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1.  A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial 
PLoS Medicine  2011;8(4):e1001018.
Philip Ayieko and colleagues report the outcomes of a cluster-randomized trial carried out in eight Kenyan district hospitals evaluating the effects of a complex intervention involving improved training and supervision for clinicians. They found a higher performance of hospitals assigned to the complex intervention on a variety of process of care measures, as compared to those receiving the control intervention.
Background
In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated.
Methods and Findings
This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n = 4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n = 4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline.
In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean = 0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05–0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%; 17.1% [8.04%–26.1%]); loading dose quinine (91.9% versus 66.7%, 26.3% [−3.66% to 56.3%]); and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%; 29.9% [10.9%–48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose >40 mg/kg/day; 1.0% versus 7.5%; −6.5% [−12.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%; −6.8% [−11.9% to −1.6%]).
Conclusions
Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings.
Trial registration
Current Controlled Trials ISRCTN42996612
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In 2008, nearly 10 million children died in early childhood. Nearly all these deaths were in low- and middle-income countries—half were in Africa. In Kenya, for example, 74 out every 1,000 children born died before they reached their fifth birthday. About half of all childhood (pediatric) deaths in developing countries are caused by pneumonia, diarrhea, and malaria. Deaths from these common diseases could be prevented if all sick children had access to quality health care in the community (“primary” health care provided by health centers, pharmacists, family doctors, and traditional healers) and in district hospitals (“secondary” health care). Unfortunately, primary health care facilities in developing countries often lack essential diagnostic capabilities and drugs, and pediatric hospital care is frequently inadequate with many deaths occurring soon after admission. Consequently, in 1996, as part of global efforts to reduce childhood illnesses and deaths, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) introduced the Integrated Management of Childhood Illnesses (IMCI) strategy. This approach to child health focuses on the well-being of the whole child and aims to improve the case management skills of health care staff at all levels, health systems, and family and community health practices.
Why Was This Study Done?
The implementation of IMCI has been evaluated at the primary health care level, but its implementation in district hospitals has not been evaluated. So, for example, interventions designed to encourage the routine use of WHO disease-specific guidelines in rural pediatric hospitals have not been tested. In this cluster randomized trial, the researchers develop and test a multifaceted intervention designed to improve the implementation of treatment guidelines and admission pediatric care in district hospitals in Kenya. In a cluster randomized trial, groups of patients rather than individual patients are randomly assigned to receive alternative interventions and the outcomes in different “clusters” of patients are compared. In this trial, each cluster is a district hospital.
What Did the Researchers Do and Find?
The researchers randomly assigned eight Kenyan district hospitals to the “full” or “control” intervention, interventions that differed in intensity but that both included more strategies to promote implementation of best practice than are usually applied in Kenyan rural hospitals. The full intervention included provision of clinical practice guidelines and training in their use, six-monthly survey-based hospital assessments followed by face-to-face feedback of survey findings, 5.5 days training for health care workers, provision of job aids such as structured pediatric admission records, external supervision, and the identification of a local facilitator to promote guideline use and to provide on-site problem solving. The control intervention included the provision of clinical practice guidelines (without training in their use) and job aids, six-monthly surveys with written feedback, and a 1.5-day lecture-based seminar to explain the guidelines. The researchers compared the implementation of various processes of care (activities of patients and doctors undertaken to ensure delivery of care) in the intervention and control hospitals at baseline and 18 months later. The performance of both groups of hospitals improved during the trial but more markedly in the intervention hospitals than in the control hospitals. At 18 months, the completion of admission assessment tasks and the uptake of guideline-recommended clinical practices were both higher in the intervention hospitals than in the control hospitals. Moreover, a lower proportion of children received inappropriate doses of drugs such as quinine for malaria in the intervention hospitals than in the control hospitals.
What Do These Findings Mean?
These findings show that specific efforts are needed to improve pediatric care in rural Kenya and suggest that interventions that include more approaches to changing clinical practice may be more effective than interventions that include fewer approaches. These findings are limited by certain aspects of the trial design, such as the small number of participating hospitals, and may not be generalizable to other hospitals in Kenya or to hospitals in other developing countries. Thus, although these findings seem to suggest that efforts to implement and scale up improved secondary pediatric health care will need to include more than the production and dissemination of printed materials, further research including trials or evaluation of test programs are necessary before widespread adoption of any multifaceted approach (which will need to be tailored to local conditions and available resources) can be contemplated.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001018.
WHO provides information on efforts to reduce global child mortality and on Integrated Management of Childhood Illness (IMCI); the WHO pocket book “Hospital care for children contains guidelines for the management of common illnesses with limited resources (available in several languages)
UNICEF also provides information on efforts to reduce child mortality and detailed statistics on child mortality
The iDOC Africa Web site, which is dedicated to improving the delivery of hospital care for children and newborns in Africa, provides links to the clinical guidelines and other resources used in this study
doi:10.1371/journal.pmed.1001018
PMCID: PMC3071366  PMID: 21483712
2.  A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis 
PLoS Medicine  2012;9(6):e1001238.
A cost-effective analysis conducted by Edwine Barasa and colleagues estimates that a complex intervention aimed at improving quality of pediatric care would be affordable and cost-effective in Kenya.
Background
To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale.
Methods and Findings
Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26–67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67–47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19–2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A “what-if” analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3.
Conclusion
Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
According to latest global estimates from UNICEF, 7.6 million children currently die every year before they reach five years of age. Half of these deaths occur in children in sub-Saharan Africa and tragically, most of these deaths are due to a few treatable and preventable diseases, such as pneumonia, malaria, and diarrhea, for which effective interventions are already available. In order to meet the target of the 4th Millennium Development Goal—which aims to reduce the under-five child mortality rate by two-thirds from 1990 levels by 2015—delivering these interventions is essential.
In Kenya, the under-five child mortality rate must be reduced by half from its 2008 level in order to meet the Millennium Development Goal (MDG) target and so improving the management of serious child illness might help achieve this goal. A study published last year in PLoS Medicine described such an approach and included the development and implementation of evidence-based clinical practice guidelines linked to health worker training, follow-up supervision, performance feedback, and facilitation in eight district hospitals in Kenya.
Why Was This Study Done?
In the study mentioned above, the researchers compared the implementation of various processes of care in intervention and control hospitals at baseline and 18 months later and found that performance improved more in the intervention hospitals than in the control hospitals. However, while this strategy was effective at improving the quality of health care, it is unclear whether scaling up the approach would be a good use of limited resources. So in this study, the same researchers performed a cost-effectiveness analysis (which they conducted alongside the original trial) of their quality improvement intervention and estimated the costs and effects of scaling up this approach to cover the entire population of Kenya.
What Did the Researchers Do and Find?
In order to perform the cost part of the analysis, the researchers collected the relevant information on costs by using clinical and accounting record reviews and interviews with those involved in developing and implementing the intervention. The researchers evaluated the effectiveness part of the analysis by comparing the implementation of their improved quality of care strategy as delivered in the intervention hospitals with the partial intervention as delivered in the control hospitals by calculating the mean percentage improvement in the 14 process of care indicators at 18 months. Finally, the researchers calculated the costs of scaling up the intervention by applying their results to the whole of Kenya—121 hospital facilities with an estimated annual child admission rate of 2,000 per facility.
The researchers found that the quality of care (as measured by the process of care indicators) was 25% higher in intervention hospitals than in control hospitals, while the cost per child admission was US$50.74 in intervention hospitals compared to US$31.1 in control hospitals. The researchers calculated that each percentage improvement in the average quality of care was achieved at an additional cost of US$0.79 per admitted child. Extrapolating these results to all of Kenya, the estimated annual cost of scaling up the intervention nationally was US$3.6 million, about 0.6% of the annual child health budget in Kenya.
