Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration

Background
Sepsis is the leading cause of death in children under five in low- and middle-income countries. The rapid identification of the sickest children and timely antibiotic administration may improve outcomes. We developed and implemented a digital triage platform to rapidly identify critically ill children to facilitate timely intravenous antibiotic administration.

Objective
This quality improvement initiative sought to reduce the time to antibiotic administration at a dedicated children’s hospital outpatient department in Mbarara, Uganda.

Intervention and study design
The digital platform consisted of a mobile application that collects clinical signs, symptoms, and vital signs to prioritize children through a combination of emergency triggers and predictive risk algorithms. A computer-based dashboard enabled the prioritization of children by displaying an overview of all children and their triage categories. We evaluated the impact of the digital triage platform over an 11-week pre-implementation phase and an 11-week post-implementation phase. The time from the end of triage to antibiotic administration was compared to evaluate the quality improvement initiative.

Results
There was a difference of -11 minutes (95% CI, -16.0 to -6.0; p < 0.001; Mann-Whitney U test) in time to antibiotics, from 51 minutes (IQR, 27.0–94.0) pre-implementation to 44 minutes (IQR, 19.0–74.0) post-implementation. Children prioritized as emergency received the greatest time benefit (-34 minutes; 95% CI, -9.0 to -58.0; p < 0.001; Mann-Whitney U test). The proportion of children who waited more than an hour until antibiotics decreased by 21.4% (p = 0.007). Conclusion A data-driven patient prioritization and continuous feedback for healthcare workers enabled by a digital triage platform led to expedited antibiotic therapy for critically ill children with sepsis. This platform may have a more significant impact in facilities without existing triage processes and prioritization of treatments, as is commonly encountered in low resource settings.

Is the Whole Greater Than the Sum of Its Parts? The Implementation and Outcomes of a Whole Blood Program in Ecuador

Background: Hemorrhagic shock is a major cause of mortality in low-and-middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood program in Latin America and discuss the outcomes of the patients that received whole blood (WB).

Methods: We conducted a retrospective review of patients resuscitated with WB from 2013-2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included: sex, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, Shock Index, intraoperative crystalloid and colloid administration, symptoms of transfusion reaction, length-of-stay and in-hospital mortality.

Results: The sample includes a total of 101 patients, 57 of whom were trauma and acute care surgery (TACS) patients and 44 of whom were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. Average shock index was 1.16 (±0.55). On average, patients received 1.66 (±0.80) units of whole blood. Overall mortality was 14/101 (13.86%) in the first 24 hours and 6/101 (5.94%) after 24 hours.

Conclusion: Implementing a WB protocol is achievable in LMICs. Whole blood allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a whole blood program implemented in a civilian hospital in Latin America.

How to Implement a Small Blood Bank in Low and Middle-Income Countries Work in Progress?

Compared to High-Income countries (HIC), a shortfall in the provision of blood remains a multifaceted problem in Low and Middle-Income Countries (LMIC) with a direct negative effect on clinical care. The reasons are multifactorial: not only lack of knowledge, skills, and resources, but also huge differences in environment climate, endemic transfusion transmittable infections, clinical set-up, availability of clean water, electricity. It is therefore obvious that simple translation of guidelines, standards, experiences, and the total organization from HIC to LMIC is not the best way to proceed. Adapted, but not less adequate methods for blood transfusion training, organization, and accreditation are required. The Global Advisory Panel (GAP) already formulated an adapted specific answer in terms of training and accreditation. But this is not enough. Academic centres, the GAP, countries, non-governmental organizations, and others need to test current and innovative diagnostic, production, and storage methods in a joint venture with the industry. Also, medical decisions focused on transfusion must be tested before implementation in facilities allowing pre-qualification of tests and devices. The entire transfusion chain needs to be simulated in a competence and training centre, focusing on the region where it will be applied. One of the renowned tropical institutes, currently fulfilling all these requirements could be the ideal place for such a competence centre. This review highlights this and suggests possible ways and solutions.

