We have described the development of CPGs for emergency and hospital care for children (0 - 4 years) as well as a means for their implementation that has been attempted in four district hospitals in Kenya as part of a longer term evaluation of their impact. District hospitals are the primary targets for the CPGs as although staffed by health workers with little or no specialist paediatric training they are the major referral sites for sick newborns and children from peripheral health units and therefore represent the clinical service area with the greatest potential for reducing mortality[41
Interestingly although aimed at the district hospital the CPG booklets that also contain drug, fluid and feeding guidelines are being introduced by the MoH and WHO-Kenya to major provincial and national hospital settings and training facilities at a cost of $0.85 per copy. This perhaps reflects the fact that the development of the CPG booklet was a long term, careful process including the government, academics, clinical teachers, paediatricians and others from the stage of priority setting [3
] through drafting guidelines, evidence review, development of job aides [2
], peer review of draft guidelines and dissemination so enhancing local ownership. The CPGs produced consist of clear and direct recommendations for ‘best practice’ in delivering emergency and early inpatient care for common problems and largely reflect international recommendations for provision of life-support and care presented in the “WHO Pocket Book of Hospital Care for Children”. As such our CPGs reflect an attempt to implement referral level or inpatient IMCI.
However, the CPGs will be useless if they are not understood and if recommended practices are not delivered appropriately. We therefore designed a training approach around the CPGs adapting and considerably extending the scope of an existing WHO course (ETAT) to produce ETAT+. This course links our local CPG booklet and training to standardized admission forms that appear to be acceptable and effective [2
], and should cost less than $30 per 1,000 patients admitted to sustain. We hypothesise that the approach of ‘institutional learning’ will promote change in the short term and minimize negative social influences [42
]. Such an approach could go some way to mitigate the effect of the rapid staff turnover that is a feature in many Kenyan hospitals. Training health providers of different clinical backgrounds together may also empower cadres with less perceived authority to prompt and promote change. Although there are challenges to delivering training at an institutional level we have shown that district hospitals in Kenya are willing to work to make such an approach possible if given adequate time to prepare. Further, our decision not to offer a per diem
payment (the former norm for most government or NGO run trainings) did not appear to threaten the training as 99% of the participants completed the course and punctuality was excellent. This, together with the decision to host the training in sites close to these relatively rural hospitals and the need for only 5 facilitators resulted in relatively low training costs.
From the commencement of the training our observations indicate that it became progressively apparent to the participants that there was a major ‘gap’ between what they had been practicing and the ‘best practices’ possible even in a situation with limited resources. We feel this created a positive motivation for learning in order to change practice. Thus, by the end of the course over 80% of participants performed well in their practical assessment, nearly 20% excellently. We had made no attempt to formally characterise those who performed poorly. However, our observations suggested that some of the older clinicians (although interestingly not nurses) with deeply engrained practices were the least likely to have completed their pre-reading, were the most likely to perceive change as disadvantageous in terms of the personal effort required and the least likely to perform well.
Decay of knowledge and loss of skills pose a real threat to the ongoing success of best practice care interventions [43
]. We are currently attempting to evaluate the real-life effectiveness of CPGs allied to support supervision in selected district hospitals. Further challenges for implementing and maintaining best practice care at a national scale include the capacity to update CPGs and sustain provision of job aides, to provide peer leadership and expert instructors, and, ideally, to integrate best practice into training institutions. Particularly if training institutions can promote the use of evidence and CPGs in Kenya then in time an increasing number of health workers, sensitised to the concept and aware that practice change is ongoing may accept and even demand updated best practice advice.