在马拉维一家三级转诊艾滋病毒诊所将分诊任务转移给同行专家非正式护理人员：一项横断面操作评估。
Task shifting of triage to peer expert informal care providers at a tertiary referral HIV clinic in Malawi: a cross-sectional operational evaluation.
作者信息
Landes Megan, Thompson Courtney, Mwinjiwa Edson, Thaulo Edith, Gondwe Chrissie, Akello Harriet, Chan Adrienne K
机构信息
Dignitas International-Malawi Country Program, Zomba, Malawi.
Department of Emergency Medicine, University Health Network, Toronto, Canada.
出版信息
BMC Health Serv Res. 2017 May 9;17(1):341. doi: 10.1186/s12913-017-2291-3.
BACKGROUND
HIV 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.
METHODS
As 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.
RESULTS
A 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.
CONCLUSIONS
Our 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.
背景
非洲的艾滋病治疗模式劳动强度大，需要大量技术熟练的工作人员。在这种情况下，任务转移被认为是提供抗逆转录病毒治疗服务的一种可行替代方案。2006年，马拉维宗巴一家三级转诊艾滋病诊所的非专业健康骨干专家患者（EPs）得到了能力提升。在这种情况下，对专家患者项目疗效的评估很少。分诊是根据患者病情的严重程度对患者进行优先排序的过程，可确保治疗和护理不会出现有害的延误。本研究评估了在资源匮乏的门诊环境中，将分诊任务转移给专家患者的安全性。
方法
作为2010年4月的一项质量改进活动，根据世界卫生组织紧急分诊评估和治疗分诊模块指南进行了正式的分诊培训。在干预两年后进行了一项横断面观察研究。由临床干事（金标准）重复专家患者进行的分诊评估，以评估专家患者分诊分数的敏感性、特异性、阳性和阴性预测值。通过按专家患者和临床医生的分诊分数分层，计算处置类别的比例。
结果
7名专家患者对总共467名患者进行了分诊，并由临床干事进行了重新分诊。对于急诊和优先患者的综合分诊分数，我们报告专家患者评分的敏感性为85%，特异性为74%，阳性预测值低（41%），阴性预测值高（96%）。我们计算出专家患者评分的严重漏诊率（即漏诊的优先或急诊患者）为2.2%。在被专家患者（21%）或临床医生（83%）分诊为急诊病例的患者中，住院率最高。被专家患者（5%）或临床医生（15%）分诊为优先的患者中，住院的较少，但这些患者当日实验室检测和/或专科转诊的患病率最高。
结论
我们的研究表明，在进行充分培训和持续监督的情况下，将分诊任务转移给非专业医护人员不一定会导致分诊准确性降低。专家患者在过度分诊患者方面往往更保守。
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