Unmet need of essential treatments for critical illness in Malawi

Kayambankadzanja, Raphael Kazidule; Schell, Carl Otto; Mbingwani, Isaac; Mndolo, Samson Kwazizira; Castegren, Markus; Baker, Tim

doi:10.1101/2021.01.28.21250280

Cited by 7 publications

(9 citation statements)

References 14 publications

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“…We were unable to obtain this data via clinical audit as pulse oximetry coverage was too low and hypoxaemia cannot be accurately determined using clinical signs alone. 9 Alternative approaches to measuring oxygen access to patients are using cross-sectional hypoxaemia and oxygen therapy surveys, 19 crude counts of patients who receive oxygen or relying on HCW recall about oxygen supply stock-outs. 20 These approaches are problematic and provide a poor indication of whether oxygen is actually reaching those who need it.…”

Section: Is Oxygen Therapy Provided To All Patients Who Need It?mentioning

confidence: 99%

Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria

et al. 2021

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The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure ‘oxygen access’. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO2 documented) and negligible in private facilities (2%, 3/177) and primary health centres (<1%, 2/608). We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. However, triangulation of existing data suggested that no facilities were equipped to meet minimum oxygen demands. We highlight the importance of a multifaceted approach to measuring oxygen access that assesses access at the point-of-care and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.

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Section: Is Oxygen Therapy Provided To All Patients Who Need It?mentioning

confidence: 99%

Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria

et al. 2021

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“…Recent studies from Nigeria and Malawi have shown that without routine pulse oximetry to guide oxygen therapy, only around 20% of hypoxaemic patients receive oxygen – even if adequate oxygen supplies are available. 9 15 Given that pulse oximetry is essential to identifying who requires oxygen and routine pulse oximetry is rare without oxygen supplies, 5 13 pulse oximetry coverage (i.e. the proportion of patients who receive pulse oximetry and have SpO 2 documented) may be a reasonable proxy for patient oxygen access.…”

Section: Discussionmentioning

confidence: 99%

“…We were unable to obtain this data via clinical audit as pulse oximetry coverage was too low and hypoxaemia cannot be accurately determined using clinical signs alone. 8 Alternative approaches to measuring oxygen access to patients are using cross-sectional hypoxaemia and oxygen therapy surveys, 15 crude counts of patients who receive oxygen, or relying on HCW recall about oxygen supply stock-outs. 16 These approaches are problematic and provide a poor indication of whether oxygen is actually reaching those who need it.…”

Section: Patient Accessmentioning

confidence: 99%

Measuring Oxygen Access: lessons from health facility assessments in Nigeria

Graham

Olojede

Bakare

et al. 2021

Preprint

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The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure “oxygen access”. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe four key domains to consider when measuring oxygen access.Use8/58 (14%) of facilities had a functional pulse oximeter for detecting hypoxaemia (low blood oxygen level) and guiding oxygen care. Oximeters were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%), or operating theatre (4/27, 15%), not suitable for children, and infrequently used.Availability34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward.CostOxygen was free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13000 ($36 USD) and 27500 ($77 USD) naira, respectively.Patient accessNo facilities were adequately equipped to meet minimum oxygen demands for patients. We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data.We highlight the importance of a multi-faceted approach to measuring oxygen access that assesses access at the point-of-care, and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.SUMMARY BOXOxygen access is poorly understood and the most commonly used metrics (e.g. presence of an oxygen source) do not correlate well with actual access to patients.Pulse oximetry use is a critical indicator for the quality of oxygen services and may be a reasonable reflection of oxygen coverage to patients with hypoxaemia.Oxygen, and pulse oximeter, availability must be assessed at the point-of-care in all major service delivery areas, as intra-facility oxygen distribution is highly inequitable.Minimum functional requirements for oxygen sources must be assessed, as many oxygen concentrators and cylinders may be present without being in working order.

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“…The basic clinical processes specified in EECC have been overlooked in healthcare [11, 13-15, 18, 20, 51, 52] In UK hospitals, half of patients received substandard basic vital organ support prior to intensive care and 31% of preventable deaths were associated with absent clinical monitoring [13,14]. In Malawi, 89% of adult hypoxic patients, and 75% of children dying from pneumonia in hospital did not receive oxygen [17,18]. The usual organisational set-up of health services may be one underlying reason for this.…”

Section: Eecc Complements the Current Healthcare Organisationmentioning

confidence: 99%

“…Unfortunately, this care is frequently a neglected part of healthcare. The basic, life-saving clinical processes may be overlooked in specialised care [12] and in settings of both high [13][14][15] and low resources [16][17][18]. In hospitals all over the world, guidelines, equipment, and routines focusing on the care of critically ill patients, are often missing for adult [19] and paediatric patients [11], in emergency units [20], in wards [21] and in intensive care units [22].…”

Section: Introductionmentioning

confidence: 99%

Essential Emergency and Critical Care – a consensus among global clinical experts

Schell

Khalid

Wharton-Smith

et al. 2021

Preprint

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Background Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients can be overlooked in health systems. Essential and Emergency Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low-cost and low-complexity for the identification and timely treatment of critically ill patients across all medical specialities. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. Methods A Delphi process was conducted to seek consensus (>90% agreement) among a diverse panel of global clinical experts. The panel was asked to iteratively rate proposed treatments and actions based on previous guidelines and the WHO Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent, user-friendly, and feasible EECC package of clinical processes plus a list of hospital resource requirements. Results The 272 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 hospital readiness requirements. The essential diagnosis-specific care of critically ill COVID-19 patients has an additional 7 clinical processes and 9 hospital readiness requirements. Conclusion The study has specified the content of the essential emergency and critical care that should be provided to all critically ill patients. Implementation of EECC could be an effective strategy to reduce preventable deaths worldwide. As critically ill patients have high mortality rates in all hospital settings, especially where trained staff or resources are limited, even small improvements would have a large impact on survival. EECC has a vital role in the effective scale-up of oxygen and other care for critically ill patients in the COVID-19 pandemic. Policy makers should prioritise EECC, increase its coverage in hospitals, and include EECC as a component of universal health coverage.

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Unmet need of essential treatments for critical illness in Malawi

Cited by 7 publications

References 14 publications

Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria

Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria

Measuring Oxygen Access: lessons from health facility assessments in Nigeria

Essential Emergency and Critical Care – a consensus among global clinical experts

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