The ETAT+ trainings are aimed at disseminating the national paediatric clinical practice guidelines (CPGs). These CPGs cover the commonest causes of mortality in under five years in resource limited countries. The course equips health workers with knowledge and skills for triage, early recognition, rapid assessment and management of the sick children. This includes life support skills for newborns, infants and children.

KEPRECON in collaboration with KEMRI /Wellcome Trust Research Progamme and the MoH Division of Child Health. Ministry of Health, has supported courses in Emergency Triage Assessment and Treatment Plus (ETAT+) within the framework of government Provincial and District Hospital throughout the country.With its increasingly important role in supporting training, KEPRECON has became the administrative arm for the ETAT+ courses in Kenya and the entire East African Region. Through this concerted partnership approximately two thousand health workers providing initial care in a typical hospital setting were trained.

In recent times KEPRECON has worked with international partners (Uganda and Rwanda) to adopt the ETAT+ course and deliver quality training.

This project aims to reduce under five mortality, thereby contributing to MDG4, through improved quality of emergency care for infants and children in Kenya, Rwanda and Uganda

The partnership was started in 2012 between the Royal college of Paediatrics & Child Health (RCPCH), Kenya Paediatric Association and Ministry of Health. This involved the implementation of an 18 month ETAT+ intervention package in East Africa with six hospitals being targeted in Kenya.

Overall, the activities in the six hospitals included:

• A baseline survey of hospital practice, including mortality statistics
• ETAT+ training for 30 doctors, nurses and clinical officers during a five-day course
• Provision of guidelines, job aides, equipment and some hospital refurbishment to create an appropriate triage area / room
• Identification of a hospital-based ETAT+ champion to drive quality improvement
• Supervision by an in-country ETAT+ clinical lead visiting every three months
• Quality assurance visits every six months by an identified UK consultant paediatrician with assessments of hospital practice
• Assessment of impact through 6 monthly and an end of project survey of hospital clinical practice and mortality rates for comparison with baseline

The aim of RCPCH-Global Links Project- Kenya Paediatric Association (KPA), Royal College of Paediatric and Child Health (RCPCH) –UK partnership is to establish an exchange programme between Kenyan paediatricians  and UK paediatric trainees in order to contribute to improvement of child health globally.

This involves coordination of placements for Kenyan paediatricians to get visiting fellowships in UK hospitals in specialty of choice. Similarly, KEPRECON coordinate placements for UK paediatric doctors to get voluntary placements in Kenyan hospitals for visiting fellowships to familiarize with tropical paediatrics and child health.

This is a collaborative initiative between Kenya Paediatric Association (KPA) through Kenya Paediatric Research Consortium (KEPRECON) and the Royal College of Paediatrics and Child Health (RCPCH) to design, deliver, monitor and evaluate the project entitled “Advancing Child Health in Kenya using ETAT+ hospital training and quality improvement” funded by the Jersey Overseas Aid Commission (JOAC).

Project Activities

• Delivery of six ETAT + training courses and one Generic Instructor Course (GIC). RCPCH will utilise its innovative ETAT+ e-learning platform to support these courses
• Implementation of ETAT + training, guidelines and quality improvement at referral level (Mbagathi District Hospital) and at four lower level health facilities based in Kibera.
• Mentorship to Mbagathi Hospital staff and Kibera slum healthcare workers on best practices using the Change theory/cycle of audits.
• Delivery of eighteen ETAT+ based CME sessions for Mbagathi Hospital staff and Kibera healthcare workers
• Mobilisation of hospital based health workers to engage with the community and create linkage/networks with community health facilities
• Establishment of referral pathways between community services and referral facilities to ensure that effective referrals occur.
• Monitoring and Evaluation of the ETAT + interventions including data collection at hospital and community level to ensure that the programme is delivered to high standards. Data dissemination will occur through the KPA annual conference and other channels.
• Engagement with key decision makers such as the Ministry of Health to advocate for the replication of best practice and ensure the sustainability of the programme.

The following institutions have directly supported in capacity building of health care providers in Emergency Triage Assessment and Treatment Plus (ETAT+):

PRONTO International aims to optimize care during birth through the development and implementation of innovative training strategies for healthcare providers that act as a catalyst for individual, team, and system change. In East Africa, PRONTO is a collaborator on the Preterm Birth Initiative (PTBi), which aims to reduce morbidity and mortality from preterm birth by strengthening facility-based care from pregnancy through to labor, delivery, and the immediate postnatal period. For this project, PRONTO developed a facility-based simulation and team-training mentoring curriculum that focuses on identifying, triaging, and managing preterm labour and birth, and caring for preterm infants. KEPRECON’s scope is to support the work of improving the quality of care in facilities in Kenya and Uganda from September 2016 to August 2019.

