Task shifting of triage to peer expert informal care providers at a tertiary referral HIV clinic in Malawi: a cross-sectional operational evaluation

Megan Landes,Adrienne K Chan,Chrissie Gondwe,Edson Mwinjiwa,Harriet Akello,Edith Thaulo,Courtney Thompson

doi:10.1186/s12913-017-2291-3

Abstract

BackgroundHIV treatment models in Africa are labour intensive and require a high number of skilled staff. In this context, task-shifting is considered a feasible alternative for ART service delivery. In 2006, a lay health cadre of expert patients (EPs) at a tertiary referral HIV clinic in Zomba, Malawi was capacitated. There are few evaluations of EP program efficacy in this setting. Triage is the process of prioritizing patients in terms of the severity of their condition and ensures that no harmful delays occur to treatment and care. This study evaluates the safety of task-shifting triage, in an ambulatory low resource setting, to EPs.MethodsAs a quality improvement exercise in April 2010, formal triage training was conducted by adapting the World Health Organization Emergency Triage Assessment and Treatment Triage Module Guidelines. A cross sectional observation study was conducted 2 years after the intervention. Triage assessments performed by EPs were repeated by a clinical officer (gold standard) to assess sensitivities, specificities, positive and negative predictive values for EP triage scores. Proportions were calculated for categories of disposition by stratifying by EP and clinician triage scores.ResultsA total of 467 patients were triaged by 7 EPs and re-triaged by clinical officers. With combined triage scores for emergency and priority patients we report a sensitivity of 85% and specificity of 74% for the EP scoring, with a low positive predictive value (41%) and a high negative predictive value (96%). We calculate a serious miss rate of EP scoring (i.e. missed priority or emergency patients) as 2.2%. Admission rates to hospital were highest among those patients triaged as emergency cases either by the EP’s (21%) or the clinicians (83%). Fewer patients triaged as priority by either EPs (5%) or clinicians (15%) were admitted to hospital, however these patients had the highest prevalence of same day lab testing and/or specialty referral.ConclusionsOur study provides reassurance that in the context of adequate training and ongoing supervision, task-shifting triage to lay health care workers does not necessarily lead to less accurate triaging. EPs have a tendency to be more conservative in over-triaging patients.

Highlights

Human Immunodeficiency Virus (HIV) treatment models in Africa are labour intensive and require a high number of skilled staff
Some low-income countries (LICs) have piloted and scaled approaches to address this growing crisis by involving the transfer of expert knowledge on HIVtesting, treatment initiation and treatment support from nurses and clinicians to non-clinical, lay, and peer caregivers [1, 2]. An example of this is in the development of the “expert patient” (EP), a term used to refer to people living with long-term health conditions who are provided with additional training to perform various healthcare tasks such as administration or patient counseling and education [3]
In part an endorsement of the 1994 Declaration of Greater Involvement of People Living with HIV/ AIDS (PLHIV) [3], as well as a reflection of increasing trends towards patient self-management in high-resource settings [4], EP programs are being implemented as an efficient way to ensure that the ‘care continuum’ for PLHIV is being addressed

Summary

Introduction

HIV treatment models in Africa are labour intensive and require a high number of skilled staff. The current literature encompasses various aspects of assessing these programs including efficiency, cost-savings, and safety of a range of tasks [8,9,10], the meaning and utility of patient ‘expertise’ in this setting differs markedly from the biosocial underpinnings of the traditional EP model that envisioned the creation of instrumental therapeutic ties based on shared lived experience and successful selfmanagement of a specific condition [3] Unlike their counterparts in middle- and high income countries, EPs that are PLHIV and acting within a context of extreme economic scarcity, are often valued the most by the health system for their task-shifted roles in mitigating chronic and critical HRH shortages

Methods

Results

Conclusion