Browsing by Author "English, Mike"

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    Examining Which Clinicians Provide Admission Hospital Care in a High Mortality Setting and Their Adherence to Guidelines: An Observational Study in 13 Hospitals
    (BMJ, 2020-03-12) Ogero, Morris; Akech, Samuel; Malla, Lucas; Agweyu, Ambrose; Irimu, Grace; English, Mike
    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.
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    Prevalence and Fluid Management of Dehydration in Children without Diarrhoea Admitted to Kenyan Hospitals: A Multisite Observational Study
    (BMJ Open, 2021-03-17) Omoke, Sylvia; English, Mike; Aluvaala, Jalemba; Gathara, David; Agweyu, Ambrose; Akech, Samuel
    Objectives To examine the prevalence of dehydration without diarrhoea among admitted children aged 1–59 months and to describe fluid management practices in such cases. Design A multisite observational study that used routine in-patient data collected prospectively between October 2013 and December 2018. Settings Study conducted in 13 county referral hospitals in Kenya. Participants Children aged 1–59 months with admission or discharge diagnosis of dehydration but had no diarrhoea as a symptom or diagnosis. Children aged <28 days and those with severe acute malnutrition were excluded. Results The prevalence of dehydration in children without diarrhoea was 3.0% (2019/68 204) and comprised 15.9% (2019/12 702) of all dehydration cases. Only 55.8% (1127/2019) of affected children received either oral or intravenous fluid therapy. Where fluid treatment was given, the volumes, type of fluid, duration of fluid therapy and route of administration were similar to those used in the treatment of dehydration secondary to diarrhoea. Pneumonia (1021/2019, 50.6%) and malaria (715/2019, 35.4%) were the two most common comorbid diagnoses. Overall case fatality in the study population was 12.9% (260/2019). Conclusion Sixteen per cent of children hospitalised with dehydration do not have diarrhoea but other common illnesses. Two-fifths do not receive fluid therapy; a regimen similar to that used in diarrhoeal cases is used in cases where fluid is administered. Efforts to promote compliance with guidance in routine clinical settings should recognise special circumstances where guidelines do not apply, and further studies on appropriate management for dehydration in the absence of diarrhoea are required.