunization of children from 4 to 59 months of age was found to be associated with a lower risk of diarrhea (p = 0.033), severe pneumonia (p = 0.001), anemia (p = 0.026), and deaths (p = 0.035). Importantly, the risk of developing severe pneumonia (1054/1,570 [67%] vs. 202/257 [79%], p < 0.001) and case-fatality rate (57/1,570 [3.6%] vs. 19/257 [7.4%], p = 0.005) was still significantly lower among those who were immunized with PCV-10 than those who were not.

Conclusion

Children immunized as per the EPI schedule were at a lower risk of diarrhea, severe pneumonia, anemia, and death, compared to unvaccinated children. In addition, PCV-10 was found to be protective against severe pneumonia and deaths in vaccinated children. The overall results underscored the importance of the continuation of immunization, scrupulously adhering to the EPI schedule to reduce the risk of morbidities and mortalities in children, especially in resource-limited settings.

Mixed-methods evaluation of a continuing education approach to improving district hospital care for children in Lao PDR

OBJECTIVE

To understand the impact of a multifaceted intervention on improving acute hospital care provided to children in two district hospitals in northern Lao PDR.

METHODS

We developed a continuing education intervention, which integrated separate program content using a common pool of facilitators and low-fidelity simulation scenarios. Coaching was delivered over one year through two-day hospital visits to each hospital six to eight weeks apart with visits incorporating feedback. A comparative case study was conducted between two hospital sites. Medical record abstraction from inpatient cases was performed at each visit. Focus groups and interviews with staff were conducted to understand perceived changes to case management.

RESULTS

Inpatient case management scores showed incremental improvement over time, from 50% at baseline to 80% at the end of one year at Hospital A and 52% to 97% at Hospital B. The key themes that emerged from the qualitative data from both hospitals were the value of the educational method and increased belief in capability. Hospital B showed more incremental and sustained improvement. Qualitative data revealed that the directors of Hospital B demonstrated modelling and behavioural reinforcement.

CONCLUSION

Improving the quality of care in low-resource settings is feasible. A hands-on practical approach with repeated coaching visits reinforced by feedback can lead to behaviour change. Optimal impact requires harnessing leadership and motivation for change among health workers.

Pediatric Emergency and Critical Care Resources and Infrastructure in Resource-Limited Settings: A Multicountry Survey

OBJECTIVES

To describe the infrastructure and resources for pediatric emergency and critical care delivery in resource-limited settings worldwide.

DESIGN

Cross-sectional survey with survey items developed through literature review and revised following piloting.

SETTING

The electronic survey was disseminated internationally in November 2019 via e-mail directories of pediatric intensive care societies and networks and using social media.

PATIENTS

Healthcare providers who self-identified as working in resource-limited settings.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Results were summarized using descriptive statistics and resource availability was compared across World Bank country income groups. We received 328 responses (238 hospitals, 60 countries), predominantly in Latin America and Sub-Saharan Africa (n = 161, 67.4%). Hospitals were in low-income (28, 11.7%), middle-income (166, 69.5%), and high-income (44, 18.4%) countries. Across 174 PICU and adult ICU admitting children, there were statistically significant differences in the proportion of hospitals reporting consistent resource availability ("often" or "always") between country income groups (p < 0·05). Resources with limited availability in lower income countries included advanced ventilatory support, invasive and noninvasive monitoring, central venous access, renal replacement therapy, advanced imaging, microbiology, biochemistry, blood products, antibiotics, parenteral nutrition, and analgesic/sedative drugs. Seventy-seven ICUs (52.7%) were staffed 24/7 by a pediatric intensivist or anesthetist. The nurse-to-patient ratio was less than 1:2 in 71 ICUs (49.7%).

CONCLUSIONS

Contemporary data demonstrate significant disparity in the availability of essential and advanced human and material resources for the care of critically ill children in resource-limited settings. Minimum standards for essential pediatric emergency and critical care in resource-limited settings are needed.

Situational Analysis of Management of Childhood Diarrhea and Pneumonia in 13 District Hospitals in India

Objective

To generate evidence on the current situation of hospital care (emergency, inpatient and outpatient), for managing children presenting with diarrhea and pneumonia at 13 district hospitals in India.

Design

Facility-based assessment of district hospitals.

Settings

13 district hospitals in four states of Bihar, Madhya Pradesh, Odisha and Rajasthan.

Participants

Staff nurses and doctors.

Intervention

None.

Methods

An assessment was done across 13 district hospitals in four states by a group or trained assessors using an adapted quality assurance tool developed by Government of India where each aspect of care was scored (maximum score 5). Emergency services and triage, case management practices, laboratory support, and record maintenance for diarrhea and pneumonia were assessed.

Results

Separate diarrhea treatment unit was not earmarked in any of the DHs surveyed. Overall score obtained for adequate management of diarrhea and pneumonia was 2 and 2.2 which were poor. Pediatric beds were 6.8% of the total bed strength against the recommended 8–10%. There was a 65 percent shortfall in the numbers of medical officers in position and 48 percent shortfall of nurses. There were issues with availability and utilization of drugs and equipment at appropriate places with cumulative score of 2.8. Triage for sick children was absent in all the facilities.

Conclusion

The standards of pediatric care for management of diarrhea and pneumonia were far from satisfactory. This calls for improvement of pediatric care units and implementation of operational guidelines for improving management of diarrhea and pneumonia.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 1: Review of implementation features and observed quality gaps in 25 countries

BACKGROUND

A substantial proportion of maternal and neonatal mortality and morbidity is attributable to gaps in quality of care. A systematic, standard-based tool for quality assessment and improvement for maternal and neonatal hospital care (QA/QI MN tool) was developed in 2009 by the World Health Organization (WHO). The tool guides the assessment process along the whole continuum from admission to discharge, collects the views of the recipients of care and engages hospital mangers and staff in identifying gaps and drafting an action plan.

METHODS

Publications describing use of the WHO QA/QI MN tool from 2009 to 2017 and reports retrievable from WHO or other development partners' websites were searched and considered for inclusion in the review. Only assessments of hospitals were considered. Quality gaps were classified as regarding case management in maternal care, case management in neonatal care, hospital infrastructure, hospital policies and according to severity and frequency. Quotations from women regarding key issues in effective communication, respect and dignity, emotional support and costs incurred were selected.

