ORIGINAL ARTICLE
Quality and Effectiveness of a Pediatric Triage Training Program in a Guatemalan Public Hospital Heather L. Crouse, MD,* Henry Vaides, MD,† Francisco Torres, MD,† Elise M. Ishigami, MPH,‡ Michael T. Walsh, MHA,‡ Miguel A. Soto, MD,† and Susan B. Torrey, MD§ Objectives: This study aimed to develop and implement an Emergency Triage Assessment and Treatment (ETAT) training program at a Guatemalan public hospital. Collaborators included Baylor College of Medicine/ Texas Children's Hospital, the Guatemalan Ministry of Health, and the Pan American Health Organization. Methods: The ETAT is a World Health Organization program to teach pediatric assessment, triage, and initial management to health care workers in resource-limited settings. The Baylor College of Medicine/Texas Children's Hospital created ETAT training materials in Spanish (Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas [CETEP]) and conducted a train-the-trainer course for Hospital Nacional Pedro Bethancourt (HNPB) health care leadership. The HNPB subsequently conducted local trainings using a modified curriculum. Midcourse modifications based on evaluations and focus groups included distribution of manuals before training and an adding a day to the course. Course quality was assessed using participant evaluations and comparing pretest and posttest scores. Effectiveness was defined as 90% concordance between triage levels assigned by participants and facilitators. Results: A total of 249 health care workers were trained by 24 HNPB facilitators. Mean pretest and posttest scores were 55 and 70, respectively (P < 0.001). On a 4-point scale, participants rated overall course quality and effectiveness as 3.6. Mean pretest (49 vs 58, P = 0.002) and posttest scores (68 vs 72, P = 0.01) improved for groups trained after modifications, as did evaluations for course quality (3.4 vs 3.7, P < 0.001) and effectiveness (3.4 vs 3.8, P < 0.001). Triage levels were assigned with 95% concordance (confidence interval, 91.9–97.3) between participants and facilitators. Conclusions: Hospital Nacional Pedro Bethancourt experts conducted high-quality trainings with locally relevant CETEP (ETAT) material. Trainings were effective and well received. The pediatric emergency department at HNPB now uses a triage system based on CETEP (ETAT). Key Words: triage training, international emergency medicine, global health, Emergency Triage Assessment and Treatment (ETAT), Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas (CETEP)
severely ill children often experience significant delays in receiving potentially lifesaving treatments, PEM stands uniquely poised as a bridge between prevention and definitive care.1–3 A growing body of evidence indicates that interventions to improve pediatric emergency care, including the introduction of triage training and process, use of clinical practice guidelines, and supervision and monitoring of patients, reduce mortality rates for acutely ill children.4–8 This suggests that clinical, educational, and research initiatives directed at PEM entry points could have a profound impact on reducing child mortality. The Emergency Triage Assessment and Treatment (ETAT) guidelines and training program were developed by the World Health Organization (WHO) as part of the Integrated Management of Childhood Illnesses strategy to promote improved assessment, triage, and initial management of acutely ill children in resource-limited settings. They were developed by a consensus of experts who practiced in resource-limited settings and are based on recognized standards for pediatric emergency care (Advanced Pediatric Life Support, Pediatric Advanced Life Support).9 The goal for the guideline is to use only physical findings to rapidly assign (within 30 seconds to 1 minute) 1 of 3 triage categories— emergency, priority, or nonurgent. The tool was validated in Brazil and Malawi.10,11 It has been widely implemented in resource-limited settings with specific reports from Malawi, Kenya, and Lesotho.4,6,12 Emergency Triage Assessment and Treatment–based triage systems have improved pediatric outcomes in Africa.4,6,13 However, data in Latin America are lacking. The objective of this study was to develop and implement a high-quality, effective, and sustainable ETAT training program in a Latin American country that could be relevant for use throughout Latin America. Hospital Nacional Pedro Bethancourt (HNPB), a Guatemalan public hospital, led the project in collaboration with Baylor College of Medicine (BCM)/Texas Children's Hospital (TCH), Houston, TX; the Guatemalan Ministry of Health (MoH); and the Pan American Health Organization (PAHO).
