Examining which clinicians provide admission hospital care in a high mortality setting and their adherence to guidelines: an observational study in 13 hospitals.
Child, Preschool
Clinical Competence
Dehydration
/ complications
Diarrhea
/ complications
Female
Guideline Adherence
Hospitals
/ statistics & numerical data
Humans
Infant
Internship and Residency
/ standards
Kenya
/ epidemiology
Malaria
/ epidemiology
Male
Medical Staff, Hospital
/ standards
Mortality
Multimorbidity
Patient Admission
/ statistics & numerical data
Pneumonia
/ epidemiology
Practice Guidelines as Topic
Quality of Health Care
adherence to clinical guidelines
care cascade
general paediatrics
quality of care
Journal
Archives of disease in childhood
ISSN: 1468-2044
Titre abrégé: Arch Dis Child
Pays: England
ID NLM: 0372434
Informations de publication
Date de publication:
07 2020
07 2020
Historique:
received:
18
03
2019
revised:
23
12
2019
accepted:
03
01
2020
pubmed:
15
3
2020
medline:
21
10
2020
entrez:
15
3
2020
Statut:
ppublish
Résumé
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.
Sections du résumé
BACKGROUND
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.
METHODS
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.
RESULTS
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.
CONCLUSION
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.
Identifiants
pubmed: 32169853
pii: archdischild-2019-317256
doi: 10.1136/archdischild-2019-317256
pmc: PMC7361020
doi:
Types de publication
Journal Article
Observational Study
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
648-654Subventions
Organisme : Wellcome Trust
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 097170
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 207522
Pays : United Kingdom
Organisme : Medical Research Council
ID : MR/R006083/1
Pays : United Kingdom
Investigateurs
Victor Juma
(V)
Samuel Ngarngar
(S)
Nick Aduro
(N)
Boniface Nyumbile
(B)
Roselyne Malangachi
(R)
Loice Mutai
(L)
Christine Manyasi
(C)
David Kimutai
(D)
Caren Emadau
(C)
Cecilia Mutiso
(C)
Celia Muturi
(C)
Charles Nzioki
(C)
Supa Tunje
(S)
Francis Kanyingi
(F)
Agnes Mithamo
(A)
Magdalene Kuria
(M)
Samuel Otido
(S)
Alice Kariuki
(A)
Grace Wachira
(G)
Peris Njiiri
(P)
Peninah Muthoni
(P)
Rachel Inginia
(R)
Melab Musabi
(M)
Barnabas Kigen
(B)
Emma Namulala
(E)
Grace Akech Ochieng
(GA)
Lydia Thuranira
(L)
George Mbevi
(G)
Sylvia Omoke
(S)
Mercy Chepkirui
(M)
Basil Okola
(B)
Cynthia Asingwa
(C)
Informations de copyright
© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.
Déclaration de conflit d'intérêts
Competing interests: None declared.
Références
Arch Dis Child. 2017 Sep;102(9):846-851
pubmed: 28584069
BMJ Glob Health. 2018 Nov 28;3(6):e001136
pubmed: 30588346
Arch Dis Child. 2018 Nov;103(11):1013-1019
pubmed: 29514814
BMJ Glob Health. 2016 May 24;1(1):e000028
pubmed: 27398232
BMJ Glob Health. 2017 Oct 23;2(4):e000468
pubmed: 29104769
Trop Med Int Health. 2016 Oct;21(10):1334-1345
pubmed: 27391580
BMC Fam Pract. 2009 Sep 17;10:66
pubmed: 19761589
J Glob Health. 2018 Jun;8(1):010409
pubmed: 29497504
J Am Med Inform Assoc. 2016 Jan;23(1):184-92
pubmed: 26063746
Lancet. 1993 Nov 27;342(8883):1317-22
pubmed: 7901634
Int J Epidemiol. 2004 Oct;33(5):1080-91
pubmed: 15256523
N Engl J Med. 2004 Dec 30;351(27):2870-4
pubmed: 15625341
J Biomed Inform. 2009 Apr;42(2):377-81
pubmed: 18929686
BMJ Open. 2017 Nov 15;7(11):e019478
pubmed: 29146662
Malar J. 2016 Feb 24;15:112
pubmed: 26911252
Arch Dis Child. 2016 Mar;101(3):223-9
pubmed: 26662925
Arch Intern Med. 1990 Sep;150(9):1811-8
pubmed: 2203320
JAMA. 2005 Aug 10;294(6):716-24
pubmed: 16091574
BMC Int Health Hum Rights. 2006 Jul 20;6:9
pubmed: 16857044
Malar J. 2013 Sep 21;12:334
pubmed: 24053679
PLoS Med. 2011 Apr;8(4):e1001018
pubmed: 21483712
Lancet Glob Health. 2018 Feb;6(2):e203-e210
pubmed: 29389541