Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process.

OBJECTIVE: To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. DESIGN: Modified Delphi process. SETTING: Participants from 34 countries. POPULATION: Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. METHODS: We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in-person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. MAIN OUTCOME MEASURE: Consensus on bundle items. RESULTS: Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher-level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym 'FAST-M'. CONCLUSION: A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. TWEETABLE ABSTRACT: A maternal sepsis bundle for low resource settings has been developed by international consensus.

Is transcription of data on antiretroviral treatment from electronic to paper-based registers reliable in Malawi?

SETTING: Antiretroviral treatment (ART) clinics at one central hospital, three district hospitals and one mission hospital in the central and southern regions of Malawi. OBJECTIVE: To measure the extent of inaccuracies in the transcription of case registration and recorded deaths between electronic medical data (EMR) and paper registers. This was done to inform the Ministry of Health on the reliability of the paper-based system as backup in case of EMR failure. DESIGN: Retrospective analysis of routine programme data. RESULTS: A total of 31 763 registrations and 2922 deaths in the EMR were compared with those in the paper registers. In one hospital, up to 24% of overall case registrations were missing from the paper registers. At other sites, the differences were minor and included duplicate patients who should have been classified as 'transfer in' patients in the paper register. There were major differences in the number of registered deaths in two of the five facilities. CONCLUSION: There are varying degrees of agreement between the EMR and paper registers which compromise the use of the latter as a backup solution in case of EMR failure. The reasons for this unreliability and ways forward to address the problem are discussed.

Outcomes of tuberculosis patients who start antiretroviral therapy under routine programme conditions in Malawi.

SETTING: Public sector facilities in Malawi providing antiretroviral therapy (ART) to human immunodeficiency virus (HIV) positive patients, including those with tuberculosis (TB). OBJECTIVES: To compare 6-month and 12-month cohort treatment outcomes of HIV-positive TB patients and HIV-positive non-TB patients treated with ART. DESIGN: Retrospective data collection using ART patient master cards and ART patient registers. RESULTS: Between July and September 2005, 7905 patients started ART, 6967 with a non-TB diagnosis and 938 with a diagnosis of active TB. 6-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (77%) compared with non-TB patients (71%) (P < 0.001). Between January and March 2005, 4580 patients started ART, 4179 with a non-TB diagnosis and 401 with a diagnosis of active TB. 12-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (74%) compared with non-TB patients (66%) (P < 0.001). Other outcomes of default and transfer out were also significantly less frequent in TB compared with non-TB patients. CONCLUSION: HIV-positive TB patients on ART in Malawi have generally good treatment outcomes, and more patients need to access this HIV treatment.

Diagnosing anaemia in pregnancy in rural clinics: assessing the potential of the Haemoglobin Colour Scale.

Anaemia in pregnancy is a common and severe problem in many developing countries. Because of lack of resources and staff motivation, screening for anaemia is often solely by clinical examination of the conjunctiva or is not carried out at all. A new colour scale for the estimation of haemoglobin concentration has been developed by WHO. The present study compares the results obtained using the new colour scale on 729 women visiting rural antenatal clinics in Malawi with those obtained by HemoCue haemoglobinometer and electronic Coulter Counter and with the assessment of anaemia by clinical examination of the conjunctiva. Sensitivity using the colour scale was consistently better than for conjunctival inspection alone and interobserver agreement and agreement with Coulter Counter measurements was good. The Haemoglobin Colour Scale is simple to use, well accepted, cheap and gives immediate results. It shows considerable potential for use in screening for anaemia in antenatal clinics in settings where resources are limited.

PIP: In developing country settings, screening of pregnant women for anemia may be limited to inspection of the conjunctiva for the presence of pallor. The potential for anemia diagnosis of a new color scale for the estimation of hemoglobin (Hb) was assessed in a study conducted at three rural hospitals and two health centers in southern Malawi. The Hemoglobin Color Scale, recently developed by the World Health Organization, is simple to use, inexpensive, and gives an immediate result. A total of 729 pregnant women underwent conjunctiva examination, HemoCue hemoglobinometer reading, electronic Coulter Counter analysis, and at least one Hemoglobin Color Scale reading (n = 1066 observations). Each of these tests was performed by a different trained nurse-midwife to reduce the potential for bias. According to the Coulter Counter measurements, 58.1% of participants had Hb levels of 11 g/dl or less, 32.0% were 10 g/dl or less, and 4.0% were 8 g/dl or less. Sensitivity was 80.0-96.6% for HemoCue, 33.2-62.1% for conjunctiva examination, and 50.0-81.6% for the Hemoglobin Color Scale. Positive predictive values were 46.8-68.1% for HemoCue, 1.2-75.0% for conjunctival examination, and 11.0-66.2% for the color scale. The highest sensitivity for the color scale was obtained at a cut-off point of 10 g/dl and the highest positive predictive value at 11 g/dl. Agreement of the Hemoglobin Color Scale readings to within +or- 1 g/dl of the Coulter Counter measurement was obtained in 40% of cases; agreement to within 2 g/dl occurred in 67% of cases. The positive predictive value of the Hemoglobin Color Scale increases with increases in the prevalence of severe anemia.