What Do These Findings Mean?
The findings of this cost-effectiveness analysis suggests that a comprehensive quality improvement intervention is effective at improving standards of care but at an additional cost, which may be relatively cost effective compared with basic care if the improvements observed are associated with decreases in child inpatient mortality. The absolute costs for scaling up are comparable to, or even lower than, costs of other, major child health interventions. As the international community is giving an increasing focus to strengthening health systems, these findings provide a strong case for scaling up this intervention, which improves quality of care and service provision for the major causes of child mortality, in rural hospitals throughout Kenya and other district hospitals in sub-Saharan Africa.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001238.
The researchers' original article appeared in PLoS Medicine in 2011: Ayieko P, Ntoburi S, Wagai J, Opondo C, Opiyo N, et al. (2011) A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial. PLoS Med 8(4): e1001018. doi:10.1371/journal.pmed.1001018
The IDOC Africa provides further information on the ETAT+ strategy
The World Health Organization (WHO) provides information on MDG 4, including strategies to reduce global child mortality) and the WHO pocket-book “Hospital care for children” includes guidelines for the management of common but serious childhood illnesses in resource-limited settings
UNICEF www.unicef.org also publishes information on global child mortality rates and the Countdown to 2015 website tracks coverage levels for health interventions proven to reduce child mortality
doi:10.1371/journal.pmed.1001238
PMCID: PMC3373608  PMID: 22719233
3.  Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt 
BMJ Open  2013;3(1):e001852.
Background
Between 1999 and 2007, the Ministry of Health and Population in Egypt scaled up the Integrated Management of Childhood Illness (IMCI) strategy in 84% of public health facilities.
Objectives
This retrospective analysis, using routinely available data from vital registration, aimed to assess the impact of IMCI implementation between 2000 and 2006 on child mortality. It also presents a systematic and comprehensive approach to scaling-up IMCI interventions and information on quality of child health services, using programme data from supervision and surveys.
Methods
We compared annual levels of under-five mortality in districts before and after they had started implementing IMCI. Mortality data were obtained from the National Bureau for Statistics for 254 districts for the years 2000–2006, 41 districts of which were excluded. For assessment of programme activities, we used information from the central IMCI data base, annual progress reports, follow-up after training visits and four studies on quality of child care in public health facilities.
Results
Across 213 districts retained in the analysis, the estimated average annual rate of decline in under-five mortality was 3.3% before compared with 6.3% after IMCI implementation (p=0.0001). In 127 districts which started implementing IMCI between 2002 and 2005, the average annual rate of decline of under-five mortality was 2.6% (95% CI 1.1% to 4.1%) before compared with 7.3% (95% CI 5.8% to 8.7%) after IMCI implementation (p<0.0001). IMCI implementation also led to marked improvements in the quality of child health services.
Interpretation
IMCI implementation was associated with a doubling in the annual rate of under-five mortality reduction (3.3% vs 6.3%). This mortality impact is plausible, since substantial improvements occurred in quality of care provided to sick children in health facilities implementing IMCI.
doi:10.1136/bmjopen-2012-001852
PMCID: PMC3563136  PMID: 23355663
Primary Care; Public Health
4.  Using electronic technology to improve clinical care – results from a before-after cluster trial to evaluate assessment and classification of sick children according to Integrated Management of Childhood Illness (IMCI) protocol in Tanzania 
Background
Poor adherence to the Integrated Management of Childhood Illness (IMCI) protocol reduces the potential impact on under-five morbidity and mortality. Electronic technology could improve adherence; however there are few studies demonstrating the benefits of such technology in a resource-poor settings. This study estimates the impact of electronic technology on adherence to the IMCI protocols as compared to the current paper-based protocols in Tanzania.
Methods
In four districts in Tanzania, 18 clinics were randomly selected for inclusion. At each site, observers documented critical parts of the clinical assessment of children aged 2 months to 5 years. The first set of observations occurred during examination of children using paper-based IMCI (pIMCI) and the next set of observations occurred during examination using the electronic IMCI (eIMCI). Children were re-examined by an IMCI expert and the diagnoses were compared. A total of 1221 children (671 paper, 550 electronic) were observed.
Results
For all ten critical IMCI items included in both systems, adherence to the protocol was greater for eIMCI than for pIMCI. The proportion assessed under pIMCI ranged from 61% to 98% compared to 92% to 100% under eIMCI (p < 0.05 for each of the ten assessment items).
Conclusions
Use of electronic systems improved the completeness of assessment of children with acute illness in Tanzania. With the before-after nature of the design, potential for temporal confounding is the primary limitation. However, the data collection for both phases occurred over a short period (one month) and so temporal confounding was expected to be minimal. The results suggest that the use of electronic IMCI protocols can improve the completeness and consistency of clinical assessments and future studies will examine the long-term health and health systems impact of eIMCI.
doi:10.1186/1472-6947-13-95
PMCID: PMC3766002  PMID: 23981292
5.  Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers 
Background
Despite evidence supporting Integrated Management of Childhood Illness (IMCI) as a strategy to improve pediatric care in countries with high child mortality, its implementation faces challenges related to lack of or poor post-didactic training supervision and gaps in necessary supporting systems. These constraints lead to health care workers’ inability to consistently translate IMCI knowledge and skills into practice. A program providing mentoring and enhanced supervision at health centers (MESH), focusing on clinical and systems improvement was implemented in rural Rwanda as a strategy to address these issues, with the ultimate goal of improving the quality of pediatric care at rural health centers. We explored perceptions of MESH from the perspective of IMCI clinical mentors, mentees, and district clinical leadership.
Methods
We conducted focus group discussions with 40 health care workers from 21 MESH-supported health centers. Two FGDs in each district were carried out, including one for nurses and one for director of health centers. District medical directors and clinical mentors had individual in-depth interviews. We performed a hermeneutic analysis using Atlas.ti v5.2.
Results
Study participants highlighted program components in five key areas that contributed to acceptability and impact, including: 1) Interactive, collaborative capacity-building, 2) active listening and relationships, 3) supporting not policing, 4) systems improvement, and 5) real-time feedback. Staff turn-over, stock-outs, and other facility/systems gaps were identified as barriers to MESH and IMCI implementation.
Conclusion
Health care workers reported high acceptance and positive perceptions of the MESH model as an effective strategy to build their capacity, bridge the gap between knowledge and practice in pediatric care, and address facility and systems issues. This approach also improved relationships between the district supervisory team and health center-based care providers. Despite some challenges, many perceived a strong benefit on clinical performance and outcomes. This study can inform program implementers and policy makers of key components needed for developing similar health facility-based mentorship interventions and potential barriers and resistance which can be proactively addressed to ensure success.
doi:10.1186/1472-6963-14-275
PMCID: PMC4077561  PMID: 24950878
Clinical mentorship; Quality improvement; Pediatrics; Health centers; Perceptions; Acceptability; IMCI; Rwanda
6.  Factors influencing the implementation of integrated management of childhood illness (IMCI) by healthcare workers at public health centers & dispensaries in Mwanza, Tanzania 
BMC Public Health  2014;14:277.
Background
Integrated Management of Childhood Illness (IMCI) was developed by the World Health Organization (WHO) and the United Nations International Children’s Fund (UNICEF) and aims at reducing childhood morbidity and mortality in resource-limited settings including Tanzania. It was introduced in 1996 and has been scaled up in all districts in the country. The purpose of this study was to identify factors influencing the implementation of IMCI in the health facilities in Mwanza, Tanzania since reports indicates that the guidelines are not full adhered to by the healthcare workers.
