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A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda

BACKGROUND: To improve management of severely ill hospitalized patients in low-income settings, the World Health Organization (WHO) established a triage tool called “Quick Check” to provide clinicians with a rapid, standardized approach to identify patients with severe illness based on recognition o...

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Autores principales: Cummings, Matthew J., Goldberg, Elijah, Mwaka, Savio, Kabajaasi, Olive, Vittinghoff, Eric, Cattamanchi, Adithya, Katamba, Achilles, Kenya-Mugisha, Nathan, Jacob, Shevin T., Lucian Davis, J.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2017
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5674818/
https://www.ncbi.nlm.nih.gov/pubmed/29110667
http://dx.doi.org/10.1186/s13012-017-0654-0
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author Cummings, Matthew J.
Goldberg, Elijah
Mwaka, Savio
Kabajaasi, Olive
Vittinghoff, Eric
Cattamanchi, Adithya
Katamba, Achilles
Kenya-Mugisha, Nathan
Jacob, Shevin T.
Lucian Davis, J.
author_facet Cummings, Matthew J.
Goldberg, Elijah
Mwaka, Savio
Kabajaasi, Olive
Vittinghoff, Eric
Cattamanchi, Adithya
Katamba, Achilles
Kenya-Mugisha, Nathan
Jacob, Shevin T.
Lucian Davis, J.
author_sort Cummings, Matthew J.
collection PubMed
description BACKGROUND: To improve management of severely ill hospitalized patients in low-income settings, the World Health Organization (WHO) established a triage tool called “Quick Check” to provide clinicians with a rapid, standardized approach to identify patients with severe illness based on recognition of abnormal vital signs. Despite the availability of these guidelines, recognition of severe illness remains challenged in low-income settings, largely as a result of infrequent vital sign monitoring. METHODS: We conducted a staggered, pre-post quasi-experimental study at four inpatient health facilities in western Uganda to assess the impact of a multi-modal intervention for improving quality of care following formal training on WHO “Quick Check” guidelines for diagnosis of severe illness in low-income settings. Intervention components were developed using the COM-B (“capability,” “opportunity,” and “motivation” determine “behavior”) model and included clinical mentoring by an expert in severe illness care, collaborative improvement meetings with external support supervision, and continuous audits of clinical performance with structured feedback. RESULTS: There were 5759 patients hospitalized from August 2014 to May 2015: 1633 were admitted before and 4126 during the intervention period. Designed to occur twice monthly, collaborative improvement meetings occurred every 2–4 weeks at each site. Clinical mentoring sessions, designed to occur monthly, occurred every 4–6 months at each site. Audit and feedback reports were implemented weekly as designed. During the intervention period, there were significant increases in the site-adjusted likelihood of initial assessment of temperature, heart rate, blood pressure, respiratory rate, mental status, and pulse oximetry. Patients admitted during the intervention period were significantly more likely to be diagnosed with sepsis (4.3 vs. 0.4%, risk ratio 10.1, 95% CI 3.0–31.0, p < 0.001) and severe respiratory distress (3.9 vs. 0.9%, risk ratio 4.5, 95% CI 1.8–10.9, p = 0.001). CONCLUSIONS: Theory-informed quality improvement programs can improve vital sign collection and diagnosis of severe illness in low-income settings. Further implementation, evaluation, and scale-up of such interventions are needed to enhance hospital-based triage and severe illness management in these settings. TRIAL REGISTRATION: Severe illness management system (SIMS) intervention development, ISRCTN46976783 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s13012-017-0654-0) contains supplementary material, which is available to authorized users.
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spelling pubmed-56748182017-11-15 A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda Cummings, Matthew J. Goldberg, Elijah Mwaka, Savio Kabajaasi, Olive Vittinghoff, Eric Cattamanchi, Adithya Katamba, Achilles Kenya-Mugisha, Nathan Jacob, Shevin T. Lucian Davis, J. Implement Sci Research BACKGROUND: To improve management of severely ill hospitalized patients in low-income settings, the World Health Organization (WHO) established a triage tool called “Quick Check” to provide clinicians with a rapid, standardized approach to identify patients with severe illness based on recognition of abnormal vital signs. Despite the availability of these guidelines, recognition of severe illness remains challenged in low-income settings, largely as a result of infrequent vital sign monitoring. METHODS: We conducted a staggered, pre-post quasi-experimental study at four inpatient health facilities in western Uganda to assess the impact of a multi-modal intervention for improving quality of care following formal training on WHO “Quick Check” guidelines for diagnosis of severe illness in low-income settings. Intervention components were developed using the COM-B (“capability,” “opportunity,” and “motivation” determine “behavior”) model and included clinical mentoring by an expert in severe illness care, collaborative improvement meetings with external support supervision, and continuous audits of clinical performance with structured feedback. RESULTS: There were 5759 patients hospitalized from August 2014 to May 2015: 1633 were admitted before and 4126 during the intervention period. Designed to occur twice monthly, collaborative improvement meetings occurred every 2–4 weeks at each site. Clinical mentoring sessions, designed to occur monthly, occurred every 4–6 months at each site. Audit and feedback reports were implemented weekly as designed. During the intervention period, there were significant increases in the site-adjusted likelihood of initial assessment of temperature, heart rate, blood pressure, respiratory rate, mental status, and pulse oximetry. Patients admitted during the intervention period were significantly more likely to be diagnosed with sepsis (4.3 vs. 0.4%, risk ratio 10.1, 95% CI 3.0–31.0, p < 0.001) and severe respiratory distress (3.9 vs. 0.9%, risk ratio 4.5, 95% CI 1.8–10.9, p = 0.001). CONCLUSIONS: Theory-informed quality improvement programs can improve vital sign collection and diagnosis of severe illness in low-income settings. Further implementation, evaluation, and scale-up of such interventions are needed to enhance hospital-based triage and severe illness management in these settings. TRIAL REGISTRATION: Severe illness management system (SIMS) intervention development, ISRCTN46976783 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s13012-017-0654-0) contains supplementary material, which is available to authorized users. BioMed Central 2017-11-06 /pmc/articles/PMC5674818/ /pubmed/29110667 http://dx.doi.org/10.1186/s13012-017-0654-0 Text en © The Author(s). 2017 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
spellingShingle Research
Cummings, Matthew J.
Goldberg, Elijah
Mwaka, Savio
Kabajaasi, Olive
Vittinghoff, Eric
Cattamanchi, Adithya
Katamba, Achilles
Kenya-Mugisha, Nathan
Jacob, Shevin T.
Lucian Davis, J.
A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda
title A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda
title_full A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda
title_fullStr A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda
title_full_unstemmed A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda
title_short A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda
title_sort complex intervention to improve implementation of world health organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from uganda
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5674818/
https://www.ncbi.nlm.nih.gov/pubmed/29110667
http://dx.doi.org/10.1186/s13012-017-0654-0
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