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Improving care pathways for children with severe illness through implementation of the ASPIRE mHealth primary ETAT
Nicola Desmond1,2, Marc Y R Henrion1,3, Mtisunge Gondwe1
1Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi.
Insights
Mobile health (mHealth) triage using the WHO Emergency, Triage, Assessment, and Treatment (ETAT) algorithm showed moderate agreement with clinician assessments. This approach can help prioritize acute illness in low-resource settings, though referral completion needs improvement.
Area of Science:
- Public Health
- Health Informatics
- Implementation Science
Background:
- Emergency care in low-resource settings heavily relies on lower cadres of health workers (LCHW).
- Effective triage is crucial for timely and appropriate patient management in primary healthcare.
- Mobile health (mHealth) offers potential solutions for improving healthcare delivery and data collection.
Purpose of the Study:
- To develop, implement, and evaluate a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care.
- To assess the concordance between mHealth triage performed by LCHWs and clinician assessments.
- To evaluate the referral process and patient outcomes within the mHealth ETAT pathway.
Main Methods:
- An observational study design using implementation research methods in eight primary health centers in Blantyre district.
- Training of clinicians and LCHWs on the mHealth ETAT algorithm for patient triage.
- Utilizing an mHealth patient surveillance system to monitor patients from presentation to final outcome, including referrals.
Main Results:
- A total of 155,931 children had recorded mHealth and clinician triage data, showing 81.6% concordance (kappa: 0.535) between LCHW mHealth triage and clinician assessment.
- Concordance for mHealth emergency triage specifically was 0.31 (kappa: 0.42).
- 54.7% of referred patients (1,644 out of 3,004) successfully reached the tertiary site; high satisfaction reported by providers and caregivers.
Conclusions:
- An mHealth triage algorithm, when used by LCHWs, demonstrates moderate concordance with clinician triage for prioritizing acute illness.
- The ASPIRE mHealth primary ETAT approach facilitated tracking referrals but highlighted a significant gap in successful patient arrival at tertiary care.
- Further evaluation is needed to assess potential harms, such as missed referrals, and to optimize resource planning in district and national health systems.
Abstract:
Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.
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