Guideline Adherence in Slums Project - Template-based documentation and decision support for primary healthcare clinics in the private sector

由于大量贫民窟人口通过私营部门寻求治疗，因此必须开发工具，帮助这些诊所的提供者提高服务质量。例如，记录对抗生素的需求有助于减少不必要的抗生素处方病例的数量。临床实践指南（CPGs）是帮助医生和护士提供循证护理的工具。然而，在面对患者的情况下（例如，当患者坐在他/她面前时，医生正在查看手册），这些设备不容易使用。它们还需要根据当地情况进行调整（例如，一线药物是否可用或负担得起？）。要使CPGs在资源匮乏的环境中发挥作用，重要的是要解决使用指南的多重（如果不是全部）障碍，但要以不使有限资源紧张的方式解决。我们的干预包括与临床护理提供者合作，并开发模板（如清单），当他们看到病人时可以使用。模板采用橡皮图章的形式，可以打印到纸质病例表上（例如，如果一名妇女出现排尿频率增加，临床医生将尿路感染模板印在她的病例表上）。这个模板既指导了该问病人什么问题，也指导了如何处理尿路感染。其他疾病有其他模板，但一套6-8个模板涵盖了大多数进入初级保健诊所的患者。重要的是，这些模板易于数字化和分析。它们是以多项选择题的形式出现的，气泡需要被遮盖。一张已填写模板的手机图像可以在不泄露患者身份的情况下，迅速为我们提供有关该病例如何处理的数据。作为橡皮图章，我们避免了跟踪多张打印纸张的需要。当指南改变时，我们也避免了浪费，因为更换邮票上的橡胶雕刻既简单又便宜。我们现在有了一个工具，可以很容易地监控临床医生的工作，检查质量，并在定期反馈会议中，如果有偏离指导方针的原因，就与他们一起工作。这项干预措施正在内罗毕的两个贫民窟诊所使用，初步反应很好。我们现在想在内罗毕贫民窟的10个不同的私人诊所中研究这种干预措施。我们想测试这种干预是否：a)可用——不同的诊所有不同的优先级和态度，我们需要确保干预不会带来大的挑战b)有效——干预是否真的改善了临床实践（例如，通过减少不必要的抗生素处方）？c)可持续性——我们用工具和反馈来支持这些诊所需要多少成本？诊所付得起这项服务的费用吗？d)可扩展性——我们是否有现实的机会在全国（甚至省级）层面推广这种干预措施？如果取得成功，该干预措施有可能改变低资源环境中医疗保健的提供方式。越来越多的人在私营部门寻求医疗服务，但确保私营部门提供高质量医疗服务的法规、服务和工具却非常少。我们希望对向穷人提供的护理质量产生重大影响。

With large numbers of people in slums seeking care through the private sector, it is important to develop tools to help providers in these clinics improve the quality of their services. For example, documenting the need for an antibiotic helps reduce the number of cases of unnecessary antibiotic prescriptions.Clinical practice guidelines (CPGs) are tools developed to help doctors and nurses give evidence-based care. These are however not easy to use in a patient-facing scenario (e.g. a doctor looking through a manual when the patient is seated in front of him/her). They also need to be tweaked to be relevant to the local context (e.g. is the first line drug available or affordable?). For CPGs to be relevant in low-resource settings it is important to address multiple, if not all, barriers to using guidelines, but in a manner that does not strain limited resources.Our intervention involves working with clinical care providers and developing templates (think checklist) that can be used while they are seeing the patient. The templates take the form of rubber stamps that can be printed into the paper case sheet (e.g. if a woman presents with increased frequency of urination, the clinician stamps the Urinary Tract Infection template into her case sheet). This template is both a guide to what questions to ask the patient and how to manage UTIs. Other illnesses get other templates, but a set of 6-8 templates covers the majority of patients walking into primary care clinics.Importantly these templates are easy to digitise and analyse. They are in the form of a multiple choice exam paper where bubbles need to be shaded. A cell phone image of a filled-in template can quickly give us data on how the case was managed without revealing patient identity. Being rubber stamps we avoid the need to keep track of multiple printed sheets of paper. We also avoid wastage when guidelines change because changing the rubber engraving on the stamp is simple and cheap.We now have a tool to easily monitor the clinician's work, check for quality, and work with them if there are reasons to deviate from the guidelines by during regular feedback sessions. The intervention is being used in two slum clinics in Nairobi with great initial responses. We now want to study this intervention in a set of 10 different private sector clinics in Nairobi's slums. We would like to test if this intervention is:a) Usable - different clinics have different priorities and attitudes and we need to be sure that the intervention poses no big challengesb) Effective - does the intervention actually improve clinical practice (e.g. by reducing unnecessary antibiotic prescription)?c) Sustainable - how much does it cost for us to support these clinics with tools and feedback? Can the clinics afford to pay us for this service?d) Scalable - is there a realistic chance for us to roll this intervention out at national (or even provincial) level?If successful the intervention has the potential to change how healthcare is delivered in low-resource settings. More and more people are seeking care in the private sector, but very few regulations, services and tools exist to ensure that care in the private sector is of high quality. We hope to make a significant impact in the quality of care that is delivered to the poor.