Tested Changes and Applied Evidence-Based Clinical Interventions to Improve Care of Respiratory Infections Among Children in Georgia s Imereti Region

Transcription

1 Tested Changes and Applied Evidence-Based Clinical Interventins t Imprve Care f Respiratry Infectins Amng Children in Gergia s Imereti Regin Backgrund In February 2012 the USAID Health Care Imprvement Prject (HCI) and in July 2014 the USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject implemented by University Research C., LLC began t address challenges related t quality, cnsistency, and cntinuity f care f pediatric respiratry infectins in Gergia. T imprve the quality f RTI diagnstic and treatment practices, HCI and ASSIST supprted the frmatin f several quality imprvement (QI) teams in Gergia s Imereti Regin. This dcument summarizes tested changes t imprve ambulatry and hspital care f acute upper (rhinitis, sinusitis, pharyngitis) and lwer (brnchitis, pneumnia) respiratry infectins (RTIs) amng children attending health care facilities (ambulatry and hspital) in Imereti. The purpse f the tested changes was t ensure crrect and cnsistent use f evidence-based clinical interventins fr every relevant pediatric patient every time. Appendix 1 prvides illustrative gaps, changes tested, implemented and rutinely mnitred by the facility QI teams t imprve RTI care. Appendix 2 prvides best practices fr diagnsis, treatment, preventin and fllw-up while implementing the imprvement interventin ( ) per each clinical cnditin. Appendix 3 prvides indicatrs fr rutine mnitring f the quality f utpatient care f respiratry tract infectins in children. MAY 2014 This summary f tested changes and clinical cntent was prepared by University Research C., LLC (URC) fr review by the United States Agency fr Internatinal Develpment (USAID) and was authred by Tamar Chitashvili and Ekaterine Cherkezishvili f URC. The dcument was develped under the USAID Health Care Imprvement (HCI) Prject, which is managed by URC under the terms f Cntract Number GHN-I and made pssible by the supprt f the American peple thrugh USAID. The cntents f this reprt are the sle respnsibility f URC and d nt necessarily reflect the views f the USAID r the United States Gvernment.

2 Appendix 1: Illustrative gaps and changes intrduced by the QI teams t imprve the quality f diagnsis and management f acute upper (rhinitis, sinusitis, pharyngitis) and lwer (brnchitis, pneumnia) respiratry infectins amng children attending health care facilities (ambulatry and hspital) Prblem addressed Change tested by a team Change Cncept: Clinical Cmpetence Hw change was tested and implemented Evidence f success Pr knwledge Invlved care Frmatin f imprvement Prvider interview results and skills f care prviders in regular team cmprised f facility befre and after 18 mnths prviders t caching visits managers and medical f prject interventins manage acute persnnel revealed that in additin t pediatric Assessing gaps in quality imprved clinical practice, respiratry tract f RTI diagnsis and basic knwledge and skills infectins management by regular f prviders have als been accrding t peer-review f medical significantly imprved (e.g., evidence-based charts at the interventin facilities guidelines Cnditin-specific change packages fcused n essential, high-impact, cst-effective interventins develped indicatrs t measure the prgress in QI develped Assigning different rles and switching the rles t regularly mnitr the prgress n QI (case presentatin, case review and discussin, filling the rutine mnitring sheet) thrugh medical chart review and directly bserved cnsultatins Participate in regular clinical, n-jb and QI trainings, rganized by the prject and Respiratry Care Assciatin Prmting high perfrming prviders within netwrk f Ge-Hspitals by assigning higher respnsibilities (e.g. clinical supervisin f ther care prviders) Participating in quarterly meetings with ther QI team members t learn frm each-thers experience the rati f dctrs wh answered crrectly n all fur knwledge assessment multiple-chice questins abut pneumnia and respiratry tract infectins management increased frm 3.6% (April, 2012) t 96.8% (Nvember, 2013)). Clinical interventins t imprve care f respiratry infectins in children in Gergia 2

