Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Implementation Science
Published in: Implementation Science 1/2017

Open Access 01-12-2017 | Research

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

Authors: Matthew J. Cummings, Elijah Goldberg, Savio Mwaka, Olive Kabajaasi, Eric Vittinghoff, Adithya Cattamanchi, Achilles Katamba, Nathan Kenya-Mugisha, Shevin T. Jacob, J. Lucian Davis

Published in: Implementation Science | Issue 1/2017

Login to get access

Abstract

Background

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.

Trial registration

Severe illness management system (SIMS) intervention development, ISRCTN46976783
Appendix
Available only for authorised users
Literature
1.
Adhikari NKJ, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet. 2010;376:1339–46.CrossRefPubMed
2.
3.
Murthy S, Adhikari NK. Global health care of the critically ill in low-resource settings. Ann Am Thorac Soc. 2013;10:509–13.CrossRefPubMed
4.
Albert TJ, Fassier T, Chhuoy M, Bounchan Y, Tan S, Ku N, et al. Bolstering medical education to enhance critical care capacity in Cambodia. Ann Am Thorac Soc. 2015;12:491–7.CrossRefPubMed
5.
6.
Grol R, Grimshaw J. Evidence-based implementation of evidence-based medicine. Jt Comm J Qual Improv. 1999;25:503–13.PubMed
7.
Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies––a synthesis of systematic review findings. J Eval Clin Pract. 2008;14:888–97.CrossRefPubMed
8.
Ayieko P, Ntoburi S, Wagai J, Opondo C, Opiyo N, Migiro S, et al. A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomised trial. PLoS Med. 2011;8:e1001018.CrossRefPubMedPubMedCentral
9.
10.
Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42.
11.
Michie S, Atkins L, West R. The behaviour change wheel: a guide to designing interventions. London: Silverback Publishing; 2014.
12.
Ayakaka I, Ackerman S, Ggita JM, Kajubi P, Dowdy D, Haberer JE, Fair E, et al. Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach. Implement Sci. 2017;12:33.CrossRefPubMedPubMedCentral
13.
Jacob ST, Banura P, Baeten JM, Moore CC, Meya D, Nakiyingi L, et al. The impact of early monitored management on survival in hospitalized adult Ugandan patients with severe sepsis: a prospective intervention study. Crit Care Med. 2012;40:2050–8.CrossRefPubMedPubMedCentral
14.
Asiimwe SB, Okello S, Moore CC. Frequency of vital signs monitoring and its association with mortality among adults with severe sepsis admitted to a general medical ward in Uganda. PLoS One. 2014;9:e89879.CrossRefPubMedPubMedCentral
15.
Cummings MJ, Wamala JF, Bakamutumaho B, Davis JL. Vital signs: the first step in prevention and management of critical illness in resource-limited settings. Intensive Care Med. 2016;42:1519–20.CrossRefPubMed
16.
17.
Deming WE. The new economics. Cambridge: MIT Press; 1993.
18.
Zou G. A modified Poisson approach to prospective studies with binary data. Am J Epidemiol. 2004;159:702–6.CrossRefPubMed
19.
Obermeyer Z, Abujaber S, Makar M, Stoll S, Kayden SR, Wallis LA, et al. Emergency care in 59 low- and middle-income countries: a systematic review. Bull World Health Organ. 2015;93:577–86.CrossRefPubMedPubMedCentral
20.
Razzak JA, Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bull World Health Organ. 2002;80:900–5.PubMedPubMedCentral
21.
Ford N, Shubber Z, Meintjes G, Grinsztejn B, Eholie S, Mills EJ, et al. Causes of hospital admission among people living with HIV worldwide: a systematic review and meta-analysis. Lancet HIV. 2015;2:438–44.CrossRef
22.
Hirshon JM, Risko N, Calvello EJ, Stewart de Ramirez S, Narayan M, Theodosis C, et al. Health systems and services: the role of acute care. Bull World Health Organ. 2013;91:386–8.CrossRefPubMedPubMedCentral
23.
Lawn SD, Harries AD, Anglaret X, Myer L, Wood R. Early mortality among adults accessing antiretroviral treatment programmes in sub-Saharan Africa. AIDS. 2008;22:1897–908.CrossRefPubMed
24.
Molyneux E, Ahmad S, Robertson A. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting. Bull World Health Organ. 2006;84:314–9.CrossRefPubMedPubMedCentral
25.
Riviello ED, Letchford S, Achieng L, Newton MW. Critical care in resource-poor settings: lessons learned and future directions. Crit Care Med. 2011;39:860–7.CrossRefPubMed
26.
Moresky RT, Bisanzo M, Rubenstein BL, Hubbard SJ, Cohen H, Ouyang H, et al. A research agenda for acute care services delivery in low- and middle-income countries. Acad Emerg Med. 2013;20:1264–71.CrossRefPubMed
27.
Kruisselbrink R, Kwizera A, Crowther M, Fox-Robichaud A, O'Shea T, Nakibuuka J, et al. Modified early warning score (MEWS) identifies critical illness among ward patients in a resource restricted setting in Kampala, Uganda: a prospective observational study. PloS One. 2016;11:e0151408.CrossRefPubMedPubMedCentral
28.
