Development of a simple, practice-based tool to assess quality of paediatric emergency care delivery in resource-limited settings: identifying critical actions via a Delphi study

OBJECTIVE: Provision of timely, high-quality care for the initial management of critically ill children in African hospitals remains a challenge. Monitoring the completion of critical actions during resuscitations can inform efforts to reduce variability and improve outcomes. We sought to develop a practice-based tool based on contextually relevant actions identified via a Delphi process. Our goal was to develop a tool that could identify gaps in care, facilitate identification of training and standardised assessment to support quality improvement efforts. DESIGN: Six sentinel conditions were selected based on disease epidemiology and mortality at rural and urban African emergency departments. Potential critical actions were identified through focused literature review. These actions were evaluated within a three-round modified Delphi process. A set of logistical filters was applied to the candidate list to derive a practice-based tool. SETTING AND PARTICIPANTS: Attendees at an international emergency medicine conference comprised an expert panel of 25 participants, with 84% working primarily in African settings. Consensus rounds allowing novel responses were conducted via online and in-person surveys. RESULTS: The expert panel generated 199 actions that apply to six conditions in emergently ill children. Application of appropriateness criteria refined this to 92 candidate actions across the following seven categories: core skills, active seizure, altered mental status, diarrhoeal illness, febrile illness, respiratory distress and polytrauma. From these, we identified 28 actions for inclusion in a practice-based tool contextually relevant to the initial management of critically ill children in Africa. CONCLUSIONS: A group consensus process identified critical actions for severely ill children with select sentinel conditions in emergency paediatric care in an African setting. Absence of these actions during resuscitation might reflect modifiable gaps in quality of care. The resulting practice-based tool is context relevant and can serve as a foundation for training and quality improvement efforts in African hospitals and emergency departments.