Triage in the developing world--can it be done?

Implementation of the South African Triage Scale (SATS) in a New Ambulance System in Beira, Mozambique: A Retrospective Observational Study

In 2019, an urban ambulance system was deployed in the city of Beira, Mozambique to refer patients from peripheral health centres (HCs) to the only hospital of the city (Beira Central Hospital-HCB). Initially, the system worked following a first-in-first-out approach, thus leading to referrals not based on severity condition. With the aim of improving the process, the South African Triage Scale (SATS) has been subsequently introduced in three HCs. In this study, we assessed the impact of SATS implementation on the selection process and the accuracy of triage performed by nurses. We assessed 552 and 1608 referral charts from before and after SATS implementation, respectively, and we retrospectively calculated codes. We compared the expected referred patients' codes from the two phases, and nurse-assigned codes to the expected ones. The proportion of referred orange and red codes significantly increased (+12.2% and +12.9%) while the proportion of green and yellow codes decreased (-18.7% and -5.8%). The overall rates of accuracy, and under- and overtriage were 34.2%, 36.3%, and 29.5%, respectively. The implementation of SATS modified the pattern of referred patients and increased the number of severe cases receiving advanced medical care at HCB. While nurses' accuracy improved with the routine use of the protocol, the observed rates of incorrect triage suggest that further research is needed to identify factors affecting SATS application in this setting.

Triage and resuscitation tools for low and middle income countries: how to catch the killer?

Under-5 mortality rates in low and middle-income countries (LMIC) remain high. One major contributing factor is the failure to recognise critically unwell children when they first present to hospital. This leads to delayed or inadequate resuscitation and an increased risk of death.Triage is a key skill in this setting to sort the queue and prioritise patients, even when staff and equipment are scarce. In LMIC, children generally present late in their illness and often have progressed to some degree of multiorgan dysfunction.Following triage, a structured systematic primary survey is critical to ensure the detection of subtle signs of multiorgan dysfunction. Repeated physiological assessments of the child guide subsequent resuscitation management decisions, which depend somewhat on the resources available.It is possible to achieve significant improvements in survival of critically unwell children presenting for emergency care in the resource-limited setting. The three key steps in the patient's journey that we can influence in emergency care are triage, primary survey and initial stabilisation. Resources that address these steps have been developed for all settings. However, these resources were developed in a specific clinical context, and must therefore be adapted to local structures and processes. A systematic approach to triage and resuscitation saves lives.

Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya

Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation.  Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.

Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya

Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation.  Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.

Nurse-led implementation of ETAT+ is associated with reduced mortality in a children's hospital in Freetown, Sierra Leone

BACKGROUND

In the wake of the Ebola virus disease (EVD) epidemic in Sierra Leone, secondary care facilities faced an increase in admissions with few members of medical staff available to assess and treat patients. This led to long waiting times in hospital outpatient departments. The study was undertaken in the outpatient department of Ola During Children's Hospital (the tertiary paediatric hospital for Sierra Leone) in the period immediately following the EVD epidemic of 2014-2015.

AIMS

This retrospective analysis of operational programme data aimed to assess whether a quality-improvement approach and task-sharing between medical and nursing staff improved the quality of triage and the timeliness of care.

METHODS

All staff working in the outpatient department were offered a 4-week training course, followed by on-the-job supervision and support for 6 months. Nurses who successfully completed the course were given responsibility for the initial assessment of sick patients and for prescribing and giving initial treatment. Data were collected at three points: before intervention and at 3 and 6 months after initiation of the intervention. All children presenting to the hospital for medical attention between 0800 and 1400 Monday to Friday were included. Triage assessment by the outpatient nurse was compared to that made by a clinically experienced observer, and the time taken for each child to be triaged, assessed and given initial treatment was recorded.

RESULTS

Between months 0 and 6 of the intervention, detection of emergency signs by the triage nurse improved from 30% to 100%, and detection of priority signs improved from 34% to 100%. For children presenting with emergency signs, the median time between triage and full assessment improved from 57 minutes before intervention to 17 minutes at 3 months and 5 minutes at 6 months (p < 0.0005). For the same group, median time between triage and first antibiotic or antimalarial treatment improved from 220 minutes before intervention to 40 minutes at 3 months and 18 minutes at 6 months (p = 0.006).

CONCLUSION

The results indicate that, with appropriate training and support, extending the emergency assessment and treatment of sick children to nursing staff in West African hospitals may improve the accuracy of triage and the time to assessment and treatment of children presenting with signs of serious illness.

<p>Validation of the Cipto Triage Method: A Single-Centre Study from Indonesia</p>

Purpose

A national referral hospital in Indonesia developed a three-category triage acuity method called the Cipto Triage Method (CTM) for emergency departments (ED) in developing countries. This was a validation study to assess the performance of the triage method.

Methods

This cohort, retrospective, single-centre study was conducted in the ED of Cipto Mangunkusumo Hospital that receives approximately 30,000 patient visits per year. The ED medical records throughout the year 2017 were randomly selected as the study sample. Completely written forms of triage and ED initial assessment were included in this study. Validation of the CTM decision was done by using expert panel opinion as reference standard, and also using surrogate conditions such as patient outcome for hospital admission and in-hospital mortality.

Results

There were 1348 samples assigned to the following three categories: resuscitation (14.9%), urgent (63.8%) and non-urgent (21.3%). Overall accuracy was more than 80%, positive predictive value and negative predictive value for resuscitation category were 99% (95% confidence interval [CI], 96.5–99.9) and 96.9% (95% CI, 95.7−97.8), respectively. Resuscitation category had a relative risk (RR) for admission of 1.341 (95% CI, 1.259–1.429) and a RR for mortality of 4.294 (95% CI, 3.180–5.799). Undertriage increases the risk of mortality compared to correct triage (RR, 3.1; 95% CI, 2.11–4.54).

