Clinical diagnosis in paediatric patients at urban primary health care facilities in southern Malawi: a longitudinal observational study

Abstract

Background Despite health centres being the first point of contact of care, there are challenges faced in providing care to patients at this level. In Malawi, service provision barriers reported at this level included long waiting times, high numbers of patients and erratic consultation systems which lead to mis-diagnosis and delayed referrals. Proper case management at this level of care is critical to prevent severe disease and deaths in children. We aimed to adopt Emergency, Triage, Assessment and Treatment algorithm (ETAT) to improve ability to identify severe illness in children at primary health centre (PHC) through comparison with secondary level diagnoses. Methods We implemented ETAT mobile Health (mHealth) at eight urban PHCs in Blantyre, Malawi between April 2017 and September 2018. Health workers and support staff were trained in mHealth ETAT. Stabilisation rooms were established and equipped with emergency equipment. All PHCs used an electronic tracking system to triage and track sick children on referral to secondary care, facilitated by a unique barcode. Support staff at PHC triaged sick children using ETAT Emergency (E), Priority (P) and Queue (Q) symptoms and clinician gave clinical diagnosis. The secondary level diagnosis was considered as a gold standard. We used statistical computing software R (v3.5.1) and used exact 95% binomial confidence intervals when estimating diagnosis agreement proportions. Results Eight-five percentage of all cases where assigned to E (9.0%) and P (75.5%) groups. Pneumonia was the most common PHC level diagnosis across all three triage groups (E, P, Q). The PHC level diagnosis of trauma was the most commonly confirmed diagnosis at secondary level facility (85.0%), while a PHC diagnosis of pneumonia was least likely to be confirmed at secondary level (39.6%). The secondary level diagnosis least likely to have been identified at PHC level was bronchiolitis 3 (5.2%). The majority of bronchiolitis cases (n = 50; (86.2%) were classified as pneumonia at the PHC level facility. Conclusions Implementing a sustainable and consistent ETAT approach with stabilisation and treatment capacity at PHC level reinforce staff capacity to diagnose and has the potential to reduce other health system costs through fewer, timely and appropriate referrals.

Digital Solutions for Community and Primary Health Workers: Lessons From Implementations in Africa

“…Detailed background research provided first-hand information about the problem—such as an illness—to be tackled in the community as well as how best to handle it ( 47 ). Furthermore, the implementers of these user-centered digital initiatives ensured to acquire as much information about the community health workers, location, need, opportunities, and other information relevant to the implementation and acceptability of the solution ( 46 , 48 , 49 ).…”

“…Health care workers need to be adequately and continuously trained and empowered on the use of these technologies ( 24 , 39 , 46 , 49 , 53 , 56 , 63 , 71 , 72 ). There is a need to consider the integration of interventions into existing workflows alongside regular training, case management guidelines, emergency supplies, equipment, and drugs, this should also include taking into account the possibility of other ongoing interventions in the system ( 47 , 73 ). Measuring and establishing the acceptability of the mobile health interventions by health care workers is very critical in the sustainability and scalability of any mHealth pilot project ( 74 ).…”

Assessing Facilitators and Barriers to Referral of Children Under the Age of Five Years at Ndirande Health Centre in Blantyre, Malawi

“… 9 , 10 Although Malawi has made steady progress in the reduction of the under-five mortality rate from 234 deaths/1000 births in 1992 to 63 deaths/1000 live births in 2015, 11 there remain gaps that can be closed if under-fives at primary level facilities received timely treatment and referral to facilities at a higher level. 12 Moreover, the fact that PHC facilities are resource-constrained contributes to the occurrence of pediatric deaths in the first 24 hours of admission. 13 , 14 As such, timely referral provides the potential to avert mortality among children and lowers the severity of an illness.…”

“… 28 - 30 Given the benefits of timely and effective referral of a child from a primary health care level facility to a higher one and the lack of data on the barriers, enablers, and processes of such in an urban facility in Malawi, this study explored the processes, barriers, and enablers that influence the referral of children from Ndirande Primary Health Centre to Queen Elizabeth Central Hospital in Blantyre, Malawi. Cognizant that half of the population in Blantyre are under the age of 15 years (NSO) and will likely use pediatric services in the primary health facilities 12 an understanding of the referral system will optimize the effectiveness of the system to achieve timely referral which can avert mortality.…”

Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings

“…Facilities that are adequately resourced to diagnose and treat severe pneumonia need to be identified so that patients can be directed to the appropriate facility. Healthcare facilities that implement effective triage to identify the most severely ill children were able to lower inpatient mortality ( 20 , 21 ). To that end, infrastructure to facilitate transfers must exist.…”