Methods
A cross-sectional study design was used and a sample size of 95 healthcare workers drawn from health centers and dispensaries within Mwanza city were interviewed using self-administered questionnaires. Structured interview was also used to get views from the city IMCI focal person and the 2 facilitators. Data were analyzed using SPSS and presented using figures and tables.
Results
Only 51% of healthcare workers interviewed had been trained. 69% of trained Healthcare workers expressed understanding of the IMCI approach. Most of the respondents (77%) had a positive attitude that IMCI approach was a better approach in managing common childhood illnesses especially with the reality of resource constraint in the health facilities. The main challenges identified in the implementation of IMCI are low initial training coverage among health care workers, lack of essential drugs and supplies, lack of onsite mentoring and lack of refresher courses and regular supportive supervision. Supporting the healthcare workers through training, onsite mentoring, supportive supervision and strengthening the healthcare system through increasing access to essential medicines, vaccines, strengthening supply chain management, increasing healthcare financing, improving leadership & management were the major interventions that could assist in IMCI implementation.
Conclusions
The healthcare workers can implement better IMCI through the collaboration of supervisors, IMCI focal person, Council Health Management Teams (CHMT) and other stakeholders interested in child health. However, significant barriers impede a sustainable IMCI implementation. Recommendations have been made related to supportive supervision and HealthCare system strengthening among others.
doi:10.1186/1471-2458-14-277
PMCID: PMC3987128  PMID: 24666561
Lower level health facilities; Integrated Management of Childhood Illness (IMCI); Council Health Management Team (CHMT); Factors influencing the implementation of IMCI
7.  The challenges of achieving high training coverage for IMCI: case studies from Kenya and Tanzania 
Health Policy and Planning  2010;26(5):395-404.
Health worker training is a key component of the integrated management of childhood illness (IMCI). However, training coverage remains low in many countries. We conducted in-depth case studies in two East African countries to examine the factors underlying low training coverage 10 years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007–08.
Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitization and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. In Tanzania, districts could not spend more than 10% of their budgets on training. In Kenya, limited financial decentralization meant that district managers had to rely on donors for financial support. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and donor support for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI.
Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally.
doi:10.1093/heapol/czq068
PMCID: PMC3157918  PMID: 21047808
IMCI; training coverage; Tanzania; Kenya; child health
8.  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.
doi:10.1179/2046905513Y.0000000081
PMCID: PMC4153412  PMID: 24621233
Quality of paediatric care; Neonatal care; Oxygen therapy; District hospitals; Oxygen concentrators; Rural health
9.  Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study 
PLoS Medicine  2012;9(1):e1001164.
In a before-and-after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.
Background
Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error.
Methods and Results
We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention “system-related” errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%–78.3%]; 57.5% [33.8%–81.2%]; and 60.5% [48.5%–72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23–7.28) to 2.12 (95% CI 1.71–2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30–3.93) to 1.46 (95% CI 1.20–1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively −12.8% [95% CI −41.1% to 15.5%]; −11.3% [−40.1% to 17.5%]; −20.1% [−52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30–0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors.
Conclusions
Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Medication errors—for example, prescribing the wrong drug or giving a drug by the wrong route—frequently occur in health care settings and are responsible for thousands of deaths every year. Until recently, medicines were prescribed and dispensed using systems based on hand-written scripts. In hospitals, for example, physicians wrote orders for medications directly onto a medication chart, which was then used by the nursing staff to give drugs to their patients. However, drugs are now increasingly being prescribed using electronic prescribing (e-prescribing) systems. With these systems, prescribers use a computer and order medications for their patients with the help of a drug information database and menu items, free text boxes, and prewritten orders for specific conditions (so-called passive decision support). The system reviews the patient's medication and known allergy list and alerts the physician to any potential problems, including drug interactions (active decision support). Then after the physician has responded to these alerts, the order is transmitted electronically to the pharmacy and/or the nursing staff who administer the prescription.
Why Was This Study Done?
By avoiding the need for physicians to write out prescriptions and by providing active and passive decision support, e-prescribing has the potential to reduce medication errors. But, even though many countries are investing in expensive commercial e-prescribing systems, few studies have evaluated the effects of these systems on prescribing error rates. Moreover, little is known about the interactions between system design and errors despite fears that e-prescribing might introduce new errors. In this study, the researchers analyze prescribing error rates in hospital in-patients before and after the implementation of two commercial e-prescribing systems.
What Did the Researchers Do and Find?
The researchers examined medication charts for procedural errors (unclear, incomplete, or illegal orders) and for clinical errors (for example, wrong drug or dose) at two Australian hospitals before and after the introduction of commercial e-prescribing systems. At Hospital A, the Cerner Millennium e-prescribing system was introduced on one ward; three other wards acted as controls. At Hospital B, the researchers compared the error rates on two wards before and after the introduction of the iSoft MedChart e-prescribing system. The introduction of an e-prescribing system was associated with a substantial reduction in error rates in the three intervention wards; error rates on the control wards did not change significantly during the study. At Hospital A, medication errors declined from 6.25 to 2.12 per admission after the introduction of e-prescribing whereas at Hospital B, they declined from 3.62 to 1.46 per admission. This reduction in error rates was mainly driven by a reduction in procedural error rates and there was only a limited change in overall clinical error rates. Notably, however, the rate of serious errors decreased across the intervention wards from 0.25 to 0.14 per admission (a 44% reduction), whereas the serious error rate only decreased by 17% in the control wards during the study. Finally, system-related errors (for example, selection of an inappropriate drug located on a drop-down menu next to a likely drug selection) accounted for 35% of errors in the intervention wards after the implementation of e-prescribing.
What Do These Findings Mean?
These findings show that the implementation of these two e-prescribing systems markedly reduced hospital in-patient prescribing error rates, mainly by reducing the number of incomplete, illegal, or unclear medication orders. The limited decision support built into both the e-prescribing systems used here may explain the limited reduction in clinical error rates but, importantly, both e-prescribing systems reduced serious medication errors. Finally, the high rate of system-related errors recorded in this study is worrying but is potentially remediable by system redesign and user training. Because this was a “real-world” study, it was not possible to choose the intervention wards randomly. Moreover, there was no control ward at Hospital B, and the wards included in the study had very different specialties. These and other aspects of the study design may limit the generalizability of these findings, which need to be confirmed and extended in additional studies. Even so, these findings provide persuasive evidence of the current and potential ability of commercial e-prescribing systems to reduce prescribing errors in hospital in-patients provided these systems are continually monitored and refined to improve their performance.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001164.
ClinfoWiki has pages on medication errors and on electronic prescribing (note: the Clinical Informatics Wiki is a free online resource that anyone can add to or edit)
Electronic prescribing in hospitals challenges and lessons learned describes the implementation of e-prescribing in UK hospitals; more information about e-prescribing in the UK is available on the NHS Connecting for Health Website
The Clinicians Guide to e-Prescribing provides up-to-date information about e-prescribing in the USA
Information about e-prescribing in Australia is also available
Information about electronic health records in Australia
doi:10.1371/journal.pmed.1001164
PMCID: PMC3269428  PMID: 22303286
10.  Incidence and Clinical Characteristics of Group A Rotavirus Infections among Children Admitted to Hospital in Kilifi, Kenya  
PLoS Medicine  2008;5(7):e153.
Background
Rotavirus, predominantly of group A, is a major cause of severe diarrhoea worldwide, with the greatest burden falling on young children living in less-developed countries. Vaccines directed against this virus have shown promise in recent trials, and are undergoing effectiveness evaluation in sub-Saharan Africa. In this region limited childhood data are available on the incidence and clinical characteristics of severe group A rotavirus disease. Advocacy for vaccine intervention and interpretation of effectiveness following implementation will benefit from accurate base-line estimates of the incidence and severity of rotavirus paediatric admissions in relevant populations. The study objective was to accurately define the incidence and severity of group A rotavirus disease in a resource-poor setting necessary to make informed decisions on the need for vaccine prevention.
