Academic journal article Bulletin of the World Health Organization

Hypothetical Performance of Syndrome-Based Management of Acute Paediatric Admissions of Children Aged More Than 60 Days in a Kenyan District Hospital. (Research)

Academic journal article Bulletin of the World Health Organization

Hypothetical Performance of Syndrome-Based Management of Acute Paediatric Admissions of Children Aged More Than 60 Days in a Kenyan District Hospital. (Research)

Article excerpt

Introduction

Over the last ten years, considerable effort has been put into developing the Integrated Management of Childhood Illness (IMCI) initiative, a generic, but adaptable, approach to the assessment and management of sick children when they present to first-level health facilities in resource-poor countries. Under the IMCI initiative, algorithms define illness severity and make recommendations about treatment and hospital referral (l). Target facilities often are run by community nurses or medical assistants. To complement the referral strategy, a manual that addresses inpatient management was produced recently (2). A number of studies have examined the assessment and referral components of IMCI (3-8), but the possible impact on inpatient management has not been addressed. In many government district hospitals in sub-Saharan Africa, however, the health workers who manage inpatients have similar qualifications to those who make referrals. Often supervision from senior staff is limited and there is little or no access to a reliable, laboratory-based diagnostic service, which makes diagnosis difficult even in the referral facility. Syndromic management according to IMCI therefore may become the de facto approach to initial medical management for inpatients.

In essence, much clinical medicine is syndrome based. Characteristic combinations of symptoms, signs, and investigations often define a disease state. The emphasis in medical training and texts is still to use clinical skills to maximize the sensitivity and specificity of diagnosis within the paradigm of treating the single most probable cause of illness. However, this reductionist approach may be costly (in terms of mortality and morbidity) in situations in which the precision of classification is limited by the availability and quality of symptoms, signs, and results of investigations (lowering sensitivity, specificity, or both), in which illnesses are particularly severe (high case fatality), and in which true mixed pathology is more frequent. The latter two conditions apply in many resource-poor countries, notably areas where malaria is endemic. Tacit acknowledgement of this situation means that many health workers treat children for more than one possible disease--a feature also implicit in a syndromic approach to management. As a syndromic approach may offer advantages, such as simplifying training and standardizing inpatient clinical care, and because IMCI may prompt such a move anyway, we examined its potential in children admitted to a Kenyan district hospital.

Methods

The study was undertaken at Kilifi District Hospital, which is located in the Coast Province of Kenya, and is the main government inpatient facility for a district of approximately 500 000 people (although 80% of admissions are drawn from a more proximate population of 200 000). Most of the population consists of subsistence farmers who live in scattered rural homesteads, and mortality in children aged <5 years is likely to be close to the national average of 111 per 1000 live births (9). Malaria is endemic in the area, with two annual peaks of transmission and subsequent disease in June to August, and December to January. Acutely ill children who present to the hospital are assessed in the outpatient department by government clinical officers (health professionals with a minimum of three years' training, who are not members of the research team). These staff provide night and day cover and decide upon admission or discharge. Children aged [greater than or equal to] 13 years are not admitted to the paediatric ward.

The study ran prospectively from 1 September 1999 to 31 August 2000. A standardized proforma was produced .to record symptoms included in IMCI assessments and signs of proven local value (10). This proforma was completed by a clinical member of the research staff as soon as children were admitted (24-hour cover was provided). The main modifications of the IMCI assessment were the use of prostration as a clinical definition of lethargy and replacement of the clinical sign cyanosis by a measured oxygen saturation <90% (NPB 40, Nellcor, CA, USA). …

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