Implementation of Smart Triage combined with a quality improvement program for children presenting to facilities in Kenya and Uganda: An interrupted time series analysis.

J Mark Ansermino, Yashodani Pillay, Abner Tagoola, Cherri Zhang, Dustin Dunsmuir, Stephen Kamau, Joyce Kigo, Collins Agaba, Ivan Aine Aye, Bella Hwang, Stefanie K Novakowski, Charly Huxford, Matthew O. Wiens, David Kimutai, Mary Ouma, Ismail Ahmed, Paul Mwaniki, Florence Oyella, Emmanuel Tenywa, Harriet Nambuya, Bernard Opar Toliva, Nathan Kenya-Mugisha, Niranjan Kissoon, Samuel Akech
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Abstract

PLOS DH (298/300 word limit) Sepsis occurs predominantly in low-middle-income countries. Sub-optimal triage contributes to poor early case recognition and outcomes from sepsis. We evaluated the impact of Smart Triage using improved time to intravenous antimicrobial administration in a multisite interventional study. Smart Triage 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, but less in Uganda (3 minutes) at the intervention site. Then, during the implementation period in Kenya, the time to IVA 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 IVA initially decreased but was not sustained, and there was no significant difference between intervention and control sites. At the intervention sites, there was a significant reduction in IVA utilization of 47% (Kenya) and 33% (Uganda), a reduction in admission rates of 47% (Kenya) and 33% (Uganda) and a 25% (Kenya) and 75% (Uganda) reduction in mortality rates 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 but should be interpreted cautiously as these were secondary outcomes. This study underlines the difficulty of implementing technologies and sustaining quality improvement in resource-poor health systems.
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在肯尼亚和乌干达的医疗机构实施智能分诊与儿童医疗质量改进计划:间断时间序列分析。
PLOS DH (298/300 字限制)败血症主要发生在中低收入国家。分诊不理想是导致败血症早期病例识别率和治疗效果不佳的原因之一。我们在一项多地点干预研究中评估了智能分诊对改善静脉注射抗菌药物时间的影响。智能分诊在肯尼亚(2021 年 2 月至 2022 年 12 月)和乌干达(2020 年 4 月至 2022 年 4 月)实施(有对照地点)。在肯尼亚(2021 年 2 月至 2022 年 12 月)和乌干达(2020 年 4 月至 2022 年 4 月)实施了智能分诊(含对照点)。采用受控间断时间序列评估从到达医疗机构到静脉注射抗菌药物的时间影响。在基线期间,肯尼亚对照组和干预组的抗菌药物使用时间显著缩短(分别为 132 分钟和 58 分钟),但乌干达干预组的缩短幅度较小(3 分钟)。然后,在肯尼亚的实施期间,干预地点的静脉注射抗菌药物时间减少了 98 分钟(57%,95% CI 81-114),但对照地点增加了 49 分钟(21%,95% CI:23-76)。在乌干达,静脉输液时间起初有所减少,但并未持续,干预地点和对照地点之间也没有显著差异。在干预地点,与基线期相比,静脉注射抗生素的使用率显著降低了 47%(肯尼亚)和 33%(乌干达),入院率降低了 47%(肯尼亚)和 33%(乌干达),死亡率降低了 25%(肯尼亚)和 75%(乌干达)。抗菌药物使用率、入院率和死亡率的降低是显著而可喜的成果,但由于这些都是次要成果,因此应谨慎解读。这项研究强调了在资源匮乏的卫生系统中实施技术和持续提高质量的难度。
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