RESULTS

In the period 2009-2017, use of the WHO QA/QI MN tool was documented in 25 countries, belonging to Central and Eastern Europe (8), Central Asia (4), Sub-Saharan Africa (11), Latin America (1) and Middle East (1). Overall, 133 hospitals were assessed. The tool allowed to identify in great detail serious quality gaps including: insufficient or incomplete adherence to recommended evidence-based procedures for normal childbirth and maternal and neonatal complications; excess of inappropriate or unnecessary interventions; insufficient infection control; failure to provide respectful care, adequate communication and emotional support to mothers and babies; poor use of information generated locally to analyse processes and outcomes. These gaps were observed in all countries. Significant differences were observed among facilities belonging to the same health systems, ie, with very similar staffing, infrastructure and equipment.

CONCLUSIONS

The experience made, the largest of this kind, provides comprehensive and detailed insight into the existing quality gaps in a wide variety of settings. QI cycles at facility level should be primarily based on assessments made by multidisciplinary teams of professionals to identify the parts of the care pathways which require improvement through a participatory approach involving managers, staff and patients.

Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, controlled trial

BACKGROUND

Intravenous iron sucrose is a promising therapy for increasing haemoglobin concentration; however, its effect on clinical outcomes in pregnancy is not yet established. We aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy.

METHODS

We did a multicentre, open-label, phase 3, randomised, controlled trial at four government medical colleges in India. Pregnant women, aged 18 years or older, at 20-28 weeks of gestation with a haemoglobin concentration of 5-8 g/dL, or at 29-32 weeks of gestation with a haemoglobin concentration of 5-9 g/dL, were randomly assigned (1:1) to receive intravenous iron sucrose (dose was calculated using a formula based on bodyweight and haemoglobin deficit) or standard oral iron therapy (100 mg elemental iron twice daily). Logistic regression was used to compare the primary maternal composite outcome consisting of potentially life-threatening conditions during peripartum and postpartum periods (postpartum haemorrhage, the need for blood transfusion during and after delivery, puerperal sepsis, shock, prolonged hospital stay [>3 days following vaginal delivery and >7 days after lower segment caesarean section], and intensive care unit admission or referral to higher centres) adjusted for site and severity of anaemia. The primary outcome was analysed in a modified intention-to-treat population, which excluded participants who refused to participate after randomisation, those who were lost to follow-up, and those whose outcome data were missing. Safety was assessed in both modified intention-to-treat and as-treated populations. The data safety monitoring board recommended stopping the trial after the first interim analysis because of futility (conditional power 1·14% under the null effects, 3·0% under the continued effects, and 44·83% under hypothesised effects). This trial is registered with the Clinical Trial Registry of India, CTRI/2012/05/002626.

FINDINGS

Between Jan 31, 2014, and July 31, 2017, 2018 women were enrolled, and 999 were randomly assigned to the intravenous iron sucrose group and 1019 to the standard therapy group. The primary maternal composite outcome was reported in 89 (9%) of 958 patients in the intravenous iron sucrose group and in 95 (10%) of 976 patients in the standard therapy group (adjusted odds ratio 0·95, 95% CI 0·70-1·29). 16 (2%) of 958 women in the intravenous iron sucrose group and 13 (1%) of 976 women in the standard therapy group had serious maternal adverse events. Serious fetal and neonatal adverse events were reported by 39 (4%) of 961 women in the intravenous iron sucrose group and 45 (5%) of 982 women in the standard therapy group. At 6 weeks post-randomisation, minor side-effects were reported by 117 (16%) of 737 women in the intravenous iron sucrose group versus 155 (21%) of 721 women in the standard therapy group. None of the serious adverse events was found to be related to the trial procedures or the interventions as per the causality assessment made by the trial investigators, ethics committees, and regulatory body.

INTERPRETATION

The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia.

FUNDING

WHO, India.

Nutritional services for children in Beira, Mozambique: a study reporting on participatory use of data to generate quality improvement recommendations

Background

Existing literature suggest frequent gaps in the quality of care (QoC) provided to children with malnutrition in low-income and middle-income countries. Beira is the second largest city in Mozambique. This study included two phases: phase 1 was a systematic assessment of the QoC provided to malnourished children in Beira; phase 2 aimed at using findings of the assessment to develop recommendations, with a participatory approach, to improve QoC.

Methods

In phase 1, all facilities offering nutritional care to children in Beira were included, and exit health outcomes were reviewed against international SPHERE standards. A sample of four (66%) facilities was randomly selected for a comprehensive assessment of all areas contributing to QoC using an adapted WHO tool. In phase 2, key stakeholders were identified, and using a participatory approach, a list of actions for improving the QoC for malnourished children was agreed.

Results

In phase 1, outcomes of 1428 children with either severe acute malnutrition or moderate acute malnutrition (MAM) were reviewed. In-hospital recovery rate (70.1%) was almost in line with the SPHERE standard (75%), while at outpatient level, it was significantly lower (48.2%, risk ratio (RR) 0.68, p<0.0001). Recovery rate was significantly lower in HIV seropositive compared with seronegative (39.2% vs 52.8%, RR 1.34, p=0.005). High heterogeneity in MAM recovery rate was detected among facilities (range 32.5%-61.0%). Overall, out of all domains contributing to QoC in the sample, 28/46 (60.8%) indicated suboptimal care with significant health hazards and 13/46 (28.2%) indicated totally inadequate care with severe health hazards. In phase 2, a list of 38 actions to improve QoC for malnourished children was agreed among 33 local and national stakeholders.

Conclusions

Large heterogeneity in QoC for malnourished children in Beria was detected. The study documents a concrete example of using data proactively, for agreeing actions to improve QoC.

Day clinic vs. hospital care of pneumonia and severe malnutrition in children under five: a randomised trial

OBJECTIVES

To evaluate the clinical outcomes and costs of managing pneumonia and severe malnutrition in a day clinic (DC) management model (outpatient) vs. hospital care (inpatient).

METHODS

Randomised clinical trial where children aged 2 months to 5 years with pneumonia and severe malnutrition were randomly allocated to DC or inpatient hospital care. We used block randomisation of variable length from 8 to 20 and produced computer-generated random numbers that were assigned to one of the two interventions. Successful management was defined as resolution of clinical signs of pneumonia and being discharged from the model of care (DC or hospital) without need for referral to a hospital (DC), or referral to another hospital. All the children in both DC and hospital received intramuscular ceftriaxone, daily nutrition support and micronutrients.

