Irimu G.W., Gathara D., Zurovac D., Kihara H., Maina C., Mwangi J., Mbori-Ngacha D., Todd J., Greene A., English M.
Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya; Centre for Geographic Medicine Research - Coast, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom; Center for Global Health and Development, Boston University, Boston, MA, United States; Kenyatta National Hospital, Nairobi, Kenya; London School of Hygiene and Tropical Medicine, London, United Kingdom; Child Health, University of Dundee, Dundee, United Kingdom; Department of Paediatrics, University of Oxford, Oxford, United Kingdom
Irimu, G.W., Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya, Centre for Geographic Medicine Research - Coast, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya; Gathara, D., Centre for Geographic Medicine Research - Coast, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya; Zurovac, D., Centre for Geographic Medicine Research - Coast, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom, Center for Global Health and Development, Boston University, Boston, MA, United States; Kihara, H., Kenyatta National Hospital, Nairobi, Kenya; Maina, C., Kenyatta National Hospital, Nairobi, Kenya; Mwangi, J., Kenyatta National Hospital, Nairobi, Kenya; Mbori-Ngacha, D., Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya; Todd, J., London School of Hygiene and Tropical Medicine, London, United Kingdom; Greene, A., Child Health, University of Dundee, Dundee, United Kingdom; English, M., Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya, Centre for Geographic Medicine Research - Coast, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
Background: Implementation of WHO case management guidelines for serious common childhood illnesses remains a challenge in hospitals in low-income countries. The impact of locally adapted clinical practice guidelines (CPGs) on the quality-of-care of patients in tertiary hospitals has rarely been evaluated. Methods and Findings: We conducted, in Kenyatta National Hospital, an uncontrolled before and after study with an attempt to explore intervention dose-effect relationships, as CPGs were disseminated and training was progressively implemented. The emergency triage, assessment and treatment plus admission care (ETAT+) training and locally adapted CPGs targeted common, serious childhood illnesses. We compared performance in the pre-intervention (2005) and post-intervention periods (2009) using quality indicators for three diseases: pneumonia, dehydration and severe malnutrition. The indicators spanned four domains in the continuum of care namely assessment, classification, treatment, and follow-up care in the initial 48 hours of admission. In the pre-intervention period patients' care was largely inconsistent with the guidelines, with nine of the 15 key indicators having performance of below 10%. The intervention produced a marked improvement in guideline adherence with an absolute effect size of over 20% observed in seven of the 15 key indicators; three of which had an effect size of over 50%. However, for all the five indicators that required sustained team effort performance continued to be poor, at less than 10%, in the post-intervention period. Data from the five-year period (2005-09) suggest some dose dependency though the adoption rate of the best-practices varied across diseases and over time. Conclusion: Active dissemination of locally adapted clinical guidelines for common serious childhood illnesses can achieve a significant impact on documented clinical practices, particularly for tasks that rely on competence of individual clinicians. However, more attention must be given to broader implementation strategies that also target institutional and organisational aspects of service delivery to further enhance quality-of-care. © 2012 Irimu et al.