METHODS
(Pediatr Emer Care 2014;00: 00–00)
P
ediatric emergency medicine (PEM), with its focus on the early recognition and stabilization of acutely ill infants and children, improves outcomes. In less sourced settings, where
From the *Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX; †Department of Pediatrics, Hospital Nacional Pedro Bethancourt, La Antigua, Guatemala; ‡Global Health Initiative, Texas Children's Hospital, Houston, TX; and § Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine, New York, NY. Disclosure: The authors declare no conflict of interest. Reprints: Heather Crouse, MD, 6621 Fannin St, Suite A2210, Houston, TX 77030 (e‐mail: [email protected]). Internal grants from Texas Children's Hospital were awarded to fund the project. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2014
The Partnership The initial collaboration between HNPB and BCM/TCH began when HNPB agreed to accept residents from BCM/TCH for global health electives. Through that relationship, we identified synergy between HNPB's identification of the development of a formal triage system as a priority for their hospital and BCM/ TCH's expertise with ETAT, quality training materials, and institutional leadership/infrastructure. The Guatemalan MoH was engaged from the beginning of the project. They were essential partners for ensuring that our program was consistent with country norms as well as for developing the program locally and scaling it up in Guatemala. Finally, our partnership included the PAHO because of their relationship with the Guatemalan MoH and their interest in the potential to disseminate ETAT on a larger scale throughout the region. www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
Pediatric Emergency Care • Volume 00, Number 00, Month 2014
Crouse et al
Setting and Study Population The HNPB is a secondary-level, public hospital in La Antigua, Guatemala, located approximately 45 km from Guatemala City. It is the referral hospital for the Department of Sacatepéquez and surrounding areas, serving a population of approximately 329,547 people. Their pediatric services include a pediatric emergency department (PED) that evaluates approximately 20,000 children 0 to 12 years old each year, an outpatient clinic that staffs approximately 900 encounters per month, a 30-bed inpatient pediatric ward, a 30-bed neonatology ward, and small neonatal and pediatric intensive care units. All subspecialty needs are referred to the children's hospital in Guatemala City. The HNPB has an established pediatric residency training program and has developed multiple innovative programs including the first certified human milk bank in Latin America. All pediatric health care workers at HNPB who trained in ETAT from May 2010 to February 2012 were included in the study.
course (dates and location, course agenda, participants and their demographics, facilitators). Outcome measures included participant knowledge acquisition (as measured by written test scores) and participant satisfaction (as indicated by satisfaction surveys that used a 4-point Likert scale to rate course quality and effectiveness). We also compared the pretests and posttests and participant satisfaction surveys between those trained before and after February 2011, when significant course modifications were made. Missing or incomplete written tests and/or participant surveys were not included in the statistical analysis. To measure course effectiveness, namely, the accuracy of triage category assignments after CETEP (ETAT) trainings, we paired a triage expert (HNPB course facilitator) and a novice (recent course participant) to simultaneously and blindly assign triage categories for a convenience sample of patients presenting to the HNPB PED. Each participant was expected to assign an accurate triage category 90% of the time. For an accuracy of ±2.5%, a sample size of 285 patients was required. We then calculated the concordance between the 2.
Intervention
Statistical Analyses
Materials The BCM/TCH faculty in collaboration with Baylor Pediatric AIDS Initiative at TCH in Lesotho had previously created educational material (including didactic, case-based, and hands-on training as well as evaluation tools) to supplement the participant and facilitator manuals provided by the WHO. These included the following: (1) participant course (5 modules: general overview of triage and the “ABCD” concept, Airway/Breathing, Circulation, Coma/Convulsion, and Dehydration) based on the original WHO ETAT participant manual; (2) facilitator course that trains facilitators how to teach (5 lectures), based on the WHO effective teaching course; and (3) logistics and templates (course agenda, evaluation forms, pretests and posttests). The BCM/TCH translated the materials into Spanish. In partnership with the HNPB and with collaborative input from the MoH and PAHO, the content was modified to reflect local health care systems/needs, including the recognition of national protocols and the use of regional terminology and available medications and equipment. We chose the name Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas (CETEP) for the Spanish course.
Training The BCM/TCH conducted an initial train-the-trainer course for a group of multidisciplinary pediatric health care leaders at the HNPB in May 2010. This group subsequently conducted all local trainings with TCH support that included regular follow-up site visits, e-mails, and telephone calls. The course agenda followed the process used in Lesotho12: it combined didactic lectures with hands-on practice sessions. During BCM/TCH follow-up site visits, we conducted informal focus groups with both facilitators and participants to assess the content and logistics of the course to help determine where improvements could be made. Based on this feedback, we modified the course significantly in February 2011 (approximately 8 months after trainings began). Modifications included distributing the manuals 1 week in advance of the course and adding a third day to the course, which extended the existing agenda from 12 hours to 16 hours, allowing more time for small-group work.
