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
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Date
2017
Journal Title
Journal ISSN
Volume Title
Publisher
Implementation Science
Abstract
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.
Methods: 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.
Results: 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). Conclusions: 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.
Description
Keywords
Implementation, Quality improvement, Critical care, Africa South of the Sahara, Global health
Citation
Cummings, M. J., Goldberg, E., Mwaka, S., Kabajaasi, O., Vittinghoff, E., Cattamanchi, A., ... & Davis, J. L. (2017). 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. Implementation Science, 12(1), 1-11. DOI 10.1186/s13012-017-0654-0