Tropical Medicine and International Health
doi:10.1111/tmi.12453
volume 20 no 4 pp 484–492 april 2015
Implementing WHO hospital guidelines improves quality of paediatric care in central hospitals in Lao PDR Amy Zigrida Gray1, Douangdao Soukaloun2,3, Bandith Soumphonphakdy2,3 and Trevor Duke1,4,5 1 2 3 4 5
Centre for International Child Health, University of Melbourne, Melbourne, Vic., Australia Mahosot Hospital, Vientiane, Lao PDR University of Health Sciences, Vientiane, Lao PDR Royal Children’s Hospital, Melbourne, Vic., Australia Murdoch Childrens Research Institute, Melbourne, Vic., Australia
Abstract
objectives To evaluate the impact of implementing a multifaceted intervention based on the WHO Pocketbook of Hospital Care for Children on the quality of case management of common childhood illnesses in hospitals in Lao PDR. methods The quality of case management of four sentinel conditions was assessed in three central hospitals before and after the implementation of the WHO Pocketbook as part of a broader mixedmethods study. Data on performance of key steps in case management in more than 600 admissions were collected by medical record abstraction pre- and post-intervention, and change was measured according to the proportion of cases which key steps were performed as well as an overall score of case management for each condition. results Improvements in mean case management scores were observed post-intervention for three of the four conditions, with the greatest change in pneumonia (53–91%), followed by diarrhoea and low birthweight. Rational drug prescribing, appropriate use of IV fluids and appropriate monitoring all occurred more frequently post-intervention. Non-recommended practices such as prescription of antitussives became less frequent. conclusions A multifaceted intervention based on the WHO Pocketbook of Hospital Care for children led to better paediatric care in central Lao hospitals. The degree of improvement was dependent on the condition assessed. keywords clinical guidelines, quality of care, paediatric, Lao PDR
Introduction Improving child survival requires a range of approaches across the health system and other sectors. The most seriously ill children require hospital care, yet there is mounting evidence of deficiencies in the care delivered in these facilities [1–4]. In low-resource settings many of the deficits highlighted by previous studies relate to the actions of healthcare providers, although hospital care may be limited by infrastructure, finance and supplies [1, 5]. Bridging evidence-practice gaps implies changing provider practice and is difficult. Educational interventions, guidelines, supervision and feedback have modest effects, and there is significant variation in the effect of the same intervention in different contexts [6–9]. Simply extrapolating lessons from interventions to improve hospital care from one setting to another, particularly from high resource to low-resource settings, is likely to fail. Examples of effective interventions to improve the quality of 484
hospital care in a range of low-resource settings are needed along with understanding of why change occurs [9]. The WHO Pocketbook of Hospital care for Children is one strategy, providing evidence-based guidelines for the treatment of common childhood illnesses [10]. Despite investment of significant time and technical resources, implementation of the Pocketbook has not been widely supported nor has its impact on health providers and the care they deliver been systematically evaluated [11, 12]. Lao PDR (or Laos) is a largely rural nation of 6 million people with health indicators that remain among the lowest in South-East Asia. Laos faces challenges similar to many low-resource countries, but among its strengths is a local paediatric training programme that has graduated more than 60 paediatricians. In its latest 5 year development plan and its child health strategy, the Lao government emphasised the need to improve the quality of health care [13]. A Lao translation of the WHO
© 2014 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 20 no 4 pp 484–492 april 2015
A. Z. Gray et al. Implementation of WHO hospital guidelines
Pocketbook implemented in collaboration with the local paediatric network was one potential strategy. This research aimed to evaluate whether an intervention based on the WHO Pocketbook of Hospital Care for Children could improve the quality of paediatric hospital care in central hospitals in Lao PDR. Method A before-and-after mixed-methods study was conducted. The research design was determined by what was perceived to be the most appropriate approach to implementing the WHO Pocketbook in the Lao context. A key hypothesis was that ownership of activities by the Lao paediatric network was likely to be critical to the intervention’s success or failure. This meant engaging all paediatricians in the intervention activities to generate a common understanding and a critical mass of expertise. Experimental designs – using staged introduction of the Pocketbook to different hospitals at different times or control hospitals which did not receive the full intervention – would have acted as a barrier to local ownership [14]. Quality of hospital care was assessed in three central Lao hospitals in the capital Vientiane, in August and September 2010 and again 12 months later. Two data collection tools were used: an observational hospital assessment tool from WHO [12] and systematic abstraction of data from medical records using a standardised checklist. This article reports on the quantitative findings from medical record data. Intervention The multifaceted intervention based on the WHO Pocketbook comprised: • Development of consensus among Lao paediatricians during translation of the book and preparation for training workshops, including engagement of local opinion leaders among the paediatricians. • Distribution of individual copies of the WHO Pocketbook to all staff on paediatric wards (from October 2010 and during training workshops). • Small-group, interactive, 3-day workshops delivered to more than 90% of doctors, including paediatricians and other staff, working in paediatric wards in study hospitals. Workshops focussed on how to use the Pocketbook and were based on the sample workshop schedule accompanying the generic Pocketbook training materials [15]. Workshops involved case-based teaching introducing participants to Pocketbook chapters including emergency triage and
© 2014 John Wiley & Sons Ltd
•
treatment, young infants, cough and difficulty breathing, diarrhoea, fever (including meningitis), malnutrition and surgery. Workshops were conducted between November 2010 and January 2011 with each doctor attending one training workshop. Audit of practice using information from hospital assessments with feedback on quality of care given to participants at training workshops, and again after post-intervention hospital assessments.