3 Prblem addressed Change tested by a team Hw change was tested and implemented Evidence f success Pr knwledge Engaged health care Inviting QI team members Rutine mnitring results f medical care prviders t search t participate in f quality imprvement fr prviders t internatinal Translating Research int ambulatry management f search and evidence, critically Practice (TRIP) n-the-jb pediatric respiratry tract appraise appraise the trainings, cnducted by infectins shw, that after recmmendatins literature and share the prject, in 32 mnths (thrugh April in terms f the evidence cllabratin with NYU January 2015) f strength f summaries t the QI nursing schl interventins average evidence and its team members and Cnducting regular case cmpliance Index 1 t the applicability t larger grup f study discussins and best RTI care practice their clinical prviders in the review f evidence-based imprved by 54% frm the practice district medical literature during the QI team meetings Incentivizing care prviders t search and appraise medical literature by their participatin in reginal learning sessins and medical cnferences at lcal, reginal and natinal levels; Facility QI teams rganizing wrkshps fr ther care prviders and share the evidence updates n management f particular RTIs, c-mrbidities, rare and interesting cases baseline 45% and reached 100% level; Average cmpliance with RTI management best practices at hspital level imprved by 58% frm the baseline 40% and reached 98%; Similarly, during April Nvember 2013) after the interventin, the use f first line antibitic at the endline assessement increased frm 36.2% t 89.2% (attributable difference 32.9%, p<0.001). In interventin facilities, the use f aminglycsids decreased frm 43.08% t 7.69% (attributable difference 33.99%, p<0.001). At the baseline in 24.8% f cases, administered dsage was nt cmpliant t mdern recmmendatins, whereas at the endline assessment, this kind f gap was nt detected in any f the reviewed medical charts (attributable difference 16.88%, p=0.002). 1 Cmpsite index is an average f all selected percentage prcess indicatrs and shws average cmpliance with the best clinical practice. Results are aggregated frm all multi-facility QI teams Clinical interventins t imprve care f respiratry infectins in children in Gergia 3

4 Prblem addressed Change tested by a team Change Cncept: Imprving Efficiency Hw change was tested and implemented Evidence f success Overutilizatin f Engaged care Identifying and discussing Cst-effectiveness study unnecessary prviders in ratinal the latest evidence f cnducted by the prject diagnstic tests use f medicatins using X-rays and ther shwed that after 30 and nn- and diagnstic tests tests t diagnse mnths f quality evidence-based pneumnia and assess its imprvement interventins, medicatins, severity during the QI incremental cst-saving per including meetings and caching patient in case f antibitics bth at visits ambulatry management f ambulatry clinics Identifying and discussing pediatric RTI was 5.2 USD and hspitals the latest available due t a decreased number evidence n the evidence- f unnecessary diagnstic based medicatins t treat tests and medicatins, different RTIs (including when the interventin cst evidence n first line nly 0.9 USD per patient. In antibitic use, use f ther wrds, the antipyretics, cugh interventin saved 5.7 medicatins, β2-agnists, times mre than the cst f crticsterids and etc.) the interventin itself. during the QI meetings Assessment f incremental and caching visits cst-savings using a Cnducting several team decisin-tree analysis fr meetings, caching visits each selected indicatr and n-the-jb trainings shwed that interventin where the team fcused dminates n business-asn detailed assessment f usual alternative. histry f illness, review f systems and physical exams t imprve diagnsis and assessment f severity f the illness and determine further need f diagnstic tests Cnducting several team meetings, caching visits and n-the-jb trainings n patient fllw up after the first line empirical therapy t determine further need f additinal medicatins (including antibitics) In parallel with the increase f evidence-based practice, there was a decrease in frequency f use f nnevidence based medicatins (sterids, shrt-acting methylxantines, vitamines, s called metblics etc.) Specifically the ratin f medical charts with administratin f at least ne nn-eb medicatin decreased frm 100% at April 2012 t 40.77% (attributable difference - 61%, p<0.001) at Nvember Clinical interventins t imprve care f respiratry infectins in children in Gergia 4

