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Dr Nicola Desmond's presentation at Meningitis Research Foundation's 2013 conference, Meningitis & Septicaemia in Children & Adults
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A pilot study implementing an mHealth triage intervention for health care workers at
primary health clinics in Blantyre, Malawi
Nicola DesmondLiverpool School of Tropical Medicine
Malawi-Liverpool-Wellcome Trust
Treatment seeking for acute bacterial meningitis
• More than 1 million cases of ABM annually in SSA
• Prompt treatment vital to effective management
• Late presentation identified as major contributor to high case fatality rates for ABM
Responses to ABM
Recognition
HCW diagnosis practices
Recognition of severity
Social validation of illness
Lay interpretation of symptoms
Misdiagnosis as malaria
Action
Timeliness dependent on social
position
Financial constraints
Unsystematic triageHigh numbers of patients
Perceptions of health services
High numbers of patients
Erratic consultation systems
Unsystematic & informal triage
Primary health level contributorsPrimary health level misdiagnoses
Aims
Explore the feasibility of implementing a triage system within PHCs facilitated through the use of mHealth technologies
– To develop mHealth algorithm based on Emergency Triage component of ETAT (WHO)
– To implement prioritisation system using mHealth triage algorithm
– To encourage appropriate referral decisions to QECH & track referrals
– To evaluate triage system using mixed methods approaches
ETAT for resource-poor settings
• ETAT: Emergency Triage, Assessment and Treatment• Component of Integrated Management of Childhood
Illness (IMCI)• Identify children with immediately life-threatening
conditions • Reliance on few clinical signs• Assessment carried out quickly if negative• Easy to follow guidelines for all cadres with limited
clinical background• Easy to conduct when patients queuing
mHealth
Consistent
Improved diagnosis
Active prompts
Training & monitoring
tool
The Intervention
Pilot study framework
Training
• ETAT triage • mHealth tool• Study protocols
Intervention• 5 Blantyre PHC
• Bangwe• Chilomoni• Mpemba• Ndirande• Zingwangwa
• 0-14 year olds• Monitoring of
patient pathways
Evaluation
• Baseline & post-intervention
• Mixed methods
Oct ‘12 Dec‘12 – May ‘13 Oct‘12 – June ‘13
Chipatala RobotsOutcomes
CHILD IS EXTREMELY SICK. TO BE
SEEN IMMEDIATELY
CHILD IS VERY SICK. PRIORITY MUST BE GIVEN IN THE QUEUE
CHILD HAS MINOR
INJURY/ILLNESS. TO WAIT IN THE
QUEUE
EMERGENCY
PRIORITY
QUEUE
Improving patient pathways
Patient enters PHC
HCW conducts rapid triage
Patient assigned E, P, Q
Clinician conducts consultation &
enters dataAdapted from Sarah Bar-Zeev (2012)
Patient follows clinician
instructions
Patient Triage
PHC Clinician
QECH Fieldworker
If referred to QECH data entered on arrival
The Evaluation
mHealth tool
• Monitor patient pathways
• Assess if systematic and timely
Self completed questionnaires
• Explore accuracy of E,P and Q assignments pre and post intervention
Patient Journey Modelling
• Baseline and post intervention
• Document practice and patient flows
• Structured observations
Qualitative Interviews
• Capture staff feedback
• Impact on overall clinic management and practice
Evaluation
Quantitative Qualitative
Results
Total Cases Bangwe Ndirande Chilomoni Zingwangwa Mpemba
41358
1204310412 9191
5091 4621
Number of Cases Triaged Dec 2012 - May 2013
Total catchment population by clinic
Ndirande 213,613Zingwangwa 142,594Bangwe 131,667Chilomoni 80,940Mpemba 48,176
Total 616,990
Triage evaluation
Time taken (Mins)
Paediatric cases
E 28.34 131P 44.64 13,585
Q 59.02 26,452
Mean time between triage and consultation
(Anova: P < 0.001)
Age distribution of triage assessments
Queue Priority Emergency0.0
10.0
20.0
30.0
40.0
50.0
60.0
< 1 year1-56-10>10
Triage compared to clinician evaluation
Queue Priority Emergency0.0
20.0
40.0
60.0
80.0
100.0
Triage QueueTriage PriorityTriage Emergency
Clinician Assessment
Cadre specific levels of engagement
• Health Surveillance Assistants (HSAs) – Salaried community health workers– 10,507 (2009) across Malawi– Average clinical training of 8 weeks
• Triage conducted predominantly by Health Surveillance Assistants
• Nurses rarely involved in triage of patients
ReferralsOut of 41,358 children triaged 1.6% (644) were referred to QECH
15.5% (100) - Emergency 74.9% (482) - Priority 9.6% (62) - Queue
From the 644 referrals 37.3% (240) arrived at QECH
62.7% (404) of referrals from PHCS did not reach QECH
Overall mean time 5.5 hours
Triage evaluation
Time taken (Hours)
Paediatric cases
E 3.5 33P 5.7 193Q 6.8 14
(Anova: P = 0.39)
Successful referrals
Patient journey modelling: Bangwe
Improved patient flows
‘There is now improvement, those children don’t take long to be attended to.” HCW
‘In the past even if you come with a child who is very sick your fellow carers could not give you a chance to go in front of a queue for your child to be helped immediately but now things have improved because when a child is very sick s/he is put in front of a queue’ Carer
‘At Bangwe we are now working together as a team. It is helping us manage the children so much better. We are seeing them far more quickly than before’ HCW
Improved recognition of severe illness‘Triage is being done systematically and children with critical illnesses are being identified and treated on time’ HCW
‘Ever since ETAT started, I have never heard any news that a child died on the way or maybe in the doctor’s room’ HCW
‘I am so thankful because of what has happened today. My baby was identified among others that he was an emergency and he was taken in front of the queue to be seen immediately by the clinician and he is now better’ Carer
Conclusions
• Separation of sick from non-sick
• Paediatric definitions• Consistent quality of triage• High levels of ownership• High levels of acceptability
Health worker wearing Chipatala Robots T-Shirt
Mphatso Cheonga, 2012
“I only wish the primary health centres could improve on diagnosis
and recognising symptoms quicker...”
Acknowledgments InvestigatorsNaor Bar-ZeevQueen DubeNorman LufesiElizabeth MolyneuxSarah Bar-ZeevRob Heyderman
MRFThomasena O’ByrneChris HeadLinda GlennieSara MarshallRachel Perrin
AcMen team at MLWDeborah NyirendaBernadetta PayesaMalango MsukwaAlick MasalaLilian UlayahFarouk EdwardWilard Chilunga
Blantyre DHODr Owen MalemaDr Eltas NyirendaDr Palesa Chisala
ETAT trainersZondiwe MwanzaThembi KatangweYabwile MulambiaMtisunge Gondwe
D-Tree InternationalDr Marije GeldofDr Marc Mitchell
Phidelis Suwedi
Primary Health CentresBangwe: Martha Makuta
Christopher MkungaChilomoni: Dalitso Namasani
Ndirande: Francis PhiriMpemba: Rodgers Kuyokwa
Zingwangwa: Margaret ChingonaAll photos reproduced by kind permission of
participants