Mobile phone triage approach could benefit critically ill children at the primary health care level

17 Feb 2021
Mobile phone triage approach could benefit critically ill children at the primary health care level
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A mobile phone triage tool used to assess critically ill children in Malawi has the potential to strengthen diagnosis capacity in primary care and reduce health system costs through fewer, more timely and more appropriate referrals for specialist or emergency care. New research, published today in the BMC Health Services Research journal, compared diagnoses made with the tool in local health centres with a clinician’s findings. The study hopes to help improve identification of those who are seriously ill, so they get help faster. 

Primary health centres (PHC’s) are often the first point of contact with the healthcare system in many low-income countries, including Malawi. They are often very busy, so finding ways to ensure critically ill children are seen quickly could save lives.

Dr Nicola Desmond, a medical anthropologist at Malawi-Liverpool Wellcome (MLW) Trust, said: “A high proportion of presentations at the primary level are for paediatric services. Therefore, some childhood deaths could be prevented if critically ill children are quickly identified, treated, and referred to a secondary level hospital. However, there are many challenges in providing high-quality care at this level, including long wait times, high numbers of patients and erratic consultation systems.
“Instead of triage, it was standard practice for adults and children to queue together at PHCs and be seen on a first-come first-served basis. As a result, severe illness in children was frequently missed, leading to deaths, disability and complications. The ‘Emergency, Triage, Assessment and Treatment (ETAT)’ guidelines were designed to overcome this by quickly identifying sick children, allowing immediate start of emergency treatment.”

Image: ETAT in use at Makhwira Health Centre, Malawi, August 2018.
In this study, funded by the Scottish Government, through Meningitis Research Foundation, patients arriving at the outpatient department of Queen Elizabeth Central Hospital (QECH) which serves the PHCs in the study, were also triaged using the mHealth phones. Here, the barcode sticker was scanned to retrieve patient details and verify their arrival. Finally, the barcode was scanned by a research nurse in order to link the triage category and PHC data to QECH admissions data, and retrospectively collect information on a patient’s diagnosis.   

Results revealed that out of 233 records collected, the most frequent triage categorisation was priority, followed by non-urgent/queue, and then emergency.
Video: Video diary from our 2018 trip to Malawi.
The researchers then assessed whether the diagnoses made at the primary level were confirmed by those made at the local hospital where there was full diagnostic capacity supported by functional laboratories and highly trained clinicians.

Common childhood illnesses and pneumonia were commonly over-diagnosed at PHCs, with only 40% of pneumonia diagnoses confirmed at QECH. Cases of bronchiolitis were however found to be being missed– with only 5% of cases correctly identified at PHC. This is explained to be due to the majority of bronchiolitis cases being diagnosed as pneumonia at PHCs, due to their similar symptoms.
There was good alignment with diagnoses of trauma and malnutrition in both settings, which the authors suggest is likely due to these conditions' unique presentation. In contrast, diagnosing meningitis at PHCs is a recognised challenge due to its overlapping clinical presentation with other feverish illnesses. PHC staff are also unable to perform a lumbar puncture.

Image: The triage "traffic light" system explained within the health centre. Malawi, August 2018.
Linda Glennie, Director of Research, Evidence and Policy at Meningitis Research Foundation said: “Effective triage of sick children is essential to enable prompt referral and treatment, and critically, stop an illness from advancing and taking a child’s life. The development and implementation of mHealth ETAT in countries such as Malawi can make a significant contribution to reducing deaths from meningitis - which is a key goal of the WHO Global Roadmap to Defeat Meningitis by 2030.”
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