Global paediatric advanced life support: improving child survival in limited-resource settings

Capacity for delivery of paediatric emergency care and the current use of emergency triage, assessment and treatment in health facilities in the Busoga region, Uganda-A mixed methods study

The implementation of structured guidelines, such as the World Health Organisation's Emergency Triage, Assessment and Treatment has been shown to reduce in-hospital mortality, addressing the high burden of early in-hospital deaths. We evaluated the capacity to provide paediatric emergency care at higher-level health facilities in the Busoga sub-region, Uganda, and explored healthcare workers' perceptions of quality care. This assessment aimed to inform policy and facilitate the implementation of guidelines. A comprehensive mixed-methods study was conducted, comprising a facility audit, a survey of healthcare providers to assess their knowledge, and focus group discussions with facility staff. The study included all public and private not-for-profit facilities that provide in-patient paediatric care in Busoga. Quantitative data were analysed using descriptive statistics and linear regression, while thematic analysis with the framework method approach was applied to qualitative data. A total of 14 focus group discussions, 14 facility audits, and 100 surveys with healthcare providers were conducted. Essential equipment for paediatric emergencies and staff shortages were identified as primary barriers to quality care and key contributors to worker demotivation. Referrals were one of the main challenges, with only 25% of facilities accessing a fuelled ambulance. Knowledge scores were higher among healthcare professionals who had undergone emergency management training and participated in refresher courses (mean 13.2, 95% CI 11.6-14.8, compared to 9.2, 95% CI 8.0-10.3). Participants who felt well-prepared achieved markedly higher scores on knowledge surveys than those feeling unprepared (mean 12.2, 95% CI 11.2-13.1, versus mean 8.5, 95% CI 7.3-9.7). Qualitative discussions demonstrated positive attitudes of healthcare workers toward ETAT guidelines. Results underscore the importance of focused training with refresher sessions to enhance health workers' knowledge and confidence in managing paediatric emergency cases. However, substantial limitations in staffing numbers and the availability of necessary equipment need to be addressed for overall quality of care improvement.

Paediatric use of emergency medical services in India: A retrospective cohort study of one million children

Background

Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness.

Methods

We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory.

Results

Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection.

Conclusions

EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.

A 2-Phase Survey to Assess a Facility's Readiness for Pediatric Essential Emergency and Critical Care in Resource-Limited Settings: A Literature Review and Survey Development

OBJECTIVE

Infectious diseases, including pneumonia, malaria, and diarrheal diseases, are the leading causes of death in children younger than 5 years worldwide. The vast majority of these deaths occur in resource-limited settings where there is significant variation in the availability and type of human, physical, and infrastructural resources. The ability to identity gaps in healthcare systems that may hinder their ability to deliver care is an important step to determining specific interventions for quality improvement. Our study objective was to develop a comprehensive, digital, open-access health facility survey to assess facility readiness to provide pediatric critical care in resource-limited settings (eg, low- and lower middle-income countries).

METHODS

A literature review of existing facility assessment tools and global guidelines was conducted to generate a database of survey questions. These were then mapped to one of the following 8 domains: hospital statistics, services offered, operational flow, facility infrastructure, staff and training, medicines and equipment, diagnostic capacity, and quality of clinical care. A 2-phase survey was developed and an iterative review process of the survey was undertaken with 12 experts based in low- and middle-income countries. This was built into the REDCap Mobile Application for electronic data capture.

RESULTS

The literature review process yielded 7 facility assessment tools and 7 global guidelines for inclusion. After the iterative review process, the final survey consisted of 11 sections with 457 unique questions in the first phase, "environmental scan," focusing on the infrastructure, availability, and functionality of resources, and 3 sections with 131 unique questions in the second phase, "observation scan," focusing on the level of clinical competency.

CONCLUSIONS

A comprehensive 2-phase survey was created to evaluate facility readiness for pediatric critical care. Results will assist hospital administrators and policymakers to determine priority areas for quality improvement, enabling them to implement a Plan-Do-Study-Act cycle to improve care for the critically ill child.

Capacity building in low- and middle-income countries: The essentials of sustainable education programs

ABSTRACT

NPs are an essential resource in the organization and creation of capacity-building efforts to improve healthcare across the globe. There are limited data to guide the creation of effective supplementary education projects. Recent evidence highlights the essential components of sustainability, curriculum development, and program evaluation.

Impact of a 1-Year Pediatric Emergency Medicine Training Program for International Medical Graduates

OBJECTIVES

The Hospital for Sick Children in Toronto has offered a 1-year subspecialty residency training program in pediatric emergency medicine (PEM) to Canadian and internationally trained pediatricians and emergency physicians since 1993. The program is intended to support clinical service delivery while simultaneously offering a unique educational opportunity to Canadian and international physicians who desire 1 year of clinically focused training. We describe the experiences and career outcomes of participants who completed this program.

METHODS

Two surveys were sent to the 68 individuals who completed the clinical fellowship program from its inception in 1993 until 2014. A blinded survey focused on the fellowship experience and subsequent career activities. A nonblinded survey subsequently determined whether participants had served as a medical director or training program director.

RESULTS

Sixty of the 68 participants (88%) completed the blinded survey. Ninety-one percent were in practice in emergency medicine. Twenty-five percent of the participants were living in Canada, compared with 17% before completing the program. This net migration of 8% was not significant (P = 0.26). Thirty-six of the 50 participants (72%) who applied from outside Canada responded to the nonanonymous survey; 18 (50%) had served as an emergency department medical director, and 18 (50%) reported serving as a PEM training program director.

CONCLUSIONS

Many participants attained leadership positions in PEM in countries outside of North America and/or participated in training program development. There was no significant change in the proportion of participants living in North America at the time of application compared with the time of survey completion.

Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine

Background

Pediatric Early Warning Scores (PEWS) are nurse-administered clinical assessment tools utilizing vital signs and patient signs and symptoms to screen for patients at risk for clinical deterioration.^1–3 When utilizing a PEWS system, which consists of an escalation algorithm to alert physicians of high risk patients requiring a bedside evaluation and assessment, studies have demonstrated that PEWS systems can decrease pediatric intensive care (PICU) utilization, in-hospital cardiac arrests, and overall decreased mortality in high income settings. Yet, many hospital based settings in low and lower middle income countries (LMIC) lack systems in place for early identification of patients at risk for clinical deterioration.

Methods

A contextually adapted 16-h pediatric resuscitation program included training of a PEWS tool followed by implementation and integration of a PEWS system in a pediatric hematology/oncology ward in Beit Jala, Palestine. Four PDSA cycles were implemented post-implementation to improve uptake and scoring of PEWS which included PEWS tool integration into an existing electronic medical record (EMR), escalation algorithm and job aid implementation, data audits and ward feedback.

Results

Frequency of complete PEWS vital sign documentation reached a mean of 89.9%. The frequency and accuracy of PEWS scores steadily increased during the post-implementation period, consistently above 89% in both categories starting from data audit four and continuing thereafter. Accuracy of PEWS scoring was unable to be assessed during week 1 and 2 of data audits due to challenges with PEWS integration into the existing EMR (PDSA cycle 1) which were resolved by the 3rd week of data auditing (PDSA cycle 2).

Conclusions

Implementation of a PEWS scoring tool in an LMIC pediatric oncology inpatient unit is feasible and can improve frequency of vital sign collection and generate accurate PEWS scores.