RESULTS

Four hundred and seventy children were randomly assigned to either DC or hospital care. Successful management was achieved for 184 of 235 (78.3%) by DC alone, vs. 201 of 235 (85.5%) by hospital inpatient care [RR (95% CI) = 0.79 (0.65-0.97), P = 0.02]. During 6 months of follow-up, 30/235 (12.8%) in the DC group and 36/235 (15.3%) required readmission to hospital in the hospital care group [RR (95% CI) = 0.89 (0.67-1.18), P = 0.21]. The average overall healthcare and societal cost was 34% lower in DC (US$ 188 ± 11.7) than in hospital (US$ 285 ± 13.6) (P < 0.001), and costs for households were 33% lower.

CONCLUSIONS

There was a 7% greater probability of successful management of pneumonia and severe malnutrition when inpatient hospital care rather than the outpatient day clinic care was the initial method of care. However, where timely referral mechanisms were in place, 94% of children with pneumonia and severe malnutrition were successfully managed initially in a day clinic, and costs were substantially lower than with hospital admission.

Improving the quality of hospital care for children by supportive supervision: a cluster randomized trial, Kyrgyzstan

OBJECTIVE

To determine whether periodic supportive supervision after a training course improved the quality of paediatric hospital care in Kyrgyzstan, where inappropriate care was common but in-hospital postnatal mortality was low.

METHODS

In a cluster, randomized, parallel-group trial, 10 public hospitals were allocated to a 4-day World Health Organization (WHO) course on hospital care for children followed by periodic supportive supervision by paediatricians for 1 year, while 10 hospitals had no intervention. We assessed prospectively 10 key indicators of inappropriate paediatric case management, as indicated by WHO guidelines. The primary indicator was the combination of the three indicators: unnecessary hospitalization, increased iatrogenic risk and unnecessary painful procedures. An independent team evaluated the overall quality of care.

FINDINGS

We prospectively reviewed the medical records of 4626 hospitalized children aged 2 to 60 months. In the intervention hospitals, the mean proportion of the primary indicator decreased from 46.9% (95% confidence interval, CI: 24.2 to 68.9) at baseline to 6.8% (95% CI: 1.1 to 12.1) at 1 year, but was unchanged in the control group (45.5%, 95% CI: 25.2 to 67.9, to 64.7%, 95% CI: 43.3 to 86.1). At 1 year, the risk ratio for the primary indicator in the intervention versus the control group was 0.09 (95% CI: 0.06 to 0.13). The proportions of the other nine indicators also decreased in the intervention group (P < 0.0001 for all). Overall quality of care improved significantly in intervention hospitals.

CONCLUSION

Periodic supportive supervision for 1 year after a training course improved both adherence to WHO guidelines on hospital care for children and the overall quality of paediatric care.

From evidence to action to deliver a healthy start for the next generation

Remarkable progress has been made towards halving of maternal deaths and deaths of children aged 1-59 months, although the task is incomplete. Newborn deaths and stillbirths were largely invisible in the Millennium Development Goals, and have continued to fall between maternal and child health efforts, with much slower reduction. This Series and the Every Newborn Action Plan outline mortality goals for newborn babies (ten or fewer per 1000 livebirths) and stillbirths (ten or fewer per 1000 total births) by 2035, aligning with A Promise Renewed target for children and the vision of Every Woman Every Child. To focus political attention and improve performance, goals for newborn babies and stillbirths must be recognised in the post-2015 framework, with corresponding accountability mechanisms. The four previous papers in this Every Newborn Series show the potential for a triple return on investment around the time of birth: averting maternal and newborn deaths and preventing stillbirths. Beyond survival, being counted and optimum nutrition and development is a human right for all children, including those with disabilities. Improved human capital brings economic productivity. Efforts to reach every woman and every newborn baby, close gaps in coverage, and improve equity and quality for antenatal, intrapartum, and postnatal care, especially in the poorest countries and for underserved populations, need urgent attention. We have prioritised what needs to be done differently on the basis of learning from the past decade about what has worked, and what has not. Needed now are four most important shifts: (1) intensification of political attention and leadership; (2) promotion of parent voice, supporting women, families, and communities to speak up for their newborn babies and to challenge social norms that accept these deaths as inevitable; (3) investment for effect on mortality outcome as well as harmonisation of funding; (4) implementation at scale, with particular attention to increasing of health worker numbers and skills with attention to high-quality childbirth care for newborn babies as well as mothers and children; and (5) evaluation, tracking coverage of priority interventions and packages of care with clear accountability to accelerate progress and reach the poorest groups. The Every Newborn Action Plan provides an evidence-based roadmap towards care for every woman, and a healthy start for every newborn baby, with a right to be counted, survive, and thrive wherever they are born.

Improving paediatric and neonatal care in rural district hospitals in the highlands of Papua New Guinea: a quality improvement approach

BACKGROUND

In developing countries such as Papua New Guinea (PNG), district hospitals play a vital role in clinical care, training health-care workers, implementing immunization and other public health programmes and providing necessary data on disease burdens and outcomes. Pneumonia and neonatal conditions are a major cause of child admission and death in hospitals throughout PNG. Oxygen therapy is an essential component of the management of pneumonia and neonatal conditions, but facilities for oxygen and care of the sick newborn are often inadequate, especially in district hospitals. Improving this area may be a vehicle for improving overall quality of care.

METHOD

A qualitative study of five rural district hospitals in the highlands provinces of Papua New Guinea was undertaken. A structured survey instrument was used by a paediatrician and a biomedical technician to assess the quality of paediatric care, the case-mix and outcomes, resources for delivery of good-quality care for children with pneumonia and neonatal illnesses, existing oxygen systems and equipment, drugs and consumables, infection-control facilities and the reliability of the electricity supply to each hospital. A floor plan was drawn up for the installation of the oxygen concentrators and a plan for improving care of sick neonates, and a process of addressing other priorities was begun.

RESULTS

In remote parts of PNG, many district hospitals are run by under-resourced non-government organizations. Most hospitals had general wards in which both adults and children were managed together. Paediatric case-loads ranged between 232 and 840 patients per year with overall case-fatality rates (CFR) of 3-6% and up to 15% among sick neonates. Pneumonia accounts for 28-37% of admissions with a CFR of up to 8%. There were no supervisory visits by paediatricians, and little or no continuing professional development of staff. Essential drugs were mostly available, but basic equipment for the care of sick neonates was often absent or incomplete. Infection control measures were inadequate in most hospitals. Cylinders were the major source of oxygen for the district hospitals, and logistical problems and large indirect costs meant that oxygen was under-utilized. There were multiple electricity interruptions, but hospitals had back-up generators to enable the use of oxygen concentrators. After 6 months in each of the five hospitals, high-dependency care areas were planned, oxygen concentrators installed, staff trained in their use, and a plan was set out for improving neonatal care.

