title: Performance of health workers in the management of seriously sick children at a Kenyan tertiary hospital: before and after a training intervention.
abstract: BACKGROUND
  Implementation of WHO case management guidelines for serious common childhood illnesses remains a challenge in hospitals in low-income countries. The impact of locally adapted clinical practice guidelines (CPGs) on the quality-of-care of patients in tertiary hospitals has rarely been evaluated.
  
  
  RESULTS
  We conducted, in Kenyatta National Hospital, an uncontrolled before and after study with an attempt to explore intervention dose-effect relationships, as CPGs were disseminated and training was progressively implemented. The emergency triage, assessment and treatment plus admission care (ETAT+) training and locally adapted CPGs targeted common, serious childhood illnesses. We compared performance in the pre-intervention (2005) and post-intervention periods (2009) using quality indicators for three diseases: pneumonia, dehydration and severe malnutrition. The indicators spanned four domains in the continuum of care namely assessment, classification, treatment, and follow-up care in the initial 48 hours of admission. In the pre-intervention period patients' care was largely inconsistent with the guidelines, with nine of the 15 key indicators having performance of below 10%. The intervention produced a marked improvement in guideline adherence with an absolute effect size of over 20% observed in seven of the 15 key indicators; three of which had an effect size of over 50%. However, for all the five indicators that required sustained team effort performance continued to be poor, at less than 10%, in the post-intervention period. Data from the five-year period (2005-09) suggest some dose dependency though the adoption rate of the best-practices varied across diseases and over time.
  
  
  CONCLUSIONS
  Active dissemination of locally adapted clinical guidelines for common serious childhood illnesses can achieve a significant impact on documented clinical practices, particularly for tasks that rely on competence of individual clinicians. However, more attention must be given to broader implementation strategies that also target institutional and organisational aspects of service delivery to further enhance quality-of-care.
authors.affiliation: Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya. girimu@nairobi.kemri-wellcome.org
authors.forename: Grace W
authors.initials: GW
authors.lastname: Irimu
authors.forename: David
authors.initials: D
authors.lastname: Gathara
authors.forename: Dejan
authors.initials: D
authors.lastname: Zurovac
authors.forename: Harrison
authors.initials: H
authors.lastname: Kihara
authors.forename: Christopher
authors.initials: C
authors.lastname: Maina
authors.forename: Julius
authors.initials: J
authors.lastname: Mwangi
authors.forename: Dorothy
authors.initials: D
authors.lastname: Mbori-Ngacha
authors.forename: Jim
authors.initials: J
authors.lastname: Todd
authors.forename: Alexandra
authors.initials: A
authors.lastname: Greene
authors.forename: Mike
authors.initials: M
authors.lastname: English
mesh_terms: D003681:Dehydration / Q000401:mortality / Q000628:therapy*; D004506:Education, Nursing; D004650:Employee Performance Appraisal; D005260:Female; D006801:Humans; D007223:Infant; D007630:Kenya / Q000453:epidemiology; D008297:Male; D044342:Malnutrition / Q000401:mortality / Q000628:therapy*; D008505:Medical Staff, Hospital / Q000193:education* / Q000592:standards; D009726:Nurses / Q000592:standards; D010372:Pediatrics / Q000193:education; D011014:Pneumonia / Q000401:mortality / Q000628:therapy*; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D012720:Severity of Illness Index; D062606:Tertiary Care Centers / Q000592:standards*