Pathways of emergency care for severely ill children in Nigerian and Ugandan hospitals: A process mapping study

Child mortality remains high in countries with weak emergency care systems. Facility organisation for paediatric emergency care is heterogeneous and under-described. We examined how hospitals in Uganda and Nigeria are organised to deliver emergency care for neonates and children.

We conducted a qualitative, multi-method study in 26 purposively selected secondary and tertiary facilities in Uganda and Nigeria from October 2023 to December 2024. Embedded researchers documented patient pathways, resources for care, and care processes for severely ill children (<15 years). We used inductive content analysis to generate organisational archetypes and describe different facets of the patient journey. We identified 4 recurring patterns of facility organisation and patient flow ('archetypes'): outpatient department (OPD) 'screen and treat'; OPD 'screen and send'; emergency department (ED) 'receive and treat'; and inpatient department (IPD) 'receive and treat'. Across sites, formal triage systems were generally absent or rarely used. First contact and early sorting of children into these pathways frequently involved guards, lay bystanders, students, and caregivers. Duplication in assessment and treatment steps and misrouting from intended pathways occurred especially when initial care was spread across multiple locations. After-hours closure of OPDs shifted the place of entry to EDs or IPDs and could result in caregiver confusion. Administrative procedures (registration and payment) and recurrent stock-outs of medications and consumables could delay initiation of clinical processes. Referral pathways were inconsistent and some referrals were informal, undocumented, and enacted prior to patient stabilisation. Our findings are based on a purposive sample of facilities from Nigeria and Uganda, which may not be representative of other low-resource settings.

Process mapping can help understand context and identify opportunities for intervention to improve facility care of severely ill children. We define organisational archetypes as heuristic tools for facility leaders and policymakers that can help facilities locate their configuration and recognise context-specific priorities. Potential low-cost opportunities for improvement include: building on existing adaptations (e.g., involving non-clinical staff and families in triage), formalising triage, streamlining non-clinical care processes that can delay clinical care (e.g., clearer signage and expedited administration), and strengthening referral systems.