Missed opportunities for hospital referral of young children with severe pneumonia identified at primary care using pulse oximetry: an analysis from the AIRE study in West Africa

Background In line with the Integrated Management of Childhood Illness (IMCI) guidelines, healthcare workers (HCWs) should refer all severe pneumonia among children under 5 seen in primary care in resource-limited settings. We investigated the frequency and correlates of missed opportunities for hospital referral (MOHR) of clinical severe pneumonia. Our study was embedded within the Améliorer l'Identification des détresses Respiratoires chez l'Enfant project, which involved the routine implementation of pulse oximetry (PO) within IMCI consultations at primary healthcare centres (PHCs) in West Africa: Burkina Faso, Guinea, Mali and Niger. Methods All children aged 2–59 months attending IMCI consultations in 16 PHCs and classified as severe cases using IMCI+PO were enrolled into a prospective cohort for 14 days, with parental consent. We estimated the rate of MOHR for IMCI-defined severe pneumonia, which was either not referred, or referred but did not make it to hospital. Correlates of MOHR at day 14 were investigated using logistic mixed regression with random effect for PHCs. Results From June 2021 to June 2022, among the 1786 children aged 2–59 months classified as severe cases by IMCI+PO, 682 (38.2%) were severe pneumonia. Of these, 35 (5.1%) also had severe anaemia, 47 (6.9%) severe hypoxaemia (SpO 2 <90%) and 602 (88.3%) severe malaria. HCW made the referral decision for 125 (18.3%) children, refused by three (2.4%) families; 560 (82.1%) were MOHR. Severe anaemia reduced the odds of MOHR (adjusted OR (aOR): 0.02; 95% CI 0.01 to 0.07) whereas having an SpO 2 between 90% and 93% (aOR: 12.16; 95% CI 3.47 to 42.61) or greater than 94% (aOR: 11.81; 95% CI 3.98 to 35.02) or severe malaria (aOR:2.55; 95% CI 1.04 to 6.26) significantly increased it. Conclusion MOHR for severe pneumonia was extremely high at PHC level in these settings, mainly explained by HCW’s decisions. Strengthening the referral system and training HCW to reinforce their adherence to IMCI guidelines remains essential to improve the management of severe pneumonia. Trial registration number PACTR202206525204526; Pan African Clinical Trials Registry on 15 June 2022.