Asiimwe SB, Abdallah A, Ssekitoleko R. A simple prognostic index based on admission vital signs data among patients with sepsis in a resource-limited setting. Crit Care. 2015;19:86.
29.
Baker T, Blixt J, Lugazia E, Schell CO, Mulungu M, Milton A, et al. Single deranged physiologic parameters are associated with mortality in a low-income country. Crit Care Med. 2015;43:2171–9.CrossRefPubMed
30.
Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit. Am J Respir Crit Care Med. 2017;195:906–11.CrossRefPubMed
31.
English M, Ntoburi S, Wagai J, Mbindyo P, Opiyo N, Ayieko P, et al. An intervention to improve paediatric and newborn care in Kenyan district hospitals: understanding the context. Implement Sci. 2009;4:42.CrossRefPubMedPubMedCentral
32.
English M, Nzinga J, Mbindyo P, Ayieko P, Irimu G, Mbaabu L. Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals––interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies. Implement Sci. 2011;6:12.CrossRef
33.
34.
Squires JE, Sullivan K, Eccles MP, Worswick J, Grimshaw JM. Are multifaceted interventions more effective than single-component interventions in changing health-care professionals’ behaviours? An overview of systematic reviews. Implement Sci. 2014;9:152.CrossRefPubMedPubMedCentral
35.
English M. Designing a theory-informed, contextually appropriate intervention strategy to improve delivery of paediatric services in Kenyan hospitals. Implement Sci. 2013;8:39.CrossRefPubMedPubMedCentral
36.
Baker T, Schell CO, Lugazia E, Blixt J, Mulungu M, Castegren M, et al. Vital signs directed therapy: improving care in an intensive care unit in a low-income country. PLoS One. 2015;10:e0144801.CrossRefPubMedPubMedCentral
37.
Althabe F, Buekens P, Bergel E, Belizán JM, Campbell MK, Moss N, et al. A behavioral intervention to improve obstetrical care. N Engl J Med. 2008;358:1929–40.CrossRefPubMed
38.
Arora S, Thornton K, Murata G, Deming P, Kalishman S, Dion D, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364:2199–207.CrossRefPubMed
39.
40.
Kelly CA, Upex A, Bateman DN. Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale. Ann Emerg Med. 2004;44:108–13.CrossRefPubMed
41.
McNarry AF, Goldhill DR. Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma Scale. Anaesthesia. 2004;59:34–7.CrossRefPubMed
42.
Jacob ST, Moore CC, Banura P, Pinkerton R, Meya D, Opendi P, et al. Severe sepsis in two Ugandan hospitals: a prospective observational study of management and outcomes in a predominantly HIV-1 infected population. PLoS One. 2009;4:e7782.CrossRefPubMedPubMedCentral
43.
Riviello ED, Kiviri W, Twagirumugabe T, Mueller A, Banner-Goodspeed VM, Officer L, et al. Hospital incidence and outcomes of the acute respiratory distress syndrome using the Kigali modification of the Berlin definition. Am J Respir Crit Care Med. 2016;193:52–9.CrossRefPubMed
44.
Andrews B, Muchemwa L, Kelly P, Lakhi S, Heimburger DC, Bernard GR. Simplified severe sepsis protocol: a randomized controlled trial of modified early goal-directed therapy in Zambia. Crit Care Med. 2014;42:2315–24.CrossRefPubMedPubMedCentral
45.
McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M, Fisher P. The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol 2007;7:30.
Metadata
Title
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
Authors
Matthew J. Cummings
Elijah Goldberg
Savio Mwaka
Olive Kabajaasi
Eric Vittinghoff
Adithya Cattamanchi
Achilles Katamba
Nathan Kenya-Mugisha
Shevin T. Jacob
J. Lucian Davis
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Implementation Science / Issue 1/2017
Electronic ISSN: 1748-5908
DOI
https://doi.org/10.1186/s13012-017-0654-0

Other articles of this Issue 1/2017

Implementation Science 1/2017 Go to the issue

Study protocol

A mixed methods protocol for developing and testing implementation strategies for evidence-based obesity prevention in childcare: a cluster randomized hybrid type III trial

Research

Impact of a tailored program on the implementation of evidence-based recommendations for multimorbid patients with polypharmacy in primary care practices—results of a cluster-randomized controlled trial

Study protocol

Testing feedback message framing and comparators to address prescribing of high-risk medications in nursing homes: protocol for a pragmatic, factorial, cluster-randomized trial

Research

Evaluation of scaling-up of HPV self-collection offered by community health workers at home visits to increase screening among socially vulnerable under-screened women in Jujuy Province, Argentina

Research

Using Getting To Outcomes to facilitate the use of an evidence-based practice in VA homeless programs: a cluster-randomized trial of an implementation support strategy

Methodology

Intervention planning for a digital intervention for self-management of hypertension: a theory-, evidence- and person-based approach