Considerations for service delivery for emergency care in low resource settings

In a shift from the more traditional disease focused model of global health interventions, increasing attention is now being placed on the importance of strengthening healthcare systems as a key component for achieving improved health outcomes. As emergency care systems continue to develop and strengthen around the world, the concept of service delivery provides one way to assess how well these systems are functioning. By focusing on service delivery, a system can be evaluated based on its ability to provide patients with access to the high-quality emergency care that they deserve. While the concept of service delivery is commonly used to evaluate the effectiveness of care in high-resource settings, its use in low resource settings has previously been limited due to challenges in operationalizing the concept in a context appropriate way. This article will begin by discussing the concept of service delivery as it specifically applies to emergency care systems and then discuss some of the challenges in defining and assessing this concept in low resource settings. The article will then discuss several new tools that have been developed to specifically address ways to evaluate emergency care service delivery in low-resource settings that can be used to inform future systems strengthening activities.

Pattern of road traffic Accident and their consequences in Dhaka City

Road traffic injuries (RTIs) are one of the eight burning public health issues worldwide causing 1.3 million death every year. This study aimed to see the pattern of road traffic injuries, their consequences, and factors associated within Dhaka city. A cross-sectional study was conducted among Road Traffic Accident victims attended in three largest and tertiary care hospitals located inside the Dhaka metropolitan area through structured interviews between 25 January and 21 February 2017 with a sample size of 140. The majority of injured patients were between 18-37 years. More than 55% of injuries were severe, and intracranial injury (27.1%) was the most common type. T-junction (32.1%) and highways (31.4%) were most places for RTAs where half of the total victims were passengers. Our study indicates
age, gender, and educational status were significantly associated with consequences of RTAs (p<0.05). Moreover, among the RTAs related variables, type of vehicle, RTA type, injury place, and treatment approach found significantly associated with consequences of RTAs (P<0.05). The findings of this study could play an important role to build awareness on RTAs among policymakers and general peoples to reduce mortality due to RTIs.

A geospatial analysis of two-hour surgical access to district hospitals in South Africa

Background
In a robust health care system, at least 80% of a country’s population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa.

Methods
All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods.

Results
Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities.

Conclusion
Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.

Mechanical and surgical interventions for treating primary postpartum haemorrhage

Background: Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions.

Objectives: To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH.

Search methods: We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

Data collection and analysis: Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence.

Main results: We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review’s important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter (‘condom catheter’), an air-filled latex balloon-loaded catheter (‘latex balloon catheter’), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean ‘intraoperative’ blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75).

Authors’ conclusions: There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.

The ratio of shock index to pulse oxygen saturation predicting mortality of emergency trauma patients

Objective: To test the following hypothesis: the ratio of shock index to pulse oxygen saturation can better predict the mortality of emergency trauma patients than shock index.

Methods: 1723 Patients of trauma admitted to the Emergency Department of the First Affiliated Hospital of Soochow University from 1 November 2016 to 30 November 2019 were retrospectively evaluated. We defined SS as the ratio of SI to SPO2, and the mortality of trauma patients in the emergency department as end-point of outcome. We calculated the crude HR of SS and adjusted HR with the adjustment for risk factors including sex, age, revised trauma score (RTS) by Cox regression model. ROC curve analyses were performed to compare the area under the curve (AUC) of SS and SI.

Results: The crude HR of SS was: 4.31, 95%CI (2.89-6.42) and adjusted HR: 3.01, 95%CI(1.86-4.88); ROC curve analyses showed that AUC of SS was higher than that of shock index (SI), and the difference was statistically significant: 0.69, 95%CI(0.55-0.83) vs 0.65, 95%CI (0.51-0.79), P = 0.001.

Conclusion: The ratio of shock index to pulse oxygen saturation is good predictor for emergency trauma patients, which has a better prognostic value than shock index.