INTERPRETATION

If MGD-4 targets for child health are to be met, reducing neonatal mortality and deaths from pneumonia will have to include better quality services in district hospitals. Establishing better oxygen supplies with a systems approach can be a vehicle for addressing other areas of quality and safety in district hospitals.

Three years of paediatric morbidity and mortality at the National Hospital in Dili, East Timor

AIM

The aim of this study was to undertake a retrospective review of admissions and discharges to the paediatric wards at the National Hospital Guido Valadares, Dili, as the epidemiology of hospitalised children in East Timor cannot be easily understood from the hospital health management information system.

METHOD

Data were sourced from unit registers for 3 years, 2008-2010 inclusive. Demographic characteristics and principal diagnoses were related to the risk of dying using stepwise multivariate logistic regression.

RESULTS

There were 5909 children admitted to the wards over the study period and 60% were <2 years of age. The commonest reasons for admission were lower respiratory tract infections (LRIs) and gastroenteritis (43% and 16%, respectively). Severe malnutrition (MN) was recorded in only 5% of admissions. Overall, 6% of children died, mainly attributed to LRI (28%), central nervous system infections (16%) and MN (11%). Younger age, residence outside of Dili and admission during a busier period were independently associated with an increased risk of death. Nine per cent of hospitalised infants aged 1-6 months of age died and half of all deaths occurred within 2 days of admission.

CONCLUSIONS

The study provides, for the first time, an understanding of the admissions and outcomes of the busiest paediatric inpatient unit in East Timor. It emphasises important health system issues which impact on both data quality and hospital outcomes.

The effects of standardised protocols of obstetric and neonatal care on perinatal and early neonatal mortality at a rural hospital in Tanzania

The care of pregnant women and neonates in peripheral hospitals in many developing countries is in a critical state. Through a retrospective analysis we assessed the effects of the introduction of standardised protocols in obstetric and neonatal care (implementation from 1998 onwards) on perinatal and neonatal outcomes of all deliveries over seven years (1996-2002) at a first-referral hospital in rural Tanzania. In all, there were 18 026 deliveries (18 316 live births and 606 stillbirths). Perinatal mortality rates (PMR) varied from 42.8-54.5/1000 live births during the years. Early neonatal mortality rates (eNMR) fell from 21.9/1000 live births in 1996 to 14.8/1000 live births in 2002 (all p > 0.05). Fresh stillbirth rates decreased over time (p = 0.041), however macerated stillbirth rates increased during the second half of the period (p = 0.067). Sixty-two to seventy-two percent of eNMR occurred on the first day of life (p < 0.001). Maternal mortality ratio declined from 729/100 000 live births in 1996 to 119/100 000 live births in 2002 (p = 0.002). Our clinical project was associated with a reduction of PMR and eNMR (and maternal mortality ratios), but with considerable fluctuations during the years. Improving obstetric and neonatal care in the hospital setting in developing countries is essential, but needs long-term commitment and support.

Quality of neonatal healthcare in Kilimanjaro region, northeast Tanzania: learning from mothers' experiences

BACKGROUND

With a decline of infant mortality rates, neonatal mortality rates are striking high in development countries particularly sub Saharan Africa. The toolkit for high quality neonatal services describes the principle of patient satisfaction, which we translate as mother's involvement in neonatal care and so better outcomes. The aim of the study was to assess mothers' experiences, perception and satisfaction of neonatal care in the hospitals of Kilimanjaro region of Tanzania.

METHODS

A cross sectional study using qualitative and quantitative approaches in 112 semi structured interviews from 14 health facilities. Open ended questions for detection of illness, care given to the baby and time spent by the health worker for care and treatment were studied. Probing of the responses was used to extract and describe findings by a mix of in-depth interview skills. Closed ended questions for the quantitative variables were used to quantify findings for statistical use. Narratives from open ended questions were coded by colours in excel sheet and themes were manually counted.

RESULTS

80 mothers were interviewed from 13 peripheral facilities and 32 mothers were interviewed at a zonal referral hospital of Kilimanjaro region. 59 mothers (73.8%) in the peripheral hospitals of the region noted neonatal problems and they assisted for attaining diagnosis after a showing a concern for a request for further investigations. 11 mothers (13.8%) were able to identify the baby's diagnosis directly without any assistance, followed by 7 mothers (8.7%) who were told by a relative, and 3 mothers (3.7%) who were told of the problem by the doctor that their babies needed medical attention. 24 times mothers in the peripheral hospitals reported bad language like "I don't have time to listen to you every day and every time." 77 mothers in the periphery (90.6%) were not satisfied with the amount of time spent by the doctors in seeing their babies.

CONCLUSION

Mothers of the neonates play great roles in identifying the illness of the newborn. Mother's awareness of what might be needed during neonatal support strategies to improve neonatal care in both health facilities and the communities.

Designing a theory-informed, contextually appropriate intervention strategy to improve delivery of paediatric services in Kenyan hospitals

BACKGROUND

District hospital services in Kenya and many low-income countries should deliver proven, effective interventions that could substantially reduce child and newborn mortality. However such services are often of poor quality. Researchers have therefore been challenged to identify intervention strategies that go beyond addressing knowledge, skill, or resource inadequacies to support health systems to deliver better services at scale. An effort to develop a system-oriented intervention tailored to local needs and context and drawing on theory is described.

METHODS

An intervention was designed to improve district hospital services for children based on four main strategies: a reflective process to distill root causes for the observed problems with service delivery; developing a set of possible intervention approaches to address these problems; a search of literature for theory that provided the most appropriate basis for intervention design; and repeatedly moving backwards and forwards between identified causes, proposed interventions, identified theory, and knowledge of the existing context to develop an overarching intervention that seemed feasible and likely to be acceptable and potentially sustainable.

