Context The improvement took place in a large paediatric referral hospital in West Africa.
Problem Malaria is one of the leading causes of morbidity and mortality for children attending the hospital. There was no uniform guidance or set standard on the management of malaria. As a result, treatment varied from doctor to doctor, patient to patient.
Assessment of problem and analysis of its causes 40 clinical notes per week were randomly selected for 5 weeks (Weeks 1–5). The data collected compared current practice against the standard expected for the management of a child presenting with a fever/malaria. Multiple areas where the standards were not met were identified at all stages of the child’s journey from presenting to the hospital with fever all the way to discharge home or death.
Intervention A new malaria guideline and training package was developed. The guideline included a flow chart, investigations and 1st and 2nd line treatment options, a drug treatment table and guidance on how to prepare and prescribe the treatment on a drug chart. These guidelines were approved by the National Malaria Control Programme and then implemented across the hospital, through teaching and training workshops.
Study design The study used two cohort groups of patients; The first cohort included patients who were admitted to the hospital prior to the intervention the second cohort included patients who were admitted to the hospital after the intervention. The data analysed compared the findings between both groups.
Strategy for change The results were disseminated to the doctors and then again to the malaria quality care committee. Ninety nine percent (99%) of clinical staff received training on the new guidelines; new laboratory forms were introduced to aid the rapid diagnosis of malaria at triage and in the emergency room and every ward had malaria job aid posters. The training of all staff took approximately 5 weeks to complete.
Measurement of improvement Using the same data collection methods, 40 clinical notes per week were selected, from a total of 5 weeks (Weeks 6–10); these weeks represented the start of the training/implementation; half way through training; end of training of all staff and 2 further follow on weeks after all training had been completed.
Over a period of 6 months: The proportion of patients with fever tested for malaria increased from 76% to 94%. The proportion of malaria cases correctly classified according to the admitting doctor increased from 52% to 94%. The proportion of severe malaria cases given appropriate first line treatment increased from 50% to 95%. Overall mortality attributed to Malaria decreased from 38% to 25%
Effects of changes The improvement resulted in a higher quality of care being delivered to patients with malaria, in particular, better access to diagnostic tests, more accurate classification of malaria, improved documentation of malaria medication on prescription charts and improved sign off of doses given.
Lessons learnt The data collection process used (i.e. retrospective collection of a random selection on notes) may have given us biassed results and affected the quality of the outcome data. It was also difficult to measure certain specific areas of improvement. Prospective assessment and data collection would be a better way to measure the effects of change.
Message for others By engaging professionals, senior and junior, who are all involved in the care of a child and placing the child at the centre of the process and maintaining that focus on the child is an important way to improve the quality of their care, even in low resource settings.
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