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1.  Implementation of a structured paediatric admission record for district hospitals in Kenya – results of a pilot study 
Background
The structured admission form is an apparently simple measure to improve data quality. Poor motivation, lack of supervision, lack of resources and other factors are conceivably major barriers to their successful use in a Kenyan public hospital setting. Here we have examined the feasibility and acceptability of a structured paediatric admission record (PAR) for district hospitals as a means of improving documentation of illness.
Methods
The PAR was primarily based on symptoms and signs included in the Integrated Management of Childhood Illness (IMCI) diagnostic algorithms. It was introduced with a three-hour training session, repeated subsequently for those absent, aiming for complete coverage of admitting clinical staff. Data from consecutive records before (n = 163) and from a 60% random sample of dates after intervention (n = 705) were then collected to evaluate record quality. The post-intervention period was further divided into four 2-month blocks by open, feedback meetings for hospital staff on the uptake and completeness of the PAR.
Results
The frequency of use of the PAR increased from 50% in the first 2 months to 84% in the final 2 months, although there was significant variation in use among clinicians. The quality of documentation also improved considerably over time. For example documentation of skin turgor in cases of diarrhoea improved from 2% pre-intervention to 83% in the final 2 months of observation. Even in the area of preventive care documentation of immunization status improved from 1% of children before intervention to 21% in the final 2 months.
Conclusion
The PAR was well accepted by most clinicians and greatly improved documentation of features recommended by IMCI for identifying and classifying severity of common diseases. The PAR could provide a useful platform for implementing standard referral care treatment guidelines.
doi:10.1186/1472-698X-6-9
PMCID: PMC1555611  PMID: 16857044
2.  162 Challenges Fueling the Complexities of TB Diagnosis & TBHIV Comorbidity in Tanzania- IHV experience 
Background:
Tanzania with a population of 44.9 million is classified as one of the 22 high burden countries for tuberculosis (TB). The country houses 5,972 health facilities; the majority in urban areas while rural areas have limited access to TB diagnostic services. The TB notification rate for all cases in 2011 was 153/100,000 people with 59/100,000 being smear positive. Nevertheless, the 2013 National TB prevalence survey revealed prevalence of bacteriological confirmed TB was 354/100,000 with the rural areas more affected. The findings signify more TB than reported. TB continues to major driver of mortality in HIV patients, as reported by facilities supported by IHV, with the highest mortality in our HIV project. 20% died while on TB treatment and 73% died with symptoms of TB.
Challenges:
IHV’s program reports a low rate of TB among HIV patients. By June 2013, 20 districts treated 35,502 HIV patients, with only 1% diagnosed with TB; almost half being from 4 districts with the TB intervention project. The result is likely due to insufficient diagnostic services. In some areas, patients travel 100 km to access services. More refined diagnostic techniques to increase sensitivity like LED Microscopy, molecular technology, and sputum culture are insufficient which poses particular challenges for HIV/AIDS patients. TB detection activities have primarily remained health facility based endeavors with minimal community involvement. These circumstances do not provide for an optimal environment for increased TB case detection and hence hinders TB control efforts.
Interventions:
IHV implements a WHO funded TB program in Tanzania to support active intensified case management which has led to finding more TB cases, with 38% of all forms of TB, and 36% Smear and/or bacteriological positive. Our challenge was the inadequacy of sensitive diagnostic facilities, and hence installed one GeneXpert machine which registered an increase of 6.6% TB cases that were missed by fluorescent microscopy. Building on experience gained and lessons learned, IHV plans to impact case detection through the installation of 4 more GeneXpert machines at high prevalence sites which have limited access to diagnosis.
Conclusion and Recommendation:
Health systems strengthening for laboratory diagnosis and empowering community case identification can result in a marked increase in TB case finding. With the multidrug-resistant Mycobacterium tuberculosis emerging at an alarming rate, support is required to identify and detect suspected cases, improve diagnostic capacity with efficient technology, and improve linkage between diagnostic centers and treatment facilities.
doi:10.1097/01.qai.0000446746.99602.a8
PMCID: PMC4149658

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