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. 2025 Aug 7;20(8):e0329369.
doi: 10.1371/journal.pone.0329369. eCollection 2025.

Improving pediatric care in Uganda with a digital platform and quality improvement initiative: A retrospective review of Smart Triage + QI

Rebecca Goertzen  1 , Yashodani Pillay  1   2 , James Karugaba  3 , Ivan Aine Aye Ishebukara  3   4 , Ahmad Asdo  1   2 , Dustin Dunsmuir  1   2 , Justine Behan  1 , Charly Huxford  1 , Stefanie K Novakowski  1   2 , Fredson Tusingwire  4 , Ronald Kasyaba  5 , Gloria Kakuru  5 , John Khisa  5 , Stephen Businge  3 , Mike Kyewalyanga  3 , Niranjan Kissoon  2   6 , J Mark Ansermino  1   2
Affiliations

Improving pediatric care in Uganda with a digital platform and quality improvement initiative: A retrospective review of Smart Triage + QI

Rebecca Goertzen et al. PLoS One. .

Abstract

Objective: This is a retrospective review of the feasibility study and implementation of the Smart Triage and Quality Improvement (QI) initiative at Holy Innocents Children's Hospital (HICH), a dedicated pediatric hospital in Mbarara, Uganda, over a 5-year period. The aim of this QI initiative was to improve triaging rates and the time-to-antimicrobials in HICH's outpatient department (OPD).

Methods: Smart Triage is a risk prediction algorithm and digital platform that enables healthcare workers to triage patients and track treatments effectively. Following the feasibility study, the QI program was implemented in September 2021 using three Plan-Do-Study-Act cycles: 1) Standardize Training, 2) Adjust Workflows, and 3) QI Team Communication. Data sources were triage and hospital reports. Monthly run charts of OPD attendance, acuity of illness, triaging rates, median-time-to-antimicrobials, and mortality rates of admitted patients were created. The trajectories of the variables were assessed using linear regression with time as the explanatory variable.

Results: 121,521 children attended HICH OPD from November 2018 to October 2023. The OPD triaging rate increased to 91% by October 2023, with a sustained plateau above 90% since July 2022. There was a significant reduction in the median time-to-antimicrobials during the 5-year period, from 77.6 to 53.6 minutes, with a slope of -0.4 minutes per month (CI: -0.73 to -0.04, p-value: 0.029). The inpatient mortality rate decreased from 5.1% in August 2018 to 2.6% in October 2023, with a significant increase in the number of cases with comparable illness severity.

Conclusion: The impact of Smart Triage was sustained beyond the end of the feasibility trial and showed sustained improvements in processes such as treatment times and clinical outcomes including a reduction in mortality. HICH's leadership integrated a culture of QI across disciplines and departments, contributing to this initiative's sustainability and impact.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Smart spot and smart triage platform.
Fig 2
Fig 2. An example of a key driver diagram to optimize triage rates was developed during the quality improvement process.
The diagram was used to target specific interventions, and their effectiveness was measured during the Plan-Do-Study-Act cycles. Similar diagrams were used for other quality improvement initiatives, such as waiting times in the laboratory or completion of vital sign measurements.
Fig 3
Fig 3. HICH Smart Triage QI Interventions Timeline October 2018 – October 2023.
The platform feasibility study was conducted between 2018 and 2021, and a formal quality improvement study was conducted from 2021 to 2023.
Fig 4
Fig 4. Number of patients presenting to the OPD per month; COVID-19 Lockdowns indicated by grey bars.
Fig 5
Fig 5. Monthly count of high urgency patients based on ED-PEWS scores; COVID-19 Lockdowns indicated by grey bars.
Fig 6
Fig 6. Triaging Rate in the HICH’s Outpatient Department; COVID-19 Lockdowns indicated by grey bars.
Fig 7
Fig 7. Median time to receiving antimicrobials at HICH in the OPD; COVID-19 Lockdowns indicated by grey bars.
Fig 8
Fig 8. Mortality Rates of Admitted Patients at HICH; COVID-19 Lockdowns indicated by grey bars.
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