Family experiences with pediatric rare disease care: findings from the Canadian Inherited Metabolic Diseases Research Network Beth Potter, University of Ottawa
Rare Disease Day Conference 2020 March 9-10
Person-centred care and patient activationNuffield Trust
Richard Owen, NHS England, and Dr Natalie Armstrong of the University of Leicester present on evaluating Person Centred Care through Patient Activation Measure (PAM).
Family experiences with pediatric rare disease care: findings from the Canadian Inherited Metabolic Diseases Research Network Beth Potter, University of Ottawa
Rare Disease Day Conference 2020 March 9-10
Person-centred care and patient activationNuffield Trust
Richard Owen, NHS England, and Dr Natalie Armstrong of the University of Leicester present on evaluating Person Centred Care through Patient Activation Measure (PAM).
This resource summarizes the eight recommendations outlined in the Institute of Medicine's a new consensus study entitled, Improving Diagnosis in Health Care. The recommendations are aimed at making diagnoses more accurate, reliable, efficient, and safe. This work is a continuation of the IOM’s Quality Chasm series.
Clinical practice guidelines and quality metrics often emphasize effectiveness over patient-centered care. In this article, the authors offer three approaches to personalizing quality measurement to ensure patient preferences and values guide all clinical decisions.
Advancing Team-Based Care: Complex Care Management in Primary CareCHC Connecticut
This webinar investigated the ways that team members can contribute to the care of patients with complex medical and/or social needs. The focus was on developing the expanded care team and ensuring ready communication between the core and expanded care teams. Models for effective care management were presented.
This webinar was presented May 5, 2016 3:00 p.m. Eastern Time
Paul Bristow, BKPA, and Karen Thomas, UKRR gave a presentation at BRS2017: Embedding patient reported experience into future QI - 1st National PREM Pilot Survey 2016
Presented at the 2015 IHI International Forum byThe Royal Melbourne Hospital of Victoria,Australia, this poster,speaks to the power of Shadowing to engage patients and families in decisions of care, specifically the post-discharge planning process.
People Helping People - Patient power learning about peer-to-peer healthcar...Nesta
This presentation was delivered at People Helping People - The future of public services - 3rd September 2014. For more information on the event visit http://www.nesta.org.uk/event/people-helping-people-future-public-services
Dr Marie-Pierre Preziosi's presentation at Meningitis Research Foundation's 2013 conference, Meningitis & Septicaemia in Children & Adults http://www.meningitis.org/conference2013
This resource summarizes the eight recommendations outlined in the Institute of Medicine's a new consensus study entitled, Improving Diagnosis in Health Care. The recommendations are aimed at making diagnoses more accurate, reliable, efficient, and safe. This work is a continuation of the IOM’s Quality Chasm series.
Clinical practice guidelines and quality metrics often emphasize effectiveness over patient-centered care. In this article, the authors offer three approaches to personalizing quality measurement to ensure patient preferences and values guide all clinical decisions.
Advancing Team-Based Care: Complex Care Management in Primary CareCHC Connecticut
This webinar investigated the ways that team members can contribute to the care of patients with complex medical and/or social needs. The focus was on developing the expanded care team and ensuring ready communication between the core and expanded care teams. Models for effective care management were presented.
This webinar was presented May 5, 2016 3:00 p.m. Eastern Time
Paul Bristow, BKPA, and Karen Thomas, UKRR gave a presentation at BRS2017: Embedding patient reported experience into future QI - 1st National PREM Pilot Survey 2016
Presented at the 2015 IHI International Forum byThe Royal Melbourne Hospital of Victoria,Australia, this poster,speaks to the power of Shadowing to engage patients and families in decisions of care, specifically the post-discharge planning process.
People Helping People - Patient power learning about peer-to-peer healthcar...Nesta
This presentation was delivered at People Helping People - The future of public services - 3rd September 2014. For more information on the event visit http://www.nesta.org.uk/event/people-helping-people-future-public-services
Dr Marie-Pierre Preziosi's presentation at Meningitis Research Foundation's 2013 conference, Meningitis & Septicaemia in Children & Adults http://www.meningitis.org/conference2013
Professor Michael Levin's presentation at Meningitis Research Foundation's 2013 conference Meningitis & Septicaemia in Children & Adults www.meningitis.org/conference2013
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
How Do Front line Workers Provide the Four Cs of CBNC?