Medical record abstraction Medical abstraction tools were developed for four sentinel conditions – pneumonia, diarrhoea, low birthweight (LBW) and febrile encephalopathy – based on previous examples used in Lao hospitals. They consisted of a standardised checklist of case management steps as recommended by the WHO guidelines [16]. Each step was assessed as to whether or not it was documented in the medical record. An overall score for case management was assigned, which was the sum of key case management steps, with a maximum score of 15 for each condition. Negative scoring was applied for incorrect practices. Steps were only included in the final case management score if they were important to both perform and document. Some steps, although important, could not be included in the overall score, as they did not apply equally to all cases. For example, in febrile encephalopathy prescription of a third-generation cephalosporin was critical for meningo-encephalitis, but not febrile seizures. From each hospital, we aimed to abstract data from 30 consecutive admission records for each sentinel illness, pre- and post-intervention. Admissions were identified from ward admission books based on the primary discharge diagnosis. Secondary diagnoses were also recorded and were taken into account when determining appropriateness of case management. Pre-intervention records were collected retrospectively from September 2010 with post-intervention records collected 1 year later. Based on previous research using medical record abstraction in Lao PDR [16], a minimum sample size of 25 cases from each hospital was required to detect a 10% difference in mean scores pre- and post-intervention. Data for febrile encephalopathy were only available from two study hospitals as the third hospital transferred seriously ill children. Abstraction of data from medical records was performed by Lao paediatric residents. One individual was responsible for collection of data for each sentinel condition in each intervention period. Consistency in interpreting data from medical records was checked by comparison of data from five cases by data collectors, a 485
Tropical Medicine and International Health
volume 20 no 4 pp 484–492 april 2015
A. Z. Gray et al. Implementation of WHO hospital guidelines
senior Lao paediatrician and the primary researcher. Data were entered into Epi-data X5 by the primary researcher and checked for consistency by the data collector. Data were analysed using SPSS version 16 software. Case management scores for each sentinel condition were described according to mean and 95% confidence intervals. Scores were normally distributed. Comparison of scores pre- and post-intervention was made using analysis of variance (ANOVA). Factors other than the Pocketbook could influence any change observed in case management scores; most importantly, case management practices from the same hospital were more likely be more similar to each other than those from different hospitals. A random-effects analysis of mean case management scores was performed, taking into account the hospital as a random factor. The individual key steps in case management for each of the sentinel conditions were described according to the number and proportion of cases in which steps were documented, and compared pre- and post-intervention using Pearson’s chi-squared test. Bonferroni corrections were not made given, in most instances, strengths of associations would have not altered the significance of the result and any smaller strengths of association were treated with caution given the nature of the study design. Ethics approval was obtained from the University of Melbourne, Human Research Ethics Committee and the Lao National Ethical Committee for Health Research. Written and verbal consent for assessments was obtained from Hospital Directors. Results Data in terms of paediatric ward admissions and staffing for the study hospitals are provided in Table 1. Cases included in pre- and post-intervention assessments were comparable in terms of the number of records available for assessment, age, sex and outcome at discharge (Table 2). Overall case management scores increased post-intervention for three of the four conditions (Figure 1). No change was seen in the score for febrile encephalopathy. The magnitude of change varied according to disease. The greatest change was for pneumonia, with an absolute improvement in mean case management score of 38%, followed by diarrhoea (13%) and low birthweight (9%). Differences in mean scores pre- and post-intervention remained after taking into account the influence of the admitting hospital. Case management of pneumonia involves assessment, diagnosis and classification of pneumonia severity, using signs such as chest in-drawing and conscious state, with management based on severity. Post-intervention, chest 486
Table 1 Characteristics of study hospitals in relation to paediatric beds, admissions and staffing Hospital Hospital characteristics
C1
Paediatric inpatient admissions in 2010 Children
doi:10.1111/tmi.12453
volume 20 no 4 pp 484–492 april 2015
Implementing WHO hospital guidelines improves quality of paediatric care in central hospitals in Lao PDR Amy Zigrida Gray1, Douangdao Soukaloun2,3, Bandith Soumphonphakdy2,3 and Trevor Duke1,4,5 1 2 3 4 5
Centre for International Child Health, University of Melbourne, Melbourne, Vic., Australia Mahosot Hospital, Vientiane, Lao PDR University of Health Sciences, Vientiane, Lao PDR Royal Children’s Hospital, Melbourne, Vic., Australia Murdoch Childrens Research Institute, Melbourne, Vic., Australia
Abstract
