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It is clearly hard to claim that only eight facilities are a true, nationally representative sample. We therefore aimed to document and describe key health system attributes, related to care of the severely ill newborn or child, that would allow others to consider how representative this sample is of the wider Kenyan or regional hospital sector Surveys were conducted by three teams of four or five health workers specifically trained for the task and led by at least one full-time member of the research team.
Data were collected using multiple tools, adapted from previous work [ 4 ], that aimed to describe hospital care within the classical Donabedian framework of structure, process, and outcome [ 14 ]. Relevant tools are briefly described in Table 1. Although the specific structure attributes would be linked to those of process and both to specific outcomes in the classical health production model, this precise linear thinking is rarely possible when attempting a hospital-wide quality of care assessment such as the one described.
Instead, broad panels of indicators have been assessed that help define quality of structure, quality of process, and quality of outcomes as discrete although linked phenomena. Figure 1 Map of Kenya showing location of intervention H1 to 4 and control H5 to 8 hospitals.
Table 1 Simple description of tools used and purpose of each tool Data collection Tool Focus of data collection Facility inventory checklists. Data based on the observation of the survey team leader and, where necessary, the response of senior administrators or department heads. To document staff numbers and department allocations.
For equipment or laboratory tests, the item had to be functional as well as present. To record aspects of the organization of services — for example whether or not triage was operational in clinic areas providing walk-in services for sick newborns and children.
Medical record data abstraction tool To record what was documented for newborns and children about the admission clinical assessment, diagnosis, and treatment, key aspects of inpatient care and outcome. Aim: randomly selected case records per site from the six months prior to the survey. Caretaker interview used after gaining informed consent Structured interview questionnaire including specific data collected at patient discharge on caretaker's knowledge of the patient's diagnosis and post-discharge treatment.
Aim: 50 consecutive, prospectively identified admissions during the survey period. While data on structure facility inventory and from caretaker responses represent point-in-time, actual observation that collected from medical records and from structured interviews is retrospective in nature and potentially more subject to bias.
While it is unlikely that major events affecting hospitals would be misreported during interviews, the quality of information for less major events, such as the details of staff rotation, may be affected. Data collected from medical records suffers from the problem that it is assumed what is not recorded is not done.
For patient assessment tasks this is particularly the case, and such process indicators reflect both quality of documentation and practice. However, the assessment indicators selected are fundamental to appropriate care for sick children with common conditions for example, the child's weight and were part of existing standards of practice in the form of disease-specific government practice guidelines.
Further process indicators, based on correctness of drug or fluid prescription for example, are less subject to such biases. Using these tools, the descriptions presented of the structure, process, and outcome characteristics of the hospitals as contexts are based on comprehensive surveys conducted for two weeks at each site between 9 July and 19 August prior to any intervention Survey 1.
We planned to repeat surveys in all sites at approximately five to six months Survey 2 , 11—12 months Survey 3 , and 17—18 months Survey 4 after randomly allocating hospitals to two groups of four referred to as intervention and control hospitals, see below and [ 5 ] and after initiation of the intervention. Data on national and local policy and management changes collected during these follow-up surveys are presented, but data describing structure, process, and outcomes of care will be presented elsewhere.
For surveys, initial training was conducted for all staff over two weeks and was based around a 'Survey Workers Handbook' that described the study, approaches to data collection, and the specific rules for recording data related to every question for each tool. Practical training included: thorough familiarization with the study purpose; relevant communication skills including obtaining informed consent; discussion of bias and the importance of objectivity among survey staff; question by question discussion of each survey tool to develop a common understanding and agreed rules for data recording; role play or classroom practice for data collection with each tool and three days of practical experience in data collection at the National Hospital.
Group discussion was used to resolve remaining uncertainties over data recording with all final decisions recorded in an updated and final version of the 'Survey Workers Handbook' carried by each survey member. Documenting change in the hospitals as contexts At the outset of this programme, we established a basic approach to record, prospectively, major health system events beyond the scope of our intervention, relevant to child and newborn health, that might influence health sector performance.