Methods and Findings
Between 2002 and 2004 we conducted prospective surveillance for group A rotavirus infection at Kilifi District Hospital in coastal Kenya. Children < 13 y of age were eligible as “cases” if admitted with diarrhoea, and “controls” if admitted without diarrhoea. We calculated the incidence of hospital admission with group A rotavirus using data from a demographic surveillance study of 220,000 people in Kilifi District. Of 15,347 childhood admissions 3,296 (22%) had diarrhoea, 2,039 were tested for group A rotavirus antigen and, of these, 588 (29%) were positive. 372 (63%) rotavirus-positive cases were infants. Of 620 controls 19 (3.1%, 95% confidence interval [CI] 1.9–4.7) were rotavirus positive. The annual incidence (per 100,000 children) of rotavirus-positive admissions was 1,431 (95% CI 1,275–1,600) in infants and 478 (437–521) in under-5-y-olds, and highest proximal to the hospital. Compared to children with rotavirus-negative diarrhoea, rotavirus-positive cases were less likely to have coexisting illnesses and more likely to have acidosis (46% versus 17%) and severe electrolyte imbalance except hyponatraemia. In-hospital case fatality was 2% among rotavirus-positive and 9% among rotavirus-negative children.
Conclusions
In Kilifi > 2% of children are admitted to hospital with group A rotavirus diarrhoea in the first 5 y of life. This translates into over 28,000 vaccine-preventable hospitalisations per year across Kenya, and is likely to be a considerable underestimate. Group A rotavirus diarrhoea is associated with acute life-threatening metabolic derangement in otherwise healthy children. Although mortality is low in this clinical research setting this may not be generally true in African hospitals lacking rapid and appropriate management.
Combining prospective hospital-based surveillance with demographic data in Kilifi, Kenya, James Nokes and colleagues assess the burden of rotavirus diarrhea in young children.
Editors' Summary
Background.
Rotavirus is a leading global cause of diarrhea in babies and young children. Indeed, most children become infected at least once with this virus before their fifth birthday. Rotavirus is usually spread by children or their caregivers failing to wash their hands properly after going to the toilet and then contaminating food or drink. The symptoms of rotavirus infection—diarrhea, vomiting, and fever—are usually mild, but if the diarrhea is severe it can quickly lead to dehydration. Mild to moderate dehydration can be treated at home by providing the patient with plenty of fluids or with a special rehydration drink that replaces lost water and salts. However, for infants or toddlers who become severely dehydrated, rehydration with intravenous fluids (fluids injected directly into a vein) in hospital may be essential. Unfortunately, in developing countries in sub-Saharan Africa and elsewhere, this treatment is not widely available and every year more than half a million young children die from rotavirus infections.
Why Was This Study Done?
Two rotavirus vaccines that could reduce this burden of disease are currently undergoing clinical trials to determine their effectiveness in sub-Saharan Africa. However, very little is known about the incidence of severe rotavirus infections among children living in this region (that is, how many children develop severe disease every year) or about the clinical characteristics of the disease here. Public-health officials need this baseline information before they can make informed decisions about the mass introduction of rotavirus vaccination and to help them judge whether the intervention has been successful if it is introduced. In this study, the researchers examine the incidence and clinical characteristics of rotavirus infections (specifically, group A rotavirus [GARV] infections; there are several different rotaviruses but GARV causes most human infections) among children admitted to the district hospital in Kilifi, Kenya.
What Did the Researchers Do and Find?
During the 3-year study, more than 15,000 children under the age of 13 years were admitted to Kilifi District Hospital, a little under a quarter of whom had severe diarrhea. Nearly a third of the patients admitted with diarrhea who were tested had a GARV-specific protein in their stools (faeces); by contrast, only three in 100 children admitted without diarrhea showed any evidence of GARV infection. Two-thirds of the GARV-positive children were infants (under 1 year old). Using these figures and health surveillance data (records of births, deaths, and causes of death) collected in the area around the hospital, the researchers calculated that the annual incidence (per 100,000 children) of GARV-positive hospital admissions in the region was 1,431 for infants and 478 for children under age 5 years. Children with GARV-positive diarrhea were less likely to have other illnesses (for example, malnutrition) than those admitted with GARV-negative diarrhea, the researchers report, but were more likely to have life-threatening complications such as severe dehydration and salt imbalances in their blood. However, despite being more ill on admission, only 1 in 50 children with GARV-positive diarrhea died, compared to nearly 1 in 10 of the children with GARV-negative diarrhea; the GARV-positive children also left hospital quicker than those who were GARV-negative.
What Do These Findings Mean?
These findings indicate that severe GARV-positive diarrhea is a major cause of hospital admission among otherwise healthy young children in the Kilifi region of Kenya. By the time they are 5 years old, the researchers estimate that 1 in 50 of the children living in this region will have been admitted to hospital with severe GARV-positive diarrhea. Because rotavirus vaccines prevent virtually all severe rotavirus-associated disease (at least in developed countries where their effectiveness has been extensively tested), the researchers estimate that vaccination might prevent more than 28,000 hospitalizations annually across Kenya; however, this prediction assumes that it is valid to extrapolate from the data obtained from this one district hospital to the entire country.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050153.
The US Centers for Disease Control and Prevention provides information about rotavirus infections, surveillance, and vaccination (in English and Spanish)
The UK National Health Service Direct health encyclopedia provides information on rotavirus infections
MedlinePlus also provides links to information on rotavirus (in English and Spanish)
The African Rotavirus Surveillance Network is working to improve knowledge about rotavirus infections in Africa
The Rotavirus Vaccine Program aims to reduce child illness and death from diarrhea by increasing the availability of rotavirus vaccines in developing countries (in English and Spanish)
PATH, a nonprofit international organization that aims to create sustainable, culturally relevant solutions to global health problems, also provides detailed information on rotavirus surveillance and disease burden
doi:10.1371/journal.pmed.0050153
PMCID: PMC2488191  PMID: 18651787
11.  Factors influencing performance of health workers in the management of seriously sick children at a Kenyan tertiary hospital - participatory action research 
Background
Implementation of World Health Organization case management guidelines for serious childhood illnesses remains a challenge in hospitals in low-income countries. Facilitators of and barriers to implementation of locally adapted clinical practice guidelines (CPGs) have not been explored.
Methods
This ethnographic study based on the theory of participatory action research (PAR) was conducted in Kenyatta National Hospital, Kenya’s largest teaching hospital. The primary intervention consisted of dissemination of locally adapted CPGs. The PRECEDE-PROCEED health education model was used as the conceptual framework to guide and examine further reinforcement activities to improve the uptake of the CPGs. Activities focussed on introduction of routine clinical audits and tailored educational sessions. Data were collected by a participant observer who also facilitated the PAR over an eighteen-month period. Naturalistic inquiry was utilized to obtain information from all hospital staff encountered while theoretical sampling allowed in-depth exploration of emerging issues. Data were analysed using interpretive description.
Results
Relevance of the CPGs to routine work and emergence of a champion of change facilitated uptake of best-practices. Mobilization of basic resources was relatively easily undertaken while activities that required real intellectual and professional engagement of the senior staff were a challenge. Accomplishments of the PAR were largely with the passive rather than active involvement of the hospital management. Barriers to implementation of best-practices included i) mismatch between the hospital’s vision and reality, ii) poor communication, iii) lack of objective mechanisms for monitoring and evaluating quality of clinical care, iv) limited capacity for planning strategic change, v) limited management skills to introduce and manage change, vi) hierarchical relationships, and vii) inadequate adaptation of the interventions to the local context.