Perceptions of Non-Communicable Disease and War Injury Management in the Palestinian Health System: A Qualitative Study of Healthcare Providers Perspectives

Background: Palestine, like other low-income countries, is confronting an increasing epidemic of non-communicable disease (NCD) and trend of war injury. The management of health problems often presents a critical challenge to the Palestinian health system (PHS). Understanding the perceptions of healthcare providers is essential in exploring the gaps in the health system to develop an effective healthcare intervention. Unfortunately, health research on management of NCD and war injury has largely been neglected and received little attention. Therefore, the study aimed to explore the perspectives of healthcare providers regarding NCD and war injury management in the PHS in the Gaza Strip.
Methods: A qualitative study approach was used, based on four focus group discussions (FGDs) involving a purposive sampling strategy of 30 healthcare providers from three main public hospitals in Gaza Strip. A semi-structured topic guide was used, and the focus group interviews data were analyzed using manifest content analysis. The study was approved by the Palestinian Health Research Council (PHRC) for ethics approval.
Results: From the healthcare providers perspective, four main themes and several sub-themes have emerged from the descriptive manifest content analysis: functioning of healthcare system; system-related challenges; patients-related challenges; strategies and actions to navigating the challenges and improving care. Informants frequently discussed that despite some positive aspects in the system, fundamental changes and significant improvements are needed. Some expressed serious concerns that the healthcare system needs complete rebuilding to facilitate the management of NCD and war-related injury. They perceived important barriers to effective management of NCD and war injury such as poor hospital infrastructure and logistics, shortage of micro and sub-specialities and essential resources. Participants also expressed a dilemma and troubles in communication and interactions, especially during emergencies or crises. The informants stressed the unused of updated clinical management guidelines. There was a consensus regarding poor shared-care/task sharing, partnership, and cooperation among healthcare facilities.
Conclusion: Our findings suggest that fundamental changes and significant reforms are needed in the health system to make healthcare services more effective, timely, and efficient. The study disclosed the non-use of clinical guidelines as well as suboptimal sectorial task-sharing among different stakeholders and healthcare providers. A clear and comprehensive healthcare policy considering the gaps in the system must be adopted for the improvement and development of care in the PHS.

Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania

Background
The burden of trauma in low and middle-income countries (LMICs) is disproportionately high: LMICs account for nearly 90% of the global trauma deaths. Lack of trauma data has been identified as one of the major challenges in addressing the quality of trauma care and informing injury-preventing strategies in LMICs. This study aimed to explore the barriers and facilitators of current trauma documentation practices towards the development of a national trauma registry (TR).

Methods
An exploratory qualitative study was conducted at five regional hospitals between August 2018 and December 2018. Five focus group discussions (FGDs) were conducted with 49 participants from five regional hospitals. Participants included specialists, medical doctors, assistant medical officers, clinical officers, nurses, health clerks and information communication and technology officers. Participants came from the emergency units, surgical and orthopaedic inpatient units, and they had permanent placement to work in these units as non-rotating staff. We analysed the gathered information using a hybrid thematic analysis.

Results
Inconsistent documentation and archiving system, the disparity in knowledge and experience of trauma documentation, attitudes towards documentation and limitations of human and infrastructural resources in facilities we found as major barriers to the implementation of trauma registry. Health facilities commitment to standardising care, Ministry of Health and medicolegal data reporting requirements, and insurance reimbursements criteria of documentation were found as major facilitators to implementing trauma registry.

Conclusions
Implementation of a trauma registry in regional hospitals is impacted by multiple barriers related to providers, the volume of documentation, resource availability for care, and facility care flow processes. However, financial, legal and administrative data reporting requirements exist as important facilitators in implementing the trauma registry at these hospitals. Capitalizing in the identified facilitators and investing to address the revealed barriers through contextualized interventions in Tanzania and other LMICs is recommended by this study.