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Triage guideline for immunocompromised children with fever in an emergency centre in Ethiopia
Workeabeba Abebe1, Tigist Bacha2, Andi L Shane3
1Division of Infectious Diseases, Department of Pediatric and Child Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
Insights
Reducing antibiotic delays for children with fever and neutropenia in Ethiopia was challenging. Interventions improved timing initially but were not sustained due to high patient volumes and competing priorities.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Healthcare Quality Improvement
Background:
- Fever in children with neutropenia indicates a high risk of life-threatening bacteremia.
- Early antimicrobial therapy is crucial but understudied in resource-limited settings.
- Ethiopian tertiary care pediatric emergency centers face unique challenges.
Purpose of the Study:
- To decrease the time to antibiotic administration for pediatric patients with fever and neutropenia.
- To evaluate the effectiveness of triaging and treatment guidelines in a resource-limited emergency setting.
- To identify barriers to timely antibiotic delivery in a high-volume pediatric emergency department.
Main Methods:
- A 3-phase quality improvement project was implemented.
- Baseline data collection, guideline institution, and antibiotic provision were key components.
- Time from arrival to antibiotic initiation was the primary outcome measure.
Main Results:
- Initial reductions in time to antibiotics were observed during guideline implementation.
- These time reductions were inconsistent and not sustained over the study period.
- Competing clinical priorities in a high-volume setting were identified as a major barrier.
Conclusions:
- Quality improvement efforts focused on specific conditions like fever and neutropenia may be less effective in high-volume, resource-limited settings.
- General efficiency improvements and enhanced teamwork may yield better outcomes.
- Future interventions should consider broader strategies for improving pediatric emergency care in similar contexts.
Abstract:
Fever in children with neutropenia often portends life-threatening bacteremia that may be ameliorated with early recognition and the rapid administration of antimicrobial therapy. Studies demonstrating this effect have been done in resource-endowed countries, but not in resource-limited settings. We attempted to decrease the time to antibiotics in patients with fever and neutropenia presenting to a paediatric emergency centre at a tertiary care referral hospital in Ethiopia. In 3 phases we performed baseline data collection, instituted triaging and treatment guidelines, and provided antibiotics. We tracked a variety of outcomes, most importantly time from arrival to initiation of antibiotics. While this time was reduced during the guideline institution phase of our intervention, time reductions were inconsistent and not sustained. This was likely due to competing clinical priorities among providers caring for a high volume of ill children. While in the U.S., fever and neutropenia is easy to prioritise within the paediatric emergency centre, future quality improvement measures in this setting may have a greater benefit on critical presentations such as shock or respiratory failure. Alternative strategies geared towards general efficiency improvement and teamwork, rather than focusing on one patient group may be a higher yield approach for improving care in this paediatric emergency centre.
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