RESULTS AND DISCUSSION

In addition to human and resource constraints key problems included failures of relevant professionals to take responsibility for or ownership of the challenge of pediatric service delivery; inadequately prepared, poorly supported leaders of service units (mid-level managers) who are often professionally and geographically isolated and an almost complete lack of useful information for routinely monitoring or understanding service delivery practice or outcomes. A system-oriented intervention recognizing the pivotal role of leaders of service units but addressing the outer and inner setting of hospitals was designed to help shape and support an appropriate role for these professionals. It aims to foster a sense of ownership while providing the necessary understanding, knowledge, and skills for mid-level managers to work effectively with senior managers and frontline staff to improve services. The intervention will include development of an information system, feedback mechanisms, and discussion fora that promote positive change. The vehicle for such an intervention is a collaborative network partnering government and national professional associations. This case is presented to promote discussion on approaches to developing context appropriate interventions particularly in international health.

Global use of the WHO pocket book of hospital care for children

BACKGROUND

Studies in the last decade have identified major deficiencies in the care of seriously ill children in hospitals in developing countries. Effective implementation of clinical guidelines is an important strategy for improving quality of care. In 2005 the World Health Organization produced the Pocket Book of Hospital Care for Children - Guidelines for Management of Common Childhood Illnesses in Rural and District Hospitals with Limited Resources.

OBJECTIVE

To determine the worldwide distribution, uptake and use of the WHO Pocket Book of Hospital Care for Children.

METHODS

A systematic online and postal survey was conducted to assess coverage and uptake of the Pocket Book in low- and middle-income countries (LMICs). More than 1000 key stakeholders with varied roles and responsibilities for child health in 194 countries were invited to participate. Indicators used to measure implementation of the guidelines included local adaptation, use as standard treatment and incorporation into undergraduate and postgraduate training.

RESULTS

Information was gathered from 354 respondents representing 134 countries; these included 98 LMICs and 50 countries with under-5 childhood mortality rates >40 deaths/1000 live births. Sixty-four LMICs (44% of 145 LMICs worldwide) including 42 high-mortality countries (66% of 64 high-mortality countries worldwide) reported at least partial implementation of the Pocket Book. However, uptake remains fragmented within countries.

CONCLUSION

More than half of all LMICs with high rates of child mortality have reported use and substantial implementation activities, a considerable achievement given minimal resources available for implementation. Improving the accessibility of the Pocket Book and its implementation tools to health workers, and developing a strategic approach to implementation in each country could improve quality of hospital care for children and support efforts towards achieving the Millennium Development Goal 4 targets.

An assessment of the quality of care for children in eighteen randomly selected district and sub-district hospitals in Bangladesh

Background

Quality hospital care is important in ensuring that the needs of severely ill children are met to avert child mortality. However, the quality of hospital care for children in developing countries has often been found poor. As the first step of a country road map for improving hospital care for children, we assessed the baseline situation with respect to the quality of care provided to children under-five years age in district and sub-district level hospitals in Bangladesh.

Methods

Using adapted World Health Organization (WHO) hospital assessment tools and standards, an assessment of 18 randomly selected district (n=6) and sub-district (n=12) hospitals was undertaken. Teams of trained assessors used direct case observation, record review, interviews, and Management Information System (MIS) data to assess the quality of clinical case management and monitoring; infrastructure, processes and hospital administration; essential hospital and laboratory supports, drugs and equipment.

Results

Findings demonstrate that the overall quality of care provided in these hospitals was poor. No hospital had a functioning triage system to prioritise those children most in need of immediate care. Laboratory supports and essential equipment were deficient. Only one hospital had all of the essential drugs for paediatric care. Less than a third of hospitals had a back-up power supply, and just under half had functioning arrangements for safe-drinking water. Clinical case management was found to be sub-optimal for prevalent illnesses, as was the quality of neonatal care.

Conclusion

Action is needed to improve the quality of paediatric care in hospital settings in Bangladesh, with a particular need to invest in improving newborn care.

Decreased pediatric hospital mortality after an intervention to improve emergency care in Lilongwe, Malawi

BACKGROUND AND OBJECTIVE

Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in the developing world. This deficiency contributes to high inpatient mortality rates, particularly early during hospitalization. Our referral hospital in Lilongwe, Malawi, experiences high volume, acuity, and mortality rates. The entry point to our hospital for most children presenting with acute illness is the Under-5 Clinic. We hypothesized that early inpatient mortality and total inpatient mortality rates would decrease with an intervention to prioritize and improve pediatric emergency care at our hospital.

METHODS

We implemented the following changes as part of our intervention: (1) reallocation of senior-level clinical support from other areas of the hospital to the Under-5 Clinic for supervision of emergency care, (2) institution of a formal triage process that improved patient flow, and (3) treatment and stabilization of patients before transfer to the inpatient ward. We compared early inpatient and total inpatient mortality rates before and after the intervention.

RESULTS

After the intervention, early mortality decreased from 47.6 to 37.9 deaths per 1000 admissions (relative risk 0.80, 95% confidence interval 0.67-0.93). Total mortality also decreased from 80.5 to 70.5 deaths per 1000 admissions after the intervention (relative risk 0.88, 95% confidence interval 0.78-0.98).

CONCLUSIONS

Simple, inexpensive interventions to improve pediatric emergency care at this underresourced hospital in sub-Saharan Africa were associated with decreased hospital mortality rates. The description of this process and the associated results may influence practice and resource allocation strategies in similar clinical environments.

Case management of severe malaria--a forgotten practice: experiences from health facilities in Uganda

Introduction

Severe malaria is a life-threatening medical emergency and requires prompt and effective treatment to prevent death. There is paucity of published information on current practices of severe malaria case management in sub-Saharan Africa; we evaluated the management practices for severe malaria in Ugandan health facilities

Methods and Findings

We did a cross sectional survey, using multi-stage sampling methods, of health facilities in 11 districts in the eastern and mid-western parts of Uganda. The study instruments were adapted from the WHO hospital care assessment tools. Between June and August 2009, 105 health facilities were surveyed and 181 health workers and 868 patients/caretakers interviewed. None of the inpatient facilities had all seven components of a basic care package for the management of severe malaria consistently available during the 3 months prior to the survey. Referral practices were appropriate for <10% (18/196) of the patients. Prompt care at any health facility was reported by 29% (247/868) of patients. Severe malaria was correctly diagnosed in 27% of patients (233).Though the quinine dose and regimen was correct in the majority (611/868, 70.4%) of patients, it was administered in the correct volumes of 5% dextrose in only 18% (147/815). Most patients (80.1%) had several doses of quinine administered in one single 500 ml bottle of 5% dextrose. Medications were purchased by 385 (44%) patients and medical supplies by 478 patients (70.6%).