Contribution to the literature

This study demonstrates how to effectively implement a PEWS scoring tool into an LMIC clinical setting.

This study demonstrates how to utilize a robust feedback mechanism to ensure a quality program uptake.

This study demonstrates an effective international partnership model that other institutions may utilize for implementation science.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07157-x.

Impact of a Multifaceted Intervention to Improve Emergency Care on Newborn and Child Health Outcomes in Rwanda

Implementing context-appropriate neonatal and pediatric advanced life support management interventions has increasingly been recommended as one of the approaches to reduce under-five mortality in resource-constrained settings like Rwanda. One such intervention is ETAT+, which stands for Emergency Triage, Assessment and Treatment plus Admission care for severely ill newborns and children. In 2013, ETAT+ was implemented in Rwandan district hospitals. We evaluated the impact of the ETAT+ intervention on newborn and child health outcomes. We used monthly time series data from the DHIS2-enabled Rwanda Health Management Information System from 2012 to 2016 to examine neonatal and pediatric hospital mortality rate. Each hospital contributed data for 12 and 36 months before and after ETAT+ implementation, respectively. Using controlled interrupted time series analysis and segmented regression model, we estimated longitudinal changes in neonatal and pediatric hospital mortality rate in intervention hospitals relative to matched concurrent control hospitals. We also studied changes in case fatality rate specifically for ETAT+ targeted conditions. Our study cohort consisted of seven intervention hospitals and fourteen matched control hospitals contributing 142,424 neonatal and pediatric hospital admissions. After controlling for secular trends and autocorrelation, we found that the ETAT+ implementation had no statistically significant impact on the rate of all-cause neonatal and pediatric hospital mortality in intervention hospitals relative to control hospitals. However, the case fatality rate for ETAT+ targeted neonatal conditions decreased immediately following implementation by 5% (95% CI: -9.25, -0.77) and over time by 0.8% monthly (95% CI: -1.36, -0.25), in intervention hospitals compared with control hospitals. Case fatality rate for ETAT+ targeted pediatric conditions did not decrease following the ETAT+ implementation. While ETAT+ focuses on improving quality of hospital care for both newborns and children, we only found an impact on neonatal hospital mortality for ETAT+ targeted conditions that should be interpreted with caution given the relatively short pre-intervention period and potential regression to the mean.

Capacity Building for Health Care Workers and Support Staff in Pediatric Emergency Triage Assessment and Treatment (ETAT) at Primary Health Care Level in Resource Limited Settings: Experiences from Malawi

Primary health care facilities offer an entry point to the health care system in Malawi. Challenges experienced by these facilities include limited resources (both material and human), poor or inadequate knowledge, skills and attitudes of health care workers in emergency management, and delay in referral from primary care level to other levels of care. These contribute to poor outcomes including children dying within the first 24 hours of hospital admission. Training of health care workers and support staff in Emergency Triage Assessment and Treatment (ETAT) at primary care levels can help improve care of children with acute and severe illnesses. Health care workers and support staff in the primary care settings were trained in pediatric ETAT. The training package for health care workers was adapted from the Ministry of Health ETAT training for district and tertiary health care. Content for support staff focused on non-technical responsibility for lifesaving in emergency situations. The primary health care facilities were provided with a minimum treatment package comprising emergency equipment, supplies and drugs. Supportive supervisory visits were conducted quarterly. The training manual for health care workers was adapted from the Ministry of Health package and the support staff training manual was developed from the adapted package. Eight hundred and seventy-seven participants were trained (336 health care workers and 541 support staff). Following the training, triaging of patients improved and patients were managed as emergency, priority or non-urgent. This reduced the number of referral cases and children were stabilized before referral. Capacity building of health care workers and support staff in pediatric ETAT and the provision of a basic health center package improved practice at the primary care level. The practice was sustained through institutional mentorship and pre-service and in-service training. The practice of triage and treatment including stabilization of children with dangerous signs at the primary health care facility improves emergency care of patients, reduces the burden of patients on referral hospitals and increases the number of successful referrals.

Mentors' perspectives on strengths and weaknesses of a novel clinical mentorship programme in Rwanda: a qualitative study

OBJECTIVES

To identify mentors' perspectives on strengths and weaknesses of the Training, Support and Access Model for Maternal, Newborn and Child Health (TSAM-MNCH) clinical mentorship programme in Rwandan district hospitals. Understanding the perspectives of mentors involved in this programme can aid in the improvement of its implementation.

DESIGN

The study used a qualitative approach with in-depth interviews.

SETTING

Mentors of TSAM-MNCH clinical mentorship programme mentoring health professionals at district hospitals of Rwanda.

PARTICIPANTS

14 TSAM mentors who had at least completed six mentorship visits on a regular basis in three selected district hospitals.

RESULTS

Mentors' accounts demonstrated an appreciation of the two mentoring structures which are interprofessional collaboration and training. These structures are highlighted as the strengths of the mentoring programme and they play a significant role in the successful implementation of the mentorship model. Inconsistency of mentoring activities and lack of resources emerged as major weaknesses of the clinical mentorship programme which could hinder the effectiveness of the mentoring scheme.

CONCLUSION

The findings of this study highlight the strengths and weaknesses perceived by mentors of the TSAM-MNCH clinical mentorship programme, providing insights that can be used to improve its implementation. The study represents unique TSAM-MNCH structural settings, but its findings shed light on Rwandan health system issues that need to be further addressed to ensure better quality of care for mothers, newborns and children.

Clinical diagnosis in paediatric patients at urban primary health care facilities in southern Malawi: a longitudinal observational study

Background

Despite health centres being the first point of contact of care, there are challenges faced in providing care to patients at this level. In Malawi, service provision barriers reported at this level included long waiting times, high numbers of patients and erratic consultation systems which lead to mis-diagnosis and delayed referrals. Proper case management at this level of care is critical to prevent severe disease and deaths in children. We aimed to adopt Emergency, Triage, Assessment and Treatment algorithm (ETAT) to improve ability to identify severe illness in children at primary health centre (PHC) through comparison with secondary level diagnoses.

Methods

We implemented ETAT mobile Health (mHealth) at eight urban PHCs in Blantyre, Malawi between April 2017 and September 2018. Health workers and support staff were trained in mHealth ETAT. Stabilisation rooms were established and equipped with emergency equipment. All PHCs used an electronic tracking system to triage and track sick children on referral to secondary care, facilitated by a unique barcode. Support staff at PHC triaged sick children using ETAT Emergency (E), Priority (P) and Queue (Q) symptoms and clinician gave clinical diagnosis. The secondary level diagnosis was considered as a gold standard. We used statistical computing software R (v3.5.1) and used exact 95% binomial confidence intervals when estimating diagnosis agreement proportions.

Results

Eight-five percentage of all cases where assigned to E (9.0%) and P (75.5%) groups. Pneumonia was the most common PHC level diagnosis across all three triage groups (E, P, Q). The PHC level diagnosis of trauma was the most commonly confirmed diagnosis at secondary level facility (85.0%), while a PHC diagnosis of pneumonia was least likely to be confirmed at secondary level (39.6%). The secondary level diagnosis least likely to have been identified at PHC level was bronchiolitis 3 (5.2%). The majority of bronchiolitis cases (n = 50; (86.2%) were classified as pneumonia at the PHC level facility.

