An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care?

Abstract

BackgroundMeasurement and correct interpretation of vital signs is part of routine clinical care. Repeated measurement enhances early recognition of deterioration, may help prevent morbidity and mortality and is a standard of care in most countries.ObjectiveTo examine documentation of vital signs by clinicians for admissions to paediatric wards in Kenyan hospitals, to describe monitoring frequency by nurses and explore factors influencing frequency.MethodsVital signs information (temperature, respiratory and pulse rate) for the first 48 hours of admission was collected from case records of children admitted with non-surgical conditions to 13 Kenyan county hospitals between September 2013 and April 2016. A mixed effect negative binomial regression model was used to explore whether the severity of illness (indicated by danger signs or severe diagnostic episodes) is associated with increased vital signs observation frequency.ResultsWe examined 54 800 admission episodes with an overall mortality 6.1%. Nurse to bed ratios were very low (1:10 to 1:41 across hospitals). Admitting clinicians documented all or no vital signs in 57.0% and 8.4% cases respectively. For respiratory and pulse rates there was pronounced even end-digit preference (an indicator of incorrect information) and high frequency recording of specific values (P < 0.001) suggesting approximation. Monitoring frequency was explored in 41 738 children. Those with inpatient stays ≥48 hours were expected to have a vital signs count of 18, hospitals varied but most did not achieve this benchmark (median 9, range 2-30). There were clinically small but significant associations between vital signs count and presence of multiple severe illnesses or presence of severe pallor (adjusted relative risk ratio = 1.04, P < 0.01, 95% confidence interval CI = 1.02-1.06 and 1.05, P = 0.02, 95% CI = 1.01-1.09, respectively).ConclusionsData suggest accurate admission measures are sometimes missing especially for pulse and respiratory rates, possibly linked to manual measurement. Monitoring frequency is often low in the high risk population studied probably indicating how quality of nursing care is undermined by considerable human resource shortages.

Examining which clinicians provide admission hospital care in a high mortality setting and their adherence to guidelines: an observational study in 13 hospitals

“…A heightened concern for risk might perhaps explain the association of poor adherence with multimorbidity 23 24. Overtreatment as a result of overdiagnosing may be both wasteful and potentially could cause harm, for example, overuse of intravenous fluids in settings with poor inpatient monitoring 25…”

Prognostic models for predicting in-hospital paediatric mortality in resource-limited countries: a systematic review

“…Information Network 3 which has been collected over time from a number of referral hospitals now exist in Kenya and it has been used to answer a number of salient clinical questions relevant across a range of resource-limited setting. [71][72][73] Future studies on prognostic research should leverage such datasets to externally validate competing models identified in this review for comparative performances as recommended by Collins and Moons 74 and if necessary, predictive performance of such models should be improved by addition of new prognostic factors. We also noted that most of the included models simplified the original predictor coefficients by rounding them to a nearest integer.…”

Use of ultra-low cost fitness trackers as clinical monitors in low resource emergency departments

“…Demands faced by nursing staff in emergency department and hospital settings in low-and middle-income countries often far exceed what would be considered safe and appropriate in developed countries. 8,9 The average nurse to patient ratio in the United States and Canada is 1:4.4 on general medicine wards, and there are several states with legislation in place mandating nursing ratios of 1:1 or 1:2 for critically ill patients. 9 On the other hand, studies in sub-Saharan Africa routinely demonstrate nursing ratios between 1:10 and 1:41.…”

“…A study of 13 Kenyan hospitals demonstrated a mean nursing ratio of 1:31. 8 With such limitations of workforce, it is often difficult to safely care for patients. In these settings, tasks as routine and fundamental as vital sign monitoring can become unattainable.…”

“…11 Similarly, in a quality improvement study in two Sierra Leonean hospitals, daily vital signs were documented in only 26.6% of patients, 1 and in a larger study of 13 Kenyan county hospitals more than a third (37.1%) of pediatric admissions had no documented heart rate. 8 While the magnitude of its contribution to patient outcomes is difficult to study directly, the lack of frequent vital sign monitoring certainly results in a decreased identification of clinical deterioration and disease progression. The growing science of automated and remote monitoring may offer the potential to help lift this burden from overworked nursing and hospital staff.…”