5 Prblem addressed Change tested by a team Hw change was tested and implemented Evidence f success Limited Engaged hspital Discussing the issue with During the fcus grup availability f manager and Ge- crprate and facility interviews, the QI team evidence-based Hspitals management t purchase reprted that since (EB) medicatins Crpratin the first chice antibitics identifying the prblem, the in the hspitals, management t instead f wide spectrum management was regularly included in a imprve access t f antibitics (e.g. purchasing EB medicatins recmmended EB medicatins amxicillin) dsage and frm Practively identifying the (e.g., Amxicillin) need f purchasing evidence-based medicatins in guideline recmmended dse and frm Change Cncept: Patient/Parent Educatin Miscnceptin Imprved parent Discussing during the QI The results f phne amng parents cunselling n team meetings n the best interview f patients parents n the need t imprtance f strategies t cmmunicate indicated imprved prescribe ratinal use f t parents n the knwledge and practice f antibitics and antipyretic medicatins t treat pediatric RTIs: it is believed that excess intravenus manipulatins, parenteral medicatins, plypragmasis and antibitic prescriptin is partly driven by the demand and expectatins f parents antibitics, ther medicatins and challenges assciated with inapprpriate/access use f medicatins, including selftreatment f their children with RTIs imprtance f the ratinal use f antibitics, ther medicatins and challenges assciated with inapprpriate/access use f medicatins, including self-treatment f their children with RTIs Cunselled patients/parents f the children with RTIs abut ratinal medicatin use at every patient visit Cunselled parents n when t give antipyretic medicatin and danger signs that require fllw up with care prvider Discussed the issue f irratinal use f medicatins at medical cnferences meetings and shared the success f their effrts reducing nn- EB medicatins Shared the massages via lcal media and TV by well-respected clinicians, including head f respiratry care assciatin respiratry tract infectin self-management after 18 mnths f prject interventins (frm April 2012 t Nvember 2013). Particularly, the number f respndents naming medicatins prescribed by the dctr that are relevant t the parent-reprted diagnsis increased 28.4% (attributable difference +20.1%, p<0.006); Average number f medicatins prescribed by ambulatry care prvider nt relevant t diagnsis reprted by patients/parents decreased frm 3.8 t 1.5. Survey result als shw desirable change in the prescriptin practice f ral antibitics and antihistamines, as well as imprved verall satisfactin. Despite the assumed nnppularity f interventins(s) at the endiline, % f parents very satisfied with the the ambulatry care and hspital services prvided increased frm 35.6% t 55.7% while this has nt changed by mre than 5% in cntrl facilities Clinical interventins t imprve care f respiratry infectins in children in Gergia 5

6 Appendix 2: Essential care elements/evidence-based interventins fr ambulatry and hspital management f respiratry tract infectins in children 1. Essential Care Elements 1.1. Diagnsis Histry f illness: Duratin f respiratry symptms (cugh, fever, sre thrat, earache), any sick expsures Past Medical Histry: any relevant histry (e.g. asthma, prir pneumnia, immune cmprmised status, etc.) Review f Systems: Vital signs (HR, RR, temperature) Fever (extent & duratin) Fluid intake and urinatin (especially infants/yung children) Breathing truble Physical Exam: Respiratry status recrded (RR, accessry muscle use, pulsximetry, if available) Pulmnary auscultatin exam: Lcatin and extent f any rales, rhnchi r wheezes Pharyngscpy, tscpy, if needed 1.2. Diagnstic criteria fr each acute RTIs amng children Pneumnia Main criteria: 1) symptms: cugh, difficult breathing, age-adjusted tachypnea: (age 0-2 mnths 60, 2 12 mnths, 50/min; 1 5 years, 40/min; 5 years, >20 breaths/min), fever. 2) diagnstic criteria: fcal findings n auscultatin (rales, decreased resnance); fever, lwer chest indrawing, nasal flaring, r grunting, cyansis, in presence f fcal cnslidatin finding. Pssible assciated symptms: inability t drink r vmiting everything, r lethargy/uncnsciusness/cnvulsins (Harris et al., 2011). Brnchitis Main clinical criteria 1): cugh with r withut sputum prductin with duratin mre than 3 days; 2) physical examinatin findings: rhnchi; absence f fcal rales (t supprt pneumnia diagnsis); additinal criteria t be assessed: fever, r vmiting in infants after swallwing sputum. Pharyngitis Main criteria: 1) at least ne f fllwing reprted symptms: sre thrat, dysphagia; 2) at least ne f fllwing physical examinatin findings: tnsillitis (increased erythema/edema f psterir pharynx), tnsillar exudate, beefy red swllen uvula, and palatal petechiae, tender enlarged anterir cervical ndes. Additinal criteria t be assessed fr diagnsis: absence f cugh, fever, weakness, headache. Suspected bacterial pharyngitis Sudden nset f sre thrat, Age 5 15 years, fever, headache, nausea, vmiting, abdminal pain, tnsillpharyngeal inflammatin, patchy tnsillpharyngeal exudates, palatal petechiae, Aanterir cervical adenitis (tender ndes), scarlatinifrm rash. Suspected viral pharyngitis: Cnjunctivitis, cryza, cugh, diarrhea, harseness, viral exanthema Clinical interventins t imprve care f respiratry infectins in children in Gergia 6

