Heather L. Crouse

Impact of an Emergency Triage Assessment and Treatment (ETAT)-based triage process in the paediatric emergency department of a Guatemalan public hospital

Background: Triage process implementation has been shown to be effective at improving patient outcomes. This study sought to develop, implement and assess the impact of an Emergency Triage Assessment and Treatment (ETAT)-based emergency triage process in the paediatric emergency department (PED) of a public hospital in Guatemala. Methods: The study was a quality improvement comparison with a before/after design. Uptake was measured by percentage of patients with an assigned triage category. Outcomes were hospital admission rate, inpatient length of stay (LOS), and mortality as determined by two distinct medical record reviews for 1 year pre- and post-intervention: a random sample (RS) of all PED patients and records for all critically-ill (CI) children [serious diagnoses or admission to the paediatric intensive care unit (PICU)]. Demographics, diagnoses and disposition were recorded. Results: The RS totalled 1027 (51.4% male); median ages pre- and post-intervention were 2.0 and 2.4 years, respectively. There were 196 patients in the CI sample, of whom 56.6% were male and one-third were neonates; median ages of the CI group pre- and post-intervention were 3.1 and 5.6 months, respectively. One year after implementation, 97.5% of medical records had been assigned triage categories. Triage categories (RS/CI) were: emergency (2.9%/54.6%), priority (47.6%/44.4%) and non-urgent (49.4%/1.0%). The CI group was more frequently diagnosed with shock (25%/1%), seizures (9%/0.5%) and malnutrition (6%/0.5%). Admission rates for the RS (8% vs 4%, P=0.01) declined after implementation. For the CI sample, admission rate to the PICU (47% vs 24%, P=0.002) decreased and LOS (7.3 vs 5.7 days, P=0.09) and mortality rates (12% vs 6%, P=0.15) showed trends toward decreasing post-implementation. Conclusions: Paediatric-specific triage algorithms can be implemented and sustained in resource-limited settings. Significant decreases in admission rates (both overall and for the PICU) and trends towards decreased LOS and mortality rates of critically ill children suggest that ETAT-based triage systems have the potential to greatly improve patient care in Latin America.

Quality and Effectiveness of a Pediatric Triage Training Program in a Guatemalan Public Hospital.

Objectives This study aimed to develop and implement an Emergency Triage Assessment and Treatment (ETAT) training program at a Guatemalan public hospital. Collaborators included Baylor College of Medicine/Texas Childrens Hospital, the Guatemalan Ministry of Health, and the Pan American Health Organization. Methods The ETAT is a World Health Organization program to teach pediatric assessment, triage, and initial management to health care workers in resource-limited settings. The Baylor College of Medicine/Texas Childrens Hospital created ETAT training materials in Spanish (Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas [CETEP]) and conducted a train-the-trainer course for Hospital Nacional Pedro Bethancourt (HNPB) health care leadership. The HNPB subsequently conducted local trainings using a modified curriculum. Midcourse modifications based on evaluations and focus groups included distribution of manuals before training and an adding a day to the course. Course quality was assessed using participant evaluations and comparing pretest and posttest scores. Effectiveness was defined as 90% concordance between triage levels assigned by participants and facilitators. Results A total of 249 health care workers were trained by 24 HNPB facilitators. Mean pretest and posttest scores were 55 and 70, respectively (P < 0.001). On a 4-point scale, participants rated overall course quality and effectiveness as 3.6. Mean pretest (49 vs 58, P = 0.002) and posttest scores (68 vs 72, P = 0.01) improved for groups trained after modifications, as did evaluations for course quality (3.4 vs 3.7, P < 0.001) and effectiveness (3.4 vs 3.8, P < 0.001). Triage levels were assigned with 95% concordance (confidence interval, 91.9–97.3) between participants and facilitators. Conclusions Hospital Nacional Pedro Bethancourt experts conducted high-quality trainings with locally relevant CETEP (ETAT) material. Trainings were effective and well received. The pediatric emergency department at HNPB now uses a triage system based on CETEP (ETAT).

Partnerships for Global Child Health

This literature-based expert consensus review presents the definition, scope, genesis, evolution, and models of GCH partnerships, including benefits and challenges, guiding principles and core practices. Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.

Building Sustainable Partnerships to Strengthen Pediatric Capacity at a Government Hospital in Malawi

Introduction To achieve sustained reductions in child mortality in low- and middle-income countries, increased local capacity is necessary. One approach to capacity building is support offered via partnerships with institutions in high-income countries. However, lack of cooperation between institutions can create barriers to successful implementation of programs and may inadvertently weaken the health system they are striving to improve. A coordinated approach is necessary. Background Three U.S.-based institutions have separately supported various aspects of pediatric care at Kamuzu Central Hospital (KCH), the main government referral hospital in the central region of Malawi, for several years. Within each institution’s experience, common themes were recognized, which required attention in order to sustain improvements in care. Each recognized that support of clinical care is a necessary cornerstone before initiating educational or training efforts. In particular, the support of emergency and acute care is paramount in order to decrease in-hospital mortality. Through the combined efforts of Malawian partners and the US-based institutions, the pediatric mortality rate has decreased from >10 to <4% since 2011, yet critical gaps remain. To achieve further improvements, representatives with expertise in pediatric emergency medicine (PEM) from each US-based institution hypothesized that coordinated efforts would be most effective, decrease duplication, improve communication, and ensure that investments in education and training are aligned with local priorities. Call to action Together with local stakeholders, the three US-based partners created a multi-institutional partnership, Pediatric Alliance for Child Health Improvement in Malawi at Kamuzu Central Hospital and Environs (PACHIMAKE). Representatives from each institution gathered in Malawi late 2016 and sought input and support from local partners at all levels to prioritize interventions, which could be collectively undertaken by this consortium. Long- and short-term goals were identified and approved by local partners and will be implemented through a phased approach. Conclusion The development of a novel partnership between relevant stakeholders in Malawi and US-based partners with expertise in PEM should help to further decrease pediatric mortality through the coordinated provision of acute care expertise and training as well as investment in the development of educational, research, and clinical efforts in PEM at KCH.