Contact with newborns, case identification, care and completion of treatment. A qualitative Study.
June 2015
Safe transition for young people to adulthood
Dr Jacqueline Cornish,
National Clinical Director Children, Young People and Transition to
Adulthood - NHS England
NHS Improving Quality held an event in London on 31 July 2013 to progress the children and young people transition to adult services work with a focus on turning the rhetoric into practice entitled “Working to Define a Generic Service Specification for Transition”
ISS Service Innovation Leadership Seminar, 28 March - Mrs Chew Kwee TiangNUS-ISS
ISS Service Innovation Leadership Seminar, 28 March - "Design Thinking and Service Innovation - The Khoo Teck Puat Hospital's Journey" by Mrs Chew Kwee Tiang, CEO, Khoo Tech Puat Hospital
Improving follow-up and HIV testing rates of exposed infants through a suppor...3GDR
Katherine De Tolly, Cell-Life.org
Similar to Implementing an mHealth triage intervention for health care workers at primary health centres in urban Blantyre, Malawi - a pilot study (20)
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Implementing an mHealth triage intervention for health care workers at primary health centres in urban Blantyre, Malawi - a pilot study
1. A pilot study implementing an mHealth triage
intervention for health care workers at
primary health clinics in Blantyre, Malawi
Nicola Desmond
Liverpool School of Tropical Medicine
Malawi-Liverpool-Wellcome Trust
2.
3. Treatment seeking for acute bacterial meningitis
• More than 1 million cases of
ABM annually in SSA
• Prompt treatment vital to
effective management
• Late presentation identified as
major contributor to high case
fatality rates for ABM
4. Responses to ABM
HCW
diagnosis
practices
Timeliness
dependent on
social position
Misdiagnosis
as malaria
Recognition
of severity
Perceptions of
health
services
Recognition
Lay
interpretation
of symptoms
Social
validation of
illness
Financial
constraints
Action
High numbers
of patients
Unsystematic
triage
5. Primary health level contributors
High numbers
of patients
Primary health level
misdiagnoses
Erratic consultation
systems
Unsystematic & informal
triage
6. Aims
Explore the feasibility of implementing a triage system within
PHCs facilitated through the use of mHealth technologies
– To develop mHealth algorithm based on Emergency Triage
component of ETAT (WHO)
– To implement prioritisation system using mHealth triage
algorithm
– To encourage appropriate referral decisions to QECH &
track referrals
– To evaluate triage system using mixed methods
approaches
7. ETAT for resource-poor settings
• ETAT: Emergency Triage, Assessment and Treatment
• Component of Integrated Management of Childhood
Illness (IMCI)
• Identify children with immediately life-threatening
conditions
• Reliance on few clinical signs
• Assessment carried out quickly if negative
• Easy to follow guidelines for all cadres with limited
clinical background
• Easy to conduct when patients queuing
12. Improving patient pathways
Triage
Patient
Patient
assigned E, P, Q
Patient
enters PHC
HCW conducts
rapid triage
QECH
Fieldworker
If referred to QECH
data entered on arrival
Adapted from Sarah Bar-Zeev (2012)
PHC
Clinician
Patient follows
clinician
instructions
Clinician conducts
consultation &
enters data
14. Evaluation
Quantitative
mHealth tool
• Monitor
patient
pathways
• Assess if
systematic
and timely
Self completed
questionnaires
• Explore
accuracy of
E,P and Q
assignments
pre and post
intervention
Qualitative
Patient Journey
Modelling
• Baseline and
post
intervention
• Document
practice and
patient flows
• Structured
observations
Qualitative
Interviews
• Capture staff
feedback
• Impact on
overall clinic
management
and practice
16. 41358
Number of Cases Triaged
Dec 2012 - May 2013
Total catchment population by clinic
Ndirande
Zingwangwa
Bangwe
Chilomoni
Mpemba
Total
12043
10412
213,613
142,594
131,667
80,940
48,176
616,990
9191