Conclusion

CTM has a good criterion and construct validity; it is also easy to understand and can accommodate a simple ED design in the majority of hospitals in Indonesia.

Assessment of Attitudes Toward the Emergency Triage System in Belize

Objective. Triage in resource-limited settings (RLS) improves outcomes. Emergency Triage Assessment and Treatment (ETAT) is a simple triage algorithm that improves assessment and initial management of children in RLS. In Belize, pediatric triage varies with setting, from a 5-level Emergency Severity Index (ESI) used at the National Referral Hospital to a lack of triage at government health centers (GHC). Most data on ETAT implementation are in settings where no triage system existed; data on how to integrate ETAT into existing, heterogeneous triage systems are lacking. The aim of this study is to explore health care providers' (HCPs) attitudes toward the current triage system prior to national pediatric triage process implementation. Methods. A qualitative study was performed via convenience sampling of HCPs who participated in an ETAT training course using focus groups immediately and 1 year after an initial ETAT training. Focus groups were digitally recorded and transcribed. Three coders analyzed all transcripts to identify emerging themes. Constant comparison analysis was performed until achieving thematic saturation. Results. The following principal themes emerged: (1) importance of triage education and implementation to standardize and improve communication; (2) major limitations of ESI include its complexity, lack of pediatric-specific criteria, and dependence on equipment not consistently available; and (3) desire to implement a simple, low-resource pediatric-specific triage system. Conclusions. Participants believe triage education and process implementation is essential to improve communication and pediatric emergency care. Simple, low-resource pediatric-specific triage systems, like ETAT, may improve utilization by providing faster recognition and improved care for acutely ill children.

Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya

Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation.  Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.

Modified systemic inflammatory response syndrome and provider gestalt predicting adverse outcomes in children under 5 years presenting to an urban emergency department of a tertiary hospital in Tanzania

BACKGROUND

Modified systemic inflammatory response syndrome (mSIRS) criteria for the pediatric population together with the provider gestalt have the potential to predict clinical outcomes. However, this has not been studied in low-income countries. We investigated the ability of mSIRS and provider gestalt to predict mortality and morbidity among children presenting to the ED of a tertiary level hospital in Tanzania.

METHODS

This prospective observational study enrolled a convenience sample of children under 5 years old, presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2015 to April 2016. Trained researchers used a structured case report form to record patient demographics, clinical presentation, initial provider gestalt of severity of illness, and the mSIRS criteria. Primary outcomes were 24-h mortality and overall in-hospital mortality. Data was analyzed using simple descriptive statistics, Kruskal-Wallis, Mann-Whitney U, and chi-squared tests.

RESULTS

We enrolled 1350 patients, median age 17 months (interquartile range 8-32 months), and 58% were male. Provider gestalt estimates of illness severity were recorded for all patients and 1030 (76.3%) had complete data for mSIRS categorization. Provider gestalt classified 97 (7.2%) patients as healthy, 546 (40.4%) as mildly ill, 457 (33.9%) as moderately ill, and 250 (18.5%) as severely ill. Of the patients, classifiable by mSIRS, 411/1030 (39.9%) had ≥ 2 mSIRS criteria. In predicting 24-h mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 82% and 81%, respectively, and specificity of 61% and 84%, respectively. In predicting overall in-hospital mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 66% and 70% with a specificity of 62% and 86% respectively.

CONCLUSION

Both the mSIRS and provider gestalt were highly specific for predicting 24-h and overall in-hospital mortality in our patient population. The clinical utility of these assessment methods is limited by the low positive predictive value.

Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review

OBJECTIVE

Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs.

METHODS

We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria.

RESULTS

Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence.

CONCLUSION

The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.

Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial

BACKGROUND

Although the African "Fluid Expansion as Supportive therapy" (FEAST) trial showed fluid resuscitation was harmful in children with severe febrile illness managed in resource-limited hospitals, the most recent evidence reviewed World Health Organization (WHO) guidelines continue to recommend fluid boluses in children with shock according to WHO criteria "WHO shock", arguing that the numbers included in the FEAST trial were too small to provide reasonable certainty.

METHODS

We re-analysed the FEAST trial results for all international definitions for paediatric shock including hypotensive (or decompensated shock) and the WHO criteria. In addition, we examined the clinical relevance of the WHO criteria to published and unpublished observational studies reporting shock in resource-limited settings.

RESULTS

We established that hypotension was rare in children with severe febrile illness complicating only 29/3170 trial participants (0.9%). We confirmed that fluid boluses were harmful irrespective of the definitions of shock including the very small number with WHO shock (n = 65). In this subgroup 48% of bolus recipients died at 48 h compared to 20% of the non-bolus control group, an increased absolute risk of 28%, but translating to an increased relative risk of 240% (p = 0.07 (two-sided Fisher's exact test)). Examining studies describing the prevalence of the stringent WHO shock criteria in children presenting to hospital we found this was rare (~ 0.1%) and in these children mortality was very high (41.5-100%).

CONCLUSIONS

The updated WHO guidelines continue to recommend boluses for a very limited number of children presenting at hospital with the strict definition of WHO shock. Nevertheless, the 3% increased mortality from boluses seen across FEAST trial participants would also include this subgroup of children receiving boluses. Recommendations aiming to differentiate WHO shock from other definitions will invariably lead to "slippage" at the bedside, with the potential of exposing a wider group of children to the harm of fluid-bolus therapy.

Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience

BACKGROUND

Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available.

OBJECTIVES

To evaluate the feasibility of integrating a high-intensity ultrasound training program into the formal curriculum for emergency medicine resident physicians in an LMIC.

METHODS

We conducted a pilot ultrasound training program focusing on CPUS for 20 emergency medicine resident physicians in Kumasi, Ghana, which consisted of didactic sessions and hands-on practice. Competency was assessed by comparing pretest and posttest scores and with an Objective Structured Clinical Examination (OSCE) performed after the final training session.