7 Sinusitis Main criteria: 1) at least ne f fllwing reprted symptms: blcked nse/ purulent nasal drainage x at least 2 weeks; facial pain r sinus pain particularly if aggravated by pstural changes r by valsalva maneuver; additinal criteria t be assessed fr diagnsis: fever, maxillary r tthache, facial edema, headache, hypsmia/ansmia, nausea, cugh, ear pain/feeling f pressure. Otitis Media Main criteria: at least ne frm fllwing symptms: 1) ear pain (especially in infants crying while swallw), fever; 2) physical exam findings: retracted r bulging Tympanic membrane with decreased mbility; ear effusin, additinal criteria t be assessed fr diagnsis: irritability, r fever, lethargy, anrexia r vmiting, symptms f rhinitis in 90% f early childhd Treatment In case f pneumnia Age apprpriate antibitic with apprpriate dse: Amxicillin ( mg/kg daily). Alternatives are Amxicillin-clavulanate (20 mg/5 mg/kg/day t 60 mg/15 mg/kg/day fr children <40kg, r 500mg/125mg fr children >40kg);), ral cefalsprin,r macrlide (azithrmycin (10mg/kg daily) and clarithrmycin) Macrlide antibitics may be added t amxicillin if there is n respnse t first-line empirical therapy Macrlide shuld be used if mucplasm r clamidial pneumnia is suspected; In flu-assciated pneumnia, first chice medicatin is Amxicillin-clavulanate. Intravenus antibitics (cefurxime, ceftaxime r ceftriaxne (e.g.ceftriaxne 50-75mg/kg in 24 hurs)) shuld be used when the child is unable t absrb ral antibitics (e.g., because f vmiting) r presents with signs f cmplicated pneumnia with severe distress. Antipyretic: Paracetaml r Ibuprfen with age apprpriate dse Chest X-ray referral if: If symptms nt imprving within 2-3 days n antibitics Knwn T.B. expsure r risk factr Suspected freign bdy (e.g. child swallwed smething) In case f brnchitis Calm cmfrtable envirnment; Additinal liquids; Antipyretics; Effectiveness and benefit f muclytics in children nt prven; Cugh medicatins d nt decrease duratin f disease in children, meanwhile if the phlegm evacuatin depressed, bacterial cmplicatins may develp; There is n evidence fr effectiveness f β2-agnists in case f acute brnchitis; Antihistamines are nt recmmended because they can cause dryness f phlegm and therefre reinfrce cugh. Cnsider antibitic therapy if: General cnditin wrsens; Fever duratin mre than ne week; Clinical interventins t imprve care f respiratry infectins in children in Gergia 7

