Assessment of Attitudes Toward the Emergency Triage System in Belize.

Objective. Triage in resource-limited settings (RLS) improves outcomes. Emergency Triage Assessment and Treatment (ETAT) is a simple triage algorithm that improves assessment and initial management of children in RLS. In Belize, pediatric triage varies with setting, from a 5-level Emergency Severity Index (ESI) used at the National Referral Hospital to a lack of triage at government health centers (GHC). Most data on ETAT implementation are in settings where no triage system existed; data on how to integrate ETAT into existing, heterogeneous triage systems are lacking. The aim of this study is to explore health care providers' (HCPs) attitudes toward the current triage system prior to national pediatric triage process implementation. Methods. A qualitative study was performed via convenience sampling of HCPs who participated in an ETAT training course using focus groups immediately and 1 year after an initial ETAT training. Focus groups were digitally recorded and transcribed. Three coders analyzed all transcripts to identify emerging themes. Constant comparison analysis was performed until achieving thematic saturation. Results. The following principal themes emerged: (1) importance of triage education and implementation to standardize and improve communication; (2) major limitations of ESI include its complexity, lack of pediatric-specific criteria, and dependence on equipment not consistently available; and (3) desire to implement a simple, low-resource pediatric-specific triage system. Conclusions. Participants believe triage education and process implementation is essential to improve communication and pediatric emergency care. Simple, low-resource pediatric-specific triage systems, like ETAT, may improve utilization by providing faster recognition and improved care for acutely ill children.

Childhood malnutrition within the indigenous Wayuú children of northern Colombia.

Malnutrition contributes to nearly half of all preventable deaths in children under the age of five. While the burden of disease is heaviest in Sub-Saharan Africa, South, and Southeast Asia, malnutrition in Latin America remains high, especially within indigenous communities. This study evaluates the prevalence of malnutrition and its relationship with access to healthcare resources within 172 indigenous Wayuú communities in La Guajira, Colombia. Healthcare workers administered a health questionnaire and collected anthropometric measurements on all children 6 months to 5 years of age within the Wayuú households. These data were utilised to calculate the prevalence of acute malnutrition, stunting, and underweight. Of all surveyed Wayuú children, 22.9% and 18.3% met criteria for moderate and severe malnutrition, 33.4% and 28.1% met criteria for moderate and severe stunting, and 28.1% and 16.6% were moderately and severely underweight. Across all categories, malnourished children were older, less likely to have had a medical professional present at birth, less likely to have received medical care after birth, and more likely to have been born in a non-medical, community setting. The prevalence of malnutrition is much higher than national levels in Colombia. This population requires urgent assistance to address their disproportionately high rates of malnutrition.

Chikungunya in a Pediatric Traveler.

Chikungunya is a mosquito-transmitted virus found primarily in Africa and Asia. In late 2013, chikungunya virus emerged in the Western hemisphere, spreading from the Caribbean to South, Central, and North America (MMWR Morb Mortal Wkly Rep. 2014;63:1121-1128). Symptoms can be similar to nonspecific viral presentations including fever, joint pain, joint swelling, and rash. The diagnosis of infectious tropical diseases in the emergency department often requires a high index of suspicion, given the nonspecific early findings that characterize many of these tropical diseases. This report presents a case of chikungunya in a pediatric patient traveling from Guatemala to the United States. Proper recognition of infection and diagnosis are vital from a public health perspective. Considering patients will remain viremic for up to a week and potentially expose local mosquitoes to infection, it is important to educate the patient on mosquito bite prevention in geographic areas of the United States where competent mosquito vectors exist as a means of avoiding further spread.

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.

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.

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 Children's 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 Children's 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).

Utilization of a mobile medical van for delivering pediatric care in the bateys of the Dominican Republic.

BACKGROUND: Bateys are impoverished areas of housing for migrant Haitian sugar cane workers in the Dominican Republic (DR). In these regions, preventative health care is almost non-existent, public service accessibility is limited, and geographic isolation prevents utilization of care even by those families with resources. Consequently, the development of a viable mobile system is vital to the delivery of acute and preventative health care in this region. AIMS: This study evaluated an existing mobile medical system. The primary goal was to describe the population served, diseases treated, and resources utilized. A secondary goal was to determine qualitatively an optimal infrastructure for sustainable health care delivery within the bateys. METHODS: Information on basic demographic data, diagnosis, chronicity of disease, and medications dispensed was collected on all pediatric patients seen in conjunction with an existing mobile medical system over a 3-month period in the DR. Health statistics for the region were collected and interviews were conducted with health care workers (HCWs) and community members on existing and optimal health care infrastructure. RESULTS: Five hundred eighty-four pediatric patients were evaluated and treated. Median age was 5 years (range 2 weeks to 20 years), and 53.7% of patients seen were 5 years of age or younger. The mean number of complaints per patient was 2.8 (range 0 to 6). Thirty-six percent (373) of all diagnoses were for acute complaints, and 64% (657) were chronic medical problems. The most common pediatric illnesses diagnosed clinically were gastrointestinal parasitic infection (56.6%), skin/fungal infection (46.2%), upper respiratory tract infections (URIs) (22.8%), previously undiagnosed asthma and allergies (8.2%), and symptomatic anemia (7.2%). Thirty HCWs and community members were interviewed, and all cited the need for similar resources: a community clinic and hospital referral site, health promoters within each community, and the initiation of pediatric training for community HCWs. CONCLUSION: A mobile medical system is a sustainable, efficient mechanism for delivering acute and preventive care in the Haitian bateys of the Dominican Republic. The majority of patients served were 8 years of age or younger with multiple presenting symptoms. A pediatric protocol for identifying the most appropriate drugs and supplies for mobile units in the DR can be created based upon diseases evaluated. Qualitative data from HCWs and community members identified the need for an integrative health care delivery infrastructure and community health promoters versed in pediatric care who can aid in education of batey members and monitor chronic and acute illnesses. We are planning follow-up visits to implement these programs.