RESULTS

The mean score on the pretest was 61%, and after training, the posttest score was 96%. All residents obtained passing scores above 70% on the OSCE.

CONCLUSION

A high-intensity ultrasound training program can be successfully integrated into an emergency medicine training curriculum in an LMIC.

Suspected infection in afebrile patients: Are they septic?

We prospectively evaluated afebrile patients admitted to an emergency department (ED), with suspected infection and only tachycardia or tachypnea.The white blood cell count (WBC) was obtained, and patients were considered septic if leukocyte count was >12,000 μL-1 or <4000 μL-1 or with >10% of band forms. Clinical data were collected to examine whether sepsis could be predicted.Seventy patients were included and 37 (52.86%) met sepsis criteria. Self-measured fever showed an odds ratio (OR) of 5.936 (CI95% 1.450-24.295; P = 0.0133) and increased pulse pressure (PP) showed an OR of 1.405 (CI95% 1.004-1.964; P = 0.0471) on multivariate analysis. When vital signs were included in multivariate analysis, the heart rate showed an OR of 2.112 (CI95% 1.400-3.188; P = 0.0004). Self-measured fever and mean arterial pressure <70 mm Hg had high positive likelihood ratios (3.86 and 2.08, respectively). The nomogram for self-measured fever showed an increase of sepsis chance from 53% (pretest) to approximately 80% (post-test).The recognition of self-measured fever, increased PP, and the intensity of heart rate response may improve sepsis recognition in afebrile patients with tachycardia or tachypnea. These results are important for medical assessment of sepsis in remote areas, crowded and low-resourced EDs, and low-income countries, where WBC may not be readily available.

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.

Reliability and validity of pediatric triage tools evaluated in Low resource settings: a systematic review

BACKGROUND

Despite the high burden of pediatric mortality from preventable conditions in low and middle income countries and the existence of multiple tools to prioritize critically ill children in low-resource settings, no analysis exists of the reliability and validity of these tools in identifying critically ill children in these scenarios.

METHODS

The authors performed a systematic search of the peer-reviewed literature published, for studies pertaining to for triage and IMCI in low and middle-income countries in English language, from January 01, 2000 to October 22, 2013. An updated literature search was performed on on July 1, 2015. The databases searched included the Cochrane Library, EMBASE, Medline, PubMed and Web of Science. Only studies that presented data on the reliability and validity evaluations of triage tool were included in this review. Two independent reviewers utilized a data abstraction tool to collect data on demographics, triage tool components and the reliability and validity data and summary findings for each triage tool assessed.

RESULTS

Of the 4,717 studies searched, seven studies evaluating triage tools and 10 studies evaluating IMCI were included. There were wide varieties in method for assessing reliability and validity, with different settings, outcome metrics and statistical methods.

CONCLUSIONS

Studies evaluating triage tools for pediatric patients in low and middle income countries are scarce. Furthermore the methodology utilized in the conduct of these studies varies greatly and does not allow for the comparison of tools across study sites.

Setting up and running a paediatric emergency department in a hospital in Malawi: 15 years on

Paediatric emergency care is not recognised as a specialty in many countries in Africa but is being practised increasingly. Setting up a paediatric emergency care unit takes time and often involves trial and error. Here we describe the start of the paediatric emergency department in Blantyre, Malawi, a low-income country and how it has continued to evolve over 15 years, in the hope that our experience will inform and assist others who are already developing their own emergency unit or wishing to do so.

Exploring the third delay: an audit evaluating obstetric triage at Mulago National Referral Hospital

BACKGROUND

Mulago National Referral Hospital has the largest maternity unit in sub-Saharan Africa. It is situated in Uganda, where the maternal mortality ratio is 310 per 100,000 live births. In 2010 a 'Traffic Light System' was set up to rapidly triage the vast number of patients who present to the hospital every day. The aim of this study was to evaluate the effectiveness of the obstetric department's triage system at Mulago Hospital with regard to time spent in admissions and to identify urgent cases and factors adversely affecting the system.

METHODS

A prospective audit of the obstetric admissions department was carried out at the Mulago Hospital. Data were obtained from tagged patient journeys using two data collection tools and compiled using Microsoft Excel. StatsDirect was used to compose graphs to illustrate the results.

RESULTS

Informal triage was occurring 46 % of the time at the first checkpoint in a woman's journey, but the 'Traffic Light System' was not being used and many of the patient's vital signs were not being recorded.

CONCLUSIONS

It is hypothesised that the 'Traffic Light System' is not being used due to its focus on examination finding and diagnosis, implying that it is not suitable for an early stage in the patient's journey. Replacing it with a simple algorithm to categorise women into the urgency with which they need to be seen could rectify this.

Impact of an Emergency Triage Assessment and Treatment (ETAT)-based triage process in the paediatric emergency department of a Guatemalan public hospital

BACKGROUND

Triage process implementation has been shown to be effective at improving patient outcomes. This study sought to develop, implement and assess the impact of an Emergency Triage Assessment and Treatment (ETAT)-based emergency triage process in the paediatric emergency department (PED) of a public hospital in Guatemala.

METHODS

The study was a quality improvement comparison with a before/after design. Uptake was measured by percentage of patients with an assigned triage category. Outcomes were hospital admission rate, inpatient length of stay (LOS), and mortality as determined by two distinct medical record reviews for 1 year pre- and post-intervention: a random sample (RS) of all PED patients and records for all critically-ill (CI) children [serious diagnoses or admission to the paediatric intensive care unit (PICU)]. Demographics, diagnoses and disposition were recorded.

