Academic journal article Bulletin of the World Health Organization

Clinical Assessment and Treatment in Paediatric Wards in the North-East of the United Republic of Tanzania/Evaluation Clinique et Traitement Dans Les Hopitaux Pediatriques Du Nord-Est De la Republique-Unie De Tanzanie/Examen Y Tratamiento Clinicos En Las Salas De Pediatria En El Noreste De la Republica Unida De Tanzania

Academic journal article Bulletin of the World Health Organization

Clinical Assessment and Treatment in Paediatric Wards in the North-East of the United Republic of Tanzania/Evaluation Clinique et Traitement Dans Les Hopitaux Pediatriques Du Nord-Est De la Republique-Unie De Tanzanie/Examen Y Tratamiento Clinicos En Las Salas De Pediatria En El Noreste De la Republica Unida De Tanzania

Article excerpt

Introduction

Hospital care for severely ill children can make an important contribution to child survival, especially in Africa where typically one in six children dies before their fifth birthday from treatable conditions such as malaria, pneumonia, gastroenteritis and malnutrition. (1,2) Good-quality inpatient care in a rural district in Kenya has been estimated to have averted up to 60% of childhood deaths in the surrounding population, (3) although this potential is probably not realized in many areas of Africa due to lack of trained staff and other resources, few and unreliable diagnostic tests and poor organization of care. (4-6)

The limited diagnostic and treatment options available in most district hospitals have led in recent years to the development of syndromic-based guide lines for care. In the United Republic of Tanzania, the Referral Care Manual (RCM) based on Integrated Management of Childhood Illness (IMCI) was adopted as policy in 2005. (7) Although not widely implemented, this defines a framework within which current standards of care can be evaluated and improved.

In this study, we aimed to determine if clinical assessments of children admitted to hospital were sufficient to make effective use of the RCM and if treatment of common conditions was consistent with the RCM. The study was conducted in 13 hospitals in the north-east of the United Republic of Tanzania as part of a baseline assessment before implementing a three-year capacity-building programme to improve paediatric inpatient care in the area.

Methods

The study area

The north-east of the United Republic of Tanzania is characterized by the Eastern Arc mountains stretching from the coastal plain to Mount Kilimanjaro. Populations living at an altitude of up to 2000 m create a wide natural variation in malaria transmission intensity. (8) There are two administrative regions with a combined population of 3.4 million, (9) 90% of whom live in rural areas where subsistence agriculture is supplemented by plantations of sisal, bananas and coffee.

Childhood mortality in 2002 was estimated at 67 out of 1000 and 162 out of 1000 in the Kilimanjaro and Tanga regions respectively; (9) a difference that follows known differences in malaria transmission intensity and socioeconomic status in the regions. In the year before the start of the study, an IMCI "focal person" had been trained in each hospital in the regions, but IMCI was not systematically practised at any site.

Background and retrospective data

"Thirteen hospitals were assessed; two were regional, seven were government district and four were mission "district-designated" hospitals. Hospital ecologies varied; five were highland district hospitals (> 1200 m of altitude), two were urban regional hospitals and six were lowland district hospitals. Clinical paediatric care was provided by clinical officers (with 2-3 years of training) and assistant medical officers (with an additional 2 years of training), except in three hospitals that had a fully-qualified medical doctor.

Data on all paediatric admissions and deaths during 2004 were extracted from the paediatric ward register in each site. The number of calendar days between admission and discharge or death was calculated in approximately 50 consecutive fatal and non-fatal admissions in each hospital to estimate the time from admission to death or discharge respectively.

The ward and hospital pharmacy were inspected for the presence of essential drugs, infusions and oxygen, as absence of these might explain a failure to seek indications for their use.

Outpatient and inpatient data

The basic methods of the assessment used established WHO evaluation tools (10) adapted for use in east Africa. (5) Outpatient consultations were silently observed by a medically trained research assistant who recorded whether IMCI diagnostic criteria were obtained either by examination or enquiry of the caretaker. …

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