We used paired t tests to compare means between normally distributed groups and Mann-Whitney U test to compare data that were not normally distributed. All data were analyzed using SPSS 21.0 (IBM SPSS Statistics; August 2012). For all comparisons, statistical significance was achieved with P value of less than 0.05.
RESULTS A total of 24 facilitators and 249 participants were trained in CETEP (ETAT). The facilitators included 12 senior physicians (50.0%), 7 residents (29.2%), and 5 nurses (20.8%). The participants represented a wide variety of health care professions: 10 physicians (4.0%), 12 residents (4.8%), 142 senior medical students (57.0%), 73 nurses (29.3%), and 12 firemen (4.8%). With regard to the quality of the course, overall participant mean posttest scores were significantly greater than the mean pretest scores (Table 1). Mean pretests and posttests of those trained after the course modifications (manuals were distributed earlier, and the training extended to 12 hours) were made were significantly higher than those trained before the change (Table 2). As for overall participant satisfaction, participants rated the course quality as 3.57 (n = 238; SD, 0.41; confidence interval [CI], 3.52–3.63) and the course effectiveness as 3.57 (n = 238; SD, 0.45; CI, 3.57–3.69), where 4.0 was the highest score for each. Similarly, comparison of evaluations between those trained before and those trained after February 2011 showed improvements by a statistically significant amount in each quality category (Table 3). Evaluation of the effectiveness of the course (ie, the ability of recent course participants to translate the knowledge from the course into everyday care of patients) demonstrated excellent concordance between experts (HNPB course facilitators) and novices (recent course participants) in assigning triage levels to actual TABLE 1. Overall CETEP (ETAT) Written Test Scores (Scale 0–100)
Outcomes/Measurements A prospective cohort design, approved by institutional review boards at both BCM and HNPB, was used to assess the quality of the course. We collected basic information for each
2
www.pec-online.com
Pretest Posttest
Mean (N = 238)
SD
95% CI
P
54.66 70.37
16.05 10.60
(52.61–56.71) (69.01–71.72)
Quality and Effectiveness of a Pediatric Triage Training Program in a Guatemalan Public Hospital Heather L. Crouse, MD,* Henry Vaides, MD,† Francisco Torres, MD,† Elise M. Ishigami, MPH,‡ Michael T. Walsh, MHA,‡ Miguel A. Soto, MD,† and Susan B. Torrey, MD§ Objectives: This study aimed to develop and implement an Emergency Triage Assessment and Treatment (ETAT) training program at a Guatemalan public hospital. Collaborators included Baylor College of Medicine/ Texas Children's Hospital, the Guatemalan Ministry of Health, and the Pan American Health Organization. Methods: The ETAT is a World Health Organization program to teach pediatric assessment, triage, and initial management to health care workers in resource-limited settings. The Baylor College of Medicine/Texas Children's Hospital created ETAT training materials in Spanish (Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas [CETEP]) and conducted a train-the-trainer course for Hospital Nacional Pedro Bethancourt (HNPB) health care leadership. The HNPB subsequently conducted local trainings using a modified curriculum. Midcourse modifications based on evaluations and focus groups included distribution of manuals before training and an adding a day to the course. Course quality was assessed using participant evaluations and comparing pretest and posttest scores. Effectiveness was defined as 90% concordance between triage levels assigned by participants and facilitators. Results: A total of 249 health care workers were trained by 24 HNPB facilitators. Mean pretest and posttest scores were 55 and 70, respectively (P < 0.001). On a 4-point scale, participants rated overall course quality and effectiveness as 3.6. Mean pretest (49 vs 58, P = 0.002) and posttest scores (68 vs 72, P = 0.01) improved for groups trained after modifications, as did evaluations for course quality (3.4 vs 3.7, P < 0.001) and effectiveness (3.4 vs 3.8, P < 0.001). Triage levels were assigned with 95% concordance (confidence interval, 91.9–97.3) between participants and facilitators. Conclusions: Hospital Nacional Pedro Bethancourt experts conducted high-quality trainings with locally relevant CETEP (ETAT) material. Trainings were effective and well received. The pediatric emergency department at HNPB now uses a triage system based on CETEP (ETAT). Key Words: triage training, international emergency medicine, global health, Emergency Triage Assessment and Treatment (ETAT), Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas (CETEP)
