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.

Journal: Implementation science : IS

Volume: 12

Issue: 1

Year of Publication: 2018

Affiliated Institutions:  Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY, USA. ImpactMatters, New York, NY, USA. Walimu, Kampala, Uganda. Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, CA, USA. Division of Pulmonary and Critical Care Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA. School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda. Walimu, Kampala, Uganda. shevin@walimu.org. Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT, USA.

Abstract summary 

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.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.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).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.Severe illness management system (SIMS) intervention development, ISRCTN46976783.

Authors & Co-authors:  Cummings Matthew J MJ Goldberg Elijah E Mwaka Savio S Kabajaasi Olive O Vittinghoff Eric E Cattamanchi Adithya A Katamba Achilles A Kenya-Mugisha Nathan N Jacob Shevin T ST Davis J Lucian JL

Study Outcome 

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Statistics
Citations :  Adhikari NKJ, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet. 2010;376:1339–1346. doi: 10.1016/S0140-6736(10)60446-1.
Authors :  10
Identifiers
Doi : 126
SSN : 1748-5908
Study Population
Male,Female
Mesh Terms
Adult
Other Terms
Africa South of the Sahara;Critical care;Global health;Implementation;Quality improvement;Uganda
Study Design
Cross Sectional Study,Quasi Experimental Study
Study Approach
Country of Study
Uganda
Publication Country
England