This involved monitoring the passage of any parliamentary bills, directives from the Minister of Health or Finance or key senior civil servants in these ministries, and monitoring the countries two major newspapers.
In addition, data were collected using structured interviews with hospital staff see Table 1 and cross-checked during contact with facilitators. Relevant findings from these activities, organized with respect to the conduct of hospital surveys, are presented together with a brief overview of the Kenyan health sector collated from published data or reports.
Experience and results Study hospitals Key characteristics of the study hospitals at baseline are illustrated in Additional File 1 and their location in Figure 1. Structure and service organisation Study hospitals had generators and for the main part were able to maintain electricity supplies but in four hospitals three intervention, one control considerable problems with water supply were present.
Acute, walk-in care for sick children under five years of age is generally provided as part of maternal and child health clinics during the working week, and by general outpatient or casualty departments at nights and weekends.
In five hospitals three intervention, two control clinical officer interns, and in two hospitals medical officer interns one intervention, one control , were part of the clinical workforce providing admission paediatric care.
Both cadres of intern rotate for three months through the paediatric department, and although they considerably increase the total number of clinical service providers the result is a rapidly changing clinical workforce. Nursing numbers are low, with one nurse for each 12 to 18 paediatric beds even during the day. At night in smaller hospitals hospitals H1, H4 and H5 there was often only one nurse on duty on the paediatric ward, and even during the day it was rare for a nurse to be specifically assigned to the newborn nursery.
Hospitals were relatively poorly equipped to deal with a seriously ill child. Process of care Medical records documenting the admission event for infants and children aged 7 days to 59 months were written as short, non-standardised, free-text notes at all eight sites. Retrieval of archived records was possible in seven sites, but in one control site H5 large numbers of patient records were missing.
This was attributed to a lack of stationery and therefore use of a patient-held outpatient book retained by the caretaker on discharge even for inpatient documentation.
At Southmead Hospital, Bristol, initial opposition from obstetricians lessened after quadruplets born there in were successfully cared for in the new unit. Incubators were expensive, so the whole room was often kept warm instead. Cross-infection between babies was greatly feared.
Strict nursing routines involved staff wearing gowns and masks, constant hand-washing and minimal handling of babies. Parents were sometimes allowed to watch through the windows of the unit. Much was learned about feeding—frequent, tiny feeds seemed best—and breathing. Oxygen was given freely until the end of the s, when it was shown that the high concentrations reached inside incubators caused some babies to go blind. Monitoring conditions in the incubator, and the baby itself, was to become a major area of research.
The s were a time of rapid medical advances, particularly in respiratory support, that were at last making the survival of premature newborn babies a reality. Very few babies born before thirty two weeks survived and those who did often suffered neurological impairment.
Herbert Barrie in London pioneered advances in resuscitation of the newborn. Barrie published his seminal paper on the subject in The Lancet in Barrie developed an underwater safety valve in the oxygen circuit. The tubes were originally made of rubber, but these had the potential to cause irritation to sensitive newborn tracheas: Barrie switched to plastic. In later years, further research allowed technology to play a larger role in the decline of infant mortality.
The development of pulmonary surfactant , which facilitates the oxygenation and ventilation of underdeveloped lungs, has been the most important development in neonatology to date. In Britain, some early units ran community programmes, sending experienced nurses to help care for premature babies at home. But increasingly technological monitoring and therapy meant special care for babies became hospital-based. The emergency dash from home to the NICU with baby in a transport incubator had become a thing of the past, though transport incubators were still needed.
Specialist equipment and expertise were not available at every hospital, and strong arguments were made for large, centralised NICUs. On the downside was the long travelling time for frail babies and for parents. Centralised or not, by the s few questioned the role of NICUs in saving babies. From , pediatricians in Britain could train and qualify in the sub-specialty of neonatal medicine.
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