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Automated messaging through text (SMS) and instant messaging services (IMS) offers low-cost solutions for patient follow-up in resource-constrained contexts. This study aims to evaluate a quality improvement (QI) initiative to improve caregiver response rates to an automated messaging system for post-discharge follow-up of children in rural Uganda. From June 2022 to June 2024, caregivers of children triaged through the Smart Triage platform at Gulu Regional Referral Hospital were invited to participate in an automated follow-up program. Messages were sent seven days after discharge via SMS and IMS (WhatsApp), prompting caregivers to report if their child had \"improved\" or \"not improved\". Non-responders and \"not improved\" cases were followed up with a phone call from a study nurse. From April 2023 to November 2023, a QI initiative refined the messaging system to improve response rates and a post-QI period then continued the intervention with no changes until June 2024. Response rates were analyzed over three periods: historical (pre-QI, June 2022 - March 2023), QI intervention, and post-QI. Additionally, data on message delivery rates, improvement strategies, and health outcomes were analyzed. Of 6826 participants, 6469 (95%) messages were successfully delivered. Response rates improved from 20% in April 2023 to 40% in June 2024 and remained stable between 33% and 41% during the post-QI period. Compared to the historical period, post-QI response rates were significantly higher (95% CI: 12.5% to 18.2%, p < 0.001). This improvement reflected a statistically significant positive trend during the QI period. Overall, 1856 caregivers responded: 1244 (67%) reported improvement and 612 (33%) reported no improvement. Follow-up phone calls for those \"not improved\" revealed 58 (9%) sought care, 12 (2%) were readmitted, and no deaths occurred. For non-responders, 206 (5%) sought care, 33 (0.7%) were readmitted, and 3 (0.07%) deaths occurred. Automated two-way text messages for post-discharge pediatric follow-up yielded high delivery and moderate response rates. Iterative QI efforts increased response rates, highlighting the importance of tailored communication strategies. Automated messages can facilitate timely intervention for high-risk children and enable efficient collection of health outcomes, offering a viable alternative to in-person follow-up in resource-poor settings.

This is a retrospective review of the feasibility study and implementation of the Smart Triage and Quality Improvement (QI) initiative at Holy Innocents Children's Hospital (HICH), a dedicated pediatric hospital in Mbarara, Uganda, over a 5-year period. The aim of this QI initiative was to improve triaging rates and the time-to-antimicrobials in HICH's outpatient department (OPD). Smart Triage is a risk prediction algorithm and digital platform that enables healthcare workers to triage patients and track treatments effectively. Following the feasibility study, the QI program was implemented in September 2021 using three Plan-Do-Study-Act cycles: 1) Standardize Training, 2) Adjust Workflows, and 3) QI Team Communication. Data sources were triage and hospital reports. Monthly run charts of OPD attendance, acuity of illness, triaging rates, median-time-to-antimicrobials, and mortality rates of admitted patients were created. The trajectories of the variables were assessed using linear regression with time as the explanatory variable. 121,521 children attended HICH OPD from November 2018 to October 2023. The OPD triaging rate increased to 91% by October 2023, with a sustained plateau above 90% since July 2022. There was a significant reduction in the median time-to-antimicrobials during the 5-year period, from 77.6 to 53.6 minutes, with a slope of -0.4 minutes per month (CI: -0.73 to -0.04, p-value: 0.029). The inpatient mortality rate decreased from 5.1% in August 2018 to 2.6% in October 2023, with a significant increase in the number of cases with comparable illness severity. The impact of Smart Triage was sustained beyond the end of the feasibility trial and showed sustained improvements in processes such as treatment times and clinical outcomes including a reduction in mortality. HICH's leadership integrated a culture of QI across disciplines and departments, contributing to this initiative's sustainability and impact.

Sepsis occurs predominantly in low-middle-income countries. Sub-optimal triage contributes to poor early case recognition and outcomes from sepsis. Improved recognition and quality of care can lead to improved outcomes. We evaluated the impact of Smart Triage using improved time to intravenous antimicrobial administration in a multisite interventional study. Smart Triage, a digital platform with a risk score and clinical dashboard, 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. In Uganda, the time to antimicrobials marginally decreased (3 minutes) at the intervention site. Then, during the implementation period in Kenya, the time to antimicrobials 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 antimicrobials initially decreased but was not sustained and there was no significant difference between intervention and control sites. At both intervention sites, there was a significant reduction in antimicrobial utilization of 47% (Kenya) and 33% (Uganda) compared to baseline. There was a reduction in admission rates of 47% (Kenya) and 33% (Uganda) compared to baseline. Mortality reduced by 25% (Kenya) and 75% (Uganda) 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. The admission and mortality rates should be interpreted cautiously as these were secondary outcomes. This study underlines the difficulty of implementing technologies and sustaining quality improvement in health systems.

ObjectiveThis is a retrospective review of the feasibility study and implementation of the Smart Triage and Quality Improvement (QI) initiative at Holy Innocents Children's Hospital (HICH), a dedicated pediatric hospital in Mbarara, Uganda, over a 5-year period. The aim of this QI initiative was to improve triaging rates and the time-to-antimicrobials in HICH's outpatient department (OPD).MethodsSmart Triage is a risk prediction algorithm and digital platform that enables healthcare workers to triage patients and track treatments effectively. Following the feasibility study, the QI program was implemented in September 2021 using three Plan-Do-Study-Act cycles: 1) Standardize Training, 2) Adjust Workflows, and 3) QI Team Communication. Data sources were triage and hospital reports. Monthly run charts of OPD attendance, acuity of illness, triaging rates, median-time-to-antimicrobials, and mortality rates of admitted patients were created. The trajectories of the variables were assessed using linear regression with time as the explanatory variable.Results121,521 children attended HICH OPD from November 2018 to October 2023. The OPD triaging rate increased to 91% by October 2023, with a sustained plateau above 90% since July 2022. There was a significant reduction in the median time-to-antimicrobials during the 5-year period, from 77.6 to 53.6 minutes, with a slope of -0.4 minutes per month (CI: -0.73 to -0.04, p-value: 0.029). The inpatient mortality rate decreased from 5.1% in August 2018 to 2.6% in October 2023, with a significant increase in the number of cases with comparable illness severity.ConclusionThe impact of Smart Triage was sustained beyond the end of the feasibility trial and showed sustained improvements in processes such as treatment times and clinical outcomes including a reduction in mortality. HICH's leadership integrated a culture of QI across disciplines and departments, contributing to this initiative's sustainability and impact.