Task-Sharing is Associated with Reduced In-Hospital Paediatric Mortality in Sierra Leonean Hospitals

Background: Following the Ebola epidemic in Sierra Leone, the Ministry of Health and Sanitation (MoHS) initiated measures to regain and extend improvements in healthcare for children. Within a wider strategy to reduce child mortality, UKAID supported MoHS and RCPCH to introduce locally adapted WHO Emergency Triage Assessment and Treatment (ETAT+) protocols to all district hospitals.

Objectives: Analyse operational programme data to identify trends in mortality rates and quality of care.

Methods: In 2017 two resident clinical mentors (one Sierra Leonean, one international) delivered a three-month on-the-job training programme alongside mentorship for nurses, with written and practical examinations (74% pass rate). Nurses passing the exams were authorised to initiate emergency paediatric treatment and were supported by clinical mentorship for three further months.

Mentors collected treatment data each day on children admitted the previous day and recorded discharge outcomes. These data were analysed to identify adherence to clinical protocols and to calculate mortality rates. In 2018, with intermittent support from RCPCH teams, admission and mortality data collected by hospital M&E officers were analysed in one-month blocks over six months.

Results: The 2017 data collection protocol was followed at 11 of 13 hospitals. Mean combined inpatient mortality over the first twelve weeks of the programme was 14%, and for the second twelve weeks was 9.6%. Adherence with clinical protocols improved for all emergency treatments, including appropriate use of oxygen (52% to 93%), correct antibiotic prescriptions (39% to 85%), and management of convulsions (54% to 83%). In 2018 data collection was undertaken at 12 of 13 hospitals. Combined mortality was 10.4%, and following further training fell to 7.3% in the second twelve weeks.

Conclusions: This analysis of operational data suggests that sustained reductions in hospital-level child mortality may be achievable in low-resource settings, when a task-sharing approach is combined with on-the-job training and mentorship.