Moving towards routine evaluation of quality of inpatient pediatric care in Kenya

Abstract

Background: Regular assessment of quality of care allows monitoring of progress towards system goals and identifies gaps that need to be addressed to promote better outcomes. We report efforts to initiate routine assessments in a low-income country in partnership with government.

Methods: A cross-sectional survey undertaken in 22 'internship training' hospitals across Kenya that examined availability of essential resources and process of care based on review of 60 case-records per site focusing on the common childhood illnesses (pneumonia, malaria, diarrhea/dehydration, malnutrition and meningitis).

Results: Availability of essential resources was 75% (45/61 items) or more in 8/22 hospitals. A total of 1298 (range 54-61) case records were reviewed. HIV testing remained suboptimal at 12% (95% CI 7-19). A routinely introduced structured pediatric admission record form improved documentation of core admission symptoms and signs (median score for signs 22/22 and 8/22 when form used and not used respectively). Correctness of penicillin and gentamicin dosing was above 85% but correctness of prescribed intravenous fluid or oral feed volumes for severe dehydration and malnutrition were 54% and 25% respectively. Introduction of Zinc for diarrhea has been relatively successful (66% cases) but use of artesunate for malaria remained rare. Exploratory analysis suggests considerable variability of the quality of care across hospitals.

Conclusion: Quality of pediatric care in Kenya has improved but can improve further. The approach to monitoring described in this survey seems feasible and provides an opportunity for routine assessments across a large number of hospitals as part of national efforts to sustain improvement. Understanding variability across hospitals may help target improvement efforts.

Fig 1. Organization of care and availability of essential resources.

Percentage availability is determined as the proportion of 22 hospitals in which the specific item is present. 3 items available in less than 20% (4/22) of the hospitals were omitted. **Otoscope and torch omitted in essential equipment domain; * Ampicillin omitted in antibiotics domain.

Fig 2. Cumulative availability of essential resources by domain and hospital.

Proportion of items available per domain in each of the 6 domains (total is 100%) ordered across hospitals.

Fig 3. Documentation trends of disease specific key essential signs and symptoms.

Documentation score of essential disease specific signs and symptoms stratified by PAR use for cases with no co-morbidities; x-axis is the documentation score with the disease total being the maximum value of x. *Outliers excluded.

Fig 4. Variability of hospital performance across indicators.

Variability funnel plots: X axis represents number of cases available for the indicator per hospital, Y axis represents the proportion of patients that achieve the indicator per hospital while the numbers against the data points are the hospital identifiers. The red line is the mean performance across hospitals while the dashed lines represent the 95% and 99% confidence intervals.