5091
Total Cases
Bangwe
Ndirande
4621
Chilomoni Zingwangwa Mpemba
17. Mean time between triage and consultation
Triage
evaluation
Time taken
(Mins)
Paediatric
cases
E
P
28.34
44.64
131
13,585
Q
59.02
26,452
(Anova: P < 0.001)
18. Age distribution of triage assessments
60.0
50.0
40.0
< 1 year
1-5
30.0
6-10
>10
20.0
10.0
0.0
Queue
Priority
Emergency
20. Cadre specific levels of engagement
• Health Surveillance Assistants (HSAs)
– Salaried community health workers
– 10,507 (2009) across Malawi
– Average clinical training of 8 weeks
• Triage conducted predominantly by Health
Surveillance Assistants
• Nurses rarely involved in triage of patients
21. Referrals
Out of 41,358 children triaged
1.6% (644) were referred to QECH
15.5% (100) - Emergency
74.9% (482) - Priority
9.6% (62) - Queue
From the 644 referrals 37.3% (240)
arrived at QECH
62.7% (404) of referrals from PHCS
did not reach QECH
22. Successful referrals
Overall mean time 5.5 hours
Triage
evaluation
E
P
Time taken
(Hours)
3.5
5.7
Paediatric
cases
33
193
Q
6.8
14
(Anova: P = 0.39)
24. Improved patient flows
‘There is now
improvement, those
children don’t take long to
be attended to.” HCW
‘At Bangwe we are now working
together as a team. It is helping
us manage the children so much
better. We are seeing them far
more quickly than before’ HCW
‘In the past even if you come with a child who
is very sick your fellow carers could not give
you a chance to go in front of a queue for your
child to be helped immediately but now things
have improved because when a child is very
sick s/he is put in front of a queue’ Carer
25. Improved recognition of severe illness
‘Ever since ETAT started, I
have never heard any
news that a child died on
the way or maybe in the
doctor’s room’ HCW
‘Triage is being done
systematically and children
with critical illnesses are
being identified and treated
on time’ HCW
‘I am so thankful because of what has
happened today. My baby was identified
among others that he was an emergency
and he was taken in front of the queue to
be seen immediately by the clinician and
he is now better’ Carer
26. Conclusions
Health worker wearing Chipatala
Robots T-Shirt
• Separation of sick from
non-sick
• Paediatric definitions
• Consistent quality of triage
• High levels of ownership
• High levels of acceptability
27. “I only wish the primary
health centres could
improve on diagnosis
and recognising
symptoms quicker...”
Mphatso Cheonga, 2012
28. Investigators
Naor Bar-Zeev
Queen Dube
Norman Lufesi
Elizabeth Molyneux
Sarah Bar-Zeev
Rob Heyderman
Acknowledgments
ETAT trainers
Zondiwe Mwanza
Thembi Katangwe
Yabwile Mulambia
Mtisunge Gondwe
MRF
Thomasena O’Byrne
Chris Head
Linda Glennie
Sara Marshall
Rachel Perrin
AcMen team at MLW
Deborah Nyirenda
Bernadetta Payesa
Malango Msukwa
Alick Masala
Lilian Ulayah
Farouk Edward
Wilard Chilunga
Blantyre DHO
Dr Owen Malema
Dr Eltas Nyirenda
Dr Palesa Chisala
D-Tree International
Dr Marije Geldof
Dr Marc Mitchell
Phidelis Suwedi
All photos reproduced by kind permission of
participants
Primary Health Centres
Bangwe: Martha Makuta
Christopher Mkunga
Chilomoni: Dalitso Namasani
Ndirande: Francis Phiri
Mpemba: Rodgers Kuyokwa
Zingwangwa: Margaret
Chingona
Editor's Notes
Hi my name is Nicola Desmond. I’m a medical anthropologist, and Wellcome Trust Fellow based at the MLW MOP in Blantyre Malawi. We have been working in collaboration with the Meningitis Research Foundation to develop a pilot study implementing an mHealth triage intervention for health care workers at primary health clinics. This study is part of the MRFs expansion of its focus into tackling meningitis in resource-poor settings – and is known as the AcMen project. Malawi has made significant progress in reducing deaths in children aged under five but remains with an infant mortality rate of 112 per 1000 live births. The major causes of infant deaths are pneumonia (23%), malnutrition (22%), diarrhoeal diseases (18%) and malaria (14%).