The  Kenya Paediatric Research Consortium (KEPRECON) and Eastern African Paediatric Association (EAPA) in conjunction with the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) carried out the first ever East Africa training school in Paediatric Gastroenterology, Hepatology and Nutrition. This pioneering initiative led by Dr. Ahmed Laving aimed to bring together a critical mass of specialists from across sub-saharan Africa involved in these paediatric sub-specialties. It furthermore sought to explore local experience of diseases and provide education and clinical perspectives from established GI and Hepatology units across Europe. In all, 30 health care providers from Kenya, Uganda, Tanzania, Sudan, Madagascar, Rwanda, Nigeria and Mauritius, attended this first initiative in Nairobi, Kenya.

The second European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) School will be held in Nairobi in the month of November 2017.

In 2012 Kenya Paediatric Research Consortium funded by Médecins Sans Frontières convened a meeting of experts in this field to examine the evidence on fluid resuscitation. The meeting concluded that national and international recommendations and guidelines needed to be re-examined in the light of the FEAST trial results.

This brought together leading figures from national paediatric associations in Africa, and international bodies to examine the evidence and the implications for practice in sub-Saharan Africa.

From the year 2012 the ETAT+ technical team has organized for experience exchange meetings that involve health facility ETAT+ selected champions and UK volunteers who update each other on success stories of their specific facilities and share challenges experienced and agree on solutions to the addressed challenges.  This is an annual activity organised by the ETAT+ technical team.

From 2012 Kenya Paediatric Research Consortium in collaboration Ministry of Health (MoH), through Expanded Programme on Immunisation (EPI), Network for Education and Support in Immunisation (NESI) has held experience exchange meetings.

The first meeting was held in November 2012 to discuss introduction of new vaccines whose main objective was to share information on new vaccines in the market, review issues of logistics around vaccine introduction and preparedness and foster linkages between vaccinology stake holders in the region.

The second experience exchange meeting was held in December 2014 and it focused on immunizations and current challenges in the African region and how best to deal with them, focus on advocacy engagement, and provide Paediatricians with tools to take back to their country to share with other professionals. The take home message was,that it is the role of the Paediatrician to make the value of the vaccine known by parents and caregivers. Uptake of vaccination has remained a challenge since not all children get to be immunized as required.

"Implementing human papilloma virus (HPV) vaccine vaccination in Africa: opportunities for strengthening adolescent health" Experience Exchange meeting was held in March 2016.The meeting was attended by delegates from Eastern and Southern African countries, with the objectives of promoting successful and effective introduction of HPV vaccination in the African region; creating a multi-disciplinary resourceful team of experts to support and advocate for the introduction of HPV vaccines in the African region; and increasing synergy between academics, educators and Ministries of Health to revive and strengthen school-based health programmes as delivery platforms of adolescent immunisation services in the African region.

The WHO Multicounty Survey on Abortion-related Morbidity is a large cross-sectional study that aims to investigate the frequency and in a worldwide network of health facilities. This study will collect information on all women presenting with abortion-related complications in the hospital facilities, during a two to three month period. The study will have a phased implementation, beginning with the countries in the African region, followed by the countries of South East Asia, Mediterranean and Western Pacific regions, and ending with the Americas.

Sites

In Kenya, the survey was scheduled to commenced in December 2016, 30 facilities (hospitals) were to be 23 facilities qualified for the study cutting across 11 counties namely; Nairobi, Kiambu, Muranga, Nyeri, Nakuru,

Baringo,Kericho,Bomet,Kitale,Uasin Gishu,Elgeyo Marakwet.

Activities:

1. Trainings: Conducted trainings in April 2017 and begun the three month data collection period on 1st May 2017.
2. Data Collection: The nature of survey includes data collection via individual forms and an exit computer interview for the eligible participants.
3. Site Visits: We conducted site visit between 16th- 31st May 2017 and this was to correct data errors noted during collection in the earliest time possible and also to create motivation to learn and improve data collection..

The Clinical Information Network is a collaborative partnership aiming to improve quality of hospital data and its utilization. CIN initial focus is the paediatric care. The partnership includes The Ministry of Health, 14 County Hospitals, the Kenya Paediatric Research Consortium (the research arm of Kenya Paediatric Association) and the KEMRI Wellcome Trust Research Programme. The KEMRI Wellcome Trust Research Programme has supported research in Kenya for over 25 years. At the centre of the project is the principle that policy makers, managers and care providers need 'Quality Information for Quality Care'. The partners in the Clinical Information Network are therefore working to support improved collection of clinical information so that this is rapidly used to improve the quality of care.

This partnership involves working with health care providers at all levels from the interns, nurses, medical officers and paeditricians who make initial contact with patients. and the health records personnel, who generate the data that is used currently while providing guidance and support that helps health workers deliver the best care. CIN produce 3 monthly hospital audit reports that hospitals use to identify gaps in care and plan action. CIN seeks to: improve routine mortality and morbidity data, improve information available to hospitals for quality improvement efforts, promote development of health information systems that support quality care and improved health care planning, and explore the impact of better information on quality of care.

Ongoing CIN Activities:

• Working with hospitals to identify particular areas for improving quality of care.
• Working to deliver better information to the national Health Information System.
• Working with the KEPRECON (Research arm of KPA), the hospitals and the Ministry of Health to promote the adoption of recommended best practices for sick children.
• Working to develop a similar approach for sick newborns needing care in newborn units within hospitals.

