MRF’s healthcare and awareness initiative in Malawi

MRF Meningitis Symposium 11 June 2014

Barriers to recognition and treatment of meningitis at Primary Health Level

Primary health level

misdiagnoses

High numbers of patients

Erratic consultation systems

Unsystematic & informal triage

Desmond et al 2013 PLOSone

Desmond et al 2013 PLOSone

• Negative perceptions of health services

• Low level of awareness of meningitis

• Gender and age-based decision making in community

• Financial constraints

Barriers to seeking timely treatment for meningitis at community level

Desmond et al 2013 PLOSone

Action Meningitis

• Improved recognition of severe illness• Appropriate referral

Primary Health Level

Community Level

• Community recognition & awareness of meningitis and triage system

• Initiation of timely treatment

Triage system

Theatre

Radio

‘Health Talk’ Radio

Theatre for Development

• Partnering with local theatre group

• Establish a community-level intervention to encourage recognition and response to illness

Primary Health Clinics: Blantyre

Primary Health Level Triage system

• Severe illness regularly

missed

• Limited number of HCW,

equipment & supplies

• HCW overwhelmed

• Long queues

Primary Health Clinics: Blantyre

Aims:

1. To develop a triage system, tailored for PHCs

2. To implement this system within 5 PHCs in Blantyre

3. To encourage appropriate referral decisions to

hospital & track referrals

4. To monitor, evaluate and refine this system

Implementation of Triage System

‘mHealth’ Triage Tool

• Emergency Triage, Assessment and Treatment (ETAT)

protocol developed by the WHO.

• Designed for hospital settings, in resource-poor countries.

• Specifically aimed at lower cadre staff.

Emergency

PriorityCHILD IS VERY

SICK. PRIORITY MUST BE GIVEN IN THE QUEUE

Queue

CHILD HAS MINOR

INJURY/ILLNESS.

TO WAIT IN THE QUEUE

CHILD IS EXTREMELY SICK. TO BE

SEEN IMMEDIATELY

Triage classification

‘Chipatala Robot’

Improving patient pathways

Patient enters PHC

HCW conducts rapid triage

Patient assigned E, P, Q

Clinician conducts consultation &

enters dataAdapted from Sarah Bar-Zeev (2012)

Patient follows clinician

instructions

Patient Triage

PHC ClinicianQECH

Fieldworker

If referred to QECH data entered on arrival

Bangwe clinic

Evaluation

• Measured agreement between HSA triage assessment and clinician triage assessment.

• Above chance agreement for concordance between triageand clinician assessment (kappa = 0.71)

Accuracy of triage

(Anova P < 0.001)

Triage evaluation

Time taken (mins)

Paediatric cases

Emergency 28.3 131

Priority 44.6 13,585

Queue 59.0 26,452

Mean clinic waiting times

• Out of 41,358 children triaged 1.6% (644) were referred to QECH

• From the 644 referrals 37.3% (240) arrived at QECH

• Overall mean time to QECH 5.5hrs

• 62.7% (404) of referrals from PHCS did not reach QECH

Referrals

“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”

“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”

Medical Assistant, 2013

Qualitative findings

Chikhwawa District• Rural setting, 2.5hrs outside Blantyre• Chipatala Robot triage system at two additional

Primary Clinics• Also in District Hospital• 40 HCW trained

148,131 children triaged

Triage dashboard

Next steps

• Continue triage system in 8 centres.

- High drop-out between primary level referral and arrival at tertiary (63%).

- How best to adapt triage for primary setting?

- Provide evidence that triage can be successfully implemented in a sustainable and cost-effective way.

Primary Health Level

Community Level

• Continue to develop theatre and radio interventions.

Mphatso Cheonga, 2012

“I only wish the primary health centres could

improve on diagnosis and recognising

symptoms quicker...”

“I only wish the primary health centres could

improve on diagnosis and recognising

symptoms quicker...”

Acknowledgments MLWNicola DesmondRob HeydermanDeborah NyirendaQueen DubeElizabeth MolyneuxRob Heyderman

MRFLinda GlennieChris HeadThomasena O’ByrneZione KalvosiMeliya KwelepetaBernadetta Payesa

MoHNorman LufesiDr Owen MalemaDr Amber Manjidu

ETAT RegistrarsDr Zondiwe MwanzaDr Thembi ChirwaDr Yabwile MulambiaMtisunge Gondwe

D-Tree InternationalDr Marije GeldofDr Marc MitchellPhidelis Suwedi

Primary ClinicsBangwe: Tinkhani BophaniChilomoni: Dalitso NamasaniNdirande: Francis PhiriMpemba: Rodgers KuyokwaZingwangwa: Margaret Chingona

All photos reproduced by kind permission of participants

Referrals arriving at QECH with mean time taken between primary and tertiary

(Anova P = 0.39)

mHealth

Triage evaluation

Time taken

(hours)

Paediatric cases

E 3.5 33

P 5.7 193

Q 6.8 14

Overall mean time 5.5 hours

Background Research

• £700K MRF research in Malawi

• Late presentation at tertiary level contributes to

mortality from acute bacterial meningitis (ABM)

• Study into barriers of recognition and action in

treating ABM in Malawi…