RESULTS

The RS totalled 1027 (51.4% male); median ages pre- and post-intervention were 2.0 and 2.4 years, respectively. There were 196 patients in the CI sample, of whom 56.6% were male and one-third were neonates; median ages of the CI group pre- and post-intervention were 3.1 and 5.6 months, respectively. One year after implementation, 97.5% of medical records had been assigned triage categories. Triage categories (RS/CI) were: emergency (2.9%/54.6%), priority (47.6%/44.4%) and non-urgent (49.4%/1.0%). The CI group was more frequently diagnosed with shock (25%/1%), seizures (9%/0.5%) and malnutrition (6%/0.5%). Admission rates for the RS (8% vs 4%, P=0.01) declined after implementation. For the CI sample, admission rate to the PICU (47% vs 24%, P=0.002) decreased and LOS (7.3 vs 5.7 days, P=0.09) and mortality rates (12% vs 6%, P=0.15) showed trends toward decreasing post-implementation.

CONCLUSIONS

Paediatric-specific triage algorithms can be implemented and sustained in resource-limited settings. Significant decreases in admission rates (both overall and for the PICU) and trends towards decreased LOS and mortality rates of critically ill children suggest that ETAT-based triage systems have the potential to greatly improve patient care in Latin America.

Quality and Effectiveness of a Pediatric Triage Training Program in a Guatemalan Public Hospital

OBJECTIVES

This study aimed to develop and implement an Emergency Triage Assessment and Treatment (ETAT) training program at a Guatemalan public hospital. Collaborators included Baylor College of Medicine/Texas Children's Hospital, the Guatemalan Ministry of Health, and the Pan American Health Organization.

METHODS

The ETAT is a World Health Organization program to teach pediatric assessment, triage, and initial management to health care workers in resource-limited settings. The Baylor College of Medicine/Texas Children's Hospital created ETAT training materials in Spanish (Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas [CETEP]) and conducted a train-the-trainer course for Hospital Nacional Pedro Bethancourt (HNPB) health care leadership. The HNPB subsequently conducted local trainings using a modified curriculum. Midcourse modifications based on evaluations and focus groups included distribution of manuals before training and an adding a day to the course.Course quality was assessed using participant evaluations and comparing pretest and posttest scores. Effectiveness was defined as 90% concordance between triage levels assigned by participants and facilitators.

RESULTS

A total of 249 health care workers were trained by 24 HNPB facilitators. Mean pretest and posttest scores were 55 and 70, respectively (P < 0.001). On a 4-point scale, participants rated overall course quality and effectiveness as 3.6. Mean pretest (49 vs 58, P = 0.002) and posttest scores (68 vs 72, P = 0.01) improved for groups trained after modifications, as did evaluations for course quality (3.4 vs 3.7, P < 0.001) and effectiveness (3.4 vs 3.8, P < 0.001). Triage levels were assigned with 95% concordance (confidence interval, 91.9-97.3) between participants and facilitators.

CONCLUSIONS

Hospital Nacional Pedro Bethancourt experts conducted high-quality trainings with locally relevant CETEP (ETAT) material. Trainings were effective and well received. The pediatric emergency department at HNPB now uses a triage system based on CETEP (ETAT).

Examination of patient flow in a rural health center in Malawi

Background

Malawi, like many low-income countries, is facing a severe health worker shortage. A potential stop-gap solution to this crisis is improving the efficiency of health center operations. Given the lack of research on center efficiency in rural health centers in Malawi, we conducted a study to identify deficiencies in center organization and barriers to patient flow.

Methods

We performed a time-motion survey at a rural health center in Ntaja, Malawi over a period of 1 week. We used a standardized questionnaire to collect information on the amount of time a patient spent with each health worker, the number of center staff that attended to each patient, and the total time spent at the center. Additionally, at the end of the visit, we conducted an exit survey to collect demographic information and data on perception of quality of care with the center visit for all patients.

Results

A total of 1018 patients were seen over the five-day study. The average total time spent at the center by the patients was 123 min (2–366 min). Adults had an average total time spent at the center of 111 min (2–366 min) and children 134 min (7–365 min). Patient waiting time (PWT) was higher in the early morning hours ranging from 157 min (between 06:00 and 08:00) to 53 min (between 14:00 and 16:00). Health worker contact time (HCT) was higher for adults (2.3 min) than children (1.7 min). Shorter wait times were associated with higher perceptions of quality of service.

Conclusion

Despite shortages in health workers and funds, opportunities are available to increase efficiency in rural health centers. By removing bottlenecks to increase the productivity of health workers, centers in low-income countries can treat more patients and improve service quality.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-2144-x) contains supplementary material, which is available to authorized users.

Regional scale-up of an Emergency Triage Assessment and Treatment (ETAT) training programme from a referral hospital to primary care health centres in Guatemala

OBJECTIVE

Emergency Triage Assessment and Treatment (ETAT) was developed by the WHO to teach paediatric assessment, triage and initial management to healthcare workers (HCWs) in resource-limited hospital-based settings. This study sought to evaluate the extension of ETAT training from a regional hospital to paediatric HCWs at local primary care health centres (PHCs) in Guatemala.

METHODS

Prior to providing a 16 h ETAT training module, immediately after, and at 3, 6 and 12 months, we used written pre-tests and post-tests and five-point Likert surveys to evaluate, respectively, clinical knowledge and provider confidence in providing acute care paediatrics; hands-on clinical skills were tested at 3, 6 and 12 months.

RESULTS

Fifty-two HCWs (14 general physicians, 38 nurses) from four regional PHCs participated; 65%, 60% and 46% completed 3-month, 6-month and 12-month follow-ups, respectively. Test scores show significant acquisition of clinical knowledge initially, which was retained over time when tested at 3, 6 and 12 months (46 vs 70, p<0.001). Hands-on clinical skills scores demonstrated retention at 3, 6 and 12 months. Although participants were more confident about acute care paediatrics immediately after training (66 vs 104, p<0.001), this decreased with time, though not to pre-intervention levels.

