Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration

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Abstract

Background

Sepsis is the leading cause of death in children under five in low- and middle-income countries. The rapid identification of the sickest children and timely antibiotic administration may improve outcomes. We developed and implemented a digital triage platform to rapidly identify critically ill children to facilitate timely intravenous antibiotic administration.

Objective

This quality improvement initiative sought to reduce the time to antibiotic administration at a dedicated children’s hospital outpatient department in Mbarara, Uganda.

Intervention and study design

The digital platform consisted of a mobile application that collects clinical signs, symptoms, and vital signs to prioritize children through a combination of emergency triggers and predictive risk algorithms. A computer-based dashboard enabled the prioritization of children by displaying an overview of all children and their triage categories. We evaluated the impact of the digital triage platform over an 11-week pre-implementation phase and an 11-week post-implementation phase. The time from the end of triage to antibiotic administration was compared to evaluate the quality improvement initiative.

Results

There was a difference of -11 minutes (95% CI, -16.0 to -6.0; p < 0.001; Mann-Whitney U test) in time to antibiotics, from 51 minutes (IQR, 27.0–94.0) pre-implementation to 44 minutes (IQR, 19.0–74.0) post-implementation. Children prioritized as emergency received the greatest time benefit (-34 minutes; 95% CI, -9.0 to -58.0; p < 0.001; Mann-Whitney U test). The proportion of children who waited more than an hour until antibiotics decreased by 21.4% (p = 0.007).

Conclusion

A data-driven patient prioritization and continuous feedback for healthcare workers enabled by a digital triage platform led to expedited antibiotic therapy for critically ill children with sepsis. This platform may have a more significant impact in facilities without existing triage processes and prioritization of treatments, as is commonly encountered in low resource settings.

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Most cited references 20

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Time to Treatment and Mortality during Mandated Emergency Care for Sepsis.

Christopher W Seymour, Foster C Gesten, Hallie C Prescott … (2017)

Background In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. Methods We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. Results Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). Conclusions More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality. (Funded by the National Institutes of Health and others.).

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Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis

Marcus E Friedrich, Kathleen Terry, R Scott Watson … (2018)

IMPORTANCE The death of a pediatric patient with sepsis motivated New York to mandate statewide sepsis treatment in 2013. The mandate included a 1-hour bundle of blood cultures, broad-spectrum antibiotics, and a 20-mL/kg intravenous fluid bolus. Whether completing the bundle elements within 1 hour improves outcomes is unclear. OBJECTIVE To determine the risk-adjusted association between completing the 1-hour pediatric sepsis bundle and individual bundle elements with in-hospital mortality. DESIGN, SETTINGS, AND PARTICIPANTS Statewide cohort study conducted from April 1, 2014, to December 31, 2016, in emergency departments, inpatient units, and intensive care units across New York State. A total of 1179 patients aged 18 years and younger with sepsis and septic shock reported to the New York State Department of Health who had a sepsis protocol initiated were included. EXPOSURES Completion of a 1-hour sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour. MAIN OUTCOMES AND MEASURES Risk-adjusted in-hospital mortality. RESULTS Of 1179 patients with sepsis reported at 54 hospitals (mean [SD] age, 7.2 [6.2] years; male, 54.2%; previously healthy, 44.5%; diagnosed as having shock, 68.8%), 139 (11.8%) died. The entire sepsis bundle was completed in 1 hour in 294 patients (24.9%). Antibiotics were administered to 798 patients (67.7%), blood cultures were obtained in 740 patients (62.8%), and the fluid bolus was completed in 548 patients (46.5%) within 1 hour. Completion of the entire bundle within 1 hour was associated with lower risk-adjusted odds of in-hospital mortality (odds ratio [OR], 0.59 [95% CI, 0.38 to 0.93], P = .02; predicted risk difference [RD], 4.0% [95% CI, 0.9% to 7.0%]). However, completion of each individual bundle element within 1 hour was not significantly associated with lower risk-adjusted mortality (blood culture: OR, 0.73 [95% CI, 0.51 to 1.06], P = .10; RD, 2.6% [95% CI, −0.5% to 5.7%]; antibiotics: OR, 0.78 [95% CI, 0.55 to 1.12], P = .18; RD, 2.1% [95% CI, −1.1% to 5.2%], and fluid bolus: OR, 0.88 [95% CI, 0.56 to 1.37], P = .56; RD, 1.1% [95% CI, −2.6% to 4.8%]). CONCLUSIONS AND RELEVANCE In New York State following a mandate for sepsis care, completion of a sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour was associated with lower risk-adjusted in-hospital mortality among patients with pediatric sepsis and septic shock.