Conclusions

Management of severe malaria in Ugandan health facilities was sub-optimal. These findings highlight the challenges of correctly managing severe malaria in resource limited settings. Priority areas for improvement include triage and emergency care, referral practises, quality of diagnosis and treatment, availability of medicines and supplies, training and support supervision.

Global cost of child survival: estimates from country-level validation

OBJECTIVE

To cross-validate the global cost of scaling up child survival interventions to achieve the fourth Millennium Development Goal (MDG4) as estimated by the World Health Organization (WHO) in 2007 by using the latest country-provided data and new assumptions.

METHODS

After the main cost categories for each country were identified, validation questionnaires were sent to 32 countries with high child mortality. Publicly available estimates for disease incidence, intervention coverage, prices and resources for individual-level and programme-level activities were validated against local data. Nine updates to the 2007 WHO model were generated using revised assumptions. Finally, estimates were extrapolated to 75 countries and combined with cost estimates for immunization and malaria programmes and for programmes for the prevention of mother-to-child transmission of the human immunodeficiency virus (HIV).

FINDINGS

Twenty-six countries responded. Adjustments were largest for system- and programme-level data and smallest for patient data. Country-level validation caused a 53% increase in original cost estimates (i.e. 9 billion 2004 United States dollars [US$]) for 26 countries owing to revised system and programme assumptions, especially surrounding community health worker costs. The additional effect of updated population figures was small; updated epidemiologic figures increased costs by US$ 4 billion (+15%). New unit prices in the 26 countries that provided data increased estimates by US$ 4.3 billion (+16%). Extrapolation to 75 countries increased the original price estimate by US$ 33 billion (+80%) for 2010-2015.

CONCLUSION

Country-level validation had a significant effect on the cost estimate. Price adaptations and programme-related assumptions contributed substantially. An additional 74 billion US$ 2005 (representing a 12% increase in total health expenditure) would be needed between 2010 and 2015. Given resource constraints, countries will need to prioritize health activities within their national resource envelope.

Randomized controlled trial of day care versus hospital care of severe pneumonia in Bangladesh

OBJECTIVE

A randomized controlled trial compared day care versus hospital care management of pneumonia.

METHODS

Children 2 to 59 months of age with severe pneumonia received either day care, with antibiotic treatment, feeding, and supportive care from 8:00 am to 5:00 pm, or hospital care, with similar 24-hour treatment.

RESULTS

In 2006-2008, 360 children were assigned randomly to receive either day care or hospital care; 189 (53%) had hypoxemia, with a mean±SD oxygen saturation of 93±4%, which increased to 99±1% after oxygen therapy. The mean±SD durations of day care and hospital care were 7.1±2.3 and 6.5±2.8 days, respectively. Successful management was possible for 156 (87.7% [95% confidence interval [CI]: 80.9%-90.9%]) of 180 children in the day care group and 173 (96.1% [95% CI: 92.2%-98.1%]) of 180 children in the hospital care group (P=.001). Twenty-three children in the day care group (12.8% [95% CI: 8.7%-18.4%] and 4 children in the hospital care group (2.2% [95% CI: 0.9%-5.6%] required referral to hospitals (P<.001). During the follow-up period, 22 children in the day care group (14.1% [95% CI: 9.5%-20.4%]) and 11 children in the hospital care group (6.4% [95% CI: 3.6%-11%]) required readmission to hospitals (P=.01). The estimated costs per child treated successfully at the clinic and the hospital were US$114 and US$178, respectively.

CONCLUSION

Severe childhood pneumonia without severe malnutrition can be successfully managed at day care clinics, except for children with hypoxemia who require prolonged oxygen therapy.

Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis

Few data sources are available to assess the global and regional risk of sequelae from bacterial meningitis. We aimed to estimate the risks of major and minor sequelae caused by bacterial meningitis, estimate the distribution of the different types of sequelae, and compare risk by region and income. We systematically reviewed published papers from 1980 to 2008. Standard global burden of disease categories (cognitive deficit, bilateral hearing loss, motor deficit, seizures, visual impairment, hydrocephalus) were labelled as major sequelae. Less severe, minor sequelae (behavioural problems, learning difficulties, unilateral hearing loss, hypotonia, diplopia), and multiple impairments were also included. 132 papers were selected for inclusion. The median (IQR) risk of at least one major or minor sequela after hospital discharge was 19.9% (12.3-35.3%). The risk of at least one major sequela was 12.8% (7.2-21.1%) and of at least one minor sequela was 8.6% (4.4-15.3%). The median (IQR) risk of at least one major sequela was 24.7% (16.2-35.3%) in pneumococcal meningitis; 9.5% (7.1-15.3%) in Haemophilus influenzae type b (Hib), and 7.2% (4.3-11.2%) in meningococcal meningitis. The most common major sequela was hearing loss (33.9%), and 19.7% had multiple impairments. In the random-effects meta-analysis, all-cause risk of a major sequela was twice as high in the African (pooled risk estimate 25.1% [95% CI 18.9-32.0%]) and southeast Asian regions (21.6% [95% CI 13.1-31.5%]) as in the European region (9.4% [95% CI 7.0-12.3%]; overall I(2)=89.5%, p<0.0001). Risks of long-term disabling sequelae were highest in low-income countries, where the burden of bacterial meningitis is greatest. Most reported sequelae could have been averted by vaccination with Hib, pneumococcal, and meningococcal vaccines.

Survey of children accessing HIV services in a high prevalence setting: time for adolescents to count?

OBJECTIVE

To establish the proportion of adolescents among children infected with human immunodeficiency virus (HIV) in Zimbabwe who receive HIV care and support, and what clinic staff perceives to be the main problems faced by HIV-infected children and adolescents.

METHODS

In July 2008, we sent a questionnaire to all 131 facilities providing HIV care in Zimbabwe. In it we requested an age breakdown of the children (aged 0-19 years) registered for care and asked what were the two major problems faced by younger children (0-5 years) and adolescents (10-19 years).

FINDINGS

Nationally, 115 (88%) facilities responded. In 98 (75%) that provided complete data, 196 032 patients were registered and 24 958 (13%) of them were children. Of children under HIV care, 33% were aged 0-4 years; 25%, 5-9 years; 25%, 10-14 years; and 17%, 15-19 years. Staff highlighted differences in the problems most commonly faced by younger children and adolescents. For younger children, such problems were malnutrition and lack of appropriate drugs (cited by 46% and 40% of clinics, respectively); for adolescents they concerned psychosocial issues and poor drug adherence (cited by 56% and 36%, respectively).

