Level Of Knowledge Of Healthcare Providers In Mbagathi County Hospital And Mama Lucy Kibaki Hospital On The Ispad Management Guidelines Of Diabetic Ketoacidosis.

Abstract

Background: Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with diabetes mellitus. Most healthcare workers especially in sub-Saharan Africa are not able to recognize signs and symptoms of DKA in children at presentation and therefore often misdiagnose it. Standard DKA management guidelines have been developed to guide health care providers as they care for these patients, to ensure optimal patient care. Despite provision of these guidelines, in-patient mortality is still high especially in developing countries. Factors giving rise to this high mortality include poor healthcare systems, patient related issues and healthcare provider problems. Among healthcare provider problems, a lack of adequate knowledge on standard DKA management has been shown to be one of the many causes of poor outcomes among DKA patients. Study Objectives: Primary objective: To determine the level of knowledge of healthcare providers (HCPs) in Mbagathi County Hospital and Mama Lucy Kibaki Hospital on DKA management using the International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines. Secondary Objective: To describe the barriers to recommended DKA management as reported by the healthcare providers. Methods: We carried out a cross-sectional survey at the two county hospitals to establish HCP knowledge on DKA management. The study targeted nurses, clinical officers and doctors who attend to children aged 0 to 12 years. Mean knowledge level was assessed using questionnaires which were developed based on the ISPAD guidelines. The questionnaires were administered by the principle investigator to HCPs working in the pediatric wards, newborn unit and outpatient departments. Each HCP who consented to take part in the study was given approximately 10-15 minutes to fill out their questionnaire before returning it to the principle investigator. A total of 19 questions were used to assess the level of knowledge. Paediatricians were assessed based on the entire set of questions; however only selected questions were used to assess, medical officers, clinical officers (COs) and nurses in accordance with their level of training. Information obtained from the questionnaires on DKA included: DKA definition, pathophysiology and criteria for diagnosis, fluid and insulin therapy, potassium replacement, bicarbonate replacement, emergency assessment, clinical signs and management of cerebral oedema, management of shock and x severe dehydration, when to refer and frequency of monitoring biochemical changes. Barriers to appropriate DKA management were derived from the responses given by the healthcare providers in the last question, of which, was an open ended question. Data analysis: Data was obtained and checked daily for errors and entered into a computerized database using SPSS version 22 and later exported to STATA version 17 for further analyses. Descriptive data analysis for continuous variables was done using means and that of categorical variables was done using frequencies and percentages. Multivariate logistic regression and Chi square test of associations was carried out to assess factors associated with level of knowledge on DKA management. All statistical tests were considered significant at 95% confidence interval. Barriers to recommended DKA management among HCPs were analyzed descriptively. They were identified, grouped into categories and reported. Results: The overall mean level of knowledge of healthcare providers regarding DKA management in two county hospitals was 53.08%. Mean knowledge score of each cadre was: paediatricians 70.18%, medical officers 63.39%, clinical officers 52.20%, and nurses 41.74%. The barriers to appropriate DKA management as reported by HCPs were: lack of medical supplies and equipment, lack of standard operating procedures and continuous medical education, high workload, and inadequate in service training on DKA management. Conclusions: Mean Knowledge on DKA management among HCPs in two secondary level hospitals in Nairobi was at 53.08% with 35.9% of HCPs scoring below average. The barriers in DKA management as reported by HCPs include: Lack of enough medical supplies and equipment, absence of standard operating procedures (SOPs) and treatment guidelines, lack of continuous medical education and in-service training and increased workload due to understaffing. Recommendation: 1. Continuous medical education and educational programs on all HCPs on key aspects of DKA management. 2. Availing standard protocols on ISPAD guidelines at the workplace to serve as a reminder on key aspects on DKA management thereby ensuring recommended DKA care. 3. Hospital management teams to look into the various barriers and come up with ways of addressing them. 4. Involve regulatory bodies such as nursing council, medical board, and clinical officers‟ board to improve knowledge through educational programs. Involve the ministry of Health (MOH) to find ways of addressing the barriers.