Background We explored who actually provides most admission care in hospitals offering supervised experiential training to graduating clinicians in a high mortality setting where practices deviate from guideline recommendations.
Methods We used a large observational data set from 13 Kenyan county hospitals from November 2015 through November 2018 where patients were linked to admitting clinicians. We explored guideline adherence after creating a cumulative correctness of Paediatric Admission Quality of Care (cPAQC) score on a 5-point scale (0–4) in which points represent correct, sequential progress in providing care perfectly adherent to guidelines comprising admission assessment, diagnosis and treatment. At the point where guideline adherence declined the most we dichotomised the cPAQC score and used multilevel logistic regression models to explore whether clinician and patient-level factors influence adherence.
Results There were 1489 clinicians who could be linked to 53 003 patients over a period of 3 years. Patients were rarely admitted by fully qualified clinicians and predominantly by preregistration medical officer interns (MOI, 46%) and diploma level clinical officer interns (COI, 41%) with a median of 28 MOI (range 11–68) and 52 COI (range 5–160) offering care per study hospital. The cPAQC scores suggest that perfect guideline adherence is found in ≤12% of children with malaria, pneumonia or diarrhoea with dehydration. MOIs were more adherent to guidelines than COI (adjusted OR 1.19 (95% CI 1.07 to 1.34)) but multimorbidity was significantly associated with lower guideline adherence.
Conclusion Over 85% of admissions to hospitals in high mortality settings that offer experiential training in Kenya are conducted by preregistration clinicians. Clinical assessment is good but classifying severity of illness in accordance with guideline recommendations is a challenge. Adherence by MOI with 6 years’ training is better than COI with 3 years’ training, performance does not seem to improve during their 3 months of paediatric rotations.
- general paediatrics
- quality of care
- care cascade
- adherence to clinical guidelines
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Collaborators Victor Juma and Samuel Ngarngar (Vihiga County Hospital), Nick Aduro, Boniface Nyumbile and Roselyne Malangachi (Kakamega County Hospital), Loice Mutai, Christine Manyasi and David Kimutai (Mbagathi County Hospital), Caren Emadau, Cecilia Mutiso and Celia Muturi (Mama Lucy Kibaki County Hospital), Charles Nzioki and Supa Tunje (Machakos County Hospital), Francis Kanyingi and Agnes Mithamo (Nyeri County Hospital), Magdalene Kuria (Kisumu East County Hospital), Samuel Otido (Embu County Hospital), Alice Kariuki and Grace Wachira (Karatina County Hospital), Peris Njiiri and Peninah Muthoni (Kerugoya County Hospital), Rachel Inginia and Melab Musabi (Kitale County Hospital), Barnabas Kigen and Emma Namulala (Busia County Hospital), Grace Akech Ochieng and Lydia Thuranira (Kiambu County Hospital), George Mbevi, Sylvia Omoke, Mercy Chepkirui, Basil Okola and Cynthia Asingwa (KEMRI-Wellcome Trust Research Programme).
Contributors All authors contributed to data collection and network activities. ME, GI, AA and SA initiated the study and MO conducted the analyses with support from LM. MO drafted the initial manuscript with ME, and AA, SA and ME contributed to its development. All authors read and approved the final manuscript.
Funding Funds from the Wellcome Trust (207522) awarded to ME as a Senior Fellowship together with additional funds from a Wellcome Trust core grant awarded to the KEMRI-Wellcome Trust Research Programme (092654) supported this work.
Disclaimer The funders had no role in drafting or submitting this manuscript.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval KEMRI Scientific and Ethical Review Committee approved the CIN study (3459). The Kenya Ministry of Health gave permission for this work which entailed use of deidentified routine patient care data abstracted from medical records after discharge without need for individual patient/clinician consent.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.
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