8 Secnd wave f fever present; Prfuse r purulent phlegm; Mycplasma, Chlamydia infectin r Pertussis suspected due t epidemilgic situatin; Sinusitis r Otitis at the same time with brnchitis present; C-mrbid cnditins that may increase risk f pneumnia (immundeficiency, chrnic heart failure, chrnic pulmnary disease) In case f pharyngitis Adequate analgesia (Paracetaml r ibuprphen); Initiatin f antibitics if centr scre >4 (fever, tnsillar exudates, enlargement and pain f cervical lymph ndes, fever, age<15) due t high prbability f bacterial infectin; Chice antibitic in case f bacterial pharyngitis: Amxicillin, ral 50 mg/kg nce daily (max = 1000 mg) fr 10 days; Fr individuals with penicillin allergy: Cephalexin,b ral 20 mg/kg/dse twice daily (max = 500 mg/dse) 10 days; Azithrmycin,c ral 12 mg/kg nce daily (max = 500 mg) 5 days; Clarithrmycin,c ral 7.5 mg/kg/dse twice daily (max = 250 mg/dse) 10 days; If patient unlikely t cmplete a full 10-day curse f ral therapy: Penicillin G (Benzathyn Penicillin) single dse i/m, U in children >27 kg, and U in children with bdy weight under 27kg (Shulman et al., 2012) In case f sinusitis Antibitic therapy if fllwing clinical symptms: Persistent symptms (e.g. if clinical symptms cntinue mre than7-10 days); Severe symptms e.g. prfuse purulent nasal discharge, facial pain and signs f system impairment); Deteriratin f patients symptms and cnditin. Amxicillin-clavulanate rather than amxicillin alne is recmmended as empiric antimicrbial therapy fr ABRS in children in dsage 90 mg/kg/day rally twice daily (Chw et al., 2012) In case f titis Assessment f pain in case f acute titis and if pain, use f apprpriate analgesic (Paracetaml Ibuprfen). Avid ear drps if perfratin f tympanic membrane suspected. Rutine use f antibitics in children under 6 mnths; Frm 6 mnths t 2 years ld, antibitic shuld be prescribed if bilateral titis present. Children ver 2 years shuld receive antibitics if diagnsis clear and severe cnditin. If diagnsis is nt clear, r clear but cnditin nt severe, bservatin during 72 hurs and use f analgesics is reasnable. Antibitic f first chice is Amxicillin (80-90mg/kg/day divided by 2 times). If child s age ver 2 years, he/she nt rganized in cllective and antibitic has nt been used during past 3 mnths, recmmended dse is 40mg/kg/day. If treatment ineffective after 72 hurs, r allergic reactin t first chice antibitic, amxicillin/clavulanic acid r cephalsprins are recmmended. If symptms persist after amxicillin/clavulanic acid, r child unable t take ral medicatin, intramuscular injectins f cephalsprins (cefurxim, ceftriaxn) are reasnable. Clinical interventins t imprve care f respiratry infectins in children in Gergia 8

9 High-dse amxicillin n (80 90 mg/ kg per day in 2 divided dses) is recmmended as the firstline treatment. In children wh have taken amxicillin in the previus 30 days, therapy shuld be initiated with high-dse amxicillin-clavulanate (90 mg/kg/day f amxicillin, with 6.4 mg/kg/day f clavulanate. Alternative initial antibitics include cefdinir (14 mg/kg per day in 1 r 2 dses), cefurxime (30 mg/kg per day in 2 divided dses), cefpdxime (10 mg/kg per day in 2 divided dses), r ceftriaxne (50 mg/kg, administered intramuscularly) (Lieberthal et al., 2013) Severity Classificatin & Decisin fr Ambulatry versus Hspital Management Ambulatry Treatment all children with suspected pneumnia unless: Age < 2 mnth Pulsxymetry < 92% Respiratry Distress (Age-specific increase f RR [<2 mnth - >60/min, 2-12 mnth->50/min, 1-5 year > 40/min, >5 year>30/min], accessry muscle use, etc.) Dehydratin r lethargy Inability t take ral medicatin Significant c-mrbid cnditins (e.g. cngenital heart disease, HIV, T.B.) r uncertain diagnsis In case f brnchitis ambulatry treatment f all children unless: C-mrbid cnditins (cngenital heart disease, chrnic lung disease, neurlgic impairment); Scial prblems lack f care in family, absence f transprtatin ability Duratin f symptms mre than 2-3 weeks; Signs f txicsis Presence f danger signs; Inability t take fd and liquids In case f brnchitis ambulatry treatment f all children unless: Stridr r shrtness f breath with pain In case f sinusitis: Cmplicatins: rbital (rbital cellulites), lcal (muccelle r mucpycelle), intracranial (bacterial meningitis, cerebral abscesses, epidural abscesses, stemyelitis etc.) Ineffective treatment with medicatins f secnd chice; Recurrence f disease (mre than 3 episdes per year); Cngenital anmaly f upper respiratry tract f child In case f titis: Appearance f purulent discharge, especially if pulsating Develpment f cmplicatins such as facial paralysis r mastiditis. Three r mre episdes f acute titis during 6 mnths r fur episdes during 12 mnths. Suspicin n hearing deficiency after treatment 1.5. In case f Ambulatry Management: Specific fllw-up specified (time and place) Medicatin & dehydratin preventin instructins dcumented (esp. infants/yung children) Danger sign & urgent fllw-up cunseling dcumented Clinical interventins t imprve care f respiratry infectins in children in Gergia 9

