1. Strathmore University
The Guidelines Adherence in Slums Project (GASP)
Business School
Is modern information technology always the best?
Rubber stamp templates improve clinical documentation in private primary healthcare facilities in Kenya
Bernadette Kleczka1,2, Anita Musiega3, Grace Rabut1,3, Mercy Njeru4, Michael Marx2, Pratap Kumar1,3*
1. Health-E-Net Limited; 2. Institute of Public Health, University of Heidelberg; 3. Institute of Healthcare Management, Strathmore Business School; 4. Centre for Public Health Research, Kemri *
1) Background
4) Guiding antibiotic use
Adherence to clinical practice guidelines (CPGs) is key to quality of care delivery.
Evidence-based practices for rational antibiotic use are difficult to monitor in private primary healthcare facilities in LMIC settings.
Here we present data from the Guideline Adherence in Slums project on antibiotic use in four communicable conditions:
Urinary tract infections (UTI), Sexually transmitted infections (STI), Gastro-intestinal infections (GI) and Upper respiratory infections (URTI).
Some templates include a checklist for antibiotic justification.
In URTI the rate of cases with clear indication for antibiotic use was 59% while the actual prescription rate was 77%.
In GI this gap was wider: 47% “ideal” vs 91% “actual” prescription rate.
Clinical quality
Guideline use
Clinical audit
Identify gaps
Targeted CME
2) The intervention
The guideline adherence in slums project supports non-physician clinicians (NPCs) in adhering to clinical practice guidelines (CPGs) using:
Rubber stamp templates for commonly encountered out-patient conditions containing important algorithms for diagnosis and management
Mobile phones for easy digitization of RSTs
Clinical audit and feedback to the facilities
Monthly targeted trainings based on gaps in quality of care identified in the audit.
In a chart audit of UTI cases we looked at two aspects:
Completeness of clinical documentation and
Guideline adherence.
5) Choice of antibiotic
3) Improved documentation
Information in charts and templates were scored along four dimensions:
General patient data, Assessment, Testing and Management.
Post-intervention in charts improved slightly, but significantly (33.0% vs. 38.3%, p=<0.01).
Documentation scores in templates (69%) were much higher than both pre-and post-intervention charts (p<0.0001).
Documentation of presenting complaints did not change, suggesting that use of templates does not compromise narrative documentation.
We did not see a change in the number of antibiotics used in UTI (0.97 pre and 1.01 post), but in types of antibiotics prescribed:
Nitrofurantoin as a first line, narrow-spectrum antibiotic increased from 9.2% (pre chart) to 38.4% (all RSTs) while
Amoxicillin decreased by 16.4% from 23.8% to 7.4% (p<0.0001).
While the rate of antibiotic prescription in URTI varied among facilities between 58% to 97%, we saw less variation in the types of antibiotics used (Amoxicillin / Amoxicillin clavulanate and cephalosporins prescribed in over 90% of cases).
6) Discussion
7) Conclusions
Our study confirms our hypotheses that
Rubber stamp templates improve completeness of documentation as a first step to address quality of care.
Antibiotics are overused in primary healthcare.
There is high use of second-line and broad-spectrum antibiotics.
Learning lessons:
Guideline adherence cannot easily be addressed through trainings and checklists but has to take into account the difficult environment clinicians are operating in.
The gap between “ideal” and “actual” antibiotic prescribing suggests that there are other factors than knowledge that influence prescribing behaviour.
Data from rubber stamp templates provide a basis for targeted trainings and feedback for healthcare providers.
Data driven continuous audit and feedback cycles provide a promising strategy to measure improvement and address gaps in guideline adherence.
While templates were not primarily designed for antibiotic surveillance, they provide a useful and affordable tool to obtain high quality clinical data on prescription behaviours in primary healthcare.
Data on antibiotic prescriptions in primary healthcare should be used to inform strategies to counter the crisis of antibiotic resistance and promote rational antibiotic use.