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Pediatric Hospital Improvement Collaborative Addresses Neglected Area of Child Survival
by Janis Berman

Women with child in Eritrea

Studies sponsored by the World Health Organization (WHO) suggest that 10 to 20 percent of sick children treated with Integrated Management of Childhood Illness (IMCI) guidelines at primary level facilities in developing countries would require referral to hospitals for life-saving treatment of conditions such as cough and difficult breathing (indicators of severe pneumonia, respiratory distress); diarrhea with dehydration; febrile conditions (meningitis, cerebral malaria, sepsis); severe malnutrition; and HIV/AIDS. Although solid data are limited, some evidence indicates widespread gaps between actual care and WHO guidelines for pediatric care at first level referral hospitals.

To address this gap in the continuum of care for sick children in developing countries, QAP in collaboration with WHO, launched The Pediatric Hospital Improvement Collaborative (PHI). PHI which began in late 2002, is now underway in five countries: Eritrea, Niger, Nicaragua, Guatemala, and Malawi. In partnership with each country’s Ministry of Health, PHI is working to improve hospital care of sick children with serious infections and severe malnutrition through implementation of the evidence-based case management guidelines described in WHO’s Referral Care Manual and through ongoing quality improvement activities. The PHI Collaborative also seeks to improve recognition and management of emergency conditions and decrease hospital fatality rates in young children.

Child's Blood Pressure being taken

PHI relies on a collaborative approach—an organized effort of shared learning by a network of facilities or teams—to adapt to local situations a best practice model of care for a specific priority health area. A collaborative seeks to achieve significant results in a relative short period of time (from 12 to 18 months) in order to reduce the gap between best and current practices and subsequently to scale up the adapted model throughout the health system using an intentional spread strategy. Through PHI, QAP has assisted each Ministry of Health to adapt the WHO Referral Care guidelines, identify technical advisory groups and coordinating bodies for the improvement initiative, and agree upon the common indicators to measure progress. Special materials to support teams in their quality improvement activities has been adapted or developed, such as the Emergency Triage, Assessment and Treatment (ETAT) training course, booklets for self-monitoring common indicators, and forms for documenting the specific changes tested to improve the quality of care according to the standards.

Currently PHI is in various stages of implementation in the five countries. Teams are making improvements in care in 10 hospitals in Eritrea, 10 hospitals in Nicaragua, and 14 hospitals in Niger, while baseline assessments are being completed in Guatemala and Malawi. The initiative has already shown promising preliminary results in Eritrea, Nicaragua, and Niger, the three countries in which the program was initially implemented. Hospitals are beginning to show improvements in common indicators measured over time, including an increase in the number of cases managed according to standards. Some reductions in hospital fatality rates have also been documented.

To assess baseline levels of practice, assessments conducted in 2002 in Eritrea, and in 2003, in Nicaragua and Niger, observed treatment of more than 800 children in 39 hospitals. Assessment findings showed that children receiving treatment according to guidelines ranged from about 6 percent in Niger to 45 percent in Nicaragua. In all countries, case management of diarrhea/severe dehydration (especially in severely malnourished children) and of severe malnutrition needed significant improvement. Studies showed that major areas requiring improvement included provision of emergency triage, assessment, and treatment; patient monitoring; and nutritional support for hospitalized children.

24-hour death rate among children 0-59 months admitted in ER, Maradi Regional Hospital, Niger
(Jan - May 04)

Since implementation of PHI, improvements in standards compliance, case management, ETAT, monitoring, and nutritional support are beginning to be realized in hospitals throughout the three countries. Among improvements implemented in Eritrean hospitals have been the establishment of triage systems to rapidly identify and treat children with emergency signs, implementation of nutritional programs appropriate for a pediatric diet, and improved patient monitoring practices. In Niger, where the initial focus was ETAT, performance monitoring results from the Regional Hospital Centre of Maradi show an increase in the number of cases managed in compliance with standards, despite sharp increase in numbers of new emergencies. Also at the Regional Hospital Centre, the 24-hour death rate among children 0-59 months admitted to the Emergency Room has steadily declined in 2004 (see graph above). Among improvements implemented in Niger have been introduction of triage systems; increased accessibility to essential emergency drugs; and improved patient monitoring practices. In Nicaragua, two hospitals (of the four documented on graph below) showed a sustained increase in adherence to norms to guarantee adequate medical and nursing care for the severe and very severe pneumonia patient, with both teams achieving 100 percent adherence .

Percentage of children 0-59 months admitted with severe pneumonia managed according to norms at four Nicaraguan hospitals (baseline – May 04)

For more on information on the Pediatric Hospital Improvement Collaborative, please view or download:

Improving the Care of Hospitalized Children with Serious Infections and Severe Malnutrition: Results from Pediatric Hospital Improvement (PHI) Collaboratives in Three Developing Countries (Poster presentation offered by QAP Deputy Director Diana Silimperi, MD, at 2004 Global Healthcare Conference)
(Accompanying handout)

Or contact Dr. Stephen Kinoti at skinoti@urc-chs.com.

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID) under Contract Number GPH-C-00-02-00004-00.