CONCLUSIONS

ETAT trainings were successfully extended to PHCs in a resource-limited setting with significant knowledge acquisition and retention over time and improved HCW confidence with acute care paediatrics. This process could serve as a successful model for in-country and international scale-up of ETAT.

How vital are the vital signs? A multi-center observational study from emergency departments of Pakistan

BACKGROUND

Vital signs play a critical role in prioritizing patients in emergency departments (EDs), and are the foundation of most triage methods and disposition decisions. This study was conducted to determine the frequency of vital signs documentation anytime during emergency department treatment and to explore if abnormal vital signs were associated with the likelihood of admission for a set of common presenting complaints.

METHODS

Data were collected over a four-month period from the EDs of seven urban tertiary care hospitals in Pakistan. The variables included age, sex, hospital type (government run vs. private), presenting complaint, ED vital signs, and final disposition. Patients who were >12 years of age were included in the analysis. The data were analyzed to describe the proportion of patients with documented vitals signs, which was then crossed-tabulated with top the ten presenting complaints to identify high-acuity patients and correlation with their admission status.

RESULTS

A total of 274,436 patients were captured in the Pakistan National Emergency Department Surveillance (Pak-NEDS), out of which 259,288 patients were included in our study. Vital signs information was available for 90,569 (34.9%) patients and the most commonly recorded vitals sign was pulse (25.7%). Important information such as level of consciousness was missing in the majority of patients with head injuries. Based on available information, only 13.3% with chest pain, 12.8% with fever and 12.8% patients with diarrhea could be classified as high-acuity. In addition, hospital admission rates were two- to four-times higher among patients with abnormal vital signs, compared with those with normal vital signs.

CONCLUSION

Most patients seen in the EDs in Pakistan did not have any documented vital signs during their visit. Where available, the presence of abnormal vital signs were associated with higher chances of admission to the hospital for the most common presenting symptoms.

Admission Risk Score to Predict Inpatient Pediatric Mortality at Four Public Hospitals in Uganda

Mortality rates among hospitalized children in many government hospitals in sub-Saharan Africa are high. Pediatric emergency services in these hospitals are often sub-optimal. Timely recognition of critically ill children on arrival is key to improving service delivery. We present a simple risk score to predict inpatient mortality among hospitalized children. Between April 2010 and June 2011, the Uganda Malaria Surveillance Project (UMSP), in collaboration with the National Malaria Control Program (NMCP), set up an enhanced sentinel site malaria surveillance program for children hospitalized at four public hospitals in different districts: Tororo, Apac, Jinja and Mubende. Clinical data collected through March 2013, representing 50249 admissions were used to develop a mortality risk score (derivation data set). One year of data collected subsequently from the same hospitals, representing 20406 admissions, were used to prospectively validate the performance of the risk score (validation data set). Using a backward selection approach, 13 out of 25 clinical parameters recognizable on initial presentation, were selected for inclusion in a final logistic regression prediction model. The presence of individual parameters was awarded a score of either 1 or 2 based on regression coefficients. For each individual patient, a composite risk score was generated. The risk score was further categorized into three categories; low, medium, and high. Patient characteristics were comparable in both data sets. Measures of performance for the risk score included the receiver operating characteristics curves and the area under the curve (AUC), both demonstrating good and comparable ability to predict deathusing both the derivation (AUC =0.76) and validation dataset (AUC =0.74). Using the derivation and validation datasets, the mortality rates in each risk category were as follows: low risk (0.8% vs. 0.7%), moderate risk (3.5% vs. 3.2%), and high risk (16.5% vs. 12.6%), respectively. Our analysis resulted in development of a risk score that ably predicted mortality risk among hospitalized children. While validation studies are needed, this approach could be used to improve existing triage systems.

Application of SIRS criteria to a paediatric surgical population in Malawi

INTRODUCTION

Little is known regarding systemic inflammatory response syndrome (SIRS) criteria and mortality in developing countries. We evaluated the utility of the SIRS criteria to predict death among a paediatric surgical population in Lilongwe, Malawi.

METHODS

Age, SIRS variables (temperature, heart rate, systolic blood pressure, respiratory rate and leucocyte count), diagnosis, surgical procedure and outcome were analysed for paediatric surgical patients during 2012. Age-specific criteria for SIRS variables were then applied to the data.

RESULTS

Using published SIRS criteria, temperature was the only variable that correlated with mortality. When norms for an African population were used, leucocyte count also correlated with mortality.

DISCUSSION

With the exception of temperature, published SIRS criteria were not predictive of mortality. Leucocyte count became predictive of death using norms specific to an African population. SIRS and its component data are a worthwhile area of future prospective research in developing countries.

The implementation of the South African Triage Score (SATS) in an urban teaching hospital, Ghana

INTRODUCTION

Triage is the process of sorting patients based on the level of acuity to ensure the most severely injured and ill patients receive timely care before their condition worsens. The South African Triage Scale (SATS) was developed out of a need for an accurate and objective measure of urgency based on physiological parameters and clinical discriminators that is easily implemented in low resource settings. SATS was introduced in the emergency center (EC) of Komfo Anokye Teaching Hospital (KATH) in January 2010. This study seeks to evaluate the accurate use of the SATS by nurses at KATH.

METHODS

This cross-sectional study was conducted in the EC at KATH in Kumasi, Ghana. Patients 12 years and over with complete triage information were included in this study. Each component of SATS was calculated (i.e. for heart rate of 41-50, a score of 1 was given) and summed. This score was compared to the original triage score. When scores did not equate, the entire triage record was reviewed by an emergency physician and an advanced practice emergency nurse separately to determine if the triage was appropriate. These reviews were compared and consensus reached.

RESULTS

52 of 903 adult patients (5.8%) were judged to have been mis-triaged by expert review; 49 under-triaged (sent to a zone that corresponded to a lower acuity level than they should have been, based on their vital signs) and 3 over-triaged. Of the 49 patients who were under-triaged, 34 were under-triaged by one category and 7 by two categories.