So to begin I want to introduce you to Edith Cheonga who lives in a village outside of Blantyre with her young parents and elder brother, Ronald.Following a fever lasting three days Edith, then aged 3, was taken by her father to the nearest primary health centre. The clinician at the health centre conducted a malaria test and although this showed neagtive, prescribed her with a local malaria treatment, LA and sent her home. Despite giving her the prescribed medication Edith’s fever continued and three days later she was crying incessantly and developed a bulging fontanel. Her parents returned to the health centre with her and after insistence from her father was referred to Queen Elizabeth Central Referral Hospital in Blantyre. She was diagnosed with meningitis and remained in hospital for ten days. After returning home Edith continued to cry a lot and her parents returned to Queens with her. Fluids were found on her brain and she was operated on.Edith is now 4 and can no longer see, hear or sit up properly.Why am I telling you about the story of Edith?
Edith is a case study from research carried out by MLW in 2010 into health seeking pathways which was based on the fact that late presentation is a driving factor for death from bacterial meningitis and other severe illnesses where prompt treatment is essential to effective management.
From this initial research we identified a number of factors that impact at both community and primary health level on the recognition of meningitis and the capacity to do something about it – those coloured green reflect community level factors, those coloured blue represent primary health level factors and those coloured yellow represent problems in recognition that occur at both community and primary health levels.
So we knew that something was needed to be done at both community and primary health level. In this presentation I focus on our response to factors impacting on recognition of ABM and other severe illness amongst paediatrics at primary level. These areUnsystematic and informal triage where adults and children sit together and are seen on a first come first served basis rather than prioritised systematically. High numbers of patients seen on a daily basis in busy PHCs which creates additional burdens on healthcare workers, further exacerbating an erratic consultation system. Malaria season exacerbates primary clinic burdens from December to March. And finally high levels of misdiagnoses for sever illness.
So we wanted to explore the feasibility of implementing a triage system within PHCs through the use of mHealth technologiesWe had four specific objectives for this pilot study:To develop an mHealth algorithm based on WHO approved ETAT To implement a prioritisation system using this mHealth triage algorithmWhich we hoped to encourage appropriate referral decisions and track referrals to Queen Elizabeth Central HospitalAnd then to evaluate triage system using mixed method approaches
Our intervention is adapted from the ETAT protocol. This stands for Emergency Triage Assessment and Treatment and was developed for tertiary settings to identify and respond to severe illness as a component of the Integrated management of childhood Illneses or IMCI protocol.Our focus was on the triage component which facilitates the early identification of children with immediately life-threatening conditions based on identification of a few important clinical signs and the ability to identify negative symptoms quickly.The algorithm is simple with easy to follow guidelines appropriate for application by all cadres of staff and requiring limited clinical training. It is also easy to conduct when patients are queuing.
Recognising the need for consistent application of the triage algorithm we decided to explore the use of mobile health technologies. Mobile health or mhealth is the practice of public health and medicine supported by mobile devices. Phones have been generally used for data collection especially in hard to reach areas or as point of care tools including the provision of clinical algorithms. Through the use of active prompts consistent across all cases mHealth has the capacity to improve diagnosis and act as a training and monitoring tool.
So now I want to describe the intervention we developed which is the first time mHealth has been used for triage in this setting
Our intervention had three main components: a training package including ETAT, the use of the mHealth tool and study specific protocols. We trained a total of 74 health care workers in collaboration with paediatric registrars at Queens hospital and mHealth collaborators from D-Tree International.We conducted this pilot over a six month period between December 2012 and May 2013 in the 5 busiest primary health clinics in Blantyre District. We focused on paediatrics defining the age range as 0 to 14 following ETAT definitions used within tertiary settings. We monitored patients through the primary to tertiary system. To evaluate the intervention we carried out pre and post intervention activities using a mixed methods approach. I will expand on the intervention and evaluation components in the next few slides.
