Triage in Rural Primary/Urgent Care Clinics
Overview of the Problem
As word has spread through nearby villages that Nyaya provides modern, physician-led healthcare, demand has increased rapidly. From 7 patients on our inaugural day, we now see an average of 140 patients per day. This has strongly challenged our clinical team to provide high-quality, equitable care to our patients.
To provide some context, we have one physician (the only one for area of approximately 500,000 people), two mid-level practitioners known as health assistants, a lab technician, five midwives, and several community health workers. The nearest surgical and inpatient referral facility is 10 hours away. Approximately 60% of our patients walk from over 2 hours away to get to the clinic. We are essentially the only serious medical care for a large area spanning several hours and tens of thousands of patients. We presently have limited capacity for dealing with complex primary care/psychosocial issues, and need to focus our resources on the dire public health problems in the area that we can effectively address and measure, such as pneumonia, trauma, malnutrition, dehydration, tuberculosis, antenatal care, safe delivery. For patients who require more complex primary care, we need to offer them clear counseling on what they can do and what we can and cannot provide.
Main Challenges
The essence of the challenge is figuring out which patients should be seen by which providers, and making those encounters efficient and effective. This challenge cuts at some of the fundamental issues of providing comprehensive health services in rural, resource-deprived areas, including:
1) What are the core conditions that can be effectively addressed in an area that is just rolling out primary/urgent care?
2) What types of staff are required, and what are their core knowledge and experiential needs?
3) What are the most useful/appropriate protocols and reporting systems for this?
4) What laboratory and diagnostic equipment are most useful for primary care in resource limited settings?
5) How to provide some level of counseling and preventive medicine to those patients that the clinic/health system is not presently equipped to adequately address?
Categories of Patients
Patients can be divided into the following broad categories:
Acute condition with warning signs.
These patients have been screened in as having one of the warning signs/symptoms (see below). Typically, it will warranted that they are seen at some point by the physician. Examples: pyelonephritis, pneumonia.
Acutely/sub-acutely ill without warning signs.
These patients, while not having warning signs, can benefit from a protocolized intervention with measurable outcomes. Oftentimes, these patients can be managed effectively by mid-level providers. Example: uncomplicated UTI, upper respiratory tract infection.
Non-acutely ill.
These patients have vague primary care symptoms that are not easy for minimally trained staff with limited resources to diagnose and treat. It is difficult to measure the impact of any interventions for these symptoms. It is important, however, to screen these patients for underlying conditions that fall within the first two categories that are treatable and, once screened out, to provide effective counseling. Example: diffuse aches and pains.
These categories are diagnoses relevant from a systems perspective rather than a physiological one. The categories are likely to evolve in fact as access to services increases. Another way to frame this is that in the initial phase of essential services roll-out, it is important to focus on diseases for which interventions and outcomes are well-defined, protocolized, and measurable. The strongest argument in fact for the "vertical" health systems approach (versus our attempts at creating a "horizontal", comprehensive one) is that it is easier to monitor and measure discretized interventions.
Categories of providers
Although the terms may differ across countries and contexts, the general categories of providers should be quite similar. Here we leave out lab technicians, mechanics, and administrators who play a critical role in overall clinical functioning but are not involved in direct patient care or triage.
Generalist physician.
In Nepal, since very few physicians want to work long-term in rural areas, most of the physicians available for initial health roll out are young, freshly-minted MBBS physicians. Without postgraduate training, their diagnostic skills are limited. In Far Western Nepal, however, they are often the only physician at a district hospital serving 250,000 people and simultaneously overseeing all public health programs. In our case, the district hospital is run by a naturopathic doctor, making our physician the only allopathic doctor in Achham.
Auxiliary Nurse Widwives.
These providers are trained in basic deliveries, antenatal care, diagnostics, and procedures. Given the acute need for maternal and child health services and the poor status of women, ANMs are a critical first-line provider.
Health Assistant.
This is a mid-level provider capable of basic diagnostics, symptomatic treatment, and procedures. The quality of HAs varies considerably with experience.
Community health worker/health aide.
The only formal training for these workers will come from community-based trainings, such as those conducted by Nyaya Health.
It is important to point out a two types of providers who are not typically available in the initial health services roll-out phase but who ideally would be incorporated quickly as services expanded; see our expansion plan for example.
Seasoned primary care physician.
This would be someone with post-graduate training in internal medicine or family practice and with at least 2-5 years of primary care practice who has the clinical knowledge and experience to manage complex primary care issues. These are typically not available at the start of health system roll-out; there is probably not a single such physician in all of Far Western Nepal (5 million people) that meets this description.
Physician with essential surgical skills.
This would be someone with post-graduate training in surgery or obstetrics capable of performing safely and aseptically routine, common surgies like c-sections, cholecystectomy, orthopedics, appendectomies.
Scheduling for outpatient services
In any triage system in which there are a limited number of end-process providers, there needs to be some arrangement for disease- or condition-specific scheduling. One challenge in a place where our physician is the only one for the entire district is that that most patients expect to see a doctor and need to be informed that not all patients will see the doctor and seeing/not seeing the doctor is a function of their particular condition and not their economic, social, or political status.