CONCLUSION

Interventions for the large cohort of adolescents who are receiving HIV care in Zimbabwe need to target the psychosocial concerns and poor drug adherence reported by staff as being the main concerns in this age group.

Implementation experience during an eighteen month intervention to improve paediatric and newborn care in Kenyan district hospitals

BACKGROUND

We have conducted an intervention study aiming to improve hospital care for children and newborns in Kenya. In judging whether an intervention achieves its aims, an understanding of how it is delivered is essential. Here, we describe how the implementation team delivered the intervention over 18 months and provide some insight into how health workers, the primary targets of the intervention, received it.

METHODS

We used two approaches. First, a description of the intervention is based on an analysis of records of training, supervisory and feedback visits to hospitals, and brief logs of key topics discussed during telephone calls with local hospital facilitators. Record keeping was established at the start of the study for this purpose with analyses conducted at the end of the intervention period. Second, we planned a qualitative study nested within the intervention project and used in-depth interviews and small group discussions to explore health worker and facilitators' perceptions of implementation. After thematic analysis of all interview data, findings were presented, discussed, and revised with the help of hospital facilitators.

RESULTS

Four hospitals received the full intervention including guidelines, training and two to three monthly support supervision and six monthly performance feedback visits. Supervisor visits, as well as providing an opportunity for interaction with administrators, health workers, and facilitators, were often used for impromptu, limited refresher training or orientation of new staff. The personal links that evolved with senior staff seemed to encourage local commitment to the aims of the intervention. Feedback seemed best provided as open meetings and discussions with administrators and staff. Supervision, although sometimes perceived as fault finding, helped local facilitators become the focal point of much activity including key roles in liaison, local monitoring and feedback, problem solving, and orientation of new staff to guidelines. In four control hospitals receiving a minimal intervention, local supervision and leadership to implement new guidelines, despite their official introduction, were largely absent.

CONCLUSION

The actual content of an intervention and how it is implemented and received may be critical determinants of whether it achieves its aims. We have carefully described our intervention approach to facilitate appraisal of the quantitative results of the intervention's effect on quality of care. Our findings suggest ongoing training, external supportive supervision, open feedback, and local facilitation may be valuable additions to more typical in-service training approaches, and may be feasible.

The prevalence of hypoxaemia among ill children in developing countries: a systematic review

Hypoxaemia is a common complication of childhood infections, particularly acute lower respiratory tract infections. In pneumonia-a disease that disproportionately impacts developing countries, and accounts for more than two million deaths of children worldwide-hypoxaemia is a recognised risk factor for death, and correlates with disease severity. Hypoxaemia also occurs in severe sepsis, meningitis, common neonatal problems, and other conditions that impair ventilation and gas exchange or increase oxygen demands. Despite this, hypoxaemia has been overlooked in worldwide strategies for pneumonia control and reducing child mortality. Hypoxaemia is also often overlooked in developing countries, mainly due to the low accuracy of clinical predictors and the limited availability of pulse oximetry for more accurate detection and oxygen for treatment. In this Review of published and unpublished studies of acute lower respiratory tract infection, the median prevalence of hypoxaemia in WHO-defined pneumonia requiring hospitalisation (severe and very severe classifications) was 13%, but prevalence varied widely. This corresponds to at least 1.5 to 2.7 million annual cases of hypoxaemic pneumonia presenting to health-care facilities. Many more people do not access health care. With mounting evidence of the impact that improved oxygen systems have on mortality due to acute respiratory infection in limited-resource health-care facilities, there is a need for increased awareness of the burden of hypoxaemia in childhood illness.

Experience in managing severe malnutrition in a government tertiary treatment facility in Bangladesh

Children with severe acute malnutrition, defined as weight-for-height <70% of the reference median or bilateral pedal oedema or mid-arm circumference <110 mm having complications, were managed in the Nutrition Unit of the Chittagong Medical College Hospital (CMCH) following the guidelines of the World Health Organization, with support from Concern Worldwide Bangladesh and ICDDR,B. In total, 171 children aged less than five years (mean +/- SD age 23.5 +/- 15.3 months) were admitted during June 2005-May 2006. Of them, 66% were aged less than two years, and 84.2% belonged to households with a monthly income of less than US$ 40. The main reason for bringing children by their families to the hospital was associated major illnesses: bronchopneumonia (33%), oedema (24%), diarrhoea (11%), pulmonary tuberculosis (9%), or other conditions, such as meningitis, septicaemia, and infections of the skin, eye, or ear. The exit criteria from the Nutrition Unit were: (a) for children admitted without oedema, an absolute weight gain of > or = 500 and > or = 700 g for children aged less than two years and 2-5 years respectively; and for children admitted with oedema, complete loss of oedema and weight-for-height >70% of the reference median, and (b) the mother or caretaker has received specific training on appropriate feeding and was motivated to follow the advice given. Of all the admitted children, 7.6% of parents insisted for discharging their children early due to other urgent commitments while 11.7% simply left with their children against medical advice. Of the 138 remaining children, 88% successfully graduated from the Nutrition Unit with a mean weight gain of 10.6 g/kg per day (non-oedematous children) and loss of -1.9 g/kg per day (oedematous children), 86% graduated in less than three weeks, and the case-fatality rate was 10.8%. The Nutrition Unit of CMCH also functions as a training centre, and 197 health functionaries (82 medical students, 103 medical interns, and 12 nurses) received hands-on training on management of severe malnutrition. The average cost of overall treatment was US$ 14.6 per child or approximately US$ 1 per child-day (excluding staff-cost). Food and medicines accounted for 42% and 58% of the total cost respectively. This study demonstrated the potential of addressing severe acute malnutrition (with complications) effectively with minimum incremental expenditure in Bangladesh. This public-private approach should be used for treating severe acute malnutrition in all healthcare facilities and the treatment protocol included in the medical and nursing curricula.

Critical care in low-income countries

Critical care in low-income countries remains rudimentary. When defined as all aspects of care for patients with sudden, serious, reversible disease, critical care is not disease or age specific and includes triage and emergency medicine, hospital systems, quality of care and Intensive Care Units. This review collates the literature on critical care in low-income countries and explores how the care can be both feasible and effective. Emergency care including triage is often one of the weakest parts of the health system; but if well organized it can be life-saving and cost-effective. Emergency triage and treatment has been developed for paediatric admissions with promising results. Hospital systems do not currently prioritize the critically ill and few hospitals have Intensive Care Units. The quality of care given to inpatients on hospital wards is often poor and could be improved in many ways. There is a lack of training and awareness of the principles of critical care. Basic critical care concentrating on ABC - airway, breathing and circulation - need not be resource intensive. Oxygen is a cheap and effective treatment for pneumonia and other severe disease, but is not always available. Improved critical care could have a significant effect on the burden of disease and effects of ill health. Research into the most cost-effective treatments and methods of caring for critically ill patients is urgently needed.

