Effect of an emergency care training on the management of acute childhood diarrhoea in Nakuru district, Kenya
Ndedda, Ouma Crispin
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Every year there are approximately 1.5 billion acute diarrhoea episodes and 4 million deaths in children less than five years of age (most from 6 months to 12 months). Acute diarrhoea accounts for approximately 7% of all paediatric admissions in the under 5 age group. Appropriate secondary prevention would reduce these deaths considerably however, studies done in resource rich and poor settings confirm that the management of this common illness by health professionals remains sub-optimal. The aim of this study was to determine the effect of a five day emergency care training namely-Emergency Triage Assessment and Treatment plus admission care (ETAT+) on the case management of acute childhood diarrhoea in a busy public hospital in Kenya. This training has been conducted in most Provincial General Hospitals. Nakuru PGH is one of the health facilities where training has been undertaken and there are plans to roll out to district hospitals. The study design was cross-sectional with historical controls of acute diarrhoea episodes managed without ETAT+ training compared to episodes managed with ETAT+ training in a paediatric out patient setting. The assessment, classification and treatment of acute childhood diarrhoea episodes in children aged 2months up to 59 months was observed and documented using the basic paediatric protocols as the "Gold standard". A total of 334 acute childhood diarrhea episodes were assessed. The primary outcomes were the proportions of acute childhood diarrhoea episodes appropriately assessed, classified and treated for shock and dehydration. The study found out that ETAT+ training improved the assessment of signs of dehydration --checking AVPU from 37.1% to 69.6% p=0.001, RR 0.511 - 0.811 at 95% CI); checking for sunken eyes from 55.0% to 80.9% p=0.010, RR 0.700 - 0.961 at 95% CI); checking skin pinch reaction increased from 40.7% to 70.6% p=0.0.001, RR 0.561 - 0.863 at 95% CI) and checking ability to drink which was least practiced, also significantly rose from 11.4% to 34.5% p=0.001, RR 0.243 - 0.651 at 95% CI). In. regard to treatment practices, selection fo the correct treatment plan for dehydration improved from 26.45 to 67.55 p=0.001, RR 0.353 - 0.631 at 95% CI); correct fluid therapy rose from 44.3% to 69.1% p=0.01 1, RR 0.631 - 0.948 at 95% CI); prescription of vitamin A was poor and had no improvement 37.1% to 43.3% p=0.819, RR 0.794 - 1.350 at 95% CI); while prescription of zinc supplements was poor but improved from 0.7% to 26.6% p= 0.001, RR 0.006 - 0.286 at 95% CI) following ETAT+ training. The results suggest that ETAT+ training resulted in improved overall case management practices. It resulted in significantly higher proportions of acute diarrhoea episodes appropriately assessed for dehydration (27.9% without ETAT+ training compared to 67.0% after ETAT+ training p= <0.001, RR 0.448 - 0.658 at 95% CI), correct classifications of dehydration status documented using the terms to describe the severity as recommended in ETAT+ (45.7% without ETAT+ training compared to 78.4% with ETAT+ training p=0.03, RR 0.582 - 0.851 at 95% CI) and appropriate treatment (42.1% without ETAT+ training compared to 54.1% with ETAT+ training, p=0.001, RR (0.710 - 0.992 at 95% CI). In conclusion, ETAT+ training significantly improved the management of childhood diarrhoea however; the treatment of diarrhoea is still sub-optimal. Training alone cannot therefore be relied on to change case management practices. It has to be augmented with intensified support supervision and structured internal and external quality of care audits by embracing such strategies as Standards Based Management and Recognition (SBM-R).