The identification and initial care of children with sepsis can significantly impact survival. Delays in presentation and diagnosis are risk factors for poor outcomes and acutely ill children are often inadequately recognized and stabilized by health facilities in low-income countries (LIC). The World Health Organization recently published an updated to the Emergency Triage Assessment and Treatment (ETAT) Guidelines that explicitly detail the triage and emergency treatment process for developing countries. Unfortunately, these guidelines have not been widely adopted in sub-Saharan Africa. A cohort study in South Africa assessed if severity of illness, PICU admission or death were avoidable in critically ill children and identified key modifiable factors associated with poor outcomes: delayed identification of critically ill children, inappropriate assessment of illness severity, inadequate resuscitation, and delays in medical decision-making, all of which are key components of ETAT. In a large, qualitative study from seven LICs, 14 of 21 hospitals lacked an adequate triage system resulting in inadequate patient assessment and treatment delays. But triage systems do work in SSA; by training emergency staff to triage patients, a public tertiary hospital in Blantyre, Malawi experienced a reduction in inpatient mortality from 10-18% pre- to 6-8% post-implementation. Similarly, by improving the prioritization of ill children in the emergency room in the National Referral Hospital in Lilongwe, Malawi, early in-hospital mortality decreased from 47.6 to 37.9 deaths per 1000 admissions and total mortality decreased from 80.5 to 70.5 deaths per 1000 admissions. Early assessment and appropriate treatment prioritization are therefore critical to achieve good outcomes in acutely ill children with sepsis. Currently, Muhimbili National Hospital (MNH) in Tanzania (one of my research sites), has no formal pediatric emergency triage system. Instead, MNH relies on the triage nurse’s experience and gestalt to determine if the patient is classified as “Emergency” – triaged to the resuscitation room, “Priority” – triaged to a treatment or clinic room, or “Queue” – triaged to wait in the hallway. From preliminary data, 40% of pediatric sepsis patients were triaged to a treatment room or the hallway. Though current sepsis guidelines recommend early antibiotic therapy, identification of the infectious source, and fluid bolus administration for signs of shock, 54.1% of pediatric sepsis patients at MNH received antibiotics at any point during his/her EMD admission, 1% received a blood culture, and 38.8% of those with signs of shock received a fluid bolus. With improved, early identification of acutely ill sepsis patients as part of the MNH triage assessment, it may be possible to improve patient outcomes – morbidity, mortality and length of stay – by initiating appropriate therapy (fluid resuscitation, antibiotic administration) and sooner.
Fascinating work. You've thought a lot about this scenario, and I think that you will sharpen your "implementation science" approach by focusing on one or a bundle of evidence based clinical interventions that the children are not receiving. This could be fluids or antibiotics. This is mundane, but useful to articulate. The identification becomes then potentially a problem, a part of the "diagnosis" of the implementation gap. ETAT is a an interesting twist, this seems to prove that guidance doesn't always work. It will be interesting to work through why that is over the next few weeks.
Super interesting - it sounds like there are many layers of implementation challenges here. Is the implementation gap that you want to focus on in MNH/Tanzania one of not adopting the revised ETAT guidelines, or about the clinical practices - is the challenge that they don't have the right guidelines in place, or that they don't follow them even if they are there, and if the latter, is the same implementation gap at work across all barriers to appropriate care?