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G534(P) Improving paediatric clinical outcome indicators by a collaborative retraining of child health professionals
  1. KE Knox1,
  2. P Lutalo2,
  3. T Ntabayagirwa3,
  4. A Conayisavye4,
  5. AJ McArdle5,
  6. D Birahinduka6
  1. 1Paediatrics, North Middlesex University Hospital, London, UK
  2. 2Respiratory Medicine, Great Ormond Street Hospital, London, UK
  3. 3Paediatrics, Centre Hospitalo-Universitaire de Kamenge (CHUK), Bujumbura, Burundi
  4. 4Paediatrics, Hopital Prince Regent Charles (HPRC), Bujumbura, Burundi
  5. 5Paediatrics, London North West Healthcare NHS Trust, London, UK
  6. 6Paediatrics, University College London Hospital, London, UK

Abstract

Context PICHEAM (Programme for Improvement of Child Health Hospital Management) was founded by a group of UK healthcare professionals with the objective of reducing childhood hospital mortality from treatable conditions in low-income countries. The project commenced in Burundi in collaboration with staff at two large teaching hospitals.

Problem Healthcare provision in Burundi is under-resourced, with WHO estimates of only 0.028 doctors and 0.19 nurses per 1000 population, and an under-five mortality rate of 83 per 1,000. PICHEAM identified that the two collaborating hospitals did not have local guidelines to standardise emergency management, resulting in significant variation in patient treatment and poor outcomes.

Assessment of problem and analysis of its causes Hospital admission data was analysed at the start of the project focusing on admission diagnoses, treatment plans, hospital stay and mortality. This showed a mortality rate of 6.7%, with over 50% of children dying on the first day of admission. PICHEAM planned to standardise practice via development of local guidelines and to focus on improving emergency management as a priority.

Intervention Best practice guidelines based on WHO recommendations were drawn up in collaboration with local staff, including protocols for managing emergencies. A simulation-based training package was developed to reinforce teaching of these protocols and develop team working skills, with local staff trained as facilitators thereby establishing a sustainable model.

Study design Morbidity and mortality data are regularly collected by local clinicians using routine hospital data sources.

Strategy for change PICHEAM aims to improve child health outcomes in participating hospitals over a three year period. This involves an initial period of working in partnership to observe practice, collect data, develop guidelines and build relationships with local staff. Guidelines were produced in ‘handbook’ format and disseminated to hospital staff. Results from audit of admission data were presented at local hospital meetings in Burundi and at PICHEAM meetings in London. Admission data is re-audited and participant feedback from the training sessions collected during each visit to measure change and optimise the teaching package.

Measurement of improvement Data was analysed comparing mortality rate, common diagnosis, length of stay by treated conditions and management in each clinical context.

Effects of changes The number of children diagnosed with pneumonia decreased from 2013 to 2014 (7.2% vs 10.6%) in parallel with an increase in rates of bronchiolitis (6.5% vs 3%) following teaching on the differences between the two diagnosis in children under 1 year of age. All children diagnosed with malaria received quinine in 2014 as opposed to 98.2% in 2013; fewer children with malaria received antibiotic therapy in 2014 compared to 2013 (11.6% vs 14.2%). The number of children with gastroenteritis treated with intravenous fluids increased (18.1% vs 15%) and more were prescribed antibiotics (18.4% vs 4%). The overall mortality rate as a proportion of all admissions did not show significant difference except after 5 days of hospitalisation (survival rate at day 10, 98.5% in 2013 vs 97.5% in 2014).

Lessons learnt It is encouraging that there was an increase in bronchiolitis diagnoses, and that fewer children diagnosed with malaria were receiving unnecessary antibiotics. Implementing good data collection is an ongoing process however, and consolidation of work done so far will continue to highlight areas for improvement, such as management of gastroenteritis. The project is continually adapting based on feedback received and learning needs identified, and difficulties in accessing nursing and midwifery staff for training will be addressed in future visits.

Message for others PICHEAM is showing that an ambitious goal can been achieved by simple means; implementation and reinforcement of standardised best practice.

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