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

Abstract

Objective We aimed to improve pediatric inpatient surveillance at a busy referral hospital in Malawi with 2 new programs: (1) the provision of vital sign equipment and implementation of an inpatient triage program (ITAT) that includes a simplified pediatric severity-of-illness score; (2) task-shifting ITAT to a new cadre of health care workers called “Vital Sign Assistants” (VSAs). Methods This study, conducted on the pediatric inpatient ward of a large referral hospital in Malawi, was divided into 3 phases, each lasting 4 weeks. In Phase A, we collected baseline data. In Phase B, we provided 3 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 3,994 patients who received 5,155 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%). Conclusions 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 pediatric hospitals in the developing world.

Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

“…Feedback was provided along with remediation if needed. Lay health workers, called vital sign assistants, were trained to ensure vital signs were recorded for each hospitalized patient [17]. Data entry was checked as a part of quality assurance protocols and the original paper forms were consulted as needed during data cleaning.…”

“…Based on existing literature [6,13–17] and local clinical experience we selected the following variables a priori for investigation in the locally derived mortality prediction score: oxygen saturation, age-adjusted heart rate [19], malnutrition measured with mid-upper arm circumference (MUAC) and WHO weight-for-age z-score (WAZ), age, sex, presence of wheeze, unconsciousness, any danger sign, and vaccine status. Oxygen saturation, WAZ, MUAC and age were categorized as follows: SpO 2 as severe (<90%), moderate (90–92%) and normal (≥93%); WAZ as severe (<-3 SD), moderate (-3 to -2 SD) and normal (>-2 SD); MUAC as severe (<11.5 cm), moderate (11.5–13.5 cm) and normal nutrition (>13.5 cm); age as 2–11, 12–23 and 24–59 months.…”

“…mRISC was developed prospectively in Western Kenya from 2009–2011 in hospitalized children aged 0–59 months post Hib vaccine and pre PCV introduction. Both studies evaluated known mortality risk factors including hypoxemia, duration of symptoms, age, and nutritional status [13–17]. To the best of our knowledge, the RISC and mRISC scores have not yet been externally validated to assess whether they are generalizable to other African pediatric inpatient populations and applicable to routine, non-clinical trial datasets that are representative of programmatic care conditions.…”

Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource‐limited pediatric oncology hospital

“…There are numerous published PEWS tools which vary in accuracy predicting deterioration; 3,4 some have been successfully validated in multicenter trials, 5 and across various subspecialty populations. [7][8][9] PEWS are widely used in hospitals caring for pediatric oncology patients, 10 and one score has been validated to predict unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant (HSCT) patients. [7][8][9] PEWS are widely used in hospitals caring for pediatric oncology patients, 10 and one score has been validated to predict unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant (HSCT) patients.…”

Early warning scores in paediatrics: an overview

“…Implementation of modified PEWS decreased the number of unplanned PICU transfers and improved PICU utilisation in Guatemala and assisted in identifying children with cancer who would benefit from more intensive monitoring in the intermediate care environment 30. A prospective nested case-controlled study in Malawi indicated that a locally developed PEWS could identify children at high risk of death 31. However, further analysis revealed that children who died were much more likely to have no PEWS or vital signs recorded at all.…”