CONCLUSION

Under-triage is a concern to patient care and safety, and while the under-triage rate of 5.7% in this sample falls within the 5-10% range considered unavoidable by the American College of Surgeons Committee on Trauma, concentrated efforts to regularly train triage nurses to ensure no patients are under-triaged have been undertaken. Overall though, SATS has been implemented successfully in the EC at KATH by triage nurses.

Development of a severity of illness scoring system (inpatient triage, assessment and treatment) for resource-constrained hospitals in developing countries

OBJECTIVE

To develop a new paediatric illness severity score, called inpatient triage, assessment and treatment (ITAT), for resource-limited settings to identify hospitalised patients at highest risk of death and facilitate urgent clinical re-evaluation.

METHODS

We performed a nested case-control study at a Malawian referral hospital. The ITAT score was derived from four equally weighted variables, yielding a cumulative score between 0 and 8. Variables included oxygen saturation, temperature, and age-adjusted heart and respiratory rates. We compared the ITAT score between cases (deaths) and controls (discharges) in predicting death within 2 days. Our analysis includes predictive statistics, bivariable and multivariable logistic regression, and calculation of data-driven scores.

RESULTS

A total of 54 cases and 161 controls were included in the analysis. The area under the receiver operating characteristic curve was 0.76. At an ITAT cut-off of 4, the sensitivity, specificity and likelihood ratio were 0.44, 0.86 and 1.70, respectively. A cumulative ITAT score of 4 or higher was associated with increased odds of death (OR 4.80; 95% CI 2.39-9.64). A score of 2 for all individual vital signs was a statistically significant independent predictor of death.

CONCLUSIONS

We developed an inpatient triage tool (ITAT) appropriate for resource-constrained hospitals that identifies high-risk children after hospital admission. Further research is needed to study how best to operationalise ITAT in developing countries.

Task shifting an inpatient triage, assessment and treatment programme improves the quality of care for hospitalised Malawian children

OBJECTIVE

We aimed to improve paediatric inpatient surveillance at a busy referral hospital in Malawi with two new programmes: (i) the provision of vital sign equipment and implementation of an inpatient triage programme (ITAT) that includes a simplified paediatric severity-of-illness score, and (ii) task shifting ITAT to a new cadre of healthcare workers called 'vital sign assistants' (VSAs).

METHODS

This study, conducted on the paediatric inpatient ward of a large referral hospital in Malawi, was divided into three phases, each lasting 4 weeks. In Phase A, we collected baseline data. In Phase B, we provided three new automated vital sign poles and implemented ITAT with current hospital staff. In Phase C, VSAs were introduced and performed ITAT. Our primary outcome measures were the number of vital sign assessments performed and clinician notifications to reassess patients with high ITAT scores.

RESULTS

We enrolled 3994 patients who received 5155 vital sign assessments. Assessment frequency was equal between Phases A (0.67 assessments/patient) and B (0.61 assessments/patient), but increased 3.6-fold in Phase C (2.44 assessments/patient, P < 0.001). Clinician notifications increased from Phases A (84) and B (113) to Phase C (161, P = 0.002). Inpatient mortality fell from Phase A (9.3%) to Phases B (5.7) and C (6.9%).

CONCLUSION

ITAT with VSAs improved vital sign assessments and nearly doubled clinician notifications of patients needing further assessment due to high ITAT scores, while equipment alone made no difference. Task shifting ITAT to VSAs may improve outcomes in paediatric hospitals in the developing world.

Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study

AIM

Early warning scores (EWS) are widely used in well-resourced healthcare settings to identify patients at risk of mortality. The Modified Early Warning Score (MEWS) is a well-known EWS used comprehensively in the United Kingdom. The HOTEL score (Hypotension, Oxygen saturation, Temperature, ECG abnormality, Loss of independence) was developed and tested in a European cohort; however, its validity is unknown in resource limited settings. This study compared the performance of both scores and suggested modifications to enhance accuracy.

METHODS

A prospective cohort study of adults (≥18 yrs) admitted to medical wards at a Malawian hospital. Primary outcome was mortality within three days. Performance of MEWS and HOTEL were assessed using ROC analysis. Logistic regression analysis identified important predictors of mortality and from this a new score was defined.

RESULTS

Three-hundred-and-two patients were included. Fifty-one (16.9%) died within three days of admission. With a cut-point ≥2, the HOTEL score had sensitivity 70.6% (95% CI: 56.2 to 82.5) and specificity 59.4% (95% CI: 53.0 to 65.5), and was superior to MEWS (cut-point ≥5); sensitivity: 58.8% (95% CI: 44.2 to 72.4), specificity: 56.2% (95% CI: 49.8 to 62.4). The new score, dubbed TOTAL (Tachypnoea, Oxygen saturation, Temperature, Alert, Loss of independence), showed slight improvement with a cut-point ≥2; sensitivity 76.5% (95% CI: 62.5 to 87.2) and specificity 67.3% (95% CI: 61.1 to 73.1).

CONCLUSION

Using an EWS generated in developed healthcare systems in resource limited settings results in loss of sensitivity and specificity. A score based on predictors of mortality specific to the Malawian population showed enhanced accuracy but not enough to warrant clinical use. Despite an assumption of common physiological responses, disease and population differences seem to strongly determine the performance of EWS. Local validation and impact assessment of these scores should precede their adoption in resource limited settings.

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

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.

Mortality after fluid bolus in African children with severe infection

BACKGROUND

The role of fluid resuscitation in the treatment of children with shock and life-threatening infections who live in resource-limited settings is not established.