Pediatric emergency and critical care in low-income countries

The United Nations' Millennium Development Goal 4 is to reduce the global under-five mortality rate by two-thirds by 2015. Achieving this goal requires substantial strengthening of health systems in low-income countries. Emergency and critical care services are often one of the weakest parts of the health system and improving such care has the potential to significantly reduce mortality. Introducing effective triage and emergency treatments, establishing hospital systems that prioritize the critically ill and ensuring a reliable oxygen delivery system need not be resource intensive. Improving intensive care units, training health staff in the fundamentals of critical care concentrating on ABC - airway, breathing, and circulation - and developing guidelines for the management of common medical emergencies could all improve the quality of inpatient pediatric care. Integration with obstetrics, adult medicine and surgery in a combined emergency and critical care service would concentrate resources and expertise.

Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya

The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.

Clinical assessment and treatment in paediatric wards in the north-east of the United Republic of Tanzania

OBJECTIVE

We assessed paediatric care in the 13 public hospitals in the north-east of the United Republic of Tanzania to determine if diagnoses and treatments were consistent with current guidelines for care.

METHODS

Data were collected over a five-day period in each site where paediatric outpatient consultations were observed, and a record of care was extracted from the case notes of children on the paediatric ward. Additional data were collected from inspection of ward supplies and hospital reports.

FINDINGS

Of 1181 outpatient consultations, basic clinical signs were often not checked; e.g. of 895 children with a history of fever, temperature was measured in 57%, and of 657 of children with cough or dyspnoea only 57 (9%) were examined for respiratory rate. Among 509 inpatients weight was recorded in the case notes in 250 (49%), respiratory rate in 54 (11%) and mental state in 47 (9%). Of 206 malaria diagnoses, 123 (60%) were with a negative or absent slide result, and of these 44 (36%) were treated with quinine only. Malnutrition was diagnosed in 1% of children admitted while recalculation of nutritional Z-scores suggested that between 5% and 10% had severe acute malnutrition; appropriate feeds were not present in any of the hospitals. A diagnosis of HIV-AIDS was made in only two cases while approximately 5% children admitted were expected to be infected with HIV in this area.

CONCLUSION

Clinical assessment of children admitted to paediatric wards is disturbingly poor and associated with missed diagnoses and inappropriate treatments. Improved assessment and records are essential to initiate change, but achieving this will be a challenging task.

Beyond good intentions: lessons on equipment donation from an African hospital

OBJECTIVE

In 2000, a referral hospital in the Gambia accepted a donation of oxygen concentrators to help maintain oxygen supplies. The concentrators broke down and were put into storage. A case study was done to find the reasons for the problem and to draw lessons to help improve both oxygen supplies and the success of future equipment donations.

METHODS

A technical assessment of the concentrators was carried out by a biomedical engineer with relevant expertise. Semi-structured interviews were undertaken with key informants, and content analysis and inductive approaches were applied to construct the history of the episode and the reasons for the failure.

FINDINGS

Interviews confirmed the importance of technical problems with the equipment. They also revealed that the donation process was flawed, and that the hospital did not have the expertise to assess or maintain the equipment. Technical assessment showed that all units had the wrong voltage and frequency, leading to overheating and breakdown. Subsequently a hospital donations committee was established to oversee the donations process. On-site biomedical engineering expertise was arranged with a nongovernmental organization (NGO) partner.

CONCLUSION

Appropriate donations of medical equipment, including oxygen concentrators, can be of benefit to hospitals in resource-poor settings, but recipients and donors need to actively manage donations to ensure that the donations are beneficial. Success requires planning, technical expertise and local participation. Partners with relevant skills and resources may also be needed. In 2002, WHO produced guidelines for medical equipment donations, which address problems that might be encountered. These guidelines should be publicized and used.

Critical appraisal of the management of severe malnutrition: 1. Epidemiology and treatment guidelines

Hospital case-fatality rates for severe malnutrition in the developing world remain high, particularly in Africa where they have not changed much over recent decades. In an effort to improve case management, WHO has developed treatment guidelines. The aim of this review is to critically appraise the evidence for the guidelines and review important recent advances in the management of severe malnutrition. We conclude that not only is the evidence base deficient, but also the external generalisability of even good-quality studies is seriously compromised by the great variability in clinical practice between regions and types of health facilities in the developing world, which is much greater than between developed countries. The diagnosis of severe wasting is complicated by the dramatic change in reference standards (from CDC/WHO 1978 to CDC 2000 in EpiNut) and also by difficulties in accurate measurement of length. Although following treatment guidelines has resulted in improved outcomes, there is evidence against the statement that case-fatality rates (particularly in African hospitals) can be reduced below 5% and that higher rates are proof of poor practice, because there is wide variation in severity of illness factors. The practice of prolonged hospital treatment of severe malnutrition until wasting and/or oedema has resolved is being replaced by shorter hospital stays combined with outpatient or community follow-up because of advances in dietary management outside of hospital.

Child survival: district hospitals and paediatricians

In a previous article in this series, Zulfiquar Bhutta outlined many of the key sociopolitical issues, both national and international, that currently affect the delivery of health care to children in developing countries. The clear summary of our situation is that we are failing to provide even basic health care (both preventive and curative) that could reduce child mortality globally by more than half. Paediatricians, who have perhaps in the past felt they were at the forefront of articulating and promoting a global health agenda, should be challenged by these conclusions. The successful ratification of the United Nations Convention on the Rights of the Child that unequivocally target health was not a finishing line, a goal achieved, but rather a foundation for action. Therefore while researchers might have felt some satisfaction at successes in defining optimum treatment approaches, the pathways to delivering services were, and remain, far from clear. Progress is further complicated by the diverse conditions and obstacles that may be encountered worldwide.

Integrating health care for mothers and children in refugee camps and at district level

Health care for mothers and children is inadequate in most refugee situations and in poorly resourced countries. The authors argue that, as well as providing primary (home based) care for basic health care, there is a need to integrate primary care with adequately functioning hospital based care for a healthcare system to succeed