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Onyango OO, Willows TM, McKnight J, Schell CO, Baker T, Mkumbo E, Maiba J, Khalid K, English M, Oliwa JN. Third delay in care of critically ill patients: a qualitative investigation of public hospitals in Kenya. BMJ Open 2024; 14:e072341. [PMID: 38176878 PMCID: PMC10773318 DOI: 10.1136/bmjopen-2023-072341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVES Third delay refers to delays in delivering requisite care to patients after they arrive at a health facility. In low-resource care settings, effective triage and flow of care are difficult to guarantee. In this study, we aimed to identify delays in the delivery of care to critically ill patients and possible ways to address these delays. DESIGN This was an exploratory qualitative study using in-depth interviews and patient journeys. The qualitative data were transcribed and aggregated into themes in NVivo V.12 Plus using inductive and deductive approaches. SETTING This study was conducted in four secondary-level public Kenyan hospitals across four counties between March and December 2021. The selected hospitals were part of the Clinical Information Network. PARTICIPANTS Purposive sampling method was used to identify administrative and front-line healthcare providers and patients. We conducted 12 in-depth interviews with 11 healthcare workers and patient journeys of 7 patients. Informed consent was sought from the participants and maintained throughout the study. RESULTS We identified a cycle of suboptimal systems for care with adaptive mechanisms that prevent quality care to critically ill patients. We identified suboptimal systems for identification of critical illness, inadequate resources for continuity care and disruption of the flow of care, as the major causes of delays in identification and the initiation of essential care to critically ill patients. Our study also illuminated the contribution of inflexible bureaucratic non-clinical business-related organisational processes to third delay. CONCLUSION Eliminating or reducing delays after patients arrive at the hospital is a time-sensitive measure that could improve the care outcomes of critically ill patients. This is achievable through an essential emergency and critical care package within the hospitals. Our findings can help emphasise the need for standardised effective and reliable care priorities to maintain of care of critically ill patients.
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Affiliation(s)
| | - Tamara M Willows
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacob McKnight
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Muhimbili, Tanzania, United Republic Of
| | - Elibariki Mkumbo
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
| | - John Maiba
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
| | - Karima Khalid
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Department of Anaesthesia and Critical Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Mike English
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacquie N Oliwa
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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McKnight J, Willows TM, Oliwa J, Onyango O, Mkumbo E, Maiba J, Khalid K, Schell CO, Baker T, English M. Receive, Sustain, and Flow: A simple heuristic for facilitating the identification and treatment of critically ill patients during their hospital journeys. J Glob Health 2023; 13:04139. [PMID: 38131357 PMCID: PMC10740342 DOI: 10.7189/jogh.13.04139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background Hospital patients can become critically ill anywhere in a hospital but their survival is affected by problems of identification and adequate, timely, treatment. This is issue of particular concern in lower middle-income countries' (LMICs) hospitals where specialised units are scarce and severely under-resourced. "Cross-sectional" approaches to improving narrow, specific aspects of care will not attend to issues that affect patients' care across the length of their experience. A simpler approach to understanding key issues across the "hospital journey" could help to deliver life-saving treatments to those patients who need it, wherever they are in the facility. Methods We carried out 31 narrative interviews with frontline health workers in five Kenyan and five Tanzanian hospitals from November 2020 to December 2021 during the COVID-19 pandemic and analysed using a thematic analysis approach. We also followed 12 patient hospital journeys, through the course of treatment of very sick patients admