title: Assessing process of paediatric care in a resource-limited setting: a cross-sectional audit of district hospitals in Rwanda.
abstract: Routine assessment of quality of care helps identify deficiencies which need to be improved. While gaps in the emergency care of children have been documented across sub-Saharan Africa, data from Rwanda are lacking.
  
  
  
  To assess the care of sick infants and children admitted to Rwandan district hospitals and the extent to which it follows currently recommended clinical practice guidelines in Rwanda.
  
  
  
  Data were gathered during a retrospective cross-sectional audit of eight district hospitals across Rwanda in 2012/2013. Medical records were randomly selected from each hospital and were reviewed to assess the process of care, focusing on the leading causes of under-5 mortality, including neonatal conditions, pneumonia, malaria and dehydration/diarrhoea.
  
  
  
  Altogether, 522 medical records were reviewed. Overall completion of a structured neonatal admission record was above 85% (range 78.6-90.0%) and its use was associated with better documentation of key neonatal signs (median score 6/8 and 2/8 when used and not used, respectively). Deficiencies in the processes of care were identified across hospitals and there were rural/urban disparities for some indicators. For example, neonates admitted to urban district hospitals were more likely to receive treatment consistent with currently recommended guidelines [e.g. gentamicin (OR 2.52, 95% CI 1.03-6.43) and fluids (OR 2.69, 95% CI 1.2-6.2)] than those in rural hospitals. Likewise, children with pneumonia admitted to urban hospitals were more likely to receive the correct dosage of gentamicin (OR 4.47, 95% CI 1.21-25.1) and to have their treatment monitored (OR 3.75, 95% CI 1.57-8.3) than in rural hospitals. Furthermore, children diagnosed with malaria and admitted to urban hospitals were more likely to have their treatment (OR 2.7, 95% CI 1.15-6.41) monitored than those in rural hospitals.
  
  
  
  Substantial gaps were identified in the process of neonatal and paediatric care across district hospitals in Rwanda. There is a need to (i) train health care professionals in providing neonatal and paediatric care according to nationally adopted clinical practice guidelines (e.g. ETAT+); (ii) establish a supervision and mentoring programme to ensure that the guidelines are available and used appropriately in district hospitals; and (iii) use admission checklists (e.g. neonatal and paediatric admission records) in district hospitals.
authors.affiliation: a Faculty of Medicine, School of Population and Public Health , University of British Columbia , Vancouver , Canada.|b Faculty of Pharmaceutical Sciences, Collaboration for Outcomes Research and Evaluation , University of British Columbia , Vancouver , Canada.
authors.forename: Celestin
authors.identifier: 0000-0001-7808-4652
authors.initials: C
authors.lastname: Hategeka
authors.affiliation: a Faculty of Medicine, School of Population and Public Health , University of British Columbia , Vancouver , Canada.
authors.forename: Jeannie
authors.initials: J
authors.lastname: Shoveller
authors.affiliation: c Department of Pediatrics , University Teaching Hospital of Kigali , Kigali , Rwanda.
authors.forename: Lisine
authors.initials: L
authors.lastname: Tuyisenge
authors.affiliation: b Faculty of Pharmaceutical Sciences, Collaboration for Outcomes Research and Evaluation , University of British Columbia , Vancouver , Canada.|d Center for Health Evaluation and Outcome Sciences, Providence Health Research Institute , Vancouver , Canada.
authors.forename: Larry D
authors.initials: LD
authors.lastname: Lynd
mesh_terms: D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003906:Developing Countries; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D019983:Guideline Adherence; D006302:Health Services Research; D006767:Hospitals, District; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011787:Quality of Health Care; D012189:Retrospective Studies; D012432:Rwanda; D016019:Survival Analysis
keywords: Quality of care; child health; district hospital; health system; process of care