Elsevier

The Lancet

Volume 357, Issue 9250, 13 January 2001, Pages 106-110
The Lancet

Articles
Quality of hospital care for seriously ill children in less-developed countries

https://doi.org/10.1016/S0140-6736(00)03542-XGet rights and content

Summary

Background

Improving the quality of care for sick children referred to hospitals in less-developed countries may lead to better outcomes, including reduced mortality. Data are lacking, however, on the quality of priority screening (triage), emergency care, diagnosis, and inpatient treatment in these hospitals, and on aspects of these potential targets that would benefit most from interventions leading to improved health outcomes.

Methods

We did a qualitative study in 13 district hospitals and eight teaching hospitals in seven less-developed countries. Experienced paediatricians used a structured survey instrument to assess initial triage, emergency and inpatient care, staff knowledge and practices, and hospital support services.

Findings

Overall quality of care differed between countries and among hospitals and was generally better in teaching hospitals. 14 of 21 hospitals lacked an adequate system for triage. Initial patient assessment was often inadequate and treatment delayed. Most emergency treatment areas were poorly organised and lacked essential supplies; families were routinely required to buy emergency drugs before they could be given. Adverse factors in case management, including inadequate assessment, inappropriate treatment, and inadequate monitoring occurred in 76% of inpatient children. Most doctors in district hospitals, and nurses and medical assistants in teaching and district hospitals, had inadequate knowledge and reported practice for managing important childhood illnesses.

Interpretation

Strengthening care for sick children referred to hospital should focus on achievable objectives with the greatest potential benefit for health outcome. Possible targets for improvement include initial triage, emergency care, assessment, inpatient treatment, and monitoring. Priority targets for individual hospitals may be determined by assessing each hospital.

Introduction

Each year about 11 million children die before reaching their fifth birthday, mostly from pneumonia, diarrhoea, malaria, or measles, often with underlying malnutrition.1 More than 99% of these deaths occur in less-developed countries.2 Recent efforts to develop simple, effective, lowcost methods to diagnose and treat these problems have achieved substantial success. The WHO and the United Nations International Children's Emergency Fund (UNICEF) have used these findings to develop and promote Integrated Management of Childhood Illness (IMCI), an evidence-based strategy for assessing and treating sick children in ambulatory care facilities.3, 4 Although most sick children can be successfully managed at these sites, 12–34% are seriously ill and require referral to hospital for further assessment and possible admission.5, 6

In more-developed countries, clinical outcome for specific conditions, including the risk of death, is correlated with quality of hospital care.7, 8 There is little information, however, on the quality of hospital care available for sick young children in less-developed countries or its relation to outcome. It is known, however, that many die at home soon after being treated for their illness as inpatients or outpatients.9, 10 Reports of poorly organised triage and emergency care,11 and of increased mortality associated with non-standardised management of malnourished children,12 suggest that these and other defects may contribute to substantial avoidable morbidity and mortality. Possible targets for strengthening of hospital care include triage, emergency care, initial and follow-up assessment, in-patient management, and support services. It is unclear, however, which aspects of these potential targets would benefit most from intervention, and what specific changes would most improve health outcomes.

We have carried out an observational study in seven less-developed countries to describe the quality of care of seriously ill infants and young children in public hospitals, and to identify potentially correctable problems in the organisation and delivery of hospital care, especially those that might contribute most to poor outcomes.

Section snippets

Selection of sites and evaluators

The study involved 21 hospitals in Bangladesh, Dominican Republic, Ethiopia, Indonesia, Philippines, Tanzania, and Uganda. Countries were chosen to ensure broad geographical representation and a wide range of infant and child mortality; reported infant and under-five mortality rates in the seven countries ranged from 32 to 113 per 1000 and 38 to 177 per 1000, respectively.2 All hospitals belonged to the national health system. Those selected included both first-level (district) hospitals and

Hospital characteristics

Summary data on hospital admissions, paediatric beds, and staffing levels are given in table 1. Written guidelines were available for managing referred patients with pneumonia and diarrhoea in ten and 11 hospitals, respectively, but guidelines for the treatment of malaria, measles, meningitis, sepsis, or severe malnutrition were available in only two to four hospitals. Two hospitals in one country had guidelines for managing all of these conditions. Mortality rates for inpatient children,

Discussion

This study has at least two limitations. First, care given to sick children was assessed in only 21 hospitals in seven countries. Although selected to represent a wide range of countries and levels of development, these may not have reflected conditions in some less-developed countries, especially those in South America and the Middle East, regions that were not visited. Second, the study was largely observational. Assessments were based in part on the judgment of eight observers; unavoidable

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