Conclusions

Implementing a sustainable and consistent ETAT approach with stabilisation and treatment capacity at PHC level reinforce staff capacity to diagnose and has the potential to reduce other health system costs through fewer, timely and appropriate referrals.

Evolution of a Bidirectional Pediatric Critical Care Educational Partnership in a Resource-Limited Setting

Introduction: Children in resource-limited settings are disproportionately affected by common childhood illnesses, resulting in high rates of mortality. A major barrier to improving child health in such regions is limited pediatric-specific training, particularly in the care of children with critical illness. While global health rotations for trainees from North America and Europe have become commonplace, residency and fellowship programs struggle to ensure that these rotations are mutually beneficial and do not place an undue burden on host countries. We created a bidirectional, multimodal educational program between trainees in Manila, Philippines, and Baltimore, Maryland, United States, to improve the longitudinal educational experience for all participants. Program Components: Based on stakeholder input and a needs assessment, we established a global health training program in which pediatricians from the Philippines traveled to the United States for observerships, and pediatric residents from a tertiary care center in Baltimore traveled to Manila. Additionally, we created and implemented a contextualized simulation-based shock curriculum for pediatric trainees in Manila that can be disseminated locally. This bidirectional program was adapted to include telemedicine and regularly scheduled "virtual rounds" and educational case conferences during the COVID-19 pandemic. Providers from the two institutions have collaborated on educational and clinical research projects, offering opportunities for resource sharing, bidirectional professional development, and institutional improvements. Conclusion: Although creating a mutually beneficial global health partnership requires careful planning and investment over time, establishment of a successful bidirectional educational and professional development program in a limited-resource setting is feasible and benefits learners in both countries.

Paediatric emergencies and related mortality in Nicaragua: results from a multi-site paediatric emergency registry

BACKGROUND

We aim to describe the characteristics and outcomes of the severe spectrum of paediatric emergency visits using a multi-site registry developed as part of an international cooperation project.

METHODS

This observational registry-based study presented descriptive statistics of clinical and outcome data on urgent-emergency paediatric visits from 7 Nicaraguan hospitals, including the national referral paediatric hospital, between January and December 2017. Extensive piloting to ensure data collection feasibility, sustainability and accuracy was carried out in 2016 with substantial input and feedback from local stakeholders.

RESULTS

Overall, 3521 visits of patients <15 years of age, of whom two-thirds <5 years, met predefined inclusion criteria of urgent-emergency visits. Respiratory (1619/3498; 46%), gastrointestinal (407/3498; 12%) and neurological (368/3498; 11%) complaints were the most common symptoms. Malnutrition was reported in 18% (610/3448) of presentations. Mortality was 7% (233/3521); 52% (120/233) of deaths occurred in the <1-year subgroup; 32% (71/3521) of deaths occurred within the first 24 hours of presentation. The most common immediate causes of death were septic shock (99/233; 43%), respiratory failure (58/233; 25%) and raised intracranial pressure (24/233; 10%).

CONCLUSIONS

The mortality rate of urgent-emergency paediatric visits in Nicaragua is high, with younger children being most at risk and the majority of deaths being eventually caused by septic shock or respiratory failure. Our data provide useful information for the development of a Paediatric Emergency Care network to help direct training efforts, resources and logistic/organisational interventions to improve children's health in an emergency setting in Nicaragua.

Pediatric emergency care in a low-income country: Characteristics and outcomes of presentations to a tertiary-care emergency department in Mozambique

Background

An effective pediatric emergency care (PEC) system is key to reduce pediatric mortality in low-income countries. While data on pediatric emergencies from these countries can drive the development and adjustment of such a system, they are very scant, especially from Africa. We aimed to describe the characteristics and outcomes of presentations to a tertiary-care Pediatric Emergency Department (PED) in Mozambique.

Methods

We retrospectively reviewed PED presentations to the "Hospital Central da Beira" between April 2017 and March 2018. Multivariable logistic regression was used to identify predictors of hospitalization and death.

Results

We retrieved 24,844 presentations. The median age was 3 years (IQR 1-7 years), and 92% lived in the urban area. Complaints were injury-related in 33% of cases and medical in 67%. Data on presenting complaints (retrieved from hospital paper-based registries) were available for 14,204 (57.2%) records. Of these, respiratory diseases (29.3%), fever (26.7%), and gastrointestinal disorders (14.2%) were the most common. Overall, 4,997 (20.1%) encounters resulted in hospitalization. Mortality in the PED was 1.6% (62% ≤4 hours from arrival) and was the highest in neonates (16%; 89% ≤4 hours from arrival). A younger age, especially younger than 28 days, living in the extra-urban area and being referred to the PED by a health care provider were all significantly associated with both hospitalization and death in the PED at the multivariable analysis.

Conclusions

Injuries were a common presentation to a referral PED in Mozambique. Hospitalization rate and mortality in the PED were high, with neonates being the most vulnerable. Optimization of data registration will be key to obtain more accurate data to learn from and guide the development of PEC in Mozambique. Our data can help build an effective PEC system tailored to the local needs.

Temporal trends in coverage, quality and equity of maternal and child health services in Rwanda, 2000-2015

INTRODUCTION

Achieving the maternal and child health (MCH)-related Sustainable Development Goals (SDG) will require equitable and effective (quality-adjusted) coverage of recommended health interventions in low- and middle-income countries. We assessed effective coverage and equity of MCH services in Rwanda in the Millennium Development Goal (MDG) era to help guide policy decisions to improve equitable health gains in the SDG era and beyond.

METHODS

Using four rounds of Rwanda demographic and health surveys conducted from 2000 to 2015, we identified coverage and quality indicators for five MCH services: antenatal care (ANC), delivery care, and care for child diarrhoea, suspected pneumonia and fever. We calculated crude coverage and quality in each survey and used these to estimate effective coverage. The effective coverage should be regarded as an upper bound because there were few available quality measures. We also described equity in effective coverage of these five MCH services over time across the wealth index, area of residence and maternal education using equiplots.

RESULTS

A total of 48 910 women aged 15-49 years and 33 429 children under 5 years were included across the four survey rounds. In 2015, average effective coverage was 33.2% (range 19.9%-44.2%) across all five MCH services, 30.1% (range 19.9%-40.2%) for maternal health services (average of ANC and delivery) and 35.3% (range 27.3%-44.2%) for sick child care (diarrhoea, pneumonia and fever). This is in contrast to crude coverage which averaged 56.5% (range 43.6%-90.7%) across all five MCH services, 67.3% (range 43.9%-90.7%) for maternal health services and 49.2% (range 43.6%-53.9%) for sick child care. Between 2010 and 2015 effective coverage increased by 154.2% (range 127.3%-170.0%) for maternal health services and by 27.4% (range 4.2%-79.6%) for sick child care. These increases were associated with widening socioeconomic inequalities in effective coverage for maternal health services, and narrowing inequalities in effective coverage for sick child care.

CONCLUSION

While effective coverage of common MCH services generally improved in the MDG era, it still lagged substantially behind crude coverage for the same services due to low-quality care. Overall, effective coverage of MCH services remained suboptimal and inequitable. Policies should focus on improving effective coverage of these services and reducing inequities.

Improving Tracheostomy Care in Resource-Limited Settings

OBJECTIVES

Tracheostomy care in leading pediatric hospitals is both multidisciplinary and comprehensive, including generalized care protocols and thorough family training programs. This level of care is more difficult in resource-limited settings lacking developed healthcare infrastructure and tracheostomy education among nursing and resident staff. The objective of this study was to improve pediatric tracheostomy care in resource-limited settings.

METHODS

In collaboration with a team of otolaryngologists, respiratory therapists, tracheostomy nurses, medical illustrators, and global health educators, image-based tracheostomy education materials and low-cost tracheostomy care kits were developed for use in resource-limited settings. In addition, a pilot study was conducted, implementing the image-based tracheostomy pamphlet, manual suctioning device and low-cost ambulatory supply kit ("Go-Bags"), within a low-fidelity simulated training course for nurses and residents in Kigali, Rwanda.

RESULTS

An image-based language and literacy-independent tracheostomy care manual was created and published on OPENPediatrics, an open-access online database of clinician-reviewed learning content. Participants of the training program pilot study reported the course to be of high educational and practical value, and described improved confidence in their ability to perform tracheostomy care procedures.

CONCLUSIONS

Outpatient tracheostomy care may be improved upon by implementing image-based tracheostomy care manuals, locally-sourced tracheostomy care kits, and tailored educational material into a low-fidelity simulated tracheostomy care course. These materials were effective in improving technical skills and confidence among nurses and residents. These tools are expected to improve knowledge and skills with outpatient tracheostomy care, and ultimately, to reduce tracheostomy-related complications.

Transfusing maternal blood to her newborn baby-irrespective of ABO mismatch

Background: Though blood transfusions are the common procedures in pediatric patients, transfusion reactions are rare in children. Though in adults, uncross-matched ABO group-specific blood is used in emergencies, there are no such reports in neonates and children. There are stray case reports about transfusing maternal blood for her baby and maternal blood is de facto compatible regardless of an ABO mismatchObjective: Confirming our previous hypothesis that maternal blood is compatible with her baby's blood; and maternal blood can be used for transfusion in her newborn baby irrespective of ABO match/ mismatch.Design: Prospective interventional study.Setting and Participants: Fifty-one mother-baby pairs were recruited attending Pediatric Unit of our Community Hospital from 15 July 2013 to 13 July 2015. After obtaining consent from the parents, all the required lab tests were done. Since all lab reports were favourable; these babies qualified for transfusion of maternal blood.Interventions: Fifty-one sick newborns were transfused fresh whole maternal blood as a part of treatment; irrespective of mother-baby ABO match or mismatch.Results: All babies tolerated maternal blood well and showed significant and rapid improvement. Minimum period of observation was from a minimum of 32 to a maximum of 56 months. All the babies showed good growth and development.Conclusion: By observing a particular protocol and procedural techniques, mother's blood may be used for transfusion in her own baby in neonatal period, irrespective of ABO mismatch.Significance: This is probably the largest series in world literature of 51 newborns being transfused maternal blood either ABO match or mismatch.

A National Survey of Resources to Address Sepsis in Children in Tertiary Care Centers in Nigeria

Background: Infections leading to sepsis are major contributors to mortality and morbidity in children world-wide. Determining the capacity of pediatric hospitals in Nigeria to manage sepsis establishes an important baseline for quality-improvement interventions and resource allocations. Objectives: To assess the availability and functionality of resources and manpower for early detection and prompt management of sepsis in children at tertiary pediatric centers in Nigeria. Methods: This was an online survey of tertiary pediatric hospitals in Nigeria using a modified survey tool designed by the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The survey addressed all aspects of pediatric sepsis identification, management, barriers and readiness. Results: While majority of the hospitals 97% (28/29) reported having adequate triage systems, only 60% (16/27) follow some form of guideline for sepsis management. There was no consensus national guideline for management of pediatric sepsis. Over 50% of the respondents identified deficit in parental education, poor access to healthcare services, failure to diagnose sepsis at referring institutions, lack of medical equipment and lack of a definitive protocol for managing pediatric sepsis, as significant barriers. Conclusions: Certain sepsis-related interventions were reportedly widespread, however, there is no standardized sepsis protocol, and majority of the hospitals do not have pediatric intensive care units (PICU). These findings could guide quality improvement measures at institutional level, and healthcare policy/spending at the national level.

Performance comparison in Pediatric Fundamental Critical Care Support among staff from the USA versus those from resource-limited countries

OBJECTIVE

This study aimed to evaluate the performance of participants in the USA compared with international participants taking the Pediatric Fundamental Critical Care Support (PFCCS) course, and the significance of training for resource-limited environments.

METHODS

PFCCS courses were conducted in the USA, El Salvador, Haiti, Kenya, and Nepal between January 2011 and July 2013. All of the participants took pre- and post-tests. We compared the performance of these tests between international and USA participants. All participants answered a post-course survey to evaluate the didactic lectures and skill stations.

RESULTS

A total of 244 participants took the PFCCS course, comprising 71 from the USA, 68 from Kenya, 37 from Haiti, 48 from Nepal, and 20 from El Salvador. The mean pre-test score of USA participants (50.6%) was significantly higher than that of international participants (44.7%). There was no significant difference in the post-test score between USA and international participants (78.6% versus 81.4%). There was a significant difference between pre- and post-test scores. There was better appreciation of the course content by the USA participants.

CONCLUSION

International course takers without prior pediatric intensive care training have similar test scores to USA participants suggesting comparable efficacy.

Risk Factors for Mortality in Children Admitted for Suspected Malaria to a Pediatric Emergency Ward in a Low-Resource Setting: A Case-Control Study

OBJECTIVES

To identify the risk factors for mortality after admission for suspected malaria in a pediatric emergency ward in Sierra Leone.

DESIGN

Retrospective case-control.

SETTING

Pujehun Hospital Pediatric Ward in Pujehun, Sierra Leone.

PATIENTS

All cases were pediatric deaths after admission for suspected malaria at the Pujehun Hospital Pediatric Ward between January 1, 2015, and May 31, 2016. The case-control ratio was 1:1. The controls were infants admitted at Pujehun Hospital Pediatric Ward for malaria and discharged alive during the same period. Controls were selected as the next noncase infant admitted for malaria and discharged alive, as recorded in local medical records.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Children characteristics, vital variables on hospital access, comorbidity status at admission, antibiotic and antimalarial therapy at admission; presence of hematemesis, respiratory arrest or bradypnea, abrupt worsening, and emergency interventions during hospital stay; final diagnosis before discharge or death. In total, 320 subjects (160 cases and 160 controls) were included in the study. Multivariable analysis identified being referred from peripheral health units (odds ratio, 4.00; 95% CI, 1.98-8.43), cerebral malaria (odds ratio, 6.28; 95% CI, 2.19-21.47), malnutrition (odds ratio, 3.14; 95% CI, 1.45-7.15), dehydration (odds ratio, 3.94; 95% CI, 1.50-11.35), being unresponsive or responsive to pain (odds ratio, 2.17; 95% CI, 1.15-4.13), and hepatosplenomegaly (odds ratio, 3.20; 95% CI, 1.74-6.03) as independent risk factors for mortality.

CONCLUSIONS

Risk factors for mortality in children with suspected malaria include cerebral malaria and severe clinical conditions at admission. Being referred from peripheral health units, as proxy of logistics issue, was also associated with increased risk of mortality. These findings suggest that appropriate interventions should focus on training and resources, including the increase of dedicated personnel and available equipment.

