title: A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomised trial.
abstract: 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.
  
  
  RESULTS
  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.
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya. payieko@nairobi.kemri-wellcome.org
authors.forename: Philip
authors.initials: P
authors.lastname: Ayieko
authors.forename: Stephen
authors.initials: S
authors.lastname: Ntoburi
authors.forename: John
authors.initials: J
authors.lastname: Wagai
authors.forename: Charles
authors.initials: C
authors.lastname: Opondo
authors.forename: Newton
authors.initials: N
authors.lastname: Opiyo
authors.forename: Santau
authors.initials: S
authors.lastname: Migiro
authors.forename: Annah
authors.initials: A
authors.lastname: Wamae
authors.forename: Wycliffe
authors.initials: W
authors.lastname: Mogoa
authors.forename: Fred
authors.initials: F
authors.lastname: Were
authors.forename: Aggrey
authors.initials: A
authors.lastname: Wasunna
authors.forename: Greg
authors.initials: G
authors.lastname: Fegan
authors.forename: Grace
authors.initials: G
authors.lastname: Irimu
authors.forename: Mike
authors.initials: M
authors.lastname: English
mesh_terms: D002675:Child, Preschool; D003681:Dehydration / Q000628:therapy; D003906:Developing Countries; D004334:Drug Administration Schedule; D019317:Evidence-Based Medicine; D005260:Female; D005440:Fluid Therapy; D005839:Gentamicins / Q000008:administration & dosage; D019983:Guideline Adherence / Q000592:standards*; D019538:Health Care Surveys; D006767:Hospitals, District / Q000592:standards*; D006780:Hospitals, Rural / Q000592:standards; D006801:Humans; D007223:Infant; D007630:Kenya; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010372:Pediatrics / Q000592:standards*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011361:Professional Competence / Q000592:standards; D058996:Quality Improvement; D011803:Quinine / Q000008:administration & dosage; D012424:Rural Population; D059039:Standard of Care
chemical_list: D005839:Gentamicins; D011803:Quinine