The FAST-M complex intervention for the detection and management of maternal sepsis in low-resource settings: a multi-site evaluation.

OBJECTIVE: To evaluate whether the implementation of the FAST-M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low-resource setting. DESIGN: A before-and-after design. SETTING: Fifteen government healthcare facilities in Malawi. POPULATION: Women suspected of having maternal sepsis. METHODS: The FAST-M complex intervention consisted of the following components: the FAST-M maternal sepsis treatment bundle and the FAST-M implementation programme. Performance of selected process outcomes was compared between a 2-month baseline phase and 6-month intervention phase with compliance used as a proxy measure of feasibility. MAIN OUTCOME RESULT: Compliance with vital sign recording and use of the FAST-M maternal sepsis bundle. RESULTS: Following implementation of the FAST-M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P < 0.001). Recognition of suspected maternal sepsis improved with more cases identified following the intervention (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001). Sepsis management improved, with women more likely to receive all components of the FAST-M treatment bundle within 1 hour of recognition (0/12 [0%] versus 21/107 [19.6%], P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis. CONCLUSION: Implementation of the FAST-M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low-resource setting such as Malawi. TWEETABLE ABSTRACT: Implementation of a sepsis care bundle for low-resources improved recognition & management of maternal sepsis.

Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process.

OBJECTIVE: To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. DESIGN: Modified Delphi process. SETTING: Participants from 34 countries. POPULATION: Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. METHODS: We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in-person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. MAIN OUTCOME MEASURE: Consensus on bundle items. RESULTS: Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher-level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym 'FAST-M'. CONCLUSION: A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. TWEETABLE ABSTRACT: A maternal sepsis bundle for low resource settings has been developed by international consensus.

Impact of changing diagnostic criteria for smear-positive tuberculosis: a cohort study in Malawi.

We assessed the impact on measured burden and outcomes of the revised World Health Organization and Malawi guidelines reclassifying people with single (including 'scanty') positive smears as smear-positive pulmonary tuberculosis cases. In a retrospective cohort in rural Malawi, 567 (34%) of 1670 smear-positive episodes were based on single positive smears (including 176 with scanty smears). Mortality rates and the proportion starting treatment were similar in those with two positive smears or single, non-scanty smears. Those with single scanty smears had higher mortality and a lower proportion starting treatment. The reclassification will increase the reported burden substantially, but should improve treatment access.

Using tuberculosis suspects to identify patients eligible for antiretroviral treatment.

SETTING: A district in rural sub-Saharan Africa with a recently introduced antiretroviral (ARV) programme. The population has high human immunodeficiency virus (HIV) prevalence and high tuberculosis (TB) incidence. OBJECTIVE: To determine the prevalence of HIV and acquired immune-deficiency syndrome (AIDS) related symptoms in people presenting with chronic cough who are not diagnosed with TB. DESIGN: A cross-sectional survey of TB suspects. METHODS: Patients with chronic cough were recruited from out-patient facilities. After standard diagnostic procedures and providing informed consent, they received counselling and testing for HIV, and were interviewed and examined with respect to staging criteria for HIV/AIDS. Suspects were followed up for 3 months after the end of the recruitment period to allow for delayed diagnosis of TB. RESULTS: Of 145 suspects, 79% had not been diagnosed with TB by the end of the follow-up period. Of these, 108 (95%) agreed to HIV testing and 61 (56%) were HIV-positive. More than half of these were eligible for ARV treatment (Stage III or IV disease) under national programme criteria. CONCLUSION: Established chronic cough clinics are a useful setting for recruitment of patients to ARV clinics. Attendees should be offered HIV testing and simple clinical screening to identify those who should be referred for ARV treatment.

Touch imprint cytology of core needle biopsy specimens: a useful method for immediate reporting of symptomatic breast lesions.

AIMS: The aim of this study was to determine the diagnostic value and accuracy of touch imprint cytology (TIC) of core needle biopsy (CNB) specimens in predicting the final benign or malignant histology in patients presenting with symptomatic breast lesions. METHODS: One hundred and twenty-eight patients underwent CNB under ultrasonographic guidance with subsequent TIC preparation. TIC results were correlated with the histology of the core or the surgical resection specimen. RESULTS: The 128 lesions analysed included 106 malignancies and 22 benign lesions. TIC accurately predicted the final histology in 96.7% of cases, with a sensitivity of 96.2% and a specificity of 100%. CONCLUSIONS: The routine use of TIC to complement CNB can provide an immediate and reliable cytological diagnosis of symptomatic breast lesions. The potential use of this technique in a breast clinic setting may help allay patient anxiety and expedite the planning of further surgical management.