1. The dengue clinical practice guideline (DCPG) from household to hospital
DCPG was used for 12 weeks (June-August 2017), with 39 dengue patients who were admitted to Lansaka Hospital (72%) from the total dengue patients (54 cases) reported in the area by Nakhon Si Thammarat province’s public health officials. They were divided into 16 males and 23 females, with ages ranging from 3 to 66 years and an average age of 23 years. The signs and symptoms of 39 cases were fever (39 patients), weakness (8 patients), nausea (5 patients), headache (5 patients), stupor (3 patients), and eating less than normal (5 patients). The 39 dengue patients admitted to the IPD were divided into 30 cases visiting directly to the OPD, 4 cases visiting the ER of the district hospital, and 5 cases visiting the PCU2.
All 30 dengue patients visited the OPD and were divided into the OPD1 (go back home for continuous observation) (9 cases) and OPD2 (admitted to IPD1) (20 cases), and one patient was referred to the province (tertiary) hospital. For the 20 patients who visited the IPD1, a care map plan and DCPG grades I and II and fluid replacement guidelines were used based on disease severity. The implementation of DCPG covered eight PCUs and Lansaka Hospital. The dengue morbidity rate at 12 weeks was 124 cases/100,000 populations (54 cases), and there was no mortality rate or severe complications, such as prolonged shock. However, the DCPG’s record form of the PCUs needs to be completed. Finally, the new lines of dengue patient care are from the household to the district hospital, and they can possibly go to province hospital. Then, the conclusion of DCPG consisted of four steps of the guidelines related from household to hospital.
The first step was dengue prevention and control in the community. The step was self-care with dengue prevention in the community. This step focused on dengue prevention with the larval indices surveillance system in the “Lansaka model”, which consisted of seven steps in 44 villages . The system focused on the householder clearing their house and garbage management. Mosquito breeding site-village health volunteer surveys larval indices were performed on the 25th of every month, sent to the group’s leader on the 28th, then sent to the village leader on the 30th of month, who analysed them with a computer program (http: //Nakhonsi.denguelim.com). PCUs use training dengue knowledge and larval indices to eliminate mosquito breeding sites and avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin. The dengue solution policy of sub-district organization was conducted in communities and schools. There was communication for dengue outbreak control information that showed a dengue case index in the community as the Surveillance and Rapid Response Team (SRRT).
The second step was dengue clinical practice guidelines at the PCUs. If fever lasted > 48 hrs. and/or weakness, nausea, and vomiting were present, the patient needed to go to the primary care unit. There were two patterns: 1) PCU1 refers to a district hospital if fever ≥ 48 hr. Health care providers need to test (1) HCT. If weakness increased, and there was no fever, (2) the haemogluco test (HGT/DTX) was performed; if the patient showed signs of shock, (3) the tourniquet test ≥ 10 points/in² was performed; (4) assess signs of hypovolemic shock and bleeding, (5) fluid replacement following DCPG, and (6) practice following PCU2. 2) PCU2 needs continuous observation if fever <48 hrs., (1) give only paracetamol 10-15 mg/kg/dose, may be repeated every 4-6 hrs., (2) demonstration with tepid sponge, drinking fluid juice, electrolyte solution and voiding red or black food, and 3) avoiding mosquito bite, using lotion, and destroying mosquito breeding site.
The third step was dengue clinical practice guidelines at the outpatient department (OPD) and emergency room (ER) in secondary care hospital (Lansaka hospitals). Patient care at the OPD and ER for assessing signs of hypovolemic shock and bleeding included PE, BT, PR, RR, BP, shock signs, tourniquet test, and CBC (WBC < 5,000 cell/mm3). There were two options in OPD and IPD in that each channel was divided into 3 patterns: Dengue patient care at OPD consisted of 1) OPD1: for dengue patients, health assessment and screening were needed for advising and continuing observation; 2) OPD2: health assessment and DHF diagnosis for admission to IPD in district hospitals; and 3) OPD3: health assessment showed severe signs and symptoms as DSS and the patients were sent to tertiary (province) hospital. Dengue patient care occurred in the ER when dengue patients visited the hospital from 16.00 pm. to 8.00 am. There were three patterns: 1) ER1 pattern was health assessment and discharge to go home for observing dengue signs and symptoms, 2) ER2: taking health assessment and diagnostic DHF for admission to the IPD in secondary hospitals, and 3) ER3 pattern was a health assessment and diagnosis of dengue with severe symptoms and sending them to a tertiary hospital.