objectives To evaluate the impact of implementing a multifaceted intervention based on the WHO Pocketbook of Hospital Care for Children on the quality of case management of common childhood illnesses in hospitals in Lao PDR. methods The quality of case management of four sentinel conditions was assessed in three central hospitals before and after the implementation of the WHO Pocketbook as part of a broader mixedmethods study. Data on performance of key steps in case management in more than 600 admissions were collected by medical record abstraction pre- and post-intervention, and change was measured according to the proportion of cases which key steps were performed as well as an overall score of case management for each condition. results Improvements in mean case management scores were observed post-intervention for three of the four conditions, with the greatest change in pneumonia (53–91%), followed by diarrhoea and low birthweight. Rational drug prescribing, appropriate use of IV fluids and appropriate monitoring all occurred more frequently post-intervention. Non-recommended practices such as prescription of antitussives became less frequent. conclusions A multifaceted intervention based on the WHO Pocketbook of Hospital Care for children led to better paediatric care in central Lao hospitals. The degree of improvement was dependent on the condition assessed. keywords clinical guidelines, quality of care, paediatric, Lao PDR
Introduction Improving child survival requires a range of approaches across the health system and other sectors. The most seriously ill children require hospital care, yet there is mounting evidence of deficiencies in the care delivered in these facilities [1–4]. In low-resource settings many of the deficits highlighted by previous studies relate to the actions of healthcare providers, although hospital care may be limited by infrastructure, finance and supplies [1, 5]. Bridging evidence-practice gaps implies changing provider practice and is difficult. Educational interventions, guidelines, supervision and feedback have modest effects, and there is significant variation in the effect of the same intervention in different contexts [6–9]. Simply extrapolating lessons from interventions to improve hospital care from one setting to another, particularly from high resource to low-resource settings, is likely to fail. Examples of effective interventions to improve the quality of 484
hospital care in a range of low-resource settings are needed along with understanding of why change occurs [9]. The WHO Pocketbook of Hospital care for Children is one strategy, providing evidence-based guidelines for the treatment of common childhood illnesses [10]. Despite investment of significant time and technical resources, implementation of the Pocketbook has not been widely supported nor has its impact on health providers and the care they deliver been systematically evaluated [11, 12]. Lao PDR (or Laos) is a largely rural nation of 6 million people with health indicators that remain among the lowest in South-East Asia. Laos faces challenges similar to many low-resource countries, but among its strengths is a local paediatric training programme that has graduated more than 60 paediatricians. In its latest 5 year development plan and its child health strategy, the Lao government emphasised the need to improve the quality of health care [13]. A Lao translation of the WHO
© 2014 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 20 no 4 pp 484–492 april 2015
A. Z. Gray et al. Implementation of WHO hospital guidelines
Pocketbook implemented in collaboration with the local paediatric network was one potential strategy. This research aimed to evaluate whether an intervention based on the WHO Pocketbook of Hospital Care for Children could improve the quality of paediatric hospital care in central hospitals in Lao PDR. Method A before-and-after mixed-methods study was conducted. The research design was determined by what was perceived to be the most appropriate approach to implementing the WHO Pocketbook in the Lao context. A key hypothesis was that ownership of activities by the Lao paediatric network was likely to be critical to the intervention’s success or failure. This meant engaging all paediatricians in the intervention activities to generate a common understanding and a critical mass of expertise. Experimental designs – using staged introduction of the Pocketbook to different hospitals at different times or control hospitals which did not receive the full intervention – would have acted as a barrier to local ownership [14]. Quality of hospital care was assessed in three central Lao hospitals in the capital Vientiane, in August and September 2010 and again 12 months later. Two data collection tools were used: an observational hospital assessment tool from WHO [12] and systematic abstraction of data from medical records using a standardised checklist. This article reports on the quantitative findings from medical record data. Intervention The multifaceted intervention based on the WHO Pocketbook comprised: • Development of consensus among Lao paediatricians during translation of the book and preparation for training workshops, including engagement of local opinion leaders among the paediatricians. • Distribution of individual copies of the WHO Pocketbook to all staff on paediatric wards (from October 2010 and during training workshops). • Small-group, interactive, 3-day workshops delivered to more than 90% of doctors, including paediatricians and other staff, working in paediatric wards in study hospitals. Workshops focussed on how to use the Pocketbook and were based on the sample workshop schedule accompanying the generic Pocketbook training materials [15]. Workshops involved case-based teaching introducing participants to Pocketbook chapters including emergency triage and
© 2014 John Wiley & Sons Ltd
•
treatment, young infants, cough and difficulty breathing, diarrhoea, fever (including meningitis), malnutrition and surgery. Workshops were conducted between November 2010 and January 2011 with each doctor attending one training workshop. Audit of practice using information from hospital assessments with feedback on quality of care given to participants at training workshops, and again after post-intervention hospital assessments.