Conclusions
Educational interventions, often regarded as ‘quick-fixes’ to improve care in low-income countries, may be necessary but are unlikely to be sufficient to deliver improved services. We propose that an understanding of organizational issues that influence the behaviour of individual health professionals should guide and inform the implementation of best-practices.
doi:10.1186/1472-6963-14-59
PMCID: PMC3942276  PMID: 24507629
Clinical audits; Clinical practice guidelines; Continuous medical educational sessions; ETAT+; Ethnographic study; Implementation of best-practices; Interpretive description; Participatory action research; Participant observer; Performance of health workers
12.  Insight into implementation of facility-based integrated management of childhood illness strategy in a rural district of Sindh, Pakistan 
Global Health Action  2013;6:10.3402/gha.v6i0.20086.
Background
Integrated management of childhood illnesses (IMCI) strategy has been proven to improve health outcomes in children under 5 years of age. Pakistan, despite being in the late implementation phase of the strategy, continues to report high under-five mortality due to pneumonia, diarrhea, measles, and malnutrition – the main targets of the strategy.
Objective
The study determines the factors influencing IMCI implementation at public-sector primary health care (PHC) facilities in Matiari district, Sindh, Pakistan.
Design
An exploratory qualitative study with an embedded quantitative strand was conducted. The qualitative part included 16 in-depth interviews (IDIs) with stakeholders which included planners and policy makers at a provincial level (n=5), implementers and managers at a district level (n=3), and IMCI-trained physicians posted at PHC facilities (n=8). Quantitative part included PHC facility survey (n=16) utilizing WHO health facility assessment tool to assess availability of IMCI essential drugs, supplies, and equipments. Qualitative content analysis was used to interpret the textual information, whereas descriptive frequencies were calculated for health facility survey data.
Results
The major factors reported to enhance IMCI implementation were knowledge and perception about the strategy and need for separate clinic for children aged under 5 years as potential support factors. The latter can facilitate in strategy implementation through allocated workforce and required equipments and supplies. Constraint factors mainly included lack of clear understanding of the strategy, poor planning for IMCI implementation, ambiguity in defined roles and responsibilities among stakeholders, and insufficient essential supplies and drugs at PHC centers. The latter was further substantiated through health facilities’ survey findings, which indicated that none of the facilities had 100% stock of essential supplies and drugs. Only one out of all 16 surveyed facilities had 75% of the total supplies, while 4 out of 16 facilities had 56% of the required IMCI drug stock. The mean availability of supplies ranged from 36.6 to 66%, while the mean availability of drugs ranged from 45.8 to 56.7%.
Conclusion
Our findings indicate that the Matiari district has sound implementation potential; however, bottlenecks at health care facility and at health care management level have badly constrained the implementation process. An interdependency exists among the constraining factors, such as lack of sound planning resulting in unclear understanding of the strategy; leading to ambiguous roles and responsibilities among stakeholders which manifest as inadequate availability of supplies and drugs at PHC facilities. Addressing these barriers is likely to have a cumulative effect on facilitating IMCI implementation. On the basis of these findings, we recommend that the provincial Ministry of Health (MoH) and provincial Maternal Neonatal and Child Health (MNCH) program jointly assess the situation and streamline IMCI implementation in the district through sound planning, training, supervision, and logistic support.
doi:10.3402/gha.v6i0.20086
PMCID: PMC3703511  PMID: 23830574
IMCI; IMCI Pakistan; child health; under-five mortality; under-five morbidity; primary health care in children under five; IMCI implementation barriers and supports
13.  Knowledge of integrated management of childhood illnesses community and family practices (C-IMCI) and association with child undernutrition in Northern Uganda: a cross-sectional study 
BMC Public Health  2014;14(1):976.
Background
Childhood undernutrition is a major challenge in Uganda with a prevalence of wasting and stunting at 5% and 33%, respectively. Community and family practices of the Integrated Management of Childhood Illnesses (C-IMCI) was introduced in sub-Saharan Africa early after the year 2000. C-IMCI was postulated to address major childhood morbidity and mortality challenges with nutrition as one of the outcomes. The association between knowledge patterns of C-IMCI and undernutrition has not been fully established especially in sub-Saharan Africa. This study was done to address the prevalence of stunting and wasting and the association with the knowledge and practices of C-IMCI among caretakers in Gulu district, Northern Uganda.
Methods
This was a community-based cross-sectional study among 442 caretaker-child pairs. A standardized questionnaire was employed to assess the knowledge and practices of the C-IMCI among caretakers including four practices: breastfeeding, immunization, micronutrient supplementation and complementary feeding. Weight and height of children (6–60 months) were recorded. Wasting and stunting were defined as weight-for-height and height-for-age z-score, respectively, with a cut-off < -2 according to the World Health Organization growth standards. Logistic regression analysis reporting Odds Ratios (OR) with 95% confidence intervals (CI) was used to explore associations using SAS statistical software.
Results
The percentage of caretakers who had adequate knowledge on C-IMCI (basic knowledge within each pillar) was 13%. The prevalence of wasting and stunting were 8% and 21%, respectively. Caretakers’ lack of knowledge of C-IMCI was associated with both wasting (OR 24.5, 95% CI 4.2-143.3) and stunting (OR 4.0, 95% CI 1.3-12.4). Rural residence was also associated with both wasting (OR = 3.1, 95% CI 1.5-6.5) and stunting (OR = 1.7, 95% CI 1.0-2.7). Children younger than 25 months were more likely to be wasted (OR = 3.3, 95% CI 1.7-10.0).
Conclusion
We found a low level of overall knowledge of the C-IMCI of 13.3% (n = 59). There is also a high prevalence of childhood undernutrition in Northern Uganda. Caretakers’ limited knowledge of the C-IMCI and rural residence was associated with both wasting and stunting. Interventions to increase the knowledge of the C-IMCI practices among caretakers need reinforcement.
doi:10.1186/1471-2458-14-976
PMCID: PMC4192439  PMID: 25238966
Community and family practices of the integrated management of childhood illnesses; IMCI; Stunting; Wasting; Undernutrition; Sub-Saharan Africa; Gulu
14.  Barriers to implementation of the HIV guidelines in the IMCI algorithm among IMCI trained health workers in Zambia 
BMC Pediatrics  2010;10:93.
Background
Zambia adopted integrated management of Childhood illnesses (IMCI) in 1995 and a number of adaptations have been made to the generic WHO/UNICEF IMCI guidelines to better conform to Zambia's health service needs. One significant adaptation is the incorporation of HIV guidelines into the IMCI algorithm. Since 2004, health workers that have undergone IMCI case management training have also received training in HIV assessment. During initial follow-up visits in 11 districts 90 health workers were assessed in 2007 to determine their adherence to the IMCI algorithm. The assessment showed that 97% of the health workers assessed did not review or mention the HIV guidelines even though they had received HIV training as part of IMCI. This study aimed to explore reasons for non-adherence to HIV guidelines in the IMCI algorithm and make recommendations on how this can be improved.
Methods
Both quantitative and qualitative methods were used to collect information from eligible health workers. Forty (40) health workers were randomly selected from among those who received initial follow-up visits between March 2007 and January 2008. The health workers were selected from eight districts in four provinces of Zambia. Qualitative data was collected using Focus group discussion and key informant interviews
Results
83% of the respondents said they had no difficulties in following the HIV adapted IMCI guidelines. 17% said they had difficulties. Of those who admitted having difficulties (60%) had difficulties in HIV assessment. Interesting, prompting and focus group discussions revealed that most respondents actually had difficulties in HIV assessment but could not admit it readily. Some barriers that contributed to non-adherence to the guidelines included lack of time due to inadequate staffing, lack of privacy in the health facilities and HIV related stigma from both caregivers and health workers. Frequent use of guidelines and supervision appeared to re-enforce adherence to the guidelines.
