Use-cases for prognostic tools in the management of febrile illnesses in resource-limited settings
| Use-case | Healthcare context | Typical human and technical capacity for the management of febrile illnesses* | Relevant outcomes to assess candidate prognostic factors |
| (1) Referral or admission to hospital or maximal pre-referral care if referral not feasible. | Community health worker or village health volunteer in a rural village | Health workers are often lay people with a few days to months training and intermittent supervision by staff from the primary health centre or other actors implementing community-based healthcare programmes. A very limited range of equipment (eg, MUAC tapes, thermometers, respiratory rate counters), diagnostics (qualitative RDTs for malaria) and treatments (antipyretics, oral antibiotics or antimalarials, oral rehydration solution and nutritional supplements) may be available. | Persistence or worsening of symptoms; referral to hospital; admission to hospital |
| Healthcare provider at primary health centre | Primary healthcare providers typically include clinical officers, nurses or midwives with a few months to years training. A greater range of clinical equipment (eg, pulse oximeters, weighing scales, stethoscopes) and diagnostic tests (eg, RDTs for other diseases and basic haematology) may be available. Some facilities may have the capacity for overnight observation and the delivery of intravenous fluids, antibiotics or nebulisers. | Persistence or worsening of symptoms; referral to hospital; admission to hospital. | |
| Healthcare provider in district hospital outpatient department | Healthcare staff can range from clinical officers with a few years training to experienced physicians. Similar clinical equipment available as at a primary health centre. Laboratory tests can also include instrumented platforms (which may be batched, depending on patient throughput). Proximity to inpatient care areas means threshold for admission for observation, further investigation and inpatient treatment may be lower. | Admission to hospital; length of hospital stay; admission to high-dependency area; measures of vital organ dysfunction. | |
| (2) Prioritisation of human and material resources for hospitalised patients including admission to restricted-capacity high dependency areas and transfers to higher-level care. | Healthcare provider in district hospital inpatient department | Healthcare staff can range from clinical officers with a few years training to experienced physicians. A range of clinical equipment is available, as well as variable access to radiological (eg, point-of-care ultrasound), microbiological and laboratory testing. Frequent vital observations and delivery of supplemental oxygen therapy, intravenous medications and surgical interventions for source control may be possible. Admission of patients also permits evaluation of trends in clinical or laboratory parameters over time and response to therapeutic interventions to be observed. | Length of hospital stay; admission to high-dependency area; measures of vital organ dysfunction; mortality. |
| Physician at admission to high dependency area or critical care unit in regional or tertiary hospital | Experienced physicians with access to clinical equipment and radiological, microbiological and laboratory testing. Near-patient tests such as blood gas machines and point-of-care ultrasound may be available in some settings, as may continuous vital sign monitoring and vital organ support (eg, inotropic therapy and non-invasive or mechanical ventilation). | Length of stay in high-dependency area; length of hospital stay; measures of vital organ dysfunction; mortality. | |
| (3) Prioritisation for peri-discharge and post-discharge care interventions | Healthcare provider at hospital discharge | Range of healthcare staff, clinical equipment and radiological, microbiological and laboratory testing depending on the level of the health facility. Feasible to compare discharge measurements to those taken during the hospital stay (ability to look at trends over time and response to treatment). Some facilities may have access to community outreach teams or links with nearby community health facilities to assist with patient follow-up after discharge. | Readmission to a health facility; return to baseline health status; acute sequelae resolution; neurocognitive outcomes; mortality. |
*Human and technical capacity varies greatly within countries and across regions: the examples given are for illustrative purposes and will not reflect all settings.
MUAC, mid-upper arm circumference; RDT, rapid diagnostic test.