Knowledge Accrual Following Participation in Pediatric Fundamental Critical Care Support Course in Gaborone, Botswana

OBJECTIVES

To describe provider characteristics, knowledge acquisition, perceived relevance, and instruction quality of the Society of Critical Care Medicine's Pediatric Fundamentals of Critical Care Support course pilot implementation in Botswana.

DESIGN

Observational, single center.

SETTING

Academic, upper middle-income country.

SUBJECTS

Healthcare providers in Botswana.

INTERVENTIONS

A cohort of healthcare providers completed the standard 2-day Pediatric Fundamentals of Critical Care Support course and qualitative survey during the course. Cognitive knowledge was assessed prior to and immediately following training using standard Pediatric Fundamentals of Critical Care Support multiple choice questionnaires. Data analysis used Fisher exact, chi-square, paired t test, and Wilcoxon rank-sum where appropriate.

MAIN RESULTS

There was a significant increase in overall multiple choice questionnaires scores after training (mean 67% vs 77%; p < 0.001). Early career providers had significantly lower mean baseline scores (56% vs 71%; p < 0.01), greater knowledge acquisition (17% vs 7%; p < 0.02), but no difference in posttraining scores (73% vs 78%; p = 0.13) compared with more senior providers. Recent pediatric resuscitation or emergency training did not significantly impact baseline scores, posttraining scores, or decrease knowledge acquisition. Eighty-eight percent of providers perceived the course was highly relevant to their clinical practice, but only 71% reported the course equipment was similar to their current workplace.

CONCLUSIONS

Pediatric Fundamentals of Critical Care Support training significantly increased provider knowledge to care for hospitalized seriously ill or injured children in Botswana. Knowledge accrual is most significant among early career providers and is not limited by previous pediatric resuscitation or emergency training. Further contextualization of the course to use equipment relevant to providers work environment may increase the value of training.

The impact of "Child Care" intervention in rural Primary Health Care Program on prevalence of diarrhea among children less than 36 months of age in rural western China

BACKGROUND

It was unclear how and to what extent the "Child Care" intervention (CCI) in rural Primary Health Care Program affected the prevalence of childhood diarrhea in rural western China.

METHODS

The available data of 10,829 and 10,682 households was collected from shared 34 counties of 9 provinces of western China in 2001 and 2005 respectively. A log-binomial regression model was used to predict the effect of CCI on prevalence of childhood diarrhea.

RESULTS

In 2001, the prevalence rate of diarrhea among children less than 36 months of age was 17.01% in intervention group and 17.72% in control group, and in 2005 this crude rate declined to 4.85% in the former and 6.84% in the latter. Log-binomial regression analysis showed that CCI decreased the overall prevalence of childhood diarrhea by 27% (adjusted relative prevalence ratio (rPR) = 0.73 95% CI 0.59, 0.89). The stratification regression by social-economic status (SES) of the households showed that this effect varied with SES of the households. In the medium or rich households, this intervention was effective significantly (the medium: adjusted rPR = 0.63,95%CI 0.41,0.95; the rich: adjusted rPR = 0.72,95%CI 0.54,0.97), but in poor households it seemed to be less effective (adjusted rPR = 0.86,95%CI 0.55,1.36).

CONCLUSION

In rural Primary Health Care Program, CCI was effective in improving childhood diarrhea but this effect was inequitable among SES of the households. So, attention should be paid to the inequality when CCI was adopted to reduce childhood diarrhea in rural China.

Development of a short course on management of critically ill patients with acute respiratory infection and impact on clinician knowledge in resource-limited intensive care units

Background

The 2009 influenza A (H1N1) pandemic caused surges of patients in intensive care units (ICUs) in resource‐limited settings. Several Ministries of Health requested clinical management guidance from the World Health Organization (WHO), which had not previously developed guidance regarding critically ill patients.

Objective

To assess the acceptability and impact on knowledge of a short course about the management of critically ill patients with acute respiratory infections complicated by sepsis or acute respiratory distress syndrome delivered to clinicians in resource‐limited ICUs.

Methods

Over 4 years (2009‐2013), WHO led the development, piloting, implementation and preliminary evaluation of a 3‐day course that emphasized patient management based on evidence‐based guidelines and used interactive adult‐learner teaching methodology. International content experts (n = 35) and instructional designers contributed to development. We assessed participants’ satisfaction and content knowledge before and after the course.

Results

The course was piloted among clinicians in Trinidad and Tobago (n = 29), Indonesia (n = 38) and Vietnam (n = 86); feedback from these courses contributed to the final version. In 2013, inaugural national courses were delivered in Tajikistan (n = 28), Uzbekistan (n = 39) and Azerbaijan (n = 30). Participants rated the course highly and demonstrated increased immediate content knowledge after (vs before) course completion (P < .001).

Conclusions

We found that it was feasible to create and deliver a focused critical care short course to clinicians in low‐ and middle‐income countries. Collaboration between WHO, clinical experts, instructional designers, Ministries of Health and local clinician‐leaders facilitated course delivery. Future work should assess its impact on longer‐term knowledge retention and on processes and outcomes of care.

Assessing process of paediatric care in a resource-limited setting: a cross-sectional audit of district hospitals in Rwanda

BACKGROUND

Routine assessment of quality of care helps identify deficiencies which need to be improved. While gaps in the emergency care of children have been documented across sub-Saharan Africa, data from Rwanda are lacking.

OBJECTIVE

To assess the care of sick infants and children admitted to Rwandan district hospitals and the extent to which it follows currently recommended clinical practice guidelines in Rwanda.

METHODS

Data were gathered during a retrospective cross-sectional audit of eight district hospitals across Rwanda in 2012/2013. Medical records were randomly selected from each hospital and were reviewed to assess the process of care, focusing on the leading causes of under-5 mortality, including neonatal conditions, pneumonia, malaria and dehydration/diarrhoea.

RESULTS

Altogether, 522 medical records were reviewed. Overall completion of a structured neonatal admission record was above 85% (range 78.6-90.0%) and its use was associated with better documentation of key neonatal signs (median score 6/8 and 2/8 when used and not used, respectively). Deficiencies in the processes of care were identified across hospitals and there were rural/urban disparities for some indicators. For example, neonates admitted to urban district hospitals were more likely to receive treatment consistent with currently recommended guidelines [e.g. gentamicin (OR 2.52, 95% CI 1.03-6.43) and fluids (OR 2.69, 95% CI 1.2-6.2)] than those in rural hospitals. Likewise, children with pneumonia admitted to urban hospitals were more likely to receive the correct dosage of gentamicin (OR 4.47, 95% CI 1.21-25.1) and to have their treatment monitored (OR 3.75, 95% CI 1.57-8.3) than in rural hospitals. Furthermore, children diagnosed with malaria and admitted to urban hospitals were more likely to have their treatment (OR 2.7, 95% CI 1.15-6.41) monitored than those in rural hospitals.

CONCLUSIONS

Substantial gaps were identified in the process of neonatal and paediatric care across district hospitals in Rwanda. There is a need to (i) train health care professionals in providing neonatal and paediatric care according to nationally adopted clinical practice guidelines (e.g. ETAT+); (ii) establish a supervision and mentoring programme to ensure that the guidelines are available and used appropriately in district hospitals; and (iii) use admission checklists (e.g. neonatal and paediatric admission records) in district hospitals.

