Prevalence and correlates of pediatric guideline deviation across 9 health facilities

摘要 据估计，每天有15 000名5岁以下儿童死亡。死亡的主要原因包括肺炎 和腹泻，近一半的死亡可归因于营养不良。这些综合征都有 然而，在许多情况下，没有必要为患急性病的儿童提供降低死亡率的干预措施。 循证护理。据估计，超过一半的儿童死亡是可以预防的， 适当采取循证干预措施。儿科临床治疗指南综合证据 确保所有儿童得到高质量的护理。然而，对指南的忠诚度是可变的， 知识超过了对建议的遵守。本研究的目的是描述和评价 影响中低收入国家儿科指南偏离的复杂因素， 可预防的儿童死亡。这一证据对于制定适当的实施战略至关重要 这可以有效地提高儿科护理质量在低资源环境。这项研究涉及两个二级 数据分析和原始数据收集，并嵌套在儿童急性疾病和营养（CHAIN）中 该项目建立了一个全球研究网络，以调查急性病儿童死亡的风险因素。 这项研究将利用来自6个国家9个卫生机构的现有CHAIN队列数据， 医疗服务提供者偏离既定儿科治疗指南的频率，以及 影响偏差我们将从六个国家的每个国家提取诊断和治疗标准， 指南，特别是肺炎，腹泻和严重急性营养不良（SAM）子综合征。我们将 将这些标准映射到CHAIN队列数据中，以确定供应商偏离 他们接受培训的国家指导方针。我们还将分析CHAIN摄入量数据， 患者层面，提供者层面，和影响提供者偏离指南的背景因素。这将 产生关于影响临床决策的多层次因素的有价值的信息。 关于CHAIN中指南偏离发生率的结果将用于确定CHAIN研究中心 在所有目标综合征中观察到的指南依从性最低。主要定性数据收集 将在本网站举行，其中健康提供者和监督员将参加焦点小组讨论 （FGD）。定性数据收集和分析将遵循理论领域框架， 实施科学框架，可用于确定行为的决定因素。的组合 次级数据分析和初级数据收集将允许在自我报告的影响之间进行三角测量 并观察到了指南偏离的影响。这项研究是一种创新的方法，以快速了解 影响弱势儿童护理质量的复杂因素，提供了一个机会， 执行战略，以改进对准则的遵守，降低可预防的儿童死亡率。

ABSTRACT An estimated 15,000 children under the age of five die every day. Primary causes of mortality include pneumonia and diarrhea, and nearly half of deaths are attributable to undernutrition. These syndromes all have available interventions to reduce mortality, however in many settings acutely ill children are not provided necessary evidence-based care. It is estimated that over half of child deaths are preventable with simple, existing, appropriately applied evidence-based interventions. Pediatric clinical treatment guidelines synthesize evidence to ensure that all children are treated with high quality care. Yet, fidelity to guidelines is variable and guideline knowledge exceeds adherence to recommendations. The objective of this study is to describe and evaluate the complex factors influencing pediatric guideline deviation in low-and-middle-income countries where most preventable pediatric deaths occur. This evidence is crucial for developing appropriate implementation strategies that can effectively improve pediatric quality of care in low-resource settings. This study involves both secondary data analysis and primary data collection and is nested within the Childhood Acute Illness and Nutrition (CHAIN) project, which has established a global research network to investigate risk factors for death in acutely ill children. This study will utilize existing CHAIN cohort data from nine health facilities in six countries to evaluate the frequency with which health providers deviate from established pediatric treatment guidelines, and factors that influence deviation. We will extract diagnostic and treatment criteria from each of the six country national guidelines, specifically for pneumonia, diarrhea, and severe acute malnutrition (SAM) sub-syndromes. We will map these criteria across CHAIN cohort data to identify the frequency with which providers deviate from the national guidelines on which they have been trained. We will additionally analyze CHAIN intake data to identify patient-level, provider-level, and contextual factors influencing provider deviation from guidelines. This will generate valuable information regarding multi-level factors that influence clinical decision making. Findings regarding the prevalence of guideline deviation across CHAIN will be used to identify the CHAIN site with the lowest observed guideline adherence across targeted syndromes. Primary qualitative data collection will take place in this site wherein health providers and supervisors will participate in focus group discussions (FGDs). Qualitative data collection and analysis will be guided by the Theoretical Domains Framework, an implementation science framework that can be applied to identify determinants of behavior. The combination of secondary data analysis and primary data collection will allow for triangulation between self-reported influences and observed influences of guideline deviation. This study is an innovative approach to rapidly understand the complex factors influencing quality of care for vulnerable children, providing an opportunity to develop optimized implementation strategies to improve guideline adherence and reduce preventable child mortality.