1. Assessment of Hospital Care for Children An Assessment of Hospital Care for Children Under-five at District and Sub- District Level Hospitals in Bangladesh

2. Assessment of Hospital Care for Children Background IMCI has been institutionalized in the public health system in Bangladesh, with facility based IMCI expanded to more than 2/3 of the country IMCI advocates referral of severely ill children, and increasingly more sick children in Bangladesh are being referred as severe cases (10-15%) to sub-district (upazila) or district hospitals for appropriate management Child survival interventions thus, critically depend on functioning referral systems and good care at referral facilities Assessment is needed as part of initiating quality improvement process as there is limited information available on the quality of care in hospitals

3. Assessment of Hospital Care for Children 1. Country Orientation 2. Hospital Assessment (Baseline) 3. Agreement on standards 4. Definition of interventions & area 5. Improvement in hospitals 7. Sharing of Information 6. Monitoring and Evaluation PLAN CHECK DO ACT WHO: Framework for Hospital Improvement Process

4. Assessment of Hospital Care for Children Process Adaptation Of Tools WHO Generic hospital assessment tools were reviewed, adapted Sections Of Tools Hospital layout, essential drugs, supplies and equipment Laboratory support Emergency area and emergency management Neonatal care and case management for ARI, Diarrhoea, febrile illness and malnutrition Supportive care and monitoring Hospital administration Measure of access to hospital care Quality of care Field Testing of tools Training of the assessors

5. Assessment of Hospital Care for Children Sampling of hospitals Selection of district hospitals (DHs): One district was randomly selected from each division, for a total of six DHs. Selection of sub-district hospitals: Two facilities were selected from each of the six selected districts based on stratified sampling Process (cont.)

6. Assessment of Hospital Care for Children Assessment of hospitals Each assessment team consisting of 2 paediatricians and 2 programme personnel visited each site for 2 days in May 2009 Source of information for assessing quality Observation of clinical case management Reviewing records when there were not sufficient patients for direct case observations Interviews with hospital staff and, if needed, simulated cases when no case could be observed nor record could be found Extraction of the data from Management Information System (MIS) report Process (cont.)

7. Assessment of Hospital Care for Children Scoring system for assessment Hospital assessment tool comprised of 11 sections For individual and overall scoring, points from 5 to 1 were awarded: 5 - Good practice complying with standards of care, 4 - Showing little need for improvement to reach standard care, 3 - Meaning some need for improvement, 2 - Indicating considerable need for improvement and 1 - Services not provided, totally inadequate care or potentially life-threatening practices. Process (cont.)

8. Assessment of Hospital Care for Children

13. Key Findings

14. Assessment of Hospital Care for Children Major reasons for under five visits at hospital in 2008 Source: Hospital Routine MIS

15. Assessment of Hospital Care for Children Hospital layout and child health infrastructure All of the 6 DHs had separate paediatric corner and designated beds for children Among the 12 Sub-district hospitals (SDH), 7 had a separate paediatric corner, and only 2 had designated beds for admitting children Half of DHs and one-third of SDHs had paediatric surgery facilities, none had paediatric surgeons All of the 18 facilities had 24-hour nursing care for admitted children

16. Assessment of Hospital Care for Children Hospital support system, equipment and drugs Backup power supply was available only at one DH and 4 SDHs 5 DHs and 8 SDHs had coloured bins for waste disposal but appropriate waste disposal was practiced only in half Running water was available but provision of safe drinking water only at half of the facilities At least one injectable antibiotic for managing severe pneumonia or very severe disease (Ampicillin or Gentamycine) was available at all DHs, but not at all SDHs even though both are required Only one DH had all of the essential paediatric inpatient drugs (normal saline, injection Ampicillin, injection Gentamycine, cholera saline, syrup Amoxicillin and injection Amoxicillin) Filled oxygen cylinders were available at all the visited hospitals, although 3 SDHs had no flow-meter

17. Assessment of Hospital Care for Children Quality of laboratory support District Hospital (N = 6) Sub- district Hospital (N = 12) Availability of essential laboratory tests 1 24X7 and delivery of results in a timely fashion to the ward/emergency area 53 Prioritization of tests for emergencies 69 Performance of tests according to Standard Operating Procedures 34 Maintenance of lab safety measures 23 1 Essential laboratory tests include: blood glucose, haemoglobin or haematocrit (PCV), microscopy for malaria, microscopy for cells in CSF and urine, blood grouping and cross- matching

18. Assessment of Hospital Care for Children Availability and quality of Neonatal care Adequate Some improvement needed Substantial improvement needed DHSDHDHSDHDHSDH Presence of a clean ward, accident prevention and no dangerous objects 025317 Attention to the most seriously ill 001359 Promotion of early and exclusive breastfeeding – skin contact is ensured 144810 Practice of thermal protection 005418 Administration of immunizations 016605 Appropriate feeding of young infants and low birth weight newborns 003339 District Hospital (N = 6) Sub-district Hospital (N = 12)

19. Assessment of Hospital Care for Children Quality of case management: Pneumonia Adequate Some improvement needed Substantial improvement needed DHSDHDHSDHDHSDH Severity of pneumonia is correctly assessed and diagnosed 232425 Appropriate antibiotics are administered for pneumonia and other respiratory diagnoses 0032310 Oxygen is administered correctly and only when necessary 103824 Appropriate diagnosis and management of tuberculosis 412803 District Hospital (N = 6) Sub-district Hospital (N = 12)

20. Assessment of Hospital Care for Children Quality of case management: Diarrhoea Adequate Some improvement needed Substantial improvement needed DHSDHDHSDHDHSDH Dehydration is correctly assessed 113625 Rehydration plan is appropriate to severity of dehydration and appropriately monitored 004428 Appropriate antibiotics only given when necessary 0052110 Continued feeding given during diarrhoea 222426 District Hospital (N = 6) Sub-district Hospital (N = 12)

21. Assessment of Hospital Care for Children Adequate Some improvement needed Substantial improvement needed DHSDHDHSDHDHSDH Nutritional status assessed by weight for height, including differential diagnosis 0011511 Management of infection 003636 Management of electrolyte imbalance and micronutrients 002349 Correct management of dehydration 0021411 Hypoglycaemia and hypothermia checked and managed 0012510 Correct feeding of severely malnourished children 0012510 Quality of case management: severe malnutrition District Hospital (N = 6) Sub-district Hospital (N = 12)

22. Assessment of Hospital Care for Children Patient Monitoring System Adequate Some improvement needed Substantial improvement needed DHSDHDHSDHDHSDH Re-assessment of all admitted children by a nurse 0042210 Re-assessment of all admitted children by a doctor 115605 Assessment of nutritional status for all admitted children 0021411 Attention given to most ill children 103527 Monitoring with a monitoring chart 0022410 Overall appropriate patient monitoring 003339 District Hospital (N = 6) Sub-district Hospital (N = 12)

23. Assessment of Hospital Care for Children Hospital administration Adequate Some improvement needed Substantial improvement needed DHUHCDHUHCDHUHC Adequate and updated treatment guidelines are available at the hospital 1011411 Audits on hospital deaths100458 Availability of transport (ambulance) for transferring cases / referred cases 243414

24. Assessment of Hospital Care for Children There is no established TRIAGE system in any of the hospitals The provision of neonatal care services, especially in Sub-district hospitals, requires substantial improvement Essential laboratory supports were found to be adequate at almost all district hospitals but requires substantial improvement at majority of SDHs Weak monitoring systems and inadequate provision of care for major killers especially pneumonia, diarrhoea, and malnutrition Key Findings

25. Assessment of Hospital Care for Children Urgent need to address the following priority areas: Staffing Clinical competency in case-management and supportive care Triaging systems Essential drugs and supplies including newborn care equipments Establishment of Quality Assurance system Documentation of monitoring and assessments Major Recommendations

26. Assessment of Hospital Care for Children National benchmarking or hospital accreditation system for an integrated quality improvement approach Build capacities of currently available manpower in managing newborn and sick children with standard treatment and monitoring guidelines Creating and maintaining a master database of essential drugs and equipment may facilitate monitoring, planning and action within facilities Reassessment of the current allocation of resources to focus district and sub-district hospital Other Recommendations

27. Assessment of Hospital Care for Children Out of 61 district and 324 Upazila hospitals in Bangladesh, the assessment process covered only 18 facilities Not all practices could be observed due to time constraints and lack of cases during the visits Poor quality of patients records hindered proper assessment of existing practices Inter-observer variability in perception of the hospital performance Hawthrone effect Scoring system itself Limitations

28. Assessment of Hospital Care for Children Progress of Hospital Improvement process in Bangladesh Baseline assessment completed WHO Pocket book adapted based on agreed standards Development of SOP for MNH in process Training package for ETAT developed and facility based newborn care initiated Priority districts identified for interventions

29. Assessment of Hospital Care for Children

30. IMCI section of the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of Bangladesh SEARO/WHO for their technical assistance and financial support Bangladesh Paediatric Association (BPA) for their support and technical guidance Acknowledgements