A pediatric death audit in a large referral hospital in Malawi

BACKGROUND

Death audits have been used to describe pediatric mortality in under-resourced settings, where record keeping is often a challenge. This information provides the cornerstone for the foundation of quality improvement initiatives. Malawi, located in sub-Saharan Africa, currently has an Under-5 mortality rate of 64/1000. Kamuzu Central Hospital, in the capital city Lilongwe, is a busy government referral hospital, which admits up to 3000 children per month. A study published in 2013 reported mortality rates as high as 9%. This is the first known audit of pediatric death files conducted at this hospital.

METHODS

A retrospective chart review on all pediatric deaths that occurred at Kamuzu Central Hospital (excluding deaths in the neonatal nursery) during a 13-month period was done using a standardized death audit form. A descriptive analysis was completed, including patient demographics, HIV and nutritional status, and cause of death. Modifiable factors were identified that may have contributed to mortality, including a lack of vital sign collection, poor documentation, and delays in the procurement or results of tests, studies, and specialist review.

RESULTS

Seven hundred forty three total pediatric deaths were recorded and 700 deceased patient files were reviewed. The mortality rate by month ranged from a low of 2.2% to a high of 4.4%. Forty-four percent of deaths occurred within the first 24 h of admission, and 59% occurred within the first 48 h. The most common causes of death were malaria, malnutrition, HIV-related illnesses, and sepsis.

CONCLUSIONS

The mortality rate for this pediatric referral center has dramatically decreased in the 6 years since the last published mortality data, but remains high. Areas identified for continued development include improved record keeping, improved patient assessment and monitoring, and more timely and reliable provision of testing and treatment. This study demonstrates that in low-resource settings, where reliable record keeping is often difficult, death audits are useful tools to describe the sickest patient population and determine factors possibly contributing to mortality that may be amenable to quality improvement interventions.

A Standardized Needs Assessment Tool to Inform the Curriculum Development Process for Pediatric Resuscitation Simulation-Based Education in Resource-Limited Settings

INTRODUCTION

Under five mortality rates (UFMR) remain high for children in low- and middle-income countries (LMICs) in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities). In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO) has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal.

MATERIALS AND METHODS

The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment, and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation.

RESULTS

Infectious diseases (respiratory illnesses and diarrheal disease) were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations.

DISCUSSION AND CONCLUSION

Epidemiology of disease burden reported by respondents was relatively consistent with WHO country-specific UFMR statistics in each setting. Results of the needs assessment survey were subsequently used to refine goals and objectives for the simulation curriculum and to ensure delivery of pragmatic educational content with recommendations that were contextualized for local capacity and resource availability. Effective use of the tool in two different settings increases its potential generalizability.

Implementing the Emergency Triage, Assessment and Treatment plus admission care (ETAT+) clinical practice guidelines to improve quality of hospital care in Rwandan district hospitals: healthcare workers' perspectives on relevance and challenges

Background

An emergency triage, assessment and treatment plus admission care (ETAT+) intervention was implemented in Rwandan district hospitals to improve hospital care for severely ill infants and children. Many interventions are rarely implemented with perfect fidelity under real-world conditions. Thus, evaluations of the real-world experiences of implementing ETAT+ are important in terms of identifying potential barriers to successful implementation. This study explored the perspectives of Rwandan healthcare workers (HCWs) on the relevance of ETAT+ and documented potential barriers to its successful implementation.

Methods

HCWs enrolled in the ETAT+ training were asked, immediately after the training, their perspective regarding (i) relevance of the ETAT+ training to Rwandan district hospitals; (ii) if attending the training would bring about change in their work; and (iii) challenges that they encountered during the training, as well as those they anticipated to hamper their ability to translate the knowledge and skills learned in the ETAT+ training into practice in order to improve care for severely ill infants and children in their hospitals. They wrote their perspectives in French, Kinyarwanda, or English and sometimes a mixture of all these languages that are official in the post-genocide Rwanda. Their notes were translated to (if not already in) English and transcribed, and transcripts were analyzed using thematic content analysis.

Results

One hundred seventy-one HCWs were included in our analysis. Nearly all these HCWs stated that the training was highly relevant to the district hospitals and that it aligned with their work expectation. However, some midwives believed that the “neonatal resuscitation and feeding” components of the training were more relevant to them than other components. Many HCWs anticipated to change practice by initiating a triage system in their hospital and by using job aids including guidelines for prescription and feeding. Most of the challenges stemmed from the mode of the ETAT+ training delivery (e.g., language barriers, intense training schedule); while others were more related to uptake of guidelines in the district hospitals (e.g., staff turnover, reluctance to change, limited resources, conflicting protocols).

Conclusion

This study highlights potential challenges to successful implementation of the ETAT+ clinical practice guidelines in order to improve quality of hospital care in Rwandan district hospitals. Understanding these challenges, especially from HCWs perspective, can guide efforts to improve uptake of clinical practice guidelines including ETAT+ in Rwanda.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2193-4) contains supplementary material, which is available to authorized users.

Managing anaphylaxis in the office setting

BACKGROUND

Although the definition of anaphylaxis for clinical use may vary by professional health care organizations and individuals, the definition consistently includes the concepts of a serious, generalized or systemic, allergic or hypersensitivity reaction that can be life-threatening or even fatal.

METHODS

In this review, we presented the important topics in the treatment of anaphylaxis in the office setting. This review will discuss triggers and risk factors, clinical diagnosis, and management of anaphylaxis in the office setting.

RESULTS

Anaphylaxis in the office setting is a medical emergency. It, therefore, is important to prepare for it, to have a posted, written anaphylaxis emergency protocol, and to rehearse the plan regularly. In this review, we presented the important steps in managing anaphylaxis in the office. Treatment of anaphylaxis should start with epinephrine administered intramuscularly at the first sign of anaphylaxis. Oxygen and intravenous fluids may be needed for moderate-to-severe anaphylaxis or anaphylaxis that is quickly developing or if the patient is unresponsive to the first injection of epinephrine. Antihistamine therapy is considered adjunctive to epinephrine, which mainly relieves itching and urticaria. Corticosteroids, with an onset of action of 4-6 hours, have no immediate effect on anaphylaxis.

CONCLUSION

To prevent near-fatal and fatal reactions from anaphylaxis, the patient, the family, and the physician must remember to follow the necessary steps when treating anaphylaxis. In anaphylaxis, there is no absolute contraindication for epinephrine.

Pediatric emergency care capacity in a low-resource setting: An assessment of district hospitals in Rwanda

BACKGROUND

Health system strengthening is crucial to improving infant and child health outcomes in low-resource countries. While the knowledge related to improving newborn and child survival has advanced remarkably over the past few decades, many healthcare systems in such settings remain unable to effectively deliver pediatric advance life support management. With the introduction of the Emergency Triage, Assessment and Treatment plus Admission care (ETAT+)-a locally adapted pediatric advanced life support management program-in Rwandan district hospitals, we undertook this study to assess the extent to which these hospitals are prepared to provide this pediatric advanced life support management. The results of the study will shed light on the resources and support that are currently available to implement ETAT+, which aims to improve care for severely ill infants and children.

METHODS

A cross-sectional survey was undertaken in eight district hospitals across Rwanda focusing on the availability of physical and human resources, as well as hospital services organizations to provide emergency triage, assessment and treatment plus admission care for severely ill infants and children.

