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
Abstract 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 recog...
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doaj-4ee2bf5935db436eba9da92e200907d02020-11-25T02:13:05ZengBMCImplementation Science1748-59082017-11-0112111110.1186/s13012-017-0654-0A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from UgandaMatthew J. Cummings0Elijah Goldberg1Savio Mwaka2Olive Kabajaasi3Eric Vittinghoff4Adithya Cattamanchi5Achilles Katamba6Nathan Kenya-Mugisha7Shevin T. Jacob8J. Lucian Davis9Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical CenterImpactMattersWalimuWalimuDepartment of Epidemiology and Biostatistics, University of California San Francisco School of MedicineDivision of Pulmonary and Critical Care Medicine, University of California San Francisco School of MedicineSchool of Medicine, Makerere University College of Health SciencesWalimuWalimuDepartment of Epidemiology of Microbial Diseases, Yale University School of Public HealthAbstract 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, ISRCTN46976783http://link.springer.com/article/10.1186/s13012-017-0654-0ImplementationQuality improvementCritical careAfrica South of the SaharaUgandaGlobal health |
collection |
DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Matthew J. Cummings Elijah Goldberg Savio Mwaka Olive Kabajaasi Eric Vittinghoff Adithya Cattamanchi Achilles Katamba Nathan Kenya-Mugisha Shevin T. Jacob J. Lucian Davis |
spellingShingle |
Matthew J. Cummings Elijah Goldberg Savio Mwaka Olive Kabajaasi Eric Vittinghoff Adithya Cattamanchi Achilles Katamba Nathan Kenya-Mugisha Shevin T. Jacob J. Lucian Davis 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 Implementation Science Implementation Quality improvement Critical care Africa South of the Sahara Uganda Global health |
author_facet |
Matthew J. Cummings Elijah Goldberg Savio Mwaka Olive Kabajaasi Eric Vittinghoff Adithya Cattamanchi Achilles Katamba Nathan Kenya-Mugisha Shevin T. Jacob J. Lucian Davis |
author_sort |
Matthew J. Cummings |
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_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_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_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 |
publisher |
BMC |
series |
Implementation Science |
issn |
1748-5908 |
publishDate |
2017-11-01 |
description |
Abstract 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 |
topic |
Implementation Quality improvement Critical care Africa South of the Sahara Uganda Global health |
url |
http://link.springer.com/article/10.1186/s13012-017-0654-0 |
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