Conclusion
The findings in this study suggest that training in HIV adapted IMCI guidelines is not sufficient to enable health workers to actually use their knowledge in their daily practice. Barriers may exist which prevent them from adhering to the guidelines. Addressing these barriers is critical in increasing the uptake of paediatric ART in Zambia
doi:10.1186/1471-2431-10-93
PMCID: PMC3023733  PMID: 21167016
15.  Effect of an IMCI intervention on quality of care across four districts in Cape Town, South Africa 
Archives of Disease in Childhood  2005;90(4):397-401.
Aims: To measure the change in quality of care provided to sick children as a result of the routine implementation of the IMCI intervention.
Methods: Structured observations of consultations with sick children, exit interviews with caregivers, and facility reviews were conducted both before and after IMCI intervention in four health districts in Cape Town. Interventions were case management training, orientation courses for supervisors and medical officers, and some reorganisation of management systems.
Results: Twenty one nurses in 21 clinics were observed before and after the IMCI intervention; 90 and 70 child observations were conducted before and after IMCI intervention respectively. There was a marked improvement in assessment of danger signs in sick children (7% before versus 72% after), assessment of co-morbidity (integrated score 5.2 versus 8.2), rational prescribing (62% versus 84%), and starting treatment in the clinic (40% versus 70%). However there was no change in the treatment of anaemia or the prescribing of vitamin A or counselling of caregivers. There was no change in the knowledge of caregivers regarding medication or when to return to the health facility. Facilities were well stocked and supervision regular both before and after IMCI.
Conclusion: This study has shown that under normal operating conditions and in a context of good facility infrastructure and management support, IMCI is associated with improvements in some important aspects of care
doi:10.1136/adc.2004.059147
PMCID: PMC1720349  PMID: 15781932
16.  Global challenges with scale-up of the integrated management of childhood illness strategy: results of a multi-country survey 
BMC Public Health  2011;11:503.
Background
The Integrated Management of Childhood Illness Strategy (IMCI), developed by WHO/UNICEF, aims to contribute to reducing childhood morbidity and mortality (MDG4) in resource-limited settings. Since 1996 more than 100 countries have adopted IMCI. IMCI case management training (ICMT) is one of three IMCI components and training is usually residential over 11 consecutive days. Follow-up after ICMT is an essential part of training. We describe the barriers to rapid acceleration of ICMT and review country perspectives on how to address these barriers.
Methods
A multi-country exploratory cross-sectional questionnaire survey of in-service ICMT approaches, using quantitative and qualitative methods, was conducted in 2006-7: 27 countries were purposively selected from all six WHO regions. Data for this paper are from three questionnaires (QA, QB and QC), distributed to selected national focal IMCI persons/programme officers, course directors/facilitators and IMCI trainees respectively. QC only gathered data on experiences with IMCI follow-up.
Results
33 QA, 163 QB and 272 QC were received. The commonest challenges to ICMT scale-up relate to funding (high cost and long duration of the residential ICMT), poor literacy of health workers, differing opinions about the role of IMCI in improving child health, lack of political support, frequent changes in staff or rules at Ministries of Health and lack of skilled facilitators. Countries addressed these challenges in several ways including increased advocacy, developing strategic linkages with other priorities, intensifying pre-service training, re-distribution of funds and shortening course duration. The commonest challenges to follow-up after ICMT were lack of funding (93.1% of respondents), inadequate funds for travelling or planning (75.9% and 44.8% respectively), lack of gas for travelling (41.4%), inadequately trained or few supervisors (41.4%) and inadequate job aids for follow-up (27.6%). Countries addressed these by piggy backing IMCI follow-up with routine supervisory visits.
Conclusions
Financial challenges to ICMT scale-up and follow-up after training are common. As IMCI is accepted globally as one of the key strategies to meet MDG4 several steps need to be taken to facilitate rapid acceleration of ICMT, including reviewing core competencies followed by competency-driven shortened training duration or 'on the job' training, 'distance learning' or training using mobile phones. Linkages with other 'better-funded' programmes e.g. HIV or malaria need to be improved. Routine Primary Health Care (PHC) supervision needs to include follow-up after ICMT.
doi:10.1186/1471-2458-11-503
PMCID: PMC3155839  PMID: 21708029
17.  Causes and outcome of young infant admissions to a Kenyan district hospital 
Archives of Disease in Childhood  2003;88(5):438-443.
Aims: To provide a comprehensive description of young infant admissions to a first referral level health facility in Kenya. These data, currently lacking, are important given present efforts to standardise their care through the integrated management of childhood illness (IMCI) and for prioritising both health care provision and disease prevention strategies.
Methods: Prospective, 18 month observational study in a Kenyan district hospital of all admissions less than 3 months of age to the paediatric ward.
Results: A total of 1080 infants were studied. Mortality was 18% overall, though in those aged 0–7 days it was 34%. Within two months of discharge a further 5% of infants aged <60 days on admission had died. Severe infection and prematurity together accounted for 57% of inpatient deaths in those aged <60 days, while jaundice and tetanus accounted for another 27%. S pneumoniae, group B streptococcus, E coli, and Klebsiella spp. were the most common causes of invasive bacterial disease. Hypoxaemia, hypoglycaemia, and an inability to feed were each present in more than 20% of infants aged 0–7 days. Both hypoxaemia and the inability to feed were associated with inpatient death (OR 3.8 (95% CI 2.5 to 5.8) and 7.4 (95% CI 4.8 to 11.2) respectively).
Conclusions: Young infants contribute substantially to paediatric inpatient mortality at the first referral level, highlighting the need both for basic supportive care facilities and improved disease prevention strategies.
doi:10.1136/adc.88.5.438
PMCID: PMC1719579  PMID: 12716721
18.  Results of a multi-country exploratory survey of approaches and methods for IMCI case management training 
Background
The Integrated Management of Childhood Illness Strategy (IMCI) is effective in improving management of sick children, and thus child survival. It is currently recommended that in-service IMCI case management training (ICMT) occur over 11-days; that the participant: facilitator ratio should be ≤4:1 and that at least 30% of ICMT time be spent on clinical practice. In 2006–2007, approximately ten years after IMCI implementation, we conducted a multi-country exploratory questionnaire survey to document country experiences with ICMT, and to determine the acceptability of shortening duration of ICMT.
Methods
Questionnaires (QA) were sent to national IMCI focal persons in 27 purposively-selected countries. To probe further, questionnaires (QB and QC respectively) were also sent to course-directors or facilitators and IMCI trainees, selected using snowball sampling after applying pre-defined criteria, in these countries. Questionnaires gathered quantitative and qualitative data.
Results
Thirty-three QA, 163 QB, 272 QC and two summaries were returned from 24 countries. All countries continued to adapt course content to local disease burden. All countries offer shorter ICMT courses, ranging from 3–10 days (commonest being 5–8 days). The shorter ICMT courses offer fewer exercises, more homework, less individual feedback and reduced clinical practice (<30% time). Whereas changes to course content were usually evidence-based, changes to training methodology and course duration evolved as pressure to expand implementation mounted. Participants varied in their self-reported skill and perception about each course. However, the varied methodology and integrated approach to management of illnesses were commonly cited as strengths of ICMT, and the chart booklet and clinical practice sessions were identified as critical components of ICMT. Four themes emerged from the qualitative work, viz. the current 11-day course is too expensive and should be shortened; advocacy around IMCI should increase; content should be regularly updated, new content areas should be introduced cautiously and more attention should be paid to skills-building rather than knowledge accumulation.