RESULTS

Many of essential resources deemed necessary for the provision of emergency care for severely ill infants and children were readily available (e.g. drugs and laboratory services). However, only 4/8 hospitals had BVM for newborns; while nebulizer and MDI were not available in 2/8 hospitals. Only 3/8 hospitals had F-75 and ReSoMal. Moreover, there was no adequate triage system across any of the hospitals evaluated. Further, guidelines for neonatal resuscitation and management of malaria were available in 5/8 and in 7/8 hospitals, respectively; while those for child resuscitation and management of sepsis, pneumonia, dehydration and severe malnutrition were available in less than half of the hospitals evaluated.

CONCLUSIONS

Our assessment provides evidence to inform new strategies to enhance the capacity of Rwandan district hospitals to provide pediatric advanced life support management. Identifying key gaps in the health care system is required in order to facilitate the implementation and scale up of ETAT+ in Rwanda. These findings also highlight a need to establish an outreach/mentoring program, embedded within the ongoing ETAT+ program, to promote cross-hospital learning exchanges.

Teaching Pediatric Life Support in Limited-Resource Settings: Contextualized Management Guidelines

Of the estimated 6.3 million global annual deaths in children younger than the age of 5 years, nearly all (99%) occur in low- to middle-income countries (LMIC). Existing management guidelines for children with emergency conditions as taught in a variety of current pediatric life support courses are mostly applicable to high-income countries with a different disease range and full resources compared with LMIC. A revised curriculum with evidence-based application to limited-resource settings would expand their potential for reducing pediatric mortality worldwide. This review provides a supplemental curriculum of standards for selected pediatric emergency conditions with attention to the context of disease range and level-specific resources in LMIC. During training sessions, contextualized management guidelines create the framework for realistic and fruitful case simulations.

The Assessment, Evaluation, and Management of the Critically Ill Child When Resources are Limited-Southeast Asian Perspective

The Southeast Asia region comprises 10 independent countries with highly divergent health systems and health status. The heterogeneity in infant and child mortality rates suggests that there is still scope for improvement in the care of critically ill children. There is, however, a paucity of published data on outcomes and processes of care that could affect planning and implementation of intervention programs. Significant challenges in the delivery of care for the critically ill child remain, especially in pre-hospital and in-hospital triaging and emergency care and inpatient hospital care. Potential areas for continued improvement include strengthening of health systems through sustained commitment by local governments, capacity building, and sharing of research output. Simple, low cost, locally available, and effective solutions should be sought. The introduction of standards and auditing tools can assist in determining effectiveness and outcomes of intervention packages that are adapted to local settings. Recognition and acknowledgment of shortfalls between expectations and outcomes is a first step to overcoming some of these obstacles necessary to achieve a seamless interface among pre-hospital, emergency, inpatient, and critical care delivery processes that would improve survival of critically ill children in this region.

A model for oxygen conservation associated with titration during pediatric oxygen therapy

BACKGROUND

Continuous oxygen treatment is essential for managing children with hypoxemia, but access to oxygen in low-resource countries remains problematic. Given the high burden of pneumonia in these countries and the fact that flow can be gradually reduced as therapy progresses, oxygen conservation through routine titration warrants exploration.

AIM

To determine the amount of oxygen saved via titration during oxygen therapy for children with hypoxemic pneumonia.

METHODS

Based on published clinical data, we developed a model of oxygen flow rates needed to manage hypoxemia, assuming recommended flow rate at start of therapy, and comparing total oxygen used with routine titration every 3 minutes or once every 24 hours versus no titration.

RESULTS

Titration every 3 minutes or every 24 hours provided oxygen savings estimated at 11.7% ± 5.1% and 8.1% ± 5.1% (average ± standard error of the mean, n = 3), respectively. For every 100 patients, 44 or 30 kiloliters would be saved-equivalent to 733 or 500 hours at 1 liter per minute.

CONCLUSIONS

Ongoing titration can conserve oxygen, even performed once-daily. While clinical validation is necessary, these findings could provide incentive for the routine use of pulse oximeters for patient management, as well as further development of automated systems.

Pediatric Resuscitation Education in Low-Middle-Income Countries: Effective Strategies for Successful Program Development

Despite established international guidelines, there is considerable variability in the quality of resuscitative care received by critically ill children in low-middle-income countries. While this problem is certainly multifactorial, education of health care workers is an important determinant of care quality. This article will discuss approaches to health care worker education in pediatric resuscitation in low-middle-income countries, with emphasis on aspects of educational programs that may contribute to positive educational and clinical outcomes.

Correlates of Performance of Healthcare Workers in Emergency, Triage, Assessment and Treatment plus Admission Care (ETAT+) Course in Rwanda: Context Matters

BACKGROUND

The Emergency, Triage, Assessment and Treatment plus Admission care (ETAT+) course, a comprehensive advanced pediatric life support course, was introduced in Rwanda in 2010 to facilitate the achievement of the fourth Millennium Development Goal. The impact of the course on improving healthcare workers (HCWs) knowledge and practical skills related to providing emergency care to severely ill newborns and children in Rwanda has not been studied.

OBJECTIVE

To evaluate the impact of the ETAT+ course on HCWs knowledge and practical skills, and to identify factors associated with greater improvement in knowledge and skills.

METHODS

We used a one group, pre-post test study using data collected during ETAT+ course implementation from 2010 to 2013. The paired t-test was used to assess the effect of ETAT+ course on knowledge improvement in participating HCWs. Mixed effects linear and logistic regression models were fitted to explore factors associated with HCWs performance in ETAT+ course knowledge and practical skills assessments, while accounting for clustering of HCWs in hospitals.

RESULTS

374 HCWs were included in the analysis. On average, knowledge scores improved by 22.8/100 (95% confidence interval (CI) 20.5, 25.1). In adjusted models, bilingual (French & English) participants had a greater improvement in knowledge 7.3 (95% CI 4.3, 10.2) and higher odds of passing the practical skills assessment (adjusted odds ratio (aOR) = 2.60; 95% CI 1.25, 5.40) than those who were solely proficient in French. Participants who attended a course outside of their health facility had higher odds of passing the skills assessment (aOR = 2.11; 95% CI 1.01, 4.44) than those who attended one within their health facility.

CONCLUSIONS

The current study shows a positive impact of ETAT+ course on improving participants' knowledge and skills related to managing emergency pediatric and neonatal care conditions. The findings regarding key factors influencing ETAT+ course outcomes demonstrate the importance of considering key contextual factors (e.g., language barriers) that might affect HCWs performance in this type of continuous medical education.

Identification of Barriers to Pediatric Care in Limited-Resource Settings: A Simulation Study

OBJECTIVES

Eighty percent of the 10 million annual deaths in children aged <5 years in developing countries are estimated to be avoidable, with improvements in education for pediatric emergency management being a key factor. Education must take into account cultural considerations to be effective. Study objectives were: (1) to use simulation to identify factors posing barriers to patient care in limited resource settings (LRS); and (2) to understand how simulations in LRS can affect communication and decision-making processes.

METHODS

A qualitative study was conducted at 17 different sites in 12 developing countries in Asia, Latin America, and Africa. Data from observations of 68 in situ simulated pediatric emergencies were coded for thematic analysis. Sixty-two different "key informants" were interviewed regarding perceived benefit of simulations.