severely ill children often experience significant delays in receiving potentially lifesaving treatments, PEM stands uniquely poised as a bridge between prevention and definitive care.1–3 A growing body of evidence indicates that interventions to improve pediatric emergency care, including the introduction of triage training and process, use of clinical practice guidelines, and supervision and monitoring of patients, reduce mortality rates for acutely ill children.4–8 This suggests that clinical, educational, and research initiatives directed at PEM entry points could have a profound impact on reducing child mortality. The Emergency Triage Assessment and Treatment (ETAT) guidelines and training program were developed by the World Health Organization (WHO) as part of the Integrated Management of Childhood Illnesses strategy to promote improved assessment, triage, and initial management of acutely ill children in resource-limited settings. They were developed by a consensus of experts who practiced in resource-limited settings and are based on recognized standards for pediatric emergency care (Advanced Pediatric Life Support, Pediatric Advanced Life Support).9 The goal for the guideline is to use only physical findings to rapidly assign (within 30 seconds to 1 minute) 1 of 3 triage categories— emergency, priority, or nonurgent. The tool was validated in Brazil and Malawi.10,11 It has been widely implemented in resource-limited settings with specific reports from Malawi, Kenya, and Lesotho.4,6,12 Emergency Triage Assessment and Treatment–based triage systems have improved pediatric outcomes in Africa.4,6,13 However, data in Latin America are lacking. The objective of this study was to develop and implement a high-quality, effective, and sustainable ETAT training program in a Latin American country that could be relevant for use throughout Latin America. Hospital Nacional Pedro Bethancourt (HNPB), a Guatemalan public hospital, led the project in collaboration with Baylor College of Medicine (BCM)/Texas Children's Hospital (TCH), Houston, TX; the Guatemalan Ministry of Health (MoH); and the Pan American Health Organization (PAHO).
METHODS
(Pediatr Emer Care 2014;00: 00–00)
P
ediatric emergency medicine (PEM), with its focus on the early recognition and stabilization of acutely ill infants and children, improves outcomes. In less sourced settings, where
From the *Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX; †Department of Pediatrics, Hospital Nacional Pedro Bethancourt, La Antigua, Guatemala; ‡Global Health Initiative, Texas Children's Hospital, Houston, TX; and § Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine, New York, NY. Disclosure: The authors declare no conflict of interest. Reprints: Heather Crouse, MD, 6621 Fannin St, Suite A2210, Houston, TX 77030 (e‐mail: [email protected]). Internal grants from Texas Children's Hospital were awarded to fund the project. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2014
The Partnership The initial collaboration between HNPB and BCM/TCH began when HNPB agreed to accept residents from BCM/TCH for global health electives. Through that relationship, we identified synergy between HNPB's identification of the development of a formal triage system as a priority for their hospital and BCM/ TCH's expertise with ETAT, quality training materials, and institutional leadership/infrastructure. The Guatemalan MoH was engaged from the beginning of the project. They were essential partners for ensuring that our program was consistent with country norms as well as for developing the program locally and scaling it up in Guatemala. Finally, our partnership included the PAHO because of their relationship with the Guatemalan MoH and their interest in the potential to disseminate ETAT on a larger scale throughout the region. www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
Pediatric Emergency Care • Volume 00, Number 00, Month 2014
Crouse et al
Setting and Study Population The HNPB is a secondary-level, public hospital in La Antigua, Guatemala, located approximately 45 km from Guatemala City. It is the referral hospital for the Department of Sacatepéquez and surrounding areas, serving a population of approximately 329,547 people. Their pediatric services include a pediatric emergency department (PED) that evaluates approximately 20,000 children 0 to 12 years old each year, an outpatient clinic that staffs approximately 900 encounters per month, a 30-bed inpatient pediatric ward, a 30-bed neonatology ward, and small neonatal and pediatric intensive care units. All subspecialty needs are referred to the children's hospital in Guatemala City. The HNPB has an established pediatric residency training program and has developed multiple innovative programs including the first certified human milk bank in Latin America. All pediatric health care workers at HNPB who trained in ETAT from May 2010 to February 2012 were included in the study.
