DOI: 10.14288/1.0444184
title: Smart Discharges for vulnerable refugee children: a cohort study to validate prognostic algorithms for post-discharge readmission and mortality among children living in refugee settings

description: &lt;br /&gt;&lt;strong&gt;Background:&lt;/strong&gt; In many African countries, pediatric post-discharge mortality following in-hospital treatment for severe infectious illness is higher than in-hospital mortality (5-8%). Risk algorithms can be used to help health workers identify those most vulnerable to poor post-discharge outcomes. They can also assist health workers in providing personalized discharge counselling and recommending effective follow-up care. This can improve overall system efficiency. While this approach has shown promise among general pediatric populations, no research has addressed issues of post-discharge morbidity and mortality within the refugee context, where unique vulnerabilities exist. This study aims to validate the Smart Discharges approach to improve outcomes among children in refugee settings, and ultimately to build a generalizable and inclusive solution to improving pediatric post-discharge outcomes.&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This study is a prospective observational cohort study that will be conducted at 3 health facilities in Lamwo District, northern Uganda between April 2023 and September 2024. We will enroll 1,500 children under 13 years of age between the three study sites of Padibe HCIV, Paluda HCIII, and Palabek Kal HCIII. The primary objective is to validate, calibrate, and refine the Smart Discharges risk-prediction algorithm in a representative cohort of refugee children. Secondary objectives include: i) to describe the epidemiology of, and risk factors for, post-discharge mortality of children in the context of refugee settings; ii) to describe the post-discharge health seeking patterns of children in the context of refugee settings; and iii) to evaluate the pediatric discharge process at 3 health facilities providing discharge care to children living in refugee settings. Following enrollment a research nurse will obtain and record clinical and demographic variables required for model validation including vital signs, oxygen saturation, anthropometric data, prior care seeking, co-morbidities and diagnoses. A rapid diagnostic test using blood, which will require a finger prick to collect &lt; 0.5ml of blood, will be conducted to assess the patient's HIV status, malaria parasitemia, and hemoglobin (hemocue). All enrolled children will receive phone follow-up from study staff at 2-, 4- and 6 months following hospital discharge for research purposes. Verbal autopsies, often used in this context to determine cause of death, will be conducted for all children who die following discharge. All study sites will also undergo the discharge module of a 5-survey Facility Scan developed by the Pediatric Sepsis Data CoLaboratory’s (Sepsis CoLab) to support health facilities in identifying and assessing quality improvement priorities and initiatives.This will be done at both baseline (conclusion of clinical study activities) and 4 months following the completion of study activities to measure the facility readiness to implement improved discharge care, and its persistence over time.&lt;br /&gt; &lt;br /&gt;&lt;strong&gt;Ethics Declaration:&lt;/strong&gt; Ethical approval has been obtained from the University of British Columbia Children’s & Women’s Research Ethics Board in Canada (H23-00012) and the Makerere School of Public Health Research Ethics Board in Uganda (SPH-2023-369). &lt;br /&gt;