The fourth step was dengue clinical practice guidelines in the patient department (IPD) at the secondary care hospital. There were two patterns that consisted of 1) IPD1 treatment with a care team, such as Care Map, as the dengue practice guideline in grades I and II and dengue infection, guideline of fluid replacement in dengue grades I and II, and filling out referral form and recording intake and output of fluid, 2) the IPD2 pattern was a guideline for severe dengue or dengue grades III and IV, which are referred to province hospital with the referral form. The guidelines for dengue prevention and control in the community and clinical practice guidelines in primary- to the tertiary care (province) hospital (Maharaj nakhon si thammarat hospital) need to be integrated and communicated to all stakeholders. Moreover, SRRT needs to monitor the outbreak situation at the case index of dengue fever in the community as community mobilization and perform outbreak activity as soon as the case index of fever is known. Figure 2
2. The evaluation of health providers’ opinions, knowledge, and practices for dengue patients after using DCPG from households to hospitals
The implementation of DCPG was preparedness for the research team, and 26 participants from eight PCUs consisted of professional nurses and health care officials of district hospitals. However, tertiary level hospitals support fast channels for referring critical cases of dengue. All documents, such as the DCPG manual, flow chart, and dengue manual, were prepared. DCPG was conducted over three months (June-August 2017). During the testing period, the monitoring and support by the research team was completed one month before and after the opinion, knowledge and practice of DCPG in 12 weeks for the use of DCPG.
2.1 Personal information of health providers
There were 26 health providers who were representative of eight PCUs and district hospitals. There were five phases and testing before and after using DCPG. There were 18 women (69.2%), 13 public health officials (50.0%), 13 registered nurses (50.0%) divided into 8 from Lasaka hospital (30.8%) and 5 from PCUs (19.2%). They were practising in 20 district hospitals (76.9%). The average practice time was 21.74 years (SD. 10.35 years), current role and function average 14.30 years (SD. 8.58 years), and practising in current PCUs 9.96 years (SD. 7.62 years). They experienced dengue prevention in the community, fever stage, shock stage, convalescent stage, performing a tourniquet test, taking intravascular fluid, referral of patients, and case dengue patient death in 19 (73.1%), 16 (61.5%), 4 (15.4%), 13 (50.0%), 8 (30.8%), 6 (23.1%), 5 (19.2%) and 1 (3.8%) patients, respectively.
2.2 Dengue’s opinion of health providers before and after using the DCPG from household to hospital
The dengue’s opinions mean awareness/perception of the severity and impact of dengue disease. They showed positive opinion in 9 items from a total of 10 items, with almost all answers “yes”. Only item number 9 was negative, with “Quick notification of health officials in 72 hrs. as soon as dengue patients were found”. Item number 10 showed an increasing positive significant statistic after using DCPG (p<0.05) (Table 1).
2.3 Health providers’ knowledge of dengue before and after using DCPG from household to hospital
The comparison of 26 health providers’ dengue knowledge for 14 items found that three items, 2, 4, and 10, were significantly different before and after development guidelines were implemented (p<0.05). The differences in 11 items of dengue knowledge were not statistically significant (p>0.05) (Table 2).
2.4 Practices for dengue patients before and after DCPG
1) Practice to initially assess patient visits to the PCU/hospital for screening dengue infection. The results showed that most of the practices to initially assess patients were significantly different (p<0.001). It showed frequency of activities after more than before using DCPG, such as (1) vital signs (T, P, R, BP); (2) body weight, length (if children); (3) tourniquet test for investigation platelets; (4) history of related dengue infection, such as friend or family member, and those who were contacted in 2 weeks; (5) assessment sign and symptoms of dengue, such as headache, myalgia, eye pain, positive tourniquet test and CBC, and if fever was more than 2 days (Table 3).