Regional scale-up of an Emergency Triage Assessment and Treatment (ETAT) training programme from a referral hospital to primary care health centres in Guatemala.

Objective Emergency Triage Assessment and Treatment (ETAT) was developed by the WHO to teach paediatric assessment, triage and initial management to healthcare workers (HCWs) in resource-limited hospital-based settings. This study sought to evaluate the extension of ETAT training from a regional hospital to paediatric HCWs at local primary care health centres (PHCs) in Guatemala. Methods Prior to providing a 16 h ETAT training module, immediately after, and at 3, 6 and 12 months, we used written pre-tests and post-tests and five-point Likert surveys to evaluate, respectively, clinical knowledge and provider confidence in providing acute care paediatrics; hands-on clinical skills were tested at 3, 6 and 12 months. Results Fifty-two HCWs (14 general physicians, 38 nurses) from four regional PHCs participated; 65%, 60% and 46% completed 3-month, 6-month and 12-month follow-ups, respectively. Test scores show significant acquisition of clinical knowledge initially, which was retained over time when tested at 3, 6 and 12 months (46 vs 70, p<0.001). Hands-on clinical skills scores demonstrated retention at 3, 6 and 12 months. Although participants were more confident about acute care paediatrics immediately after training (66 vs 104, p<0.001), this decreased with time, though not to pre-intervention levels. Conclusions ETAT trainings were successfully extended to PHCs in a resource-limited setting with significant knowledge acquisition and retention over time and improved HCW confidence with acute care paediatrics. This process could serve as a successful model for in-country and international scale-up of ETAT.

Initiating a Standardized Regional Referral and Counter-Referral System in Guatemala: A Mixed-Methods Study:

Background:Few data exist for referral processes in resource-limited settings. We utilized mixed-methods to evaluate the impact of a standardized algorithm and training module developed for locally identified needs in referral/counter-referral procedures between primary health centers (PHCs) and a Guatemalan referral hospital. Methods: PHC personnel and hospital physicians participated in surveys and focus groups pre-implementation and 3, 6, and 12 months post-implementation to evaluate providers’ experience with the system. Referred patient records were reviewed to evaluate system effectiveness. Results: A total of 111 initial focus group participants included 96 (86.5%) from PHCs and 15 from the hospital. Of these participants, 53 PHC physicians and nurses and 15 hospital physicians initially completed written surveys. Convenience samples participated in follow-up. Eighteen focus groups achieved thematic saturation. Four themes emerged: effective communication; provision of timely, quality patient care with adequate resources; educational opportunities; and development of empowerment and relationships. Pre- and post-implementation surveys demonstrated significant improvement at the PHCs (P < .001) and the hospital (P = .02). Chart review included 435 referrals, 98 (22.5%) pre-implementation and 337 (77.5%) post-implementation. There was a trend toward an increased percentage of appropriately referred patients requiring medical intervention (30% vs 40%, P = .08) and of patients requiring intervention who received it prior to transport (55% vs 73%, P = .06). Conclusions: Standardizing a referral/counter-referral system improved communication, education, and trust across different levels of pediatric health care delivery. This model may be used for extension throughout Guatemala or be modified for use in other countries. Mixed-methods research design can evaluate complex systems in resource-limited settings.

A Novel Approach to Combining Pediatric Emergency Medicine and Global Health Fellowships.

ObjectivesTo describe the creation of the first known combined Pediatric Emergency Medicine-Global Health (PEM-GH) fellowship for graduates of pediatric or emergency medicine residency programs. MethodsWe detail the necessary infrastructure for a successfully combined PEM-GH fellowship including goals, objectives, curriculum, timeline, and funding. The fellowship is jointly supported by the department of pediatrics, section of pediatric emergency medicine (PEM), and the hospital. Fellows complete all requirements for the PEM fellowship and Global Health, the latter requiring an additional 12 months of training. Components of the Global Health fellowship include international fieldwork, scholarly activity abroad, advanced degree coursework, disaster training, and didactic curricula. ResultsSince 2005, 9 fellows (8 pediatric-trained and 1 emergency medicine–trained) have completed or are enrolled in the PEM-GH fellowship; 3 have graduated. All fellows have completed or are working toward advanced degrees and have or will participate in the disaster management course. Fellows have had 7 presentations at national or international meetings and have published 6 articles in peer-reviewed journals. Of the three graduates, all are working in academic PEM-GH programs and work internationally in Africa and/or Latin America. ConclusionsOur response to a global trend toward improvement in PEM care was the development of the first combined PEM-GH fellowship program. Recognizing the value of this program within our own institution, we now offer it as a model for building such programs in the future. This fellowship program promises to be a paradigm that can be used nationally and internationally, and it establishes a foundation for a full-fledged accredited and certified subspecialty.