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The global burden of sepsis: barriers and potential solutions

Kristina Rudd, Niranjan Kissoon, Direk Limmathurotsakul … (2018)

Sepsis is a major contributor to the global burden of disease. The majority of sepsis cases and deaths are estimated to occur in low and middle-income countries. Barriers to reducing the global burden of sepsis include difficulty quantifying attributable morbidity and mortality, low awareness, poverty and health inequity, and under-resourced and low-resilience public health and acute health care delivery systems. Important differences in the populations at risk, infecting pathogens, and clinical capacity to manage sepsis in high and low-resource settings necessitate context-specific approaches to this significant problem. We review these challenges and propose strategies to overcome them. These strategies include strengthening health systems, accurately identifying and quantifying sepsis cases, conducting inclusive research, establishing data-driven and context-specific management guidelines, promoting creative clinical interventions, and advocacy.

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Author and article information

Contributors

Victor Lee:

ORCID: http://orcid.org/0000-0003-3198-9512

Role: Formal analysisRole: Project administrationRole: VisualizationRole: Writing – original draft

Dustin Dunsmuir: Role: Data curationRole: InvestigationRole: MethodologyRole: SoftwareRole: Writing – review & editing

Stephen Businge: Role: InvestigationRole: SupervisionRole: Writing – review & editing

Robert Tumusiime: Role: InvestigationRole: SupervisionRole: Writing – review & editing

James Karugaba: Role: InvestigationRole: SupervisionRole: Writing – review & editing

Matthew O. Wiens: Role: ConceptualizationRole: Writing – review & editing

Matthias Görges:

ORCID: http://orcid.org/0000-0003-2193-178X

Role: ConceptualizationRole: Formal analysisRole: Writing – review & editing

Niranjan Kissoon: Role: ConceptualizationRole: Writing – review & editing

Sam Orach: Role: SupervisionRole: Writing – review & editing

Ronald Kasyaba: Role: SupervisionRole: Writing – review & editing

J. Mark Ansermino:

ORCID: http://orcid.org/0000-0001-8427-2035

Role: ConceptualizationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – review & editing

Bobak Mortazavi: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 2 October 2020

Publication date Collection: 2020

Volume: 15

Issue: 10

Electronic Location Identifier: e0240092

Affiliations

[1 ] Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada

[2 ] Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada

[3 ] Holy Innocents Children's Hospital, Mbarara, Uganda

[4 ] School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada

[5 ] Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada

[6 ] Uganda Catholic Medical Bureau, Kampala, Uganda

Texas A&M University, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: anserminos@ 123456yahoo.ca

Author information

Victor Lee http://orcid.org/0000-0003-3198-9512

Matthias Görges http://orcid.org/0000-0003-2193-178X

J. Mark Ansermino http://orcid.org/0000-0001-8427-2035

Article

Publisher ID: PONE-D-20-00589

DOI: 10.1371/journal.pone.0240092

PMC ID: 7531789

PubMed ID: 33007047

SO-VID: a282555b-e675-4f55-8adb-89b706bdc2bb

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 8 January 2020

Date accepted : 18 September 2020

Page count

Figures: 5, Tables: 2, Pages: 15

Funding

This study was funded by the Google Foundation (JMA, TFR17-00630). https://impactchallenge.withgoogle.com/canada2017. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability All relevant data are within the manuscript and its Supporting Information files.

Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration

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Abstract

Background

Objective

Intervention and study design

Results

Conclusion

Related collections

PLOS Climate

Most cited references 20

Time to Treatment and Mortality during Mandated Emergency Care for Sepsis.

Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis

The global burden of sepsis: barriers and potential solutions

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