Conclusion
Whilst the 11-day ICMT course is still recommended, as efforts intensify to increase access to quality care and meet MDG4, standardized shorter ICMT courses, that include participatory methodologies and adequate clinical practice, could be acceptable globally.
doi:10.1186/1478-4505-7-18
PMCID: PMC2723104  PMID: 19615080
19.  An Evaluation of the Clinical Assessments of Under-Five Febrile Children Presenting to Primary Health Facilities in Rural Ghana 
PLoS ONE  2011;6(12):e28944.
Background
The shift to test-based management of malaria represents an important departure from established practice under the Integrated Management of Childhood Illnesses (IMCI). The possibility of false results of tests for malaria and co-morbidity, however, make it important that guidelines in IMCI case assessment are still followed.
Methods and Findings
We conducted a cross-sectional observational study to evaluate current practices in IMCI-based assessment of febrile children in 10 health centres and 5 district hospitals, with follow up of a subset of children to determine day 7–10 post-treatment clinical outcome. Clinical consultation, examination and prescribing practices were recorded using a checklist by trained non-medical observers. The facility case management of 1,983 under-five years old febrile children was observed and 593 followed up at home on days 5–10. The mean number of tasks performed from the 11 tasks expected to be done by the IMCI guidelines was 6 (SD 1.6). More than 6 tasks were performed in only 35% of children and this varied substantially between health facilities (range 3–85%). All 11 tasks were performed in only 1% of children. The most commonly performed tasks were temperature measurement (91%) and weighing (88%). Respiratory rate was checked in only 4% of children presenting with cough or difficulty in breathing. The likelihood of performing “better than average number of tasks” (>6) was higher when the consultation was done by medical assistants than doctors (O.R. = 3.16, 1.02–9.20). The number of tasks performed during assessment did not, however, influence clinical outcome (O.R. = 1.02, 0.83–1.24).
Conclusion
Facility-tailored interventions are needed to improve adherence to IMCI guidelines incorporating test-based management of malaria. Studies are needed to re-evaluate the continued validity of tasks defined in IMCI case assessment guidelines.
doi:10.1371/journal.pone.0028944
PMCID: PMC3236777  PMID: 22174932
20.  Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries 
PLoS Medicine  2010;7(3):e1000243.
In the first of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues find low levels of surgical care provision suggesting unmet need for surgical services.
Background
Surgical conditions contribute significantly to the disease burden in sub-Saharan Africa. Yet there is an apparent neglect of surgical care as a public health intervention to counter this burden. There is increasing enthusiasm to reverse this trend, by promoting essential surgical services at the district hospital, the first point of contact for critical conditions for rural populations. This study investigated the scope of surgery conducted at district hospitals in three sub-Saharan African countries.
Methods and Findings
In a retrospective descriptive study, field data were collected from eight district hospitals in Uganda, Tanzania, and Mozambique using a standardized form and interviews with key informants. Overall, the scope of surgical procedures performed was narrow and included mainly essential and life-saving emergency procedures. Surgical output varied across hospitals from five to 45 major procedures/10,000 people. Obstetric operations were most common and included cesarean sections and uterine evacuations. Hernia repair and wound care accounted for 65% of general surgical procedures. The number of beds in the studied hospitals ranged from 0.2 to 1.0 per 1,000 population.
Conclusion
The findings of this study clearly indicate low levels of surgical care provision at the district level for the hospitals studied. The extent to which this translates into unmet need remains unknown although the very low proportions of live births in the catchment areas of these eight hospitals that are born by cesarean section suggest that there is a substantial unmet need for surgical services. The district hospital in the current health system in sub-Saharan Africa lends itself to feasible integration of essential surgery into the spectrum of comprehensive primary care services. It is therefore critical that the surgical capacity of the district hospital is significantly expanded; this will result in sustainable preventable morbidity and mortality.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 234 million major surgical procedures take place globally. Of these procedures, only a quarter are performed in low- and middle-income countries where nearly three-quarters of the world's population lives. Put another way, in high-income countries, 10,110 people out of every 100,000 have surgery each year on average compared to only 295 people out of every 100,000 in low- and middle-income countries. Yet conditions that need surgery (including complications of childbirth and traumatic injuries) are common in developing countries and contribute significantly to the burden of disease in these countries. Various organizations are working to reduce this burden by improving emergency and essential surgical care in developing countries. For example, the Bellagio Essential Surgery Group (BESG), which includes experts in surgery, anesthesia, obstetrics (the branch of medicine that cares for women during pregnancy and childbirth), and health policy from several African countries, the World Health Organization (WHO), and the US, aims to increase access to surgical services in sub-Saharan Africa.
Why Was This Study Done?
One way to improve access to surgical services in sub-Saharan Africa would be to promote the provision of essential surgical services at district hospitals. These hospitals are the first referral facilities for people living in rural areas. Traditionally, patients receive much of their primary health care at these facilities but are referred to secondary and tertiary health care facilities (regional and national referral hospitals, respectively) for more specialized care. However, many surgical conditions—in particular, obstetric emergencies—need to be treated at district hospitals if lives are to be saved. Unfortunately, very little is known about the range and volume of surgical procedures currently undertaken in district hospitals in sub-Saharan Africa and such information is needed before programs can be developed to increase access to surgical services at these facilities. In this retrospective, descriptive study, the researchers (some of whom are part of the BESG) investigate the scope of surgery undertaken in district hospitals in three sub-Saharan African countries.
What Did the Researchers Do and Find?
The researchers obtained recent data on the surgical procedures done at two representative district hospitals each in Tanzania and in Mozambique and four representative district hospitals in Uganda by examining hospital records and by interviewing administrators. The observed range of surgical procedures performed in these hospitals was narrow, they report, consisting mainly of essential and life-saving emergency procedures such as cesarean sections for the delivery of babies and wound-related procedures. Obstetric procedures accounted for around half of all surgical procedures in all the hospitals except one Ugandan hospital. Hernia repair and wound care accounted for nearly two-thirds of general surgical procedures. The surgical output across the hospitals varied from five to 45 major procedures per 10,000 people in the population (average 25 operations per 10,000 people). Across the hospitals, between one and 17 cesarean sections and between 0.5 and seven hernia repairs were performed per 10,000 people in the population. Finally, the researchers used their data and WHO estimates of the population need for cesarean sections to estimate that in the two Tanzanian district hospitals, between half and two-thirds of women that needed a cesarean section did not have access to this life-saving procedure.
What Do These Findings Mean?
These findings suggest that there are low levels of provision of surgical care in district hospitals in Tanzania, Mozambique, and Uganda. Further studies are needed to confirm that these findings are generalizable to district hospitals elsewhere in sub-Saharan Africa and to quantify the extent to which this low level of surgical care translates into unmet needs. Limitations of the study include a lack of information on outcomes, on referral of patients to higher-level facilities, and on how many of the surgical procedures undertaken at these hospitals dealt with traumatic injuries. Nevertheless, the information collected in this study, together with that in a separate paper that investigates the availability of health workers and funding for the provision of essential surgery in district hospitals in these three countries, suggests that the surgical capacity of district hospitals in sub-Saharan Africa needs to be improved. If this goal can be achieved, suggest the researchers, it should avert many illnesses and deaths in this poor region of the world.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000243.
The availability of health workers and funding for surgery in the same hospitals is investigated in a PLoS Medicine Research Article by Margaret E. Kruk et al.