Reducing physician-led OPD days
One strategy for making demand more manageable is to have the doctor doing OPD 3-4 days a week. The other days the physician may work on administration or manage scheduled procedures and surgeries. The hardest part about scheduling anything in advance is again the transportation issue of patients walking hours to reach the clinic. It is also challenging to get the word out to the community that, like any day that the clinic is closed, people aren't to come to the clinic except for serious acute emergencies.
The non-physician clinic days can be focussed on specific midwife/mid-level practitioner programs like antenatal care, malnutrition/TB follow-up, vaccines, etc. A limited OPD with referral of complex cases to a physician-led OPD day can also be undertaken by a mid-level practitioner for those patients for whom transportation to the clinic is not burdensome.
One potential benefit of not having the physican there for certain days is to increase the autonomy of the mid-level providers. All providers require significant oversight and leadership, however.
Undertaking triage/registration prior to physician's arrival
Hence registration is at least started on the first 50 patients or so by the time the end-process provider arrives.
Challenges
Poor physician training
Issue
Most MBBS physicians who graduate from Nepali medical schools are undertrained in rigorous diagnosis and charting. At the same time, they tend to be over-confident in their abilities and value speed and sheer number of patients seen over rigorous evaluation. Doctors are treated as infallible and there is little accountability for malpractice. In rural areas, the lack of diagnostic facilities, huge patient demand, and lack of health personnel reinforce this medico-educational baggage. As such, the two-minute evaluation with purely symptomatic treatment is common and many primary care clinics function in a similar way to fly-by-night health camps. This is hard when the physician is expected to be a leader and driver of improved quality services.
Possible Solutions
Changing long-standing practices and poor medical education requires persistent effort. Accountability is key. It can be helpful to provide performance incentives that rewards quality rather than volume and disciplinary action for poor documentation and follow-up.
Working on innovative strategies that decrease patient load to physicians and spreads the work to more cost-effective mid-level providers is of course critical.
Quack Healers
Issue
Traditional and “quack” healers carry weight with communities but often charge exorbitant fees for minimal benefits. There is a need to engage these practitioners at some level if they can be contribute productively, or drive them out of business.
Possible Solutions
Incorporate Quack Healers into the System
In some areas, it is possible to refer patients with symptoms not currently treatable by the ormal medical system to traditional healers. This can work in areas where the traditional healers do more psycho-spiritual interventions rather than harmful practices involving burning/cutting/low-quality and unregulated herbs/heavy metals. Ultimately, the goal would be for traditional healers to start referring acute, treatable patients to the formal medical clinic. This works when: 1) traditional healers do primarily non-physical interventions; 2) they don't do anything harmful; 3) they don't charge exorbitant fees.
Public Awareness on the dangers of Quacks
One organization (www.jamkhed.org) would do street theatre to demonstrate the various magic tricks that quack doctors would play on the patients to show people they were being duped.
Long travel time for patients
Especially for patients who ultimately are triaged to not see a physician, there can be challenges dealing with expectations. Many of our patients travel several hours by foot in the hopes of seeing a physician and being cured of various long-standing ailments. Given our limited capacity for complex cases (no rheumatology or orthopedic specialists within two days’ travel and no seasoned primary care physician), we are forced to provide very little real treatment for many conditions. Patients should be evaluated and provided counseling and preventive medicine and informed of what we can and cannot do, however.
Large volume of chronic conditions
Issue
A bonafide primary care system should be able to address, through lifestyle changes, counseling, environmental interventions, and pharmaceuticals, the chronic lower back pain, the diffuse aches and pains, the
Note in our case we do not charge for medicines, which makes our services in VERY high demand.
Possible solutions
It has become clear that we need to provide very clear guidelines as to what conditions we can treat and dispense medicines for. In the beginning, it may require saying that we cannot dispense medicines for chronic conditions unless they have been diagnosed as part of a protocol. This sounds like giving up, but the reality is that dispensing lots of analgesics and antacids with little hope for follow-up is not going to have a positive public health impact. It may be better to let the private mid-level practitioners prescribe those until a real primary care system has been developed (which of course is the ultimate goal).
Key warning signs/symptoms
This is the list we are currently using to assist us in triage.
Vitals
Temp > 101.3
BP < 80/60
BP > 180/100
HR < 60
HR > 100
Neurological
Headache
Altered mental status
Lethargy
HEENT
Purulent ear discharge
Acute ear pain (within three days)
Purulent eye discharge
Acute eye pain (within three days)
Sore throat (within three days)
Cardiac
Acute chest pain (within one day)
Palpitations (within one week)
Orthopnea
Pulmonary
Persistent productive cough (sudden onset)
Difficulty breathing (sudden onset)
Gastrointestinal
Persistent diarrhea (>5 times in one day)
No bowel movement for more than three days
Abdominal pain (sudden onset)
Genitourinary
Hematuria
Painful urination (within one week)
Flank pain (sudden onset)
Vaginal discharge
Hematological
Pallor
Easy bruising
Rheumatologic
Swollen joints
Low back pain with difficulty walking
Dermatological
Abscess
Bayalpata Hospital Emergency Triage Protocol
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