Examining which clinicians provide admission hospital care in a high mortality setting and their adherence to guidelines: an observational study in 13 hospitals

Abstract

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.

Keywords: adherence to clinical guidelines; care cascade; general paediatrics; quality of care.

Figure 1

Study population. Success with patient–clinician record linkage varied across hospitals. For instance, in eight hospitals, over 90% of all patients were linked while in the remaining five hospitals linked patients ranged from 52.5% to 86.6%. Malaria was more common among patients not linked reflecting lower success at record linkage in hospitals in settings of high malaria endemicity. CIN, Clinical Information Network; cPAQC, correctness of Paediatric Admission Quality of Care; HCW, healthcare worker.

Figure 2

Patients admitted by clinicians of various cadres across hospitals. Hospitals are arranged from left to right in the descending order according to the proportion of patients admitted by medical officer interns (MOI). Red and blue bars without values represent cadres whose admissions were <4% in a given hospital. CO, clinical officer; MO, medical officer.

Figure 3

Performance of items constituting the correctness of Paediatric Admission Quality of Care (cPAQC) score for patients with diarrhoea/dehydration, malaria and pneumonia as assessed for medical officer interns (MOI). The cPAQC score spans four items of a care cascade such that correct performance of steps later in the pathway is only possible if earlier steps are also correct (represented as progression from left to right on the X-axis where axis labels also represent progression of the cPAQC score from 1 to 4). Performance is represented as the percentage of the 10 115 patients (admitted by MOI) who achieved cPAQC scores for the respective diagnoses of 1, 2, 3 or 4.