Information on the Bellagio Essential Surgery Group is available
WHO's Global initiative for Emergency and Essential Surgical Care plans to take essential emergency, basic surgery and anesthesia skills to health care staff in low- and middle-income countries around the world; WHO also has a page describing the importance of emergency and essential surgery in primary health care
doi:10.1371/journal.pmed.1000243
PMCID: PMC2834708  PMID: 20231871
21.  Evaluating Niger's experience in strengthening supervision, improving availability of child survival drugs through cost recovery, and initiating training for Integrated Management of Childhood Illness (IMCI) 
Background
WHO and UNICEF have recently developed the "Integrated Management of Childhood Illness" (IMCI) as an efficient strategy to assist developing countries reduce childhood mortality. Early experience with IMCI implementation suggests that clinical training is essential but not sufficient for the success of the strategy. Attention needs to be given to strengthening health systems, such as supervision and drug supply.
Results
This paper presents results of evaluating an innovative approach for implementing IMCI in Niger. It starts with strengthening district level supervision and improving the availability of child survival drugs through cost recovery well before the beginning of IMCI clinical training. The evaluation documented the effectiveness of the initial IMCI clinical training and referral.
Conclusions
Strengthening supervision and assuring the availability of essential drugs need to precede the initiation of IMCI Clinical training. Longer term follow up is necessary to confirm the impact of the approach on IMCI preparation and implementation.
doi:10.1186/1472-698X-1-1
PMCID: PMC37392  PMID: 11504567
22.  Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV 
BMC Pediatrics  2009;9:59.
Background
Integrated Management of Childhood Illness (IMCI) is a WHO/UNICEF strategy to improve child survival in resource poor settings. South Africa adopted IMCI in 1997, and IMCI guidelines were adapted to include identification and management of HIV infected and exposed children. This study describes the validity of the IMCI/HIV algorithm when used by IMCI experts, the use of IMCI/HIV guidelines by IMCI trained health workers in routine clinical practice, and the burden of HIV among children under 5 years attending first level health facilities.
Methods
Seventy seven randomly selected IMCI trained health workers were observed in 74 health facilities in two provinces of South Africa. Consultations were observed with 1357 sick children; each child was reassessed by an IMCI expert to confirm the correct findings. Consent was requested for HIV testing of all children who attended with a parent or legal guardian. Positive rapid HIV tests were confirmed with HIV PCR in children aged less than 18 months. HIV positive children had a CD4 count and HIV clinical staging done.
Results
Of 1064 children with HIV results available, 76 (7.1% CI: 5.7% - 8.9%) children were confirmed HIV positive. IMCI experts using the HIV algorithm classified 54/76 (71.1% CI: 59.5%-80.9%) HIV positive children as suspected symptomatic HIV, and 15/22 remaining HIV positive children were identified as HIV exposed. Therefore, 69/76 (90.8% CI: 81.9-96.2) HIV infected children were identified by IMCI experts. No classification was made for HIV by observed health workers in 899/1357(66.2%) children.
906/1243(72.9%) mothers had been tested previously for HIV, of whom 221(24.4%) reported testing positive. Of 221 children therefore identified as HIV exposed, only 78(35.3%) had been tested for HIV within routine services.
Conclusion
The HIV algorithm is a valid tool for identifying HIV infected and exposed children when correctly and comprehensively implemented. However, it is not being used by IMCI trained health workers in routine practise, leading to a failure to implement life saving interventions.
doi:10.1186/1471-2431-9-59
PMCID: PMC2754450  PMID: 19772599
23.  Quality of hospital care for sick newborns and severely malnourished children in Kenya: A two-year descriptive study in 8 hospitals 
Background
Given the high mortality associated with neonatal illnesses and severe malnutrition and the development of packages of interventions that provide similar challenges for service delivery mechanisms we set out to explore how well such services are provided in Kenya.
Methods
As a sub-component of a larger study we evaluated care during surveys conducted in 8 rural district hospitals using convenience samples of case records. After baseline hospitals received either a full multifaceted intervention (intervention hospitals) or a partial intervention (control hospitals) aimed largely at improving inpatient paediatric care for malaria, pneumonia and diarrhea/dehydration. Additional data were collected to: i) examine the availability of routine information at baseline and their value for morbidity, mortality and quality of care reporting, and ii) compare the care received against national guidelines disseminated to all hospitals.
Results
Clinical documentation for neonatal and malnutrition admissions was often very poor at baseline with case records often entirely missing. Introducing a standard newborn admission record (NAR) form was associated with an increase in median assessment (IQR) score to 25/28 (22-27) from 2/28 (1-4) at baseline. Inadequate and incorrect prescribing of penicillin and gentamicin were common at baseline. For newborns considerable improvements in prescribing in the post baseline period were seen for penicillin but potentially serious errors persisted when prescribing gentamicin, particularly to low-birth weight newborns in the first week of life. Prescribing essential feeds appeared almost universally inadequate at baseline and showed limited improvement after guideline dissemination.
Conclusion
Routine records are inadequate to assess newborn care and thus for monitoring newborn survival interventions. Quality of documented inpatient care for neonates and severely malnourished children is poor with limited improvement after the dissemination of clinical practice guidelines. Further research evaluating approaches to improving care for these vulnerable groups is urgently needed. We also suggest pre-service training curricula should be better aligned to help improve newborn survival particularly.
doi:10.1186/1472-6963-11-307
PMCID: PMC3236590  PMID: 22078071
newborns; child malnutrition; quality of health care
24.  Paediatric referrals in rural Tanzania: the Kilombero District Study – a case series 
Background
Referral is a critical part of appropriate primary care and of the Integrated Management of Childhood Illness (IMCI) strategy. We set out to study referrals from the aspect both of primary level facilities and the referral hospital in Kilombero District, southern Tanzania. Through record review and a separate prospective study we estimate referral rates, report on delays in reaching referral care and summarise the appropriateness of pediatric referral cases in terms of admission to the pediatric ward at a district hospital
Methods
A sample of patient records from primary level government health facilities throughout 1993 were summarised by age, diagnosis, whether a new case or a reattendance, and whether or not they were referred. From August 1994 to July 1995, mothers or carers of all sick children less than five years old attending the Maternal and Child Health (MCH) clinic or outpatient department (OPD) of SFDDH were interviewed using a standard questionnaire recording age, sex, diagnosis, place of residence, whether the child was admitted to the paediatric ward, and whether the child was referred.
Results
From record review, only 0.6% of children from primary level government facilities were referred to a higher level of care. At the referral hospital, 7.8 cases per thousand under five catchment population had been referred annually. The hospital MCH clinic and OPD were generally used by children who lived nearby: 91% (n = 7,166) of sick children and 75% (n = 607) of admissions came from within 10 km. Of 235 referred children, the majority (62%) had come from dispensaries. Almost half of the referrals (48%) took 2 or more days to arrive at the hospital. Severe malaria and anaemia were the leading diagnoses in referred children, together accounting for a total of 70% of all the referrals. Most referred children (167/235, 71%) were admitted to the hospital paediatric ward.
Conclusions
The high admission rate among referrals suggests that the decision to refer is generally appropriate, but the low referral rate suggests that too few children are referred. Our findings suggest that the IMCI strategy may need to be adapted in sparsely-populated areas with limited transport, so that more children may be managed at peripheral level and fewer children need referral.
doi:10.1186/1472-698X-2-4
PMCID: PMC111197  PMID: 11983024
25.  An Evaluation of the Quality of IMCI Assessments among IMCI Trained Health Workers in South Africa 
PLoS ONE  2009;4(6):e5937.
Background
Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa.
Methodology/Principal Findings
Seventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW's had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children.
Conclusion/Significance
Health workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.
doi:10.1371/journal.pone.0005937
PMCID: PMC2693922  PMID: 19536288

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