METHODS

We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml of 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania (stratum A); children with severe hypotension were randomly assigned to one of the bolus groups only (stratum B). All children received appropriate antimicrobial treatment, intravenous maintenance fluids, and supportive care, according to guidelines. Children with malnutrition or gastroenteritis were excluded. The primary end point was 48-hour mortality; secondary end points included pulmonary edema, increased intracranial pressure, and mortality or neurologic sequelae at 4 weeks.

RESULTS

The data and safety monitoring committee recommended halting recruitment after 3141 of the projected 3600 children in stratum A were enrolled. Malaria status (57% overall) and clinical severity were similar across groups. The 48-hour mortality was 10.6% (111 of 1050 children), 10.5% (110 of 1047 children), and 7.3% (76 of 1044 children) in the albumin-bolus, saline-bolus, and control groups, respectively (relative risk for saline bolus vs. control, 1.44; 95% confidence interval [CI], 1.09 to 1.90; P=0.01; relative risk for albumin bolus vs. saline bolus, 1.01; 95% CI, 0.78 to 1.29; P=0.96; and relative risk for any bolus vs. control, 1.45; 95% CI, 1.13 to 1.86; P=0.003). The 4-week mortality was 12.2%, 12.0%, and 8.7% in the three groups, respectively (P=0.004 for the comparison of bolus with control). Neurologic sequelae occurred in 2.2%, 1.9%, and 2.0% of the children in the respective groups (P=0.92), and pulmonary edema or increased intracranial pressure occurred in 2.6%, 2.2%, and 1.7% (P=0.17), respectively. In stratum B, 69% of the children (9 of 13) in the albumin-bolus group and 56% (9 of 16) in the saline-bolus group died (P=0.45). The results were consistent across centers and across subgroups according to the severity of shock and status with respect to malaria, coma, sepsis, acidosis, and severe anemia.

CONCLUSIONS

Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa. (Funded by the Medical Research Council, United Kingdom; FEAST Current Controlled Trials number, ISRCTN69856593.).

Evaluation of fundamental critical care course in Kenya: knowledge, attitude, and practice

BACKGROUND

Critical care training for medical personnel is crucial for the survival of the highest acuity patients. The Fundamental Critical Care Course (FCCS), a critical care course developed by the Society of Critical Care Medicine, permits course adaption and, thus, has potential for global dissemination. The FCCS course was provided in two Kenyan hospitals after minimal adaption. Participant knowledge and confidence gain as well as FCCS applicability to an African context were evaluated.

METHODS

Questionnaires and a multiple-choice test were administered to assess knowledge, attitude, and self-reported confidence or self-efficacy. For applicability, the pre-course questionnaire assessed participant expectations and existing levels of confidence/knowledge in the care of the critically ill patient. Post-course, the participant evaluated the overall quality of the course, lectures, and skill stations along with context applicability questions.

RESULTS

There were 100 participants, 45 doctors, 45 nurses, and 10 clinical officers. There was a 22.7% gain in the mean test score (P < 0.0001) after the course, with 98% of participants showing improvement. Confidence to perform new skills post-course, or self-efficacy, was demonstrated by a median of 4 or greater on a Likert scale of 5 (most confident) in 10 of 12 clinical scenarios and in 11 of 14 new procedures. There was a consistency between areas reported as needed expertise, and participant evaluation of similar lecture and skill station's quality and appropriateness. The most common areas reported were mechanical ventilation, patient monitoring, and their related procedures.

CONCLUSIONS

The FCCS course met participant's expectations and was reported as applicable for the Kenyan context with minimal adaption. Post-course, knowledge improved and confidence increased for implementation of new skills in clinical care situations. We confirmed the effectiveness and relevancy of the FCCS course for other resource-constrained health care settings.

Surviving sepsis in low-income and middle-income countries: new directions for care and research

Sepsis is a disorder characterised by systemic inflammation secondary to infection. Despite recent progress in the understanding and treatment of sepsis, no data or recommendations exist that detail effective approaches to sepsis care in resource-limited low-income and middle-income countries (LMICs). Although few data exist on the burden of sepsis in LMICs, the prevalence of HIV and other comorbid conditions in some LMICs suggest that sepsis is a substantial contributor to mortality in these regions. In well-resourced countries, sepsis management relies on protocols and complex invasive technologies not widely available in most LMICs. However, the key concepts and components of sepsis management are potentially translatable to resource-limited environments. Health personnel in LMICs should be educated in the recognition of sepsis and the importance of early and appropriate antibiotic use. Simple and low-cost standardised laboratory testing should be emphasised to allow accurate diagnosis, prognosis, and monitoring of treatment response. Evidence-based interventions and treatment algorithms tailored to LMIC ecology and resources should thus be developed and validated.

Critical care in low-income countries

Critical care in low-income countries remains rudimentary. When defined as all aspects of care for patients with sudden, serious, reversible disease, critical care is not disease or age specific and includes triage and emergency medicine, hospital systems, quality of care and Intensive Care Units. This review collates the literature on critical care in low-income countries and explores how the care can be both feasible and effective. Emergency care including triage is often one of the weakest parts of the health system; but if well organized it can be life-saving and cost-effective. Emergency triage and treatment has been developed for paediatric admissions with promising results. Hospital systems do not currently prioritize the critically ill and few hospitals have Intensive Care Units. The quality of care given to inpatients on hospital wards is often poor and could be improved in many ways. There is a lack of training and awareness of the principles of critical care. Basic critical care concentrating on ABC - airway, breathing and circulation - need not be resource intensive. Oxygen is a cheap and effective treatment for pneumonia and other severe disease, but is not always available. Improved critical care could have a significant effect on the burden of disease and effects of ill health. Research into the most cost-effective treatments and methods of caring for critically ill patients is urgently needed.

