An instrument to assess acute respiratory infection case management in Egypt

Abstract

To develop an instrument to measure the quality of acute respiratory infection (ARI) case management among Egyptian children.

Methods: A baseline survey of all health facilities in a single district, using a multi-data source instrument. Data sources included providers, caretakers, patient records and observation of patient care.

Main results: Physicians did not count the respiratory rate and check for subcostal retraction. Eighty-seven per cent of children who did not require antibiotics received them. Of five children who required antibiotics, four (80%) were prescribed an oral regimen. Three of these should have been admitted to a hospital but were not. Antibiotics were available at the facilities an estimated 7.9 months per year. Oxygen for inpatient treatment was available in one of two hospitals.

Conclusions: This instrument was useful for comprehensively evaluating facility capability to provide quality case management. Deficiencies were identified but were not unexpected in a baseline survey. The Egypt ARI program has the potential to have a substantial impact on how children with ARI are diagnosed and treated in health facilities.

PIP: An instrument consisting of 10 questionnaires was developed to assess the ability of facilities to implement acute respiratory infection (ARI) case management guidelines. Data sources included interviews with physicians, nurses and area pharmacists; observation of patient care; review of patient records and an inventory of supplies. All 21 outpatient and two inpatient health facilities as well as 20 of 28 pharmacies in the district were included in the study. Of 93 child assessments observed, physicians asked the age for only 38 (41%). No child was questioned on ability to drink or experience of seizures. In addition, no physician checked for stridor, wheeze or chest indrawing, or counted the respiratory rate. 81 of 93 (87%) children with ARI were prescribed antibiotics. Among the 88 children assessed as not requiring antibiotics, 77 (88%) received them. Five children (2 pneumonia, 2 severe pneumonia, and 1 very severe disease) were determined to require antibiotics; four were prescribed an oral regimen. Of the four children that both required antibiotics and received them, three should have been admitted to the hospital for parenteral antibiotics, but were not. A variety of prescribed antibiotics were used among the 77 children. 27 (35%) children received two or three antibiotics without specifying the dose, frequency or duration on the prescription. Only two physicians mentioned the antibiotic dosage schedule for home care to the mother. Physicians at each of the outpatient facilities estimated the mean availability of antibiotics at 7.9 +or- 3.9 months. Three facilities (14%) had ampicillin suspension, none had amoxicillin and two (9%) had cotrimoxazole for the treatment of outpatient pneumonia. 19 (90%) had aspirin. Oxygen was available for inpatient care for children with pneumonia in one of the two hospitals, no nebulizers were available for treatment of wheezing, and disposable syringes were available in only one hospital. Parenteral bronchodilators were available in both, oral in neither. This instrument was useful for comprehensively evaluating facility capability to provide quality case management in the Egyptian ARI program.