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Implementation of Smart Triage combined with a quality improvement program for children presenting to facilities in
J Mark Ansermino1,2, Yashodani Pillay1,2, Abner Tagoola3
1Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
Insights
Smart Triage improved sepsis recognition and reduced antimicrobial use in Kenya. Implementation challenges in Uganda highlight the difficulties of health system technology integration.
Area of Science:
- Global Health
- Health Informatics
- Pediatric Infectious Diseases
Background:
- Sepsis disproportionately affects low-middle-income countries, with suboptimal triage hindering early recognition and outcomes.
- Improving sepsis case recognition and quality of care is crucial for better patient outcomes.
Purpose of the Study:
- To evaluate the impact of Smart Triage, a digital platform, on improving the time to intravenous antimicrobial administration for pediatric sepsis.
- To assess secondary outcomes including antimicrobial use, hospital admission rates, and mortality in a multisite interventional study.
Main Methods:
- A controlled interrupted time series study implemented Smart Triage in Kenya and Uganda, comparing intervention sites with control sites.
- Children presenting with acute illness were enrolled, with data collected on time to intravenous antimicrobials, antimicrobial use, admissions, and mortality.
- The study spanned from April 2020 to December 2022, with a specific trial registration number NCT04304235.
Main Results:
- In Kenya, Smart Triage significantly reduced the time to intravenous antimicrobials by 57% at intervention sites, while control sites saw an increase.
- In Uganda, the intervention showed no significant difference in time to antimicrobials compared to control sites, with initial improvements not sustained.
- Both intervention sites demonstrated significant reductions in antimicrobial utilization (47% Kenya, 33% Uganda), admission rates (47% Kenya, 33% Uganda), and mortality (25% Kenya, 75% Uganda).
Conclusions:
- Smart Triage demonstrated significant improvements in timely antibiotic administration in Kenya, but not Uganda, potentially due to external factors like COVID-19 and resource constraints.
- Remarkable reductions in antimicrobial use, admissions, and mortality were observed, though these secondary outcomes require cautious interpretation.
- The study underscores the complexities of implementing and sustaining health technology innovations within existing healthcare systems.
Abstract:
Sepsis occurs predominantly in low-middle-income countries. Sub-optimal triage contributes to poor early case recognition and outcomes from sepsis. Improved recognition and quality of care can lead to improved outcomes. We evaluated the impact of Smart Triage using improved time to intravenous antimicrobial administration in a multisite interventional study. Smart Triage, a digital platform with a risk score and clinical dashboard, was implemented (with control sites) in Kenya (February 2021-December 2022) and Uganda (April 2020-April 2022). Children presenting to the outpatient departments with an acute illness were enrolled. A controlled interrupted time series was used to assess the effect on time from arrival at the facility to intravenous antimicrobial administration. Secondary analyses included antimicrobial use, admission rates and mortality (NCT04304235). During the baseline period, the time to antimicrobials decreased significantly in Kenya (132 and 58 minutes) at control and intervention sites. In Uganda, the time to antimicrobials marginally decreased (3 minutes) at the intervention site. Then, during the implementation period in Kenya, the time to antimicrobials at the intervention site decreased by 98 min (57%, 95% CI 81-114) but increased by 49 min (21%, 95% CI: 23-76) at the control site. In Uganda, the time to antimicrobials initially decreased but was not sustained and there was no significant difference between intervention and control sites. At both intervention sites, there was a significant reduction in antimicrobial utilization of 47% (Kenya) and 33% (Uganda) compared to baseline. There was a reduction in admission rates of 47% (Kenya) and 33% (Uganda) compared to baseline. Mortality reduced by 25% (Kenya) and 75% (Uganda) compared to the baseline period. We showed significant improvements in time to intravenous antibiotics in Kenya but not Uganda, likely due to COVID-19, a short study period and resource constraints. The reduced antimicrobial use and admission and mortality rates are remarkable and welcome benefits. The admission and mortality rates should be interpreted cautiously as these were secondary outcomes. This study underlines the difficulty of implementing technologies and sustaining quality improvement in health systems.
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