Medical record abstraction Medical abstraction tools were developed for four sentinel conditions – pneumonia, diarrhoea, low birthweight (LBW) and febrile encephalopathy – based on previous examples used in Lao hospitals. They consisted of a standardised checklist of case management steps as recommended by the WHO guidelines [16]. Each step was assessed as to whether or not it was documented in the medical record. An overall score for case management was assigned, which was the sum of key case management steps, with a maximum score of 15 for each condition. Negative scoring was applied for incorrect practices. Steps were only included in the final case management score if they were important to both perform and document. Some steps, although important, could not be included in the overall score, as they did not apply equally to all cases. For example, in febrile encephalopathy prescription of a third-generation cephalosporin was critical for meningo-encephalitis, but not febrile seizures. From each hospital, we aimed to abstract data from 30 consecutive admission records for each sentinel illness, pre- and post-intervention. Admissions were identified from ward admission books based on the primary discharge diagnosis. Secondary diagnoses were also recorded and were taken into account when determining appropriateness of case management. Pre-intervention records were collected retrospectively from September 2010 with post-intervention records collected 1 year later. Based on previous research using medical record abstraction in Lao PDR [16], a minimum sample size of 25 cases from each hospital was required to detect a 10% difference in mean scores pre- and post-intervention. Data for febrile encephalopathy were only available from two study hospitals as the third hospital transferred seriously ill children. Abstraction of data from medical records was performed by Lao paediatric residents. One individual was responsible for collection of data for each sentinel condition in each intervention period. Consistency in interpreting data from medical records was checked by comparison of data from five cases by data collectors, a 485
Tropical Medicine and International Health
volume 20 no 4 pp 484–492 april 2015
A. Z. Gray et al. Implementation of WHO hospital guidelines
senior Lao paediatrician and the primary researcher. Data were entered into Epi-data X5 by the primary researcher and checked for consistency by the data collector. Data were analysed using SPSS version 16 software. Case management scores for each sentinel condition were described according to mean and 95% confidence intervals. Scores were normally distributed. Comparison of scores pre- and post-intervention was made using analysis of variance (ANOVA). Factors other than the Pocketbook could influence any change observed in case management scores; most importantly, case management practices from the same hospital were more likely be more similar to each other than those from different hospitals. A random-effects analysis of mean case management scores was performed, taking into account the hospital as a random factor. The individual key steps in case management for each of the sentinel conditions were described according to the number and proportion of cases in which steps were documented, and compared pre- and post-intervention using Pearson’s chi-squared test. Bonferroni corrections were not made given, in most instances, strengths of associations would have not altered the significance of the result and any smaller strengths of association were treated with caution given the nature of the study design. Ethics approval was obtained from the University of Melbourne, Human Research Ethics Committee and the Lao National Ethical Committee for Health Research. Written and verbal consent for assessments was obtained from Hospital Directors. Results Data in terms of paediatric ward admissions and staffing for the study hospitals are provided in Table 1. Cases included in pre- and post-intervention assessments were comparable in terms of the number of records available for assessment, age, sex and outcome at discharge (Table 2). Overall case management scores increased post-intervention for three of the four conditions (Figure 1). No change was seen in the score for febrile encephalopathy. The magnitude of change varied according to disease. The greatest change was for pneumonia, with an absolute improvement in mean case management score of 38%, followed by diarrhoea (13%) and low birthweight (9%). Differences in mean scores pre- and post-intervention remained after taking into account the influence of the admitting hospital. Case management of pneumonia involves assessment, diagnosis and classification of pneumonia severity, using signs such as chest in-drawing and conscious state, with management based on severity. Post-intervention, chest 486
Table 1 Characteristics of study hospitals in relation to paediatric beds, admissions and staffing Hospital Hospital characteristics
C1
Paediatric inpatient admissions in 2010 Children