Pediatric emergency and critical care in low-income countries

The United Nations' Millennium Development Goal 4 is to reduce the global under-five mortality rate by two-thirds by 2015. Achieving this goal requires substantial strengthening of health systems in low-income countries. Emergency and critical care services are often one of the weakest parts of the health system and improving such care has the potential to significantly reduce mortality. Introducing effective triage and emergency treatments, establishing hospital systems that prioritize the critically ill and ensuring a reliable oxygen delivery system need not be resource intensive. Improving intensive care units, training health staff in the fundamentals of critical care concentrating on ABC - airway, breathing, and circulation - and developing guidelines for the management of common medical emergencies could all improve the quality of inpatient pediatric care. Integration with obstetrics, adult medicine and surgery in a combined emergency and critical care service would concentrate resources and expertise.

Triage in children

The importance of triage tools designed specifically for children in major incidents and in the emergency department (ED) is being increasingly recognised. Triage tools should be clinically safe and evidence based where possible. This review aims to summarise the triage systems available for children in the pre-hospital and ED setting, discuss the differences in triage systems around the world and look at possible triage solutions of the future.

Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya

The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.

Limitations in validating emergency department triage scales

OBJECTIVE

To examine whether current validation methods of emergency department triage scales actually assess the instrument's validity.

METHODS

Optimal methods of emergency department triage scale validation are examined in developed countries and their application to developing countries is considered.

RESULTS AND CONCLUSION

Numerous limitations are embedded in the process of validating triage scales. Methods of triage scale validation in developed countries may not be appropriate and repeatable in developing countries. Even in developed countries there are problems in conceptualising validation methods. A new consensus building validation approach has been constructed and recommended for a developing country setting. The Delphi method, a consensual validation process, is advanced as a more appropriate alternative for validating triage scales in developing countries.

How can we improve the care of severely malnourished children in Africa?

Heikens discusses a new study published inPLoS Medicine that is helpful in reconsidering the applicability of the WHO treatment guidelines.

Use of clinical syndromes to target antibiotic prescribing in seriously ill children in malaria endemic area: observational study

OBJECTIVES

To determine how well antibiotic treatment is targeted by simple clinical syndromes and to what extent drug resistance threatens affordable antibiotics.

DESIGN

Observational study involving a priori definition of a hierarchy of syndromic indications for antibiotic therapy derived from World Health Organization integrated management of childhood illness and inpatient guidelines and application of these rules to a prospectively collected dataset.

SETTING

Kilifi District Hospital, Kenya.

PARTICIPANTS

11,847 acute paediatric admissions.

MAIN OUTCOME MEASURES

Presence of invasive bacterial infection (bacteraemia or meningitis) or Plasmodium falciparum parasitaemia; antimicrobial sensitivities of isolated bacteria.

RESULTS

6254 (53%) admissions met criteria for syndromes requiring antibiotics (sick young infants; meningitis/encephalopathy; severe malnutrition; very severe, severe, or mild pneumonia; skin or soft tissue infection): 672 (11%) had an invasive bacterial infection (80% of all invasive bacterial infections identified), and 753 (12%) died (93% of all inpatient deaths). Among P falciparum infected children with a syndromic indication for parenteral antibiotics, an invasive bacterial infection was detected in 4.0-8.8%. For the syndrome of meningitis/encephalopathy, 96/123 (76%) isolates were fully sensitive in vitro to penicillin or chloramphenicol.

CONCLUSIONS

Simple clinical syndromes effectively target children admitted with invasive bacterial infection and those at risk of death. Malaria parasitaemia does not justify withholding empirical parenteral antibiotics. Lumbar puncture is critical to the rational use of antibiotics.

Diagnosing and treating attentional difficulties: a nationwide survey

AIMS

To ascertain from paediatricians and child psychiatrists their views regarding the aetiology, assessment, and diagnosis of attentional difficulties in children, and the prescribing of stimulant medication for such difficulties.

METHODS

Using a questionnaire devised by the authors, 465 paediatricians and 444 child psychiatrists were surveyed.

RESULTS

The overall response rate was 73%. Some 94% of child psychiatrists and 29% of paediatricians routinely dealt with attentional difficulties. Views on aetiology, classification, and diagnosis were varied. More than 60% of both groups were prepared to prescribe stimulant medication without a formal diagnosis being made. Comorbid conduct disorder and the views of other professionals and of parents have an impact on practice.

CONCLUSIONS

This survey demonstrates that there is a range of approaches to attentional difficulties by both paediatricians and child psychiatrists.

Capillary refill: prognostic value in Kenyan children

AIMS

To determine whether delayed capillary refill time (>3 seconds) is a useful prognostic indicator in Kenyan children admitted to hospital.

METHODS

A total of 4160 children admitted to Kilifi District Hospital with malaria, malarial anaemia, acute respiratory tract infection (ARI), severe anaemia (haemoglobin <50 g/l), gastroenteritis, malnutrition, meningitis, or septicaemia were studied.

RESULTS

Overall, delayed capillary refill time (dCRT), present in 346/4160 (8%) of the children, was significantly more common in fatal cases (44/189, 23%) than survivors (7.5%), and had useful prognostic value. In children admitted with malaria, gastroenteritis, or malnutrition, likelihood ratio tests suggested that dCRT was useful in identifying high risk groups for mortality, but its prognostic value in anaemia, ARI, and sepsis was unclear due to low case fatality or limited numbers. The severity features of impaired consciousness and deep breathing were significantly associated both with the presence of dCRT and fatal outcome. In children, with either of these severity features, a less stringent value of dCRT(>2 s) identified 50% of children with hypotension (systolic BP <2SD) and 40% of those requiring volume resuscitation (for metabolic acidosis).

CONCLUSIONS

Although CRT is a simple bedside test, which may be used in resource poor settings as a guide to the circulatory status, dCRT should not be relied on in the absence of other features of severity. In non-severe disease, the additional presence of hypoxia, a moderately raised creatinine (>80 micromol/l), or a raised white cell count should prompt the need for fluid expansion.