The study is collaboration between the Kenya Medical Research Institute, the Health Sector Monitoring and Evaluation Unit at the Kenya Ministry of Health, University of Oxford and Water, Sanitation and Health officers at Geneva WHO headquarters. The research will describe the context ultimately influencing current Infection Prevention and Control (IPC) and Antibiotic Stewardship (ABS) practice in Kenya. Firstly, this will involve connecting with and describing the role of, all of the relevant stakeholders, as well as analysing all of the national policy documents they have produced. We then want to analyse the situation at the county and hospital level to get a sense of how these policy documents are being translated into action. As part of this research we will conduct a survey of resources to effect IPC-ABS in hospitals using an adapted WASH-FIT tool that also comprises an antibiotic stewardship module and a patient safety module. We will also conduct a separate survey looking at consumption of antibiotics in inpatient services in relation to clinical diagnosis. Our aim is to analyse all of these data points together with the stakeholders so that we can formulate a list of potential comprehensive interventions to improve IPC-ABS, and we can recommend a list of indicators that could help the Kenya Ministry of Health to monitor and evaluate interventions in this area.

Objective

To develop contextual knowledge that can inform the systematic formulation of (complex) behaviour change/comprehensive interventions to improve IPC-ABS and patient safety in Kenyan hospitals, and to identify indicators of IPC-ABS behaviours, performance and health outcomes that can be used to evaluate and monitor future interventions.

Newborn deaths now accounts for 45% of all child deaths in Kenya. Many of these deaths among newborns could be prevented if they had access to high quality healthcare. Providing high quality newborn care is highly dependent on the adequacy of nursing care in addition to carefully planned medical care. However, there are often shortages in the number of nurses needed. These shortages put nurses under strain to deliver adequate care and may lead to nurses consciously or unconsciously prioritising tasks and the care they provide to patients, leading to varied quality with which the tasks are performed and some tasks being left

The study will take place across Kenya in 31 counties. Nurses who have provided care to sick inpatient newborns in the previous two years will be asked to partake. These nurses will be invited to participate in the study by local coordinators associated with the National Nurses Association of Kenya. Nurses working at an additional five hospitals that contribute to inpatient newborn services within Nairobi will also be invited to participate in the study. We anticipate inviting approximately 600 nurses from across the public, private, and not-for-profit sectors to participate.

Nurses will be invited to complete a self-administered questionnaire about the tasks that they perform when delivering inpatient care to sick newborns. Nurses will be asked to report on what proportion of their time they spend performing different categories of tasks, the importance and difficulty of each task, what their view is on tasks that may be left undone, and with what other staff or non-staff carers/family they share these tasks. In a second phase of the study, an expert group of advisors will also be engaged to completely describe in detail the step-wise process of performing neonatal nursing tasks.

Quantifying nursing care delivered in newborn units and its adherence to practice guidelines aims to study and

to document nursing care provided to newborns admitted in newborn units so that we can have a better understanding of what tasks are done (or left undone) and how often. The findings will, we hope, feed into discussions on what needs to be done to support nursing care provision.

The study will take place in 6 hospitals providing 24/7 inpatient care to sick newborns within Nairobi County. The study will involve observing care given in up to 216 newborn babies for parts of one day during their admission to the newborn units with an aim to observe approximately equal numbers across the 6 hospitals. In each newborn unit, we will identify the different sections where newborns with different degrees of severity of illness are cared for. We will randomly select blocks of time of 12 hours spread out across day and night, weekend and weekday in each hospital to get a picture of care at all times. We will then observe 3 babies during each block of 12 hours observing what care it is possible for nurses to provide.

The study will observe how care is provided to newborns and document the actual care that is delivered to newborns. There are no study related interventions. We will be at the cot-side of the newborns whom we will be observing, by making observations of what is happening to newborns we will also observe other people who are not the focus of this study like care providers, who might include nurses, doctors and mothers. However, no information will be collected directly from the care providers.

Assessment of Automation of Paediatric Triage using Pulse Oximetry in a Kenyan Public Hospital is a study that used a device called pulse oximeter, which is recommended for routine use and produces a signal that it automatically reads to show a heart rate and oxygen saturation. This study will extend the use of the pulse oximetry device in two ways; first by obtaining a respiratory rate from the wave; and secondly by reading the signal further, to assess whether it can predict the triage category (emergency, priority, non-urgent), whether the child is admitted or not, and how long the child takes to recover. The former objective will be done using an analysis method called machine learning, which uses computing systems to recognise patterns. Currently, it’s uncertain how many patients present with various triage categories in hospitals and this study will also investigate the proportion of patients in various triage categories presenting to the outpatient department of this hospital. This study has the potential of finding out if there are ways reducing triage time and problems of having inadequate triage staff if successful.

The study took place at Mbagathi Hospital in Nairobi, which is currently one of 14 Clinical Information Network (CIN) health facilities taking part in an approved study examining compliance to guidance and investigating ways to improve inpatient care practices.