RESULTS

Coding of observations and interviews yielded common themes: impact of culture on team hierarchy, impact of communication and language barriers on situational awareness, systematic emergency procedures, role delineation, shared cognition and resource awareness through simulation, logistic barriers to patient care, and use of recognition-primed decision-making by experienced clinicians. Changes in clinical environments were implemented as a result of simulations.

CONCLUSIONS

Ad hoc teams in LRS face challenges in caring safely for patients; these include language and cultural barriers, as well as environmental and resource constraints. Engaging teams in simulations may promote improved communication, identification of systems issues and latent threats to target for remediation. There may be a role for training novices in use of recognition-primed or algorithmic decision-making strategies to improve rapidity and efficiency of decisions in LRS.

Quality of inpatient pediatric case management for four leading causes of child mortality at six government-run Ugandan hospitals

BACKGROUND

A better understanding of case management practices is required to improve inpatient pediatric care in resource-limited settings. Here we utilize data from a unique health facility-based surveillance system at six Ugandan hospitals to evaluate the quality of pediatric case management and the factors associated with appropriate care.

METHODS

All children up to the age of 14 years admitted to six district or regional hospitals over 15 months were included in the study. Four case management categories were defined for analysis: suspected malaria, selected illnesses requiring antibiotics, suspected anemia, and diarrhea. The quality of case management for each category was determined by comparing recorded treatments with evidence-based best practices as defined in national guidelines. Associations between variables of interest and the receipt of appropriate case management were estimated using multivariable logistic regression.

RESULTS

A total of 30,351 admissions were screened for inclusion in the analysis. Ninety-two percent of children met criteria for suspected malaria and 81% received appropriate case management. Thirty-two percent of children had selected illnesses requiring antibiotics and 89% received appropriate antibiotics. Thirty percent of children met criteria for suspected anemia and 38% received appropriate case management. Twelve percent of children had diarrhea and 18% received appropriate case management. Multivariable logistic regression revealed large differences in the quality of care between health facilities. There was also a strong association between a positive malaria diagnostic test result and the odds of receiving appropriate case management for comorbid non-malarial illnesses - children with a positive malaria test were more likely to receive appropriate care for anemia and less likely for illnesses requiring antibiotics and diarrhea.

CONCLUSIONS

Appropriate management of suspected anemia and diarrhea occurred infrequently. Pediatric quality improvement initiatives should target deficiencies in care unique to each health facility, and interventions should focus on the simultaneous management of multiple diagnoses.

A Prospective Hospital-based Surveillance to Estimate Rotavirus Disease Burden in Bhutanese Children under 5 Years of Age

As part of efforts to develop an informed policy for rotavirus vaccination, this prospective study was conducted to estimate the burden of rotavirus diarrhea among children less than 5 years old attended to the Department of Pediatrics, Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu, Bhutan. The duration of the study was three years, extending from February 2010 through December 2012. We estimated the frequency of hospitalization in the pediatric ward and dehydration treatment unit (DTU) for diarrhea and the number of events attributable to rotavirus infection among children under 5 years of age. During the study period, a total of 284 children (1 in 45) were hospitalized in the pediatric ward, and 2,220 (1 in 6) in the DTU with diarrhea among children residing in the Thimphu district. Group A rotavirus was detected in 32.5% and 18.8% of the stool samples from children hospitalized in the pediatric ward, respectively. Overall, 22.3% of the stool samples were rotavirus-positive, and the majority (90.8%) of them was detected in children under 2 years of age. From this study, we estimated that the annual incidence of hospitalization in the pediatric ward and DTU due to rotavirus diarrhea was 2.4/1000 (95% CI 1.7–3.4) and 10.8/1000 (95% CI 9.1–12.7) children, respectively. This study revealed that rotavirus is a major cause of diarrhea in Bhutanese children in Thimphu district and since no study has been performed previously, represents an important finding for policy discussions regarding the adoption of a rotavirus vaccine in Bhutan.

Knowledge and skills retention following Emergency Triage, Assessment and Treatment plus Admission course for final year medical students in Rwanda: a longitudinal cohort study

AIM

To determine whether, after the Emergency Triage, Assessment and Treatment plus Admission (ETAT+) course, a comprehensive paediatric life support course, final year medical undergraduates in Rwanda would achieve a high level of knowledge and practical skills and if these were retained. To guide further course development, student feedback was obtained.

METHODS

Longitudinal cohort study of knowledge and skills of all final year medical undergraduates at the University of Rwanda in academic year 2011-2012 who attended a 5-day ETAT+ course. Students completed a precourse knowledge test. Knowledge and clinical skills assessments, using standardised marking, were performed immediately postcourse and 3-9 months later. Feedback was obtained using printed questionnaires.

RESULTS

84 students attended the course and re-evaluation. Knowledge test showed a significant improvement, from median 47% to 71% correct answers (p<0.001). For two clinical skills scenarios, 98% passed both scenarios, 37% after a retake, 2% failed both scenarios. Three to nine months later, students were re-evaluated, median score for knowledge test 67%, not significantly different from postcourse (p>0.1). For clinical skills, 74% passed, with 32% requiring a retake, 8% failed after retake, 18% failed both scenarios, a significant deterioration (p<0.0001).

CONCLUSIONS

Students performed well on knowledge and skills immediately after a comprehensive ETAT+ course. Knowledge was maintained 3-9 months later. Clinical skills, which require detailed sequential steps, declined, but most were able to perform them satisfactorily after feedback. The course was highly valued, but several short courses and more practical teaching were advocated.

International consensus on (ICON) anaphylaxis

ICON: Anaphylaxis provides a unique perspective on the principal evidence-based anaphylaxis guidelines developed and published independently from 2010 through 2014 by four allergy/immunology organizations. These guidelines concur with regard to the clinical features that indicate a likely diagnosis of anaphylaxis -- a life-threatening generalized or systemic allergic or hypersensitivity reaction. They also concur about prompt initial treatment with intramuscular injection of epinephrine (adrenaline) in the mid-outer thigh, positioning the patient supine (semi-reclining if dyspneic or vomiting), calling for help, and when indicated, providing supplemental oxygen, intravenous fluid resuscitation and cardiopulmonary resuscitation, along with concomitant monitoring of vital signs and oxygenation. Additionally, they concur that H1-antihistamines, H2-antihistamines, and glucocorticoids are not initial medications of choice. For self-management of patients at risk of anaphylaxis in community settings, they recommend carrying epinephrine auto-injectors and personalized emergency action plans, as well as follow-up with a physician (ideally an allergy/immunology specialist) to help prevent anaphylaxis recurrences. ICON: Anaphylaxis describes unmet needs in anaphylaxis, noting that although epinephrine in 1 mg/mL ampules is available worldwide, other essentials, including supplemental oxygen, intravenous fluid resuscitation, and epinephrine auto-injectors are not universally available. ICON: Anaphylaxis proposes a comprehensive international research agenda that calls for additional prospective studies of anaphylaxis epidemiology, patient risk factors and co-factors, triggers, clinical criteria for diagnosis, randomized controlled trials of therapeutic interventions, and measures to prevent anaphylaxis recurrences. It also calls for facilitation of global collaborations in anaphylaxis research. IN ADDITION TO CONFIRMING THE ALIGNMENT OF MAJOR ANAPHYLAXIS GUIDELINES, ICON: Anaphylaxis adds value by including summary tables and citing 130 key references. It is published as an information resource about anaphylaxis for worldwide use by healthcare professionals, academics, policy-makers, patients, caregivers, and the public.