Project Details

Resuscitation, Education, Acute Care, Help (REACH) Tele-Critical Care Intervention Bundle Trial

Vanessa Denny, MD, MS

Summary

BACKGROUND: Delays in recognition and treatment of critically ill children, along with limited access to resources, contribute to poor outcomes in Sub-Saharan Africa. Rural district hospitals, often the first contact for acutely ill children, lack critical care expertise. Komfo Anokye Teaching Hospital (KATH) is the only tertiary center with pediatric critical care expertise covering northern Ghana. Systems-level solutions are urgently needed to improve early recognition, stabilization, and delivery of evidence-based emergency and critical care. A promising approach is a low-bandwidth telemedicine bundled intervention, linking district hospitals with tertiary expertise:1) telesimulation-based training, 2) real-time or asynchronous teleconsultation, 3) debriefings of simulated and real cases. GAP: Although telemedicine support has been effectively deployed for adults, there is limited evidence for effectiveness of telemedicine interventions to improve rural clinician recognition, stabilization, and management of critically ill children in Ghana. No studies have evaluated this telemedicine bundle’s impact on pediatric clinical or implementation outcomes. HYPOTHESIS: A pragmatic low-bandwidth telemedicine bundled intervention of 1) remote telesimulation-based training, 2) real-time or near-real time asynchronous teleconsultation, 3) telemedicine debriefings of simulated and real cases, will reduce hospital mortality/length of stay among pediatric transfers in the Ghanaian healthcare system. Specific Aim 1: Determine whether this bundle improves patient clinical outcomes (primary outcome: survival to 30 days with good functional status scale (FSS); secondary outcomes: hospital length of stay, process-of-care adherence for tracer conditions, transfer times, Specific Aim 2: Characterize the implementation of the telemedicine bundle intervention by assessing its penetration and fidelity within the Ghanaian healthcare system. METHODS: Thisis a hybrid Type 1 implementation-effectiveness pilot study using a pragmatic stepped-wedge cluster design across three district hospitals in Kumasi, Ghana in partnership with KATH. Each hospital will contribute a 6 -month baseline control period followed by a 6-month intervention period, with continuous data collection. RESULTS: Pending. IMPACT: This study directly targets preventable child mortality at a vulnerable point in the care continuum. Findings from this study have the potential to inform scalable, evidence-based models of care delivery contextualized to low resource settings for pediatric resuscitation that can be adapted across LMICs, advancing global child health and reducing preventable deaths. This project has the potential to transform pediatric critical care delivery in low-resource settings by improving early resuscitation and stabilization prior to transfer. Optional/Additional Comments Our recently published needs assessment conducted at KATH revealed that critically ill children referred from district hospitals arrive severely under-resuscitated and with significant delays in care1. We pilot tested this bundled telemedicine intervention at the single tertiary KATH hospital, and demonstrated acceptability, feasibility, improved performance scores, and process of care for pediatric septic shock simulated cases and significantly improved the mortality rate in real patients presenting with signs of shock (35.7% pre-intervention, 10.4% post-intervention, p=0.004). 1. https://doi.org/10.1136/bmjpo-2024-002814