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Survive and thrive – a colour-coded triage system

03.06.2022

Waiting times are often long in the accident and emergency departments in northern Mozambique. Thanks to support from SolidarMed, children are now given a coloured card on arrival at four healthcare facilities. This means that those in life-threatening situations are treated more quickly than less urgent cases and therefore have better chances of survival than before.

Child mortality in Mozambique remains high, with 74 in every 1,000 children not seeing their fifth birthday. By way of comparison, in Switzerland that figure is four in 1,000. The main cause of death in children in Mozambique is malaria. Particularly for children with pre-existing health problems, such as anaemia or malnutrition, a malaria infection can quickly become life-threatening. In some circumstances, their state of health can deteriorate within hours, which is why rapid treatment is so important. Nevertheless, at most healthcare facilities in Mozambique, patients are treated on a first come first served basis, irrespective of their state of health. In the crowded waiting rooms, that often means a wait of several hours.   

Staff member José Cardeal explains the idea behind the coloured cards to parents at the health centre in Chiúre. rf

In the health training centre in Pemba, student nurses are taught the meaning of the different coloured cards. rf

For children in particular, treatment sometimes comes too late. “We’ve seen that an alarmingly high number of children die within 24 hours of arriving at hospital,” explains Riccardo Lazzaro, SolidarMed project manager in Mozambique. “So there’s a huge need to improve the status quo.” 

Four hospitals and health centres in northern Mozambique have taken a different approach. With the support of SolidarMed, over the past four years, they have introduced an internationally-recognised colour coded triage system. Since then, treatment has not been in order of arrival but according to urgency. Reception staff at the healthcare facility ask incoming patients questions, assess their state of health and assign them a coloured card. Red means highest priority, yellow means medium priority and green means that the child’s state of health is not expected to deteriorate. Those children will then have to wait their turn. At larger hospitals there are sometimes two additional categories. 

A colour makes the difference between life and death

Eleven-month-old Gilberto is given an orange card – the second-highest priority level. Nurses in the neighbouring health centre in Mahate had referred him to the provincial hospital in Pemba because he had a high temperature and painful lesions on his tongue. He had also lost a lot of weight: he only weighed 4.6 kilos and was no longer able to crawl. The hospital receptionists were clear that treatment was urgent, and that in particular he needed to be tested for suspected malaria.

To ensure that reception staff have the necessary knowledge to carry out this type of initial medical assessment, they receive a longer training course from SolidarMed to begin with and then a refresher course every three months. The impact of this relatively small effort is significant: receptionists are then able to recognise emergencies in time and assign a coloured card accordingly. They are therefore the backbone of the colour system and take the pressure off healthcare facilities, which have an acute shortage of healthcare professionals.

"An alarmingly high number of children die within 24 hours of arriving at hospital.”

Riccardo Lazzaro, Project manager

The structural changes made in the waiting area, which SolidarMed finances where necessary also bring some relief. They help better manage the crowds of people waiting and organise the type and order of treatment according to the coloured cards.

But besides rapid treatment, quality of care and availability of equipment are also crucial. For example, the emergency doctors need to know how to help children with acute breathing difficulties; facilities need to have their own labs to rapidly analyse malaria tests; and there needs to be enough disposable gloves and dressing material. SolidarMed therefore runs training courses and refresher courses  in emergency treatment for healthcare workers at all supported healthcare facilities, and procures the necessary medical equipment. This ensures that children receive rapid and high-quality treatment in emergencies. 

Timing is critical – even when still at home

Thanks to the orange card, Gilberto received rapid treatment. The doctors at the provincial hospital carried out a malaria and a tuberculosis test, and fortunately both were negative. In the end the diagnosis was severe acute malnutrition and a fungal infection in the mouth. The little boy was immediately given therapeutic food, painkillers and an antimycotic medicine. After a few days, he was doing much better. His high temperature had subsided and he had regained his appetite. Full recovery will take a few more weeks, but the critical phase when swift action is needed is behind him.

Other children are not so lucky, because sometimes they are in such a critical state when they arrive at hospital that even rapid treatment comes too late to help them. This is why it is important to educate parents about, for example, bringing their children to hospital as soon as possible if they have a high fever. SolidarMed trains community health workers to recognise key symptoms. This allows them to advise parents and to recommend a rapid trip to hospital if need be.

To ensure that all patients and caregivers know about the coloured card triage system, SolidarMed produced a video featuring amateur actors. It is now being shown on screens in waiting rooms in the local language of Makua with Portuguese subtitles. A radio programme is also in the pipeline to inform and educate people living in the surrounding villages.

Passing on success

SolidarMed launched the project back in 2016 at Chiúre District Hospital. It was then rolled out at the healthcare facilities in Namuno, Metoro and Pemba. In 2022, SolidarMed is supporting two additional healthcare facilities with the rollout of the colour-coded triage system and with staff training.

There, too, children requiring urgent treatment are to be treated as a priority in future. “We continue to focus on gauging the effects of measures,” says project manager Riccardo Lazzaro. “This allows us to give longer-term recommendations to the authorities about how the system could be scaled up. I firmly believe that the impact would be huge.”

SolidarMed’s work has also contributed to the national and provincial health authorities declaring better emergency treatment of children a priority in 2019, and to the Ministry of Health incorporating the colour coding triage system in its national strategy. Riccardo Lazzaro and his team support the authorities in taking concrete action and introducing the system in various healthcare settings. To this end, SolidarMed is helping the Ministry of Health distribute the new handbook on the triage system using coloured cards (‘manual de triage para as urgencias’), which SolidarMed was involved in developing last year.

SolidarMed is also supporting the healthcare training centre in Pemba with the development of an adapted curriculum and running initial pilot courses. The results will subsequently be presented to the Ministry of Health to incorporate the training course in the standard curriculum.

These measures will ensure that in future, other healthcare facilities will be able to introduce the colour coding system and everything that goes with it – without direct support from SolidarMed.

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