Assessment of Hospital Care for Children An Assessment of Hospital Care for Children Under-five at District and Sub- District Level Hospitals in Bangladesh

Assessment of Hospital Care for Children Assessment of Hospital Care for Children

An Assessment of Hospital Care for An Assessment of Hospital Care for Children Under-five at District and Children Under-five at District and

Sub-District Level Hospitals in Sub-District Level Hospitals in Bangladesh Bangladesh


BackgroundBackground

• IMCI has been institutionalized in the public health system

in Bangladesh, with facility based IMCI expanded to more

than 2/3 of the country

• IMCI advocates referral of severely ill children, and

increasingly more sick children in Bangladesh are being

referred as severe cases (10-15%) to sub-district (upazila)

or district hospitals for appropriate management

• Child survival interventions thus, critically depend on

functioning referral systems and good care at referral

facilities

• Assessment is needed as part of initiating quality

improvement process as there is limited information

available on the quality of care in hospitals


1 .Country Orientation

2 .Hospital Assessment (Baseline)

3 .Agreement on standards

4 .Definition of interventions & area

5 .Improvement in hospitals

7 .Sharing of Information

6 .Monitoring and Evaluation

PLAN

CHECK

DOACT

WHO: Framework for Hospital Improvement WHO: Framework for Hospital Improvement Process Process


ProcessProcessAdaptation Of Tools•WHO Generic hospital assessment tools were reviewed,

adapted

Sections Of Tools

• Hospital layout, essential drugs, supplies and

equipment• Laboratory support• Emergency area and emergency management• Neonatal care and case management for ARI,

Diarrhoea, febrile illness and malnutrition• Supportive care and monitoring• Hospital administration• Measure of access to hospital care• Quality of care

Field Testing of tools

Training of the assessors


Sampling of hospitals

Selection of district hospitals

(DHs): One district was

randomly selected from each

division, for a total of six DHs.

Selection of sub-district

hospitals: Two facilities were

selected from each of the six

selected districts based on

stratified sampling

Process Process (cont.)(cont.)


Assessment of hospitals•Each assessment team consisting of 2 paediatricians and

2 programme personnel visited each site for 2 days in

May 2009Source of information for assessing quality•Observation of clinical case management •Reviewing records when there were not sufficient

patients for direct case observations•Interviews with hospital staff and, if needed,

simulated cases when no case could be observed nor

record could be found•Extraction of the data from Management Information

System (MIS) report



Scoring system for assessment• Hospital assessment tool comprised of 11 sections• For individual and overall scoring, points from 5 to 1

were awarded:

5 - Good practice complying with standards of

care,

4 - Showing little need for improvement to reach

standard care,

3 - Meaning some need for improvement,

2 - Indicating considerable need for improvement

and

1 - Services not provided, totally inadequate care

or potentially life-threatening practices.








Key FindingsKey Findings


Major reasons for under five visits at hospital in 2008

Source: Hospital Routine MIS


Hospital layout and child health infrastructure

• All of the 6 DHs had separate paediatric corner and

designated beds for children

• Among the 12 Sub-district hospitals (SDH), 7 had a

separate paediatric corner, and only 2 had designated

beds for admitting children

• Half of DHs and one-third of SDHs had paediatric

surgery facilities, none had paediatric surgeons

• All of the 18 facilities had 24-hour nursing care for

admitted children


Hospital support system, equipment and drugs

• Backup power supply was available only at one DH and 4 SDHs

• 5 DHs and 8 SDHs had coloured bins for waste disposal but appropriate waste disposal was practiced only in half

• Running water was available but provision of safe drinking water only at half of the facilities

• At least one injectable antibiotic for managing severe pneumonia or very severe disease (Ampicillin or Gentamycine) was available at all DHs, but not at all SDHs even though both are required

• Only one DH had all of the essential paediatric inpatient drugs (normal saline, injection Ampicillin, injection Gentamycine, cholera saline, syrup Amoxicillin and injection Amoxicillin)

• Filled oxygen cylinders were available at all the visited hospitals, although 3 SDHs had no flow-meter


Quality of laboratory support

District Hospital(N = 6)

Sub-district Hospital(N = 12)

Availability of essential laboratory tests1 24X7 and delivery of results in a timely fashion to the ward/emergency area

5 3

Prioritization of tests for emergencies6 9

Performance of tests according to Standard Operating Procedures

3 4

Maintenance of lab safety measures2 3

1Essential laboratory tests include: blood glucose, haemoglobin or haematocrit (PCV), microscopy for malaria, microscopy for cells in CSF and urine, blood grouping and cross-matching