course (dates and location, course agenda, participants and their demographics, facilitators). Outcome measures included participant knowledge acquisition (as measured by written test scores) and participant satisfaction (as indicated by satisfaction surveys that used a 4-point Likert scale to rate course quality and effectiveness). We also compared the pretests and posttests and participant satisfaction surveys between those trained before and after February 2011, when significant course modifications were made. Missing or incomplete written tests and/or participant surveys were not included in the statistical analysis. To measure course effectiveness, namely, the accuracy of triage category assignments after CETEP (ETAT) trainings, we paired a triage expert (HNPB course facilitator) and a novice (recent course participant) to simultaneously and blindly assign triage categories for a convenience sample of patients presenting to the HNPB PED. Each participant was expected to assign an accurate triage category 90% of the time. For an accuracy of ±2.5%, a sample size of 285 patients was required. We then calculated the concordance between the 2.
Intervention
Statistical Analyses
Materials The BCM/TCH faculty in collaboration with Baylor Pediatric AIDS Initiative at TCH in Lesotho had previously created educational material (including didactic, case-based, and hands-on training as well as evaluation tools) to supplement the participant and facilitator manuals provided by the WHO. These included the following: (1) participant course (5 modules: general overview of triage and the “ABCD” concept, Airway/Breathing, Circulation, Coma/Convulsion, and Dehydration) based on the original WHO ETAT participant manual; (2) facilitator course that trains facilitators how to teach (5 lectures), based on the WHO effective teaching course; and (3) logistics and templates (course agenda, evaluation forms, pretests and posttests). The BCM/TCH translated the materials into Spanish. In partnership with the HNPB and with collaborative input from the MoH and PAHO, the content was modified to reflect local health care systems/needs, including the recognition of national protocols and the use of regional terminology and available medications and equipment. We chose the name Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas (CETEP) for the Spanish course.
Training The BCM/TCH conducted an initial train-the-trainer course for a group of multidisciplinary pediatric health care leaders at the HNPB in May 2010. This group subsequently conducted all local trainings with TCH support that included regular follow-up site visits, e-mails, and telephone calls. The course agenda followed the process used in Lesotho12: it combined didactic lectures with hands-on practice sessions. During BCM/TCH follow-up site visits, we conducted informal focus groups with both facilitators and participants to assess the content and logistics of the course to help determine where improvements could be made. Based on this feedback, we modified the course significantly in February 2011 (approximately 8 months after trainings began). Modifications included distributing the manuals 1 week in advance of the course and adding a third day to the course, which extended the existing agenda from 12 hours to 16 hours, allowing more time for small-group work.
We used paired t tests to compare means between normally distributed groups and Mann-Whitney U test to compare data that were not normally distributed. All data were analyzed using SPSS 21.0 (IBM SPSS Statistics; August 2012). For all comparisons, statistical significance was achieved with P value of less than 0.05.
RESULTS A total of 24 facilitators and 249 participants were trained in CETEP (ETAT). The facilitators included 12 senior physicians (50.0%), 7 residents (29.2%), and 5 nurses (20.8%). The participants represented a wide variety of health care professions: 10 physicians (4.0%), 12 residents (4.8%), 142 senior medical students (57.0%), 73 nurses (29.3%), and 12 firemen (4.8%). With regard to the quality of the course, overall participant mean posttest scores were significantly greater than the mean pretest scores (Table 1). Mean pretests and posttests of those trained after the course modifications (manuals were distributed earlier, and the training extended to 12 hours) were made were significantly higher than those trained before the change (Table 2). As for overall participant satisfaction, participants rated the course quality as 3.57 (n = 238; SD, 0.41; confidence interval [CI], 3.52–3.63) and the course effectiveness as 3.57 (n = 238; SD, 0.45; CI, 3.57–3.69), where 4.0 was the highest score for each. Similarly, comparison of evaluations between those trained before and those trained after February 2011 showed improvements by a statistically significant amount in each quality category (Table 3). Evaluation of the effectiveness of the course (ie, the ability of recent course participants to translate the knowledge from the course into everyday care of patients) demonstrated excellent concordance between experts (HNPB course facilitators) and novices (recent course participants) in assigning triage levels to actual TABLE 1. Overall CETEP (ETAT) Written Test Scores (Scale 0–100)
Outcomes/Measurements A prospective cohort design, approved by institutional review boards at both BCM and HNPB, was used to assess the quality of the course. We collected basic information for each
2
www.pec-online.com
Pretest Posttest
Mean (N = 238)
SD
95% CI
P
54.66 70.37
16.05 10.60
(52.61–56.71) (69.01–71.72)