10 Sequential visits r parent cmmunicatin dcumented in chart per fllw up plan Specific immunizatin advice dcumented 1.6. If Hspital Care, Referral & Stabilizatin in Clinic prir t Hspital transfer Standard referral frm cmpleted accrding t prtcl including: reasn fr referral, treatments given in ambulatry center Cmmunicatin with hspital dcumented in chart Transprt plan dcumented in chart Age-apprpriate Oxygen applied by face mask if pulsximetry < 92% r if significant respiratry distress and n pulsximetry measure Fllw up plan dcumented in chart as cmmunicated t family Fllw up f patient dcumented in chart (e.g., phne call t family r hspital) Clinical interventins t imprve care f respiratry infectins in children in Gergia 10

11 Appendix 3: Indicatrs fr rutine mnitring f the quality f utpatient care f respiratry tract infectins in children % f medical charts f children with RTI related ambulatry visit in the last mnth fr whm diagnsis is supprted by medical chart dcumentatin: at least ne symptm with duratin and at least ne bjective symptm criteria & diagnsis2 is relevant with all symptms/bjective findings recrded % f medical charts f children diagnsed with respiratry tract infectin in last mnth fr whm vital signs (HR, RR, temperature) are dcumented in the medical chart % f medical charts f children treated with antibitic fr RTI in last mnth fr whm chart dcumentatin supprts antibitic use % f medical charts f children treated with antibitic fr RTI in last mnth with first-line antibitic (C-amxiclav fr sinusitis and amxicillin fr all ther cnditins) used Average # f antibitics administered fr each child treated fr RTI with an antibitic Average number f nn-evidence based medicatins prescribed per child with acute RTI diagnsis (except antibitic, antipyretic and justified by dcumented cnditin/symptm) % f medical charts f children RTI-related ambulatry visit in last mnth where cunselling n influenza vaccinatin is recrded in the chart % f medical charts f children RTI-related ambulatry visit in last mnth with adequate fllw-up visit recrded in the chart % f medical charts f children RTI-related ambulatry visit in last mnth with the signs f severe disease where referral t the hspital is recrded based n severity assessment % f medical charts f children RTI-related ambulatry visit in last mnth with parenteral medicatins prescribed % f medical charts f children RTI-related ambulatry visit in last mnth with recmmendatins, prescribed medicatins with dsage and duratin recrded in the chart 2 Fr diagnstic criteria, justified antibitic use and recmmended first line treatment, see Appendix 2 Clinical interventins t imprve care f respiratry infectins in children in Gergia 11

12 References Chw, A. W., Benninger, M. S., Brk, I., Brzek, J. L., Gldstein, E. J., Hicks, L. A.,... & File, T. M. (2012). IDSA clinical practice guideline fr acute bacterial rhinsinusitis in children and adults. Clinical Infectius Diseases, cir1043. Harris, M., Clark, J., Cte, N., Fletcher, P., Harnden, A., McKean, M., & Thmsn, A. (2011). British Thracic Sciety guidelines fr the management f cmmunity acquired pneumnia in children: update Thrax, 66 (Suppl 2), ii1-ii23 Available at: Lieberthal, A. S., Carrll, A. E., Chnmaitree, T., Ganiats, T. G., Hberman, A., Jacksn, M. A.,... & Tunkel, D. E. (2013). The diagnsis and management f acute titis media. Pediatrics, 131(3), e964- e999. Shulman, S. T., Bisn, A. L., Clegg, H. W., Gerber, M. A., Kaplan, E. L., Lee, G.,... & Van Beneden, C. (2012). Clinical practice guideline fr the diagnsis and management f grup A streptcccal pharyngitis: 2012 update by the Infectius Diseases Sciety f America. Clinical infectius diseases, cis629. Clinical interventins t imprve care f respiratry infectins in children in Gergia 12