Implementation of Smart Triage combined with a quality improvement program for children presenting to facilities in Kenya and Uganda: An interrupted time series analysis
Authors: Ansermino J Mark , Pillay Yashodani , Tagoola Abner , Zhang Cherri , Dunsmuir Dustin , Kamau Stephen , Kigo Joyce , Agaba Collins , Aye Ivan Aine , Hwang Bella , Novakowski Stefanie K , Huxford Charly , Wiens Matthew O. , Kimutai David , Ouma Mary , Ahmed Ismail , Mwaniki Paul , Oyella Florence , Tenywa Emmanuel , Nambuya Harriet , Toliva Bernard Opar , Kenya-Mugisha Nathan , Kissoon Niranjan , Akech Samuel 
Published: February 2024

Sepsis occurs predominantly in low-middle-income countries. Sub-optimal triage contributes to poor early case recognition and outcomes from sepsis. We evaluated the impact of Smart Triage using improved time to intravenous antimicrobial administration in a multisite interventional study.

Smart Triage was implemented (with control sites) in Kenya (February 2021-December 2022) and Uganda (April 2020-April 2022). Children presenting to the outpatient departments with an acute illness were enrolled. A controlled interrupted time series was used to assess the effect on time from arrival at the facility to intravenous antimicrobial administration. Secondary analyses included antimicrobial use, admission rates and mortality (NCT04304235).

During the baseline period, the time to antimicrobials decreased significantly in Kenya (132 and 58 minutes) at control and intervention sites, but less in Uganda (3 minutes) at the intervention site. Then, during the implementation period in Kenya, the time to IVA at the intervention site decreased by 98 min (57%, 95% CI 81-114) but increased by 49 min (21%, 95% CI: 23-76) at the control site. In Uganda, the time to IVA initially decreased but was not sustained, and there was no significant difference between intervention and control sites. At the intervention sites, there was a significant reduction in IVA utilization of 47% (Kenya) and 33% (Uganda), a reduction in admission rates of 47% (Kenya) and 33% (Uganda) and a 25% (Kenya) and 75% (Uganda) reduction in mortality rates compared to the baseline period.

We showed significant improvements in time to intravenous antibiotics in Kenya but not Uganda, likely due to COVID-19, a short study period and resource constraints. The reduced antimicrobial use and admission and mortality rates are remarkable and welcome benefits but should be interpreted cautiously as these were secondary outcomes. This study underlines the difficulty of implementing technologies and sustaining quality improvement in health systems.

Author Summary

Implementing the Smart Triage platform and quality improvement program for children in Kenya and Uganda resulted in inconsistent improvements in time to intravenous antimicrobial administration. The time to IVA decreased significantly in Kenya during baseline and reduced further during the intervention while increasing at the control site. In Uganda the time to treatment initially decreased but was not sustained. The treatment times were significantly influenced by the improvements during baseline data collection and multiple external health system factors such as drug shortages, the COVID -19 pandemic, staff shortages and strikes. The dramatic reduction in treatment, admission, and mortality rates should be further investigated.