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Background: Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services. Methods: We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014-2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services. Results: A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: < 1-4 min, p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4-14 min, p < 0.001) when integrated POCT with adequate ANC consult times was given compared to the baseline scenario. Mean length-of-stay increased by 2 min (95%CI: < 1-4 min, p = 0.015) with integrated POCT and by 16 min (95%CI: 10-21 min, p < 0.001) with integrated POCT and adequate consult times compared to the baseline scenario. The two nurses' overall daily utilization in the scenario with sufficient minimum consult durations were 72 and 75%. Conclusion: The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO's required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC.
Modelling was nested within an 8-month longitudinal study (December 2014 to August 2015) that implemented an integrated testing strategy for HIV, syphilis, malaria, and anaemia in seven dispensaries within the Kenya Medical Research Institute (KEMRI) and US Centers for Disease Control and Prevention’s (CDC) Health and Demographic Surveillance System (HDSS) area in Siaya County, western Kenya [7]. At the time of the study, there were 37 public health facilities in the HDSS area: one district hospital, nine health centres and 27 dispensaries. Detailed population characteristics and setting descriptions are available [39]. The Government of Kenya routinely supplied HIV POCTs per its standard national algorithm at the time: HIV (1 + 2) Antibody Colloidal Gold (KHB, Shanghai Kehua Bio-engineering Co Ltd., China) for screening, First Response HIV-1-2 kits (Premier Medical Corporation Ltd., Kachigam, India) for confirmation and Uni-Gold™ (Trinity Biotech, Ireland) for tie-breaking. The study supplied POCTs for syphilis (SD BIOLINE Syphilis 3.0, Standard Diagnostic Inc., Korea), malaria (CareStart™ Malaria HRP2 Pf, AccessBio, USA) and haemoglobin concentrations (HemoCue® Hb 201+, HemoCue AB, Sweden). During implementation, the seven study dispensaries received a monthly median of 38 (IQR: 32–38) antenatal visits, of which a median of 13 (IQR: 10–13) were first visits. Implementation outcomes from the study showed high adoption of POCTs, resulting in increased case detection and 70% treatment fidelity for syphilis and malaria [7]. Of the seven dispensaries, we conducted our modelling study in one with high client volume. The facility had the typical staffing profile of a dispensary: two nurses, one focused on maternal and child health (MCH) visits, and the other on out-patient (OP) visits; an HIV testing counsellor (HTC) who conducted provider-initiated HIV testing; a part-time clinical officer (CO) who oversaw HIV-positive clients seeking anti-retroviral treatment (ART) or prevention of mother-to-child transmission (PMTCT) services; and two to three subordinate support staff who helped with registration, weighing, and dispensing drugs. The facility had three main rooms, one each for MCH, OP, and ART/PMTCT (Fig. 1). Staff rotated among these rooms for the respective services. Facility floorplan We collected time-motion data at the facility over 4 weeks in August 2015 during the intervention. Six data collectors were stationed across each facility service point: two by the entrance, two at the MCH room, one at the OP room, and one at the ART/PMTCT room. Firstly, data collectors recorded all facility clients’ arrival times and purpose of visit (including MCH and non-MCH visit) to inform client mix and arrival time distributions. Secondly, for all MCH visits, we collected detailed information on client pathways. Any woman arriving at the facility for MCH purposes was greeted and introduced to the study. A short statement explained the study purpose (to measure activity and wait times), study procedures (wear a number badge and carry a timesheet throughout the visit), and confidentiality (no personal information such as name or test results would be collected). Women who disagreed would be free to continue their visits without timesheets and their badge numbers would be skipped. Data collectors present at each service point recorded activity process start and end times, service locations, provider type, and any blood tests done on the MCH women’s timesheets. Thirdly, data collectors recorded how healthcare workers (nurses, and COs) were spending their time (e.g. attending to clients, doing paperwork, doing miscellaneous tasks, taking breaks or unavailable) at every 15-min interval from the time of the healthcare workers’ arrival until their departure. All the data were recorded with established reference codes and any unforeseen items were given new codes that were communicated to the team immediately. Digital watches were synchronized daily at the beginning and end. All timesheets were scanned by TeleForm® (Hewlett-Packard) and exported into an excel database. A deterministic DES model of the dispensary was built in WITNESS© (Lanner Group Limited) simulation software. The model is made of entities, attributes, resources, and activities. Entities are people or items that enter the system (e.g. clients, paperwork) and require attention from resources (e.g. nurses, HTC, CO). The resources attend to entities in activities (e.g. consultation, registration). Attributes are intrinsic features of entities such as client types, pathways and the time spent on activities. Queues are generated in the DES model when entities compete for resources who are often needed in several activities simultaneously. The model outputs include waiting times, length-of-stay and nurse utilizations. We report wait times and length-of-stay in hour and minute format (hh:mm). The total wait time is defined as the sum total of time women had to wait for services and the length-of-stay is the time between women’s arrival and departure. Empirically collected time-motion data was used to inform model inputs. These inputs were: 1) all facility clients’ arrival times which included MCH and non-MCH clients; 2) all MCH clients’ activity sequences, activity durations, activity locations and activity service providers; and 3) non-MCH clients’ OP and ART consultation durations. All entities entered the model with their empirical arrival times. We made assumptions about OP and ART visits because we did not follow non-MCH clients: we assumed every OP and ART client had a consultation with either a nurse or a CO and that none of them were turned away except for those who came on the day healthcare workers were striking. Their consultation durations were given distributions estimated from those of MCH women who received OP or ART services with an average of 6.5 min for OP consult with nurses, 5 min for ART consult with nurses and 10 min for ART consult with the CO. MCH entities were given their empirical client flow sequences and activity durations as attributes. Healthcare worker availabilities and shift patterns were informed by the healthcare worker activity observations. Empirical and model-generated distributions of total wait times and length-of-stay for MCH clients were compared for validation. Before the 8-month longitudinal intervention study, only HIV testing was routinely performed at the dispensary. The intervention was defined as the integration of additional syphilis, malaria and anaemia point-of-care testing with routine antenatal HIV testing. As the time-motion data was collected while the intervention was present, we had to generate our primary output distributions without the intervention to create the baseline scenario ([0] without integrated POCT). We did this by removing the process durations of the additional testing from the empirical data. The time needed for the additional testing was estimated to be 8 min: 3 additional minutes for preparing the syphilis, malaria, and anaemia tests and 5 extra minutes to read the syphilis and malaria test results (HIV test requires 15 min for a negative reading while the syphilis and malaria tests require 20 min). We explored a ‘what-if’ scenario where all ANC consultations were of sufficient minimum durations to cover all recommended services, including integrated testing. Using data from client-provider role-play interactions in Tanzania [40], we estimated that a minimum of 58 and 36 min would be required to cover all recommended services in first visit and re-visit ANC consultations respectively (Table 1). ANC consultations that were shorter than the minimum durations were increased to their minimum values while those that were longer than the minimum durations retained their empirical values. Estimated ideal times for antenatal first visit and antenatal revisit based on consultation times estimated from Tanzania in hours and minutes (hh:mm) [40] POCTs point-of-care tests, ANC antenatal care Mean wait times and length-of-stay under the scenarios with integrated POCT [1], and with integrated POCT and adequate consult times [2] were compared with the baseline scenario [0] using paired t-tests.
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