2) Basic practice if the health care practitioner met dengue patient in 2 days. There were practices if health care practitioners met dengue patient in first 2 days of the fever phase, and the difference was statistically significant (p<0.001). The results showed frequency of practice after more than before using DCPG, such as (1) dehydration assessment, (2) force drinking fluid and fruit juice, (3) take paracetamol 10-15 mg/kg/dose repeated every 4-6 hr, (4) take antipyretic drug if high fever ≥ 38 °C, (5) caution invasive of treatment and fall, (6) drink fruit juice or mineral fluid if patient was dehydrated, and (7) do not take aspirin (Table 4).
3) Practice guidelines for dengue diagnosis with the dengue shock phase, with drowsy sign after 3 days, showed the 12 practices if health providers met patients on after more than before using DCPG was statistically significant for every item (p<0.001), such as (1) assess decreasing of fever and no alert, (2) bleeding status such as petechial, 3) severe vomiting and abdominal pain, (4) continuous severe thirst, (5) drowsy and not drinking water, (6) fidgeting or fumbling if the child cries, (7) cold hands and feet sweating, (8) little urine or no urination for more than 4-6 hours, (9) measure body temperature 39°C, (10) diastolic and systolic blood pressure were narrow at 20 mmHg, (11) evaluate the wrist pulse for light, fast, or not catching, and (12) evaluate immediately whether cold or striped body and test HCT., deliver blood sugar intravenously, and ready to be delivered to the hospital immediately (Table 5).
4) Practice guidelines for administering intravascular fluid for initial resuscitated shock. Three items were different in practice if they met patients (p <0.01) (item 1). A 5% D/NSS IV drip rate of 120 cc/hr was used (30 drop/minute) for adult patients or children ≥ 6 years, and they were then referred to the tertiary hospital (item 2). A 5% D/NSS IV rate of 60 cc/hr was used (15 drop/minute) for children < 6 years, and they were then referred to tertiary hospital. A 0.9% NSS IV drip was taken in 5-10 minutes in dengue shock, which did not measure BP (item 3). After that, a pulse should decrease the IV rate to 60 cc/hr, and then the patient should be referred to a tertiary hospital. Referral to the tertiary hospital stat, if dengue was found in a patient with weakness and blood pressure was not different before and after DCPG (item 4) (Table 6).
5) Practice if health care provider met the patient following the practice guideline for referral to tertiary (province) hospital. Comparison between before and after using practice if the patient met the practice guideline for referral to province hospital found that the practices were increasing after using DCPG and were statistically significant (p<0.001) in 6 of 8 sub-items of activities in number 3 (criteria for referral a severe dengue patient), and they can increase the practice “Go with patient during referral to province hospital”.
6) Practice if met patient following the guideline of suggestion for dengue prevention. Participants followed the practice if they met patient every time for all 8 activities both before and after. The differences between before and after for three activities were statistically significant (p<0.001), including item (1) “Suggestion with prevention mosquito bite”, (2) “Report dengue case index (Report 506 of Control Disease Centre, Thai Ministry of Public Health)”, and (6) “Monitoring BI, HI, and CI in community for dengue outbreak prevention”. In addition, three activities increased significantly (p<0.01), including (3) “Communicating the dengue control information for local organization administration such as fogging insecticide radius 100 metre around house index”, (4) “Monitoring dengue case in the area around house of case index in 28 days”, and (5) “Communicating and enhancing the community for destroying mosquito breeding site every 7 days” (Table 8).
2.4 Evaluation of the preparedness of the medical equipment and supplies for dengue treatment in the PCUs and secondary care hospital.
The medical equipment and supplies for dengue treatment were significantly increased after DCPG was used, such as “Mercury sphygmomanometer and cuff 3 level” and “Blood glucose metre” (P<0.01), and “Health care providers were trained with dengue clinical practice guideline” (p<0.05). However, “5% D/NSS or 5% DLR or 5% DAR capacity 500 cc”, “Dengue case management manual”, and “Dengue clinical practice guideline in primary care unit” were not significantly increased after DCPG was used. In addition, “Haematocrit centrifuge” and “Set IV fluid, Medicut No. 18, 20, 21, 22, and 23” did not change between before and after (Not Table).