Missed nursing care in acute care hospital settings in low-income and middle-income countries: a systematic review.

BACKGROUND: Missed nursing care undermines nursing standards of care and minimising this phenomenon is crucial to maintaining adequate patient safety and the quality of patient care. The concept is a neglected aspect of human resource for health thinking, and it remains understudied in low-income and middle-income country (LMIC) settings which have 90% of the global nursing workforce shortages. Our objective in this review was to document the prevalence of missed nursing care in LMIC, identify the categories of nursing care that are most missed and summarise the reasons for this. METHODS: We conducted a systematic review searching Medline, Embase, Global Health, WHO Global index medicus and CINAHL from their inception up until August 2021. Publications were included if they were conducted in an LMIC and reported on any combination of categories, reasons and factors associated with missed nursing care within in-patient settings. We assessed the quality of studies using the Newcastle Ottawa Scale. RESULTS: Thirty-one studies met our inclusion criteria. These studies were mainly cross-sectional, from upper middle-income settings and mostly relied on nurses' self-report of missed nursing care. The measurement tools used, and their reporting were inconsistent across the literature. Nursing care most frequently missed were non-clinical nursing activities including those of comfort and communication. Inadequate personnel numbers were the most important reasons given for missed care. CONCLUSIONS: Missed nursing care is reported for all key nursing task areas threatening care quality and safety. Data suggest nurses prioritise technical activities with more non-clinical activities missed, this undermines holistic nursing care. Improving staffing levels seems a key intervention potentially including sharing of less skilled activities. More research on missed nursing care and interventions to tackle it to improve quality and safety is needed in LMIC. PROSPERO registration number: CRD42021286897.

Quantitative decision making for investment in global health intervention trials: Case study of the NEWBORN study on emollient therapy in preterm infants in Kenya.

Background: Partners from an NGO, academia, industry and government applied a tool originating in the private sector - Quantitative Decision Making (QDM) - to rigorously assess whether to invest in testing a global health intervention. The proposed NEWBORN study was designed to assess whether topical emollient therapy with sunflower seed oil in infants with very low birthweight <1500 g in Kenya would result in a significant reduction in neonatal mortality compared to standard of care. Methods: The QDM process consisted of prior elicitation, modelling of prior distributions, and simulations to assess Probability of Success (PoS) via assurance calculations. Expert opinion was elicited on the probability that emollient therapy with sunflower seed oil will have any measurable benefit on neonatal mortality based on available evidence. The distribution of effect sizes was modelled and trial data simulated using Statistical Analysis System to obtain the overall assurance which represents the PoS for the planned study. A decision-making framework was then applied to characterise the ability of the study to meet pre-selected decision-making endpoints. Results: There was a 47% chance of a positive outcome (defined as a significant relative reduction in mortality of ≥15%), a 45% chance of a negative outcome (defined as a significant relative reduction in mortality <10%), and an 8% chance of ending in the consider zone (ie, a mortality reduction of 10 to <15%) for infants <1500 g. Conclusions: QDM is a novel tool from industry which has utility for prioritisation of investments in global health, complementing existing tools [eg, Child Health and Nutrition Research Initiative]. Results from application of QDM to the NEWBORN study suggests that it has a high probability of producing clear results. Findings encourage future formation of public-private partnerships for health.

World Health Organization and knowledge translation in maternal, newborn, child and adolescent health and nutrition.

The World Health Organization (WHO) has a mandate to promote maternal and child health and welfare through support to governments in the form of technical assistance, standards, epidemiological and statistical services, promoting teaching and training of healthcare professionals and providing direct aid in emergencies. The Strategic and Technical Advisory Group of Experts (STAGE) for maternal, newborn, child and adolescent health and nutrition (MNCAHN) was established in 2020 to advise the Director-General of WHO on issues relating to MNCAHN. STAGE comprises individuals from multiple low-income and middle-income and high-income countries, has representatives from many professional disciplines and with diverse experience and interests.Progress in MNCAHN requires improvements in quality of services, equity of access and the evolution of services as technical guidance, community needs and epidemiology changes. Knowledge translation of WHO guidance and other guidelines is an important part of this. Countries need effective and responsive structures for adaptation and implementation of evidence-based interventions, strategies to improve guideline uptake, education and training and mechanisms to monitor quality and safety. This paper summarises STAGE's recommendations on how to improve knowledge translation in MNCAHN. They include support for national and regional technical advisory groups and subnational committees that coordinate maternal and child health; support for national plans for MNCAHN and their implementation and monitoring; the production of a small number of consolidated MNCAHN guidelines to promote integrated and holistic care; education and quality improvement strategies to support guidelines uptake; monitoring of gaps in knowledge translation and operational research in MNCAHN.

Missed nursing care in newborn units: a cross-sectional direct observational study.

BACKGROUND: Improved hospital care is needed to reduce newborn mortality in low/middle-income countries (LMIC). Nurses are essential to the delivery of safe and effective care, but nurse shortages and high patient workloads may result in missed care. We aimed to examine nursing care delivered to sick newborns and identify missed care using direct observational methods. METHODS: A cross-sectional study using direct-observational methods for 216 newborns admitted in six health facilities in Nairobi, Kenya, was used to determine which tasks were completed. We report the frequency of tasks done and develop a nursing care index (NCI), an unweighted summary score of nursing tasks done for each baby, to explore how task completion is related to organisational and newborn characteristics. RESULTS: Nursing tasks most commonly completed were handing over between shifts (97%), checking and where necessary changing diapers (96%). Tasks with lowest completion rates included nursing review of newborns (38%) and assessment of babies on phototherapy (15%). Overall the mean NCI was 60% (95% CI 58% to 62%), at least 80% of tasks were completed for only 14% of babies. Private sector facilities had a median ratio of babies to nurses of 3, with a maximum of 7 babies per nurse. In the public sector, the median ratio was 19 babies and a maximum exceeding 25 babies per nurse. In exploratory multivariable analyses, ratios of ≥12 babies per nurse were associated with a 24-point reduction in the mean NCI compared with ratios of ≤3 babies per nurse. CONCLUSION: A significant proportion of nursing care is missed with potentially serious effects on patient safety and outcomes in this LMIC setting. Given that nurses caring for fewer babies on average performed more of the expected tasks, addressing nursing is key to ensuring delivery of essential aspects of care as part of improving quality and safety.