Our triage phone intervention is based on the concept of Chipatala Robots. Robots in the local language are traffic lights and chipatala means health centre. We created Chip as a character to guide patients and carers through the system. Each patient is assigned an ID number through the phones which is also stamped in patient health passports. Health passports are used in Malawi as a record of all clinic visits for each patient. Following assignment of an ID number and entry of basic demographic information of age and sex the health care worker moves through a series of screens asking questions about key clinical signs to identify severe illness. Specific responses take the health worker forward to an assignment based on the traffic lights system where red depicts an Emergency meaning the child is extremely sick and should be seen immediately, green depicts a priority where the child is very sick and should be given priority in the queue or green depicts a queue where the child has a minor injury or illness and should wait in the queue. Patients are then provided with a coloured card according to the outcome of the triage which guides them through the system
So this system is about improving pathways within the primary health setting. Let me briefly walk you through the system. A patient enters the primary health centre into the waiting area where health care workers conduct rapid triage using the smart phone including entering demographic details. The patient is then assigned an E, P or Q by the phone and given a coloured card which defines when they will see the clinician. The clinician conducts the consultation and enters further details on a second phone including their own assessment of triage priority and referral decisions. The patient then follows the clinician instructions, passing through the pharmacy as necessary. If they have been referred to Queens hospital their arrival is captured on a third phone kept by AcMen fieldworkers in the A&E department.
There have been a range of pilot studies conducted into mHealth applications but these have rarely been accompanied by any rigorous evaluation and a recent systematic review published in PlosMedicine on the effectiveness of mHealth technologies to improve health service delivery processes identified the need for rigorous evaluation and high quality trials measuring clinical outcomes. Our pilot study begins with this rigorous evaluation as a precursor to the development of a cluster randomised trial with clinical outcomes as the main endpoint.
Specifically we used both qualitative and quantitative evaluation methods to assess both feasibility and acceptabilityAs I’ve described the mHealth tool was used for the triage algorithm but also to monitor patients through the system using a system of unique ID numbers automatically assigned on initial data entry. This allowed us to assess times taken for different prioritisation groups across all patients.We also wanted to understand whether the training component of the intervention and consistent use of the triage algorithm on the phone had an impact on appropriate decisions regarding severity of illness. Using a self-completed questionnaire and presentation of different clinical scenarios we explored accuracy of E, P Q assignments pre and post intervention.We wanted to explore pathways from a more qualitative perspective to provide more contextual detail for the data produced through the smartphone as a monitoring tool. Patient journey modelling is an approach which facilitates the collation of staff perspectives on the patient journey through the clinic. These were then verified by structured observations of individual patients as they moved through the system.Finally we explored acceptability and response to the intervention amongst different stakeholders including heads of clinics, clinical and triage staff and patients.
I will now present some of the results of the evaluation.
41,358 children were triaged through the 5 primary health clinics during the six month study period. Numbers of patients passing through particular clinics did not necessarily reflect size of catchment populations. For example Zingwangwa triaged less people due to under staffing and a high volume of patients and Bangwe had the third highest catchment population but triaged the highest number of patients.
Overall we triaged a total of 131 Emergency cases, 13,585 priority cases and 26,452 queue or non-priority cases. Time taken to be seen by the clinician over the pilot intervention period was on average shorter for emergencies, than priorities and longest for queue cases, a finding that was significant and which is as we would hope to see.
Of the 41,358 children who went through the triage system the majority were aged 1-5 years across all assessment outcomes. A total of 20,751 children (over 50% of all cases) seen were aged between 1 to 5 years. Of the emergency cases, 37% were <1 and 49% were aged 1-5, whilst only 14% were aged 5y orolder.Of the priority cases, 23% were <1,52% were aged 1-5, and 25% were 5y or older.Of the queue kids, 27% were <1 and 49% were 1-<5, and 24% were 5y or olderSo there was a greater likelihood of an emergency case being aged under 1 year whilst those aged 1-5 were more likely to be given a priority assignment and those over 10 years were most likely to be assigned a queue, showing, as expected, that severity of disease decreases with age.