Assessment of Hospital Care for Children Assessment of Hospital Care for Children Availability and quality of Neonatal

care Adequate

Some improvement needed

Substantial improvemen

t neededDH SDH DH SDH DH SDH

Presence of a clean ward, accident prevention and no dangerous objects

0 2 5 3 1 7

Attention to the most seriously ill 0 0 1 3 5 9

Promotion of early and exclusive breastfeeding – skin contact is ensured

1 4 4 8 1 0

Practice of thermal protection0 0 5 4 1 8

Administration of immunizations

0 1 6 6 0 5

Appropriate feeding of young infants and low birth weight newborns

0 0 3 3 3 9




Quality of case management: Pneumonia

Adequate

Some improvemen

t needed



Severity of pneumonia is correctly assessed and diagnosed

2 3 2 4 2 5

Appropriate antibiotics are administered for pneumonia and other respiratory diagnoses

0 0 3 2 3 10

Oxygen is administered correctly and only when necessary

1 0 3 8 2 4

Appropriate diagnosis and management of tuberculosis

4 1 2 8 0 3




Quality of case management: Diarrhoea

AdequateSome

improvement needed



Dehydration is correctly assessed

1 1 3 6 2 5

Rehydration plan is appropriate to severity of dehydration and appropriately monitored

0 0 4 4 2 8

Appropriate antibiotics only given when necessary

0 0 5 2 1 10

Continued feeding given during diarrhoea

2 2 2 4 2 6




AdequateSome

improvement needed

Substantial improvement needed

DH SDH DH SDH DH SDHNutritional status assessed by weight for height, including differential diagnosis

0 0 1 1 5 11

Management of infection0 0 3 6 3 6

Management of electrolyte imbalance and micronutrients

0 0 2 3 4 9

Correct management of dehydration 0 0 2 1 4 11

Hypoglycaemia and hypothermia checked and managed

0 0 1 2 5 10

Correct feeding of severely malnourished children

0 0 1 2 5 10

Quality of case management: severe malnutrition




Patient Monitoring System

AdequateSome

improvement needed



Re-assessment of all admitted children by a nurse

0 0 4 2 2 10

Re-assessment of all admitted children by a doctor

1 1 5 6 0 5

Assessment of nutritional status for all admitted children

0 0 2 1 4 11

Attention given to most ill children

1 0 3 5 2 7

Monitoring with a monitoring chart

0 0 2 2 4 10

Overall appropriate patient monitoring

0 0 3 3 3 9




Hospital administration

AdequateSome

improvement needed

Substantial improvement needed

DH UHC DH UHC DH UHCAdequate and updated treatment guidelines are available at the hospital

1 0 1 1 4 11

Audits on hospital deaths 1 0 0 4 5 8Availability of transport (ambulance) for transferring cases / referred cases

2 4 3 4 1 4


There is no established TRIAGE system in any of

the hospitals

The provision of neonatal care services,

especially in Sub-district hospitals, requires

substantial improvement

Essential laboratory supports were found to be

adequate at almost all district hospitals but

requires substantial improvement at majority of

SDHs

Weak monitoring systems and inadequate

provision of care for major killers especially

pneumonia, diarrhoea, and malnutrition

Key Findings Key Findings


Urgent need to address the following priority areas:

Staffing

Clinical competency in case-management and

supportive care

Triaging systems

Essential drugs and supplies including

newborn care equipments

Establishment of Quality Assurance system

Documentation of monitoring and

assessments

Major Major RecommendationsRecommendations


National benchmarking or hospital accreditation

system for an integrated quality improvement

approach

Build capacities of currently available manpower in

managing newborn and sick children with standard

treatment and monitoring guidelines

Creating and maintaining a master database of

essential drugs and equipment may facilitate

monitoring, planning and action within facilities

Reassessment of the current allocation of resources

to focus district and sub-district hospital

Other RecommendationsOther Recommendations


Out of 61 district and 324 Upazila hospitals in

Bangladesh, the assessment process covered

only 18 facilities

Not all practices could be observed due to time

constraints and lack of cases during the visits

Poor quality of patients records hindered proper

assessment of existing practices

Inter-observer variability in perception of the

hospital performance

Hawthrone effect

Scoring system itself

LimitationsLimitations


Progress of Hospital Improvement Progress of Hospital Improvement process in Bangladeshprocess in Bangladesh

• Baseline assessment completed

• WHO Pocket book adapted based on agreed standards

• Development of SOP for MNH in process

• Training package for ETAT developed and facility based newborn care initiated

• Priority districts identified for interventions



IMCI section of the Directorate General of Health

Services, Ministry of Health and Family Welfare,

Government of Bangladesh

SEARO/WHO for their technical assistance and

financial support

Bangladesh Paediatric Association (BPA) for their

support and technical guidance

AcknowledgementsAcknowledgements

Documents

Assessment of Hospital Care for Children An Assessment of Hospital Care for Children Under-five at District and Sub- District Level Hospitals in Bangladesh