Examining the effectiveness of zinc treatment in children admitted with diarrhoea in Kenya's public hospitals: an observational comparative effectiveness study.

BACKGROUND: Kenyan paediatric treatment protocols recommend the use of zinc supplement for all children with diarrhoea. However, there is limited evidence of benefit for young children aged 1-5 months and those who are well-nourished. We examine effectiveness of zinc supplementation for children admitted with diarrhoea to Kenya's public hospitals with different nutritional and age categories. This is to determine whether the current policy where zinc is prescribed for all children with diarrhoea is appropriate. METHODS: We explore the effect of zinc treatment on time to discharge for children aged 1-5 and 6-59 months and amongst those classified as either severely - moderately under-nourished or well-nourished. To overcome the challenges associated with non-random allocation of treatments and missing data in these observational data, we use propensity score methods and multiple imputation to minimize bias. RESULTS: The analysis included 1645 (1-5 months) and 11 546 (6-59 months) children respectively. The estimated sub-distribution hazard ratios for being discharged in the zinc group vs the non-zinc group were 1.25 (95% confidence interval (CI) = 1.07, 1.46) and 1.17 (95% CI = 1.10, 1.24) in these respective age categories. Zinc treatment was associated with shorter time to discharge in both well and under-nourished children. CONCLUSION: Zinc treatment, in general, was associated with shorter time to discharge. In the absence of significant adverse effects, these data support the continued use of zinc for admissions with diarrhoea including those aged 1-5 months and in those who are well-nourished.

Building Learning Health Systems to Accelerate Research and Improve Outcomes of Clinical Care in Low- and Middle-Income Countries.

Mike English and colleagues argue that as efforts are made towards achieving universal health coverage it is also important to build capacity to develop regionally relevant evidence to improve healthcare.

Assessment of neonatal care in clinical training facilities in Kenya.

OBJECTIVE: An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya. DESIGN: Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data. SETTING: Neonatal units of 22 public hospitals. PATIENTS: Neonates aged <7 days. MAIN OUTCOME MEASURES: Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission. RESULTS: All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing­for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0-3) and a median score of 6 out of 8 for signs of severe illness (IQR 4-7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively. CONCLUSIONS: Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.

Audit of care for children aged 6 to 59 months admitted with severe malnutrition at kenyatta national hospital, kenya.

We conducted a prospective audit of 101 children with severe malnutrition aged 6 to 59 months admitted to Kenyatta National Hospital, Kenya's largest tertiary level health facility, from February-April 2008. A structured tool was prepared to capture data to allow assessment of implementation of the WHO guidelines steps 1-8. Overall, 58% of children had marasmus and 47% of children were younger than one year old. Common co-morbidities at admission were diarrhoea (70.3%) and pneumonia (51.4%). The highest degree of implementation was observed for Step 5, treatment of potentially severe infections (90%, (95% CI 85.1-96.9)). Only 55% of the patients had F75 prescribed although this starter formula was available in this hospital. There was a delay in initiating feeds with a median time of 14.7 hours from the time of admission. There was modest implementation of Step 2, ensuring warmth (46.5%, 36.8-56.2), Step 3, treat dehydration (54.9%, 43.3-66.5) and Step 4, correct electrolyte imbalance, (45.5%, 35.6-55.8%). There was least implementation of Step 8, transition to catch-up feeding (23.8%, 13.6-34.0). We conclude that quality of care for children admitted with severe malnutrition at KNH is inadequate and often does not follow the WHO guidelines. Improving care will require a holistic and not simply medical approach.

Invasive Gram-negative bacilli are frequently resistant to standard antibiotics for children admitted to hospital in Kilifi, Kenya.

OBJECTIVES: To determine the pattern of resistance among Gram-negative bacilli causing invasive bacterial disease for the antibiotics that are already in common use in Kilifi, Kenya and for two potential alternatives, ciprofloxacin and cefotaxime. Also, to determine whether prevalence and severity of resistance was increasing over time, to identify patients who are particularly at risk of resistant infections, and to explore which factors are associated with the development of resistance in our setting. METHODS: We used Etest to study antibiotic susceptibility patterns of 90 Gram-negative bacilli cultured in blood or CSF from paediatric inpatients over 8 years. RESULTS: Susceptibility to amoxicillin 28%, cefotaxime 95% and ciprofloxacin 99% did not vary significantly with age. Susceptibilities for isolates from children aged less than 14 days were: chloramphenicol, 81%; trimethoprim/sulfamethoxazole, 71%; and gentamicin, 91%. From older children, susceptibilities were: chloramphenicol, 62%; trimethoprim/sulfamethoxazole, 39%; and gentamicin, 73%. Chloramphenicol susceptibility was significantly more common among non-typhi salmonellae than other species (79% versus 53%, P < 0.0005). The combination of gentamicin and chloramphenicol covered 91% of all isolates. The prevalence of resistance did not increase over time and was not more common in patients with HIV or malnutrition. Age was the only clinical feature that predicted resistance. CONCLUSIONS: Gentamicin or chloramphenicol alone was suboptimal therapy for Gram-negative sepsis, although in this retrospective study, there was no association between resistance and mortality.