WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors
WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors
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DOI：
10.1016/s0140-6736(04)15894-7
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发表时间：
2004-04-03
期刊：
影响因子：
168.9
通讯作者：
Schofield, C
中科院分区：
文献类型：
--
作者：
Ashworth, A;Chopra, M;Schofield, C
背景世卫组织严重营养不良病例管理指南旨在提高医院护理质量和降低死亡率。我们的目的是评估这些准则是否是可行的和有效的，在资源不足hospital.Methods所有儿童入院诊断为严重营养不良的两个农村医院在东开普省省2000年4月至2001年4月，进行了研究，他们的病死率进行了比较，在一段时间的指导方针实施前（1997年3月至1998年2月）。通过观察医疗和护理实践、审查医疗记录以及与护理人员和工作人员的访谈来评估护理质量。死亡率审计是用来确定死亡原因和可避免的contributor-factors.Findings在玛丽特蕾莎医院，病死率从实施前的46%下降到实施后的21%。在Sipetu医院，这一比例从实施前的25%下降到2000年的18%，但在2001年又上升到38%，当时部署了没有接受过营养不良治疗培训的经验不足的医生。这一上升与钾（13% vs 77%，p < 0.0001）、革兰氏阴性菌覆盖的抗生素（15% vs 46%，p = 0.0003）和维生素A（76% vs 91%，p = 0.018）的处方频率降低一致。大多数死亡归因于败血症。2000- 2001年，这两所医院合计有50%的死亡是由于医生的失误，28%是由于护士的失误。卫生系统内的薄弱环节，特别是医生培训、护士监督和支持，损害了护理质量。解释随着世卫组织指导方针的实施，护理质量得到改善，病死率下降。虽然这些资源不足的医院在医疗和护理实践方面取得了重大变化，但并非所有任务都得到了充分的照顾，错误导致了不必要的死亡。
Background WHO case-management guidelines for severe malnutrition aim to improve the quality of hospital care and reduce mortality. We aimed to assess whether these guidelines are feasible and effective in under-resourced hospitals.Methods All children admitted with a diagnosis of severe malnutrition to two rural hospitals in Eastern Cape Province from April, 2000 to April, 2001, were studied and their case-fatality rates were compared with the rates in a period before guidelines were implemented (March, 1997 to February, 1998). Quality of care was assessed by observation of medical and nursing practices, review of medical records, and interviews with carers and staff. A mortality audit was used to identify cause of death and avoidable contributory factors.Findings At Mary Theresa Hospital, case-fatality rates fell from 46% before implementation to 21% after implementation. At Sipetu Hospital, the rates fell from 25% preimplementation to 18% during 2000, but then rose to 38% during 2001, when inexperienced doctors who were not trained in the treatment of malnutrition were deployed. This rise coincided with less frequent prescribing of potassium (13% vs 77%, p < 0.0001), antibiotics with gram-negative cover (15% vs 46%, p = 0.0003), and vitamin A (76% vs 91%, p = 0.018). Most deaths were attributed to sepsis. For the two hospitals combined, 50% of deaths in 2000-01 were due to doctor error and 28% to nurse error. Weaknesses within the health system-especially doctor training, and nurse supervision and support-compromised quality of care.Interpretation Quality of care improved with implementation of the WHO guidelines and case-fatality rates fell. Although major changes in medical and nursing practice were achieved in these under-resourced hospitals, not all tasks were done with adequate care and errors led to unnecessary deaths.