Priority assessments conducted by primary level clinicians were defined as the comparison with which to assess the quality of triage outcomes amongst lower cadres of staff conducting triage. We found in general levels of agreement were high overall between triage and clinician assessments with an above chance level of agreement (Kappa value) of 0.71. 93% of Queue assignments were consistent across triage and clinician assessment, but this was reduced for priority and emergency assessments with75% agreement for priority and only 54.5% agreement for emergency assessmentsThe total figures of 131 are low for Emergency assessments, but we would expect some Emergencies to be recognised immediately, bypassing the triage system. A total of 27 patient carers who reached tertiary care reported that they had not passed through triage due to immediate recognition of severity.
The majority of triage within each of the 5 clinics was conducted by Health Surveillance Assistants. These are salaried community health workers employed through the Department of Environmental Health, whose main role is to provide prevention and some basic curative health services at community level. However they are increasingly involved in primary level clinics, taking up a range of roles such as HIV testing and ART provision. There were a total of 10,507 HSAs working across Malawi in 2009, each possessing an average clinical training of 8 weeks from the Ministry of Health.Whilst we originally trained nurses as well as HSAs within each clinic in practice our intervention became the responsibility of HSAs due to low levels of engagement and maternal health priorities amongst nursing staff.
We captured data at the A&E department of the tertiary referral hospital around the clock so were able to capture all patients entering the hospital from all 5 participating clinics. Of all patients seen by the primary level clinicians who had been triaged using the smart phone algorithm, 644 or 1.6% were referred to Queens referral Hospital. 9.6% of these had been triaged originally as a queue whilst only 100 of the 131 emergency triage assessments were referred.However, of all those referred to Queens, only 37.3% arrived. This is a large dropout rate within the referral system, although not unexpected and is something we are investigating further.
But more positively those who reached Queens did so within a mean time of 5.5 hours. The trend for mean time across all categories reflects that within the primary system where emergencies generally took less time than queues to reach Queens. However, this trend is not significant and this is likely because the sample sizes were small for both Qs and Es.
As part of the evaluation we also conducted pre and post pilot intervention patient journey modelling, working with health staff from each clinic to define their perspectives on the primary health clinic pathway. The example here is taken from the clinic with the largest numbers of patients triaged through the phones. We acknowledge that this data is drawn from collective perceptions of health staff but what is interesting to note is that overall impressions of staff were that times taken for each stage of the primary health journey were reported to be noticeably shorter post intervention than pre intervention with the biggest differences reported in the waiting bay and consultation room.
The intervention was thus positively viewed by primary health centre staff on the whole. And this perception was reflected in patient carer perspectives on the Chipatala Robots system. Clinic staff also reported that the system had effected a positive change in separating under 5 monitoring visits from those in need of clinical assistance,
The intervention was also felt to have improved recognition of severe illness amongst both health workers and patient carers. Most of the health facilities reported that very few deaths occurred on the queues while patients were waiting to be seen by clinicians.
So to summarise theAcMen pilot intervention has proven to successfully separate the sick from the non-sick on entry to primary health clinics and we have been able to address some of the problems with primary health pathways that lead to patient dissatisfaction and lack of utilisation of primary health services.We were also able to realign primary level definitions of paediatrics to those of tertiary level definitions, ensuring older children receive appropriate services.We have also proven that triage can be consistently applied over time using the mHealth based algorithm which prevents the user from missing key steps in the process.We worked closely with each clinic in developing the new system to ensure individual clinic settings were taken into account in the design and this translated to high levels of ownership of the intervention, particularly amongst lower cadres of staff. Finally the intervention was found to be highly acceptable to health workers, service users and MoH stakeholders. This was evident in the engagement of the District Health Office in Blantyre providing equipment to carry out triage, involvement in training and clinic system design and in the support we have received for this intervention from the MoH in general.
So, returning to the story of Edith where we began. When we went back to see her last year her father said that his one wish was for phcs to improve their recognition of symptoms earlier....This study has shown that mHealth technologies have the potential to improve primary level services with high patient numbers and over burdened staff, one step in the right direction to helping improve early recognition and response to severe illness in children in Malawi.
This work has been and continues to be a collaborative effort with different individuals contributing their skillsIt is the outcome of longer-term collaborations between MLW and MRFmHealth technology support has been provided throughout by D-Tree International And it wouldn’t have been possible without the enthusiasm of the MoH through the ETAT office at the MoH and locally through the District Health Office