我们探讨了在高死亡率环境中,实践偏离指南建议的高死亡率环境中,谁实际上为毕业的临床医生提供了大多数入院护理。
我们使用了2015年11月至2018年11月来自肯尼亚13家县级医院的大量观察数据集,其中患者与入院的临床医生相关。我们在5分量表(0-4)上创建儿科入院护理质量(cPAQC)评分的累积正确性后,探索了指南依从性,其中分数代表正确,在提供完全遵循包括入院评估在内的指南的护理方面的连续进展,诊断和治疗。在指南依从性下降最多的时候,我们将cPAQC评分二分,并使用多水平逻辑回归模型来探讨临床医生和患者水平因素是否会影响依从性。
有1489名临床医生在3年内与53003名患者相关。患者很少由完全合格的临床医生收治,主要由预先注册的医务人员实习生(MOI,46%)和文凭水平的临床官员实习生(COI,41%),每个研究医院提供护理的中位数为28MOI(范围11-68)和52COI(范围5-160)。cPAQC评分表明,在≤12%的疟疾儿童中发现了完美的指南依从性,肺炎或腹泻伴脱水。与COI相比,MOI对指南的依从性更高(校正OR1.19(95%CI1.07至1.34)),但多症与较低的指南依从性显着相关。
在肯尼亚,在高死亡率环境中提供体验式培训的医院中,超过85%的入院是由预先注册的临床医生进行的。临床评估是良好的,但根据指南建议对疾病的严重程度进行分类是一个挑战。接受6年培训的MOI比接受3年培训的COI更好,在他们3个月的儿科轮换期间,表现似乎没有改善。
We explored who actually provides most admission care in hospitals offering supervised experiential training to graduating clinicians in a high mortality setting where practices deviate from guideline recommendations.
We used a large observational data set from 13 Kenyan county hospitals from November 2015 through November 2018 where patients were linked to admitting clinicians. We explored
guideline adherence after creating a cumulative correctness of Paediatric Admission Quality of Care (cPAQC) score on a 5-point scale (0-4) in which points represent correct, sequential progress in providing care perfectly adherent to
guidelines comprising admission assessment, diagnosis and treatment. At the point where guideline adherence declined the most we dichotomised the cPAQC score and used multilevel logistic regression models to explore whether clinician and patient-level factors influence adherence.
There were 1489 clinicians who could be linked to 53 003 patients over a period of 3 years. Patients were rarely admitted by fully qualified clinicians and predominantly by preregistration medical officer interns (MOI, 46%) and diploma level clinical officer interns (COI, 41%) with a median of 28 MOI (range 11-68) and 52 COI (range 5-160) offering care per study hospital. The cPAQC scores suggest that perfect
guideline adherence is found in ≤12% of children with malaria, pneumonia or diarrhoea with dehydration. MOIs were more adherent to
guidelines than COI (adjusted OR 1.19 (95% CI 1.07 to 1.34)) but multimorbidity was significantly associated with lower
guideline adherence.
Over 85% of admissions to hospitals in high mortality settings that offer experiential training in Kenya are conducted by preregistration clinicians. Clinical assessment is good but classifying severity of illness in accordance with guideline recommendations is a challenge. Adherence by MOI with 6 years\' training is better than COI with 3 years\' training, performance does not seem to improve during their 3 months of paediatric rotations.