Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trial.

BACKGROUND: Acute diarrhoeal disease management often requires rehydration alone without antibiotics. However, non-indicated antibiotics are frequently ordered and this is an important driver of antimicrobial resistance. The mHealth Diarrhoea Management (mHDM) trial aimed to establish whether electronic decision support improves rehydration and antibiotic guideline adherence in resource-limited settings. METHODS: A cluster randomised controlled trial was done at ten district hospitals in Bangladesh. Inclusion criteria were patients aged 2 months or older with uncomplicated acute diarrhoea. Admission orders were observed without intervention in the pre-intervention period, followed by randomisation to electronic (rehydration calculator) or paper formatted WHO guidelines for the intervention period. The primary outcome was rate of intravenous fluid ordered as a binary variable. Generalised linear mixed-effect models, accounting for hospital clustering, served as the analytical framework; the analysis was intention to treat. The trial is registered with ClinicalTrials.gov (NCT03154229) and is completed. FINDINGS: From March 11 to Sept 10, 2018, 4975 patients (75·6%) of 6577 screened patients were enrolled. The intervention effect for the primary outcome showed no significant differences in rates of intravenous fluids ordered as a function of decision-support type. Intravenous fluid orders decreased by 0·9 percentage points for paper electronic decision support and 4·2 percentage points for electronic decision support, with a 4·2-point difference between decision-support types in the intervention period (paper 98·7% [95% CI 91·8-99·8] vs electronic 94·5% [72·2-99·1]; pinteraction=0·31). Adverse events such as complications and mortality events were uncommon and could not be statistically estimated. INTERPRETATION: Although intravenous fluid orders did not change, electronic decision support was associated with increases in the volume of intravenous fluid ordered and decreases in antibiotics ordered, which are consistent with WHO guidelines. FUNDING: US National Institutes of Health

Medical Waste Management: An Assessment at District-Level Public Health Facilities in Bangladesh

Abstract Background Due to the heavy patient-load and various types of services, the public health facilities produce a bulk of medical wastes (MW) in Bangladesh. Improper disposal of MW increases the risk of infection among the healthcare service personnel, patients, and attendants. The current study aimed to assess the practices of MW management and quantify those to find out the gaps in the specific steps of waste management.Methods As part of a larger intervention study, a facility assessment was conducted during November 2015 to March 2016 at a District Hospital (DH) and a Mother and Child Welfare Centre (MCWC) both being located in the same district, Non-participatory observation of MW management was done using a checklist developed following the Guideline for Medical Waste Management of Bangladesh. Scoring was applied for various activities of MW management performed in the study facilities.Results The overall scores in bin management, segregation, and collection of wastes were 64.5%, 58.1%, and 62.0% in the DH and 53.1%, 41.5%, and 48.0% in the MCWC respectively. The performance of operation theatre in MCWC was the lowest among different corners (16.7–36.0%). Re-usable waste was segregated poorly (32% in DH and 0% in MCWC), and almost none was shredded (4% in DH and 0% in MCWC). The wastes were transported from in-house to out-house temporary storage area in open-bin without any trolley or specific route. Storage area was accessible to unauthorized persons, e.g. waste-picker in DH. While DH segregated 84% of its infectious wastes at source, they eventually got mixed-up with other wastes in the storage area and delivered to municipality for dumping. MCWC could segregate only 40% of its infectious wastes at source and disposed those, using pit method. Both the facilities disposed sharp medical wastes by open-air burning and liquid wastes through sewerage without any treatment.Conclusions The performance of MW management was poor in both the study facilities. Advocacy to the healthcare personnel and refresher training, along with supportive supervision and monitoring, may improve the situation. Moreover, larger study is needed to find out the reasons behind such poor MW management.</jats:p

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Additional file 1. Checklist _Normal Vaginal Delivery.doc (Nomal delivery checklist)

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Additional file 7. Checklist_PNC.doc (PNC checklist)

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Additional file 4. Checklist_Caesarean Section Delivery.doc (Cesarean delivery checklist)

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Additional file 3. Checklist_Blood Transfustion.docx (Blood transfussion checklist)

Quality of maternal and newborn healthcare services in two public hospitals of Bangladesh: identifying gaps and provisions for improvement

Abstract Background Healthcare service delivery systems need to ensure standard quality of care (QoC) for achieving expected health outcomes. Although Bangladesh has a good healthcare service delivery system, there are major concerns about the quality of maternal and newborn health (MNH) care services, which is imperative for achievements in health. The study aimed to measure the QoC for different MNH services in two selected public health facilities of Bangladesh. This study also documented the specific areas of each care which needs intervention. Methods The study was conducted in two district-level public health facilities—a district hospital (DH) and a mother and child welfare centre (MCWC). A total of 228 cases of MNH services were observed by using contextualized checklist ‘Standards-based Management and Recognition (S-BMR)’ for 8 selected MNH care services. For scoring, performed activities were calculated as percentages of the total recommended activities and categorized as high (&gt; 80%), moderate (50 to 80%), and low (&lt; 50%). Results Overall QoC scores were moderate for each DH (54.8%), and MCWC (56.1%). In DH, the QoC score was high for blood transfusion (80.3%); moderate for maternal complications management (77.0%), caesarean section (CS) (65.6%), infection prevention (64.3%), sick newborn care (54.1%), and normal vaginal delivery (NVD) (52.6%); and low for antenatal care (ANC) (25.6%) and postnatal care (PNC) (19.0%). In MCWC, the QoC scores were high for infection prevention (83.0%); moderate for CS (76.5%) and NVD (59.8%); and low for ANC (36.9%) and PNC (24.5%). Conclusions In the study facilities, the QoC for MNH services is found to be unsatisfactory, particularly for ANC and PNC. Urgent initiative needs to be taken by introducing contextualized quality monitoring tools at health facilities, along with training of the care providers and introducing a quality monitoring system. </jats:sec

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Additional file 6. Checklist_Management of Maternal Complications.docx (Maternal complications management checklist)