Children returning home after hospitalization for severe infectious illnesses suffer high mortality rates, especially in sub-Saharan Africa (SSA). After returning home, continued engagement with the health system can improve recovery and reduce post-discharge deaths. Yet, it is not feasible for every child to return to the hospital for follow-up care post-discharge. Community health workers (CHWs) can facilitate safer transitions in care by engaging with families after they return home and providing re-referrals back to higher levels of care if needed. Risk-enhanced care uses digital algorithms to provide the most appropriate intensity of care to each child depending on the estimated risk of an outcome. Embedding risk-enhanced care in SSA’s increasingly digitized health system provides an opportunity to increase the efficiency and effectiveness of health services provided by CHWs. However, digital health platforms used by CHWs in SSA do not currently communicate with digital health platforms used by facilities, creating a missed opportunity for ensuring continuity of care for vulnerable families. Here, we aim to embed our clinically-validated, risk-enhanced care approach into an existing electronic community health information system used by CHWs to create Risk-Enhanced Community Care after Discharge (REConneCteD). We will initially conduct formative research to develop and optimize the usability and accessibility of REConneCteD and then evaluate the impact of REConneCteD on post-discharge mortality in a clinical trial at 8 hospitals in Uganda and Kenya. We will also conduct a thorough economic evaluation. Our teams combines expertise and experience from community partners and researchers in Uganda, Kenya, and Canada (Walimu, KEMRI/Wellcome Trust, UBC, Brock University). We will engage with governments and healthcare providers throughout the project to ensure our findings contribute to national and regional priorities and policies.

In suv-Saharan Africa (sSA), most government-run hospitals aim to follow WHO or national syndrome-based guidelines. Clinical syndromes, such as ‘severe pneumonia’ are designed to be sensitive for pathologies like invasive bacterial disease that require specific treatments to prevent death. However, low specificity means that a far wider group of children is captured by a syndrome definition including many with a self-limiting infection and very low risk of death. Currently, decisions regarding admission, discharge, and escalating or de-escalating antimicrobials are typically made by staff with limited paediatric training, very often interns, and current guidelines have very limited or no advice on de-escalation and discharge. These factors contribute to antimicrobial over-use, overly broad-spectrum prescribing, and unnecessarily prolonged treatment ‘to be on the safe side’. Excessive duration of antibiotic treatment means a greater risk of acquiring AMR from the hospital environment, significant costs to health providers and families, overcrowding, a low nurse:patient ratio, and reduced care for higher risk children. We propose that major reductions in antibiotic use, exposure to the hospital environment and transmission of AMR can be achieved by risk stratified care enabling very low-risk children admitted to hospital to be cohorted away from longer-stay patients, stop antibiotics and go home earlier with inexpensive phone follow up. We will engage policymakers, undertake mathematical modelling of antimicrobial usage, AMR transmission and costs across sSA within risk strataand conduct a trial of risk stratified care, and develop a tool 'PPS-plus' for monitoring of AMR transmission through simple cross sectional surveys. Relevance to the work programme includes combatting the major global threat from AMR through identification of personalised treatment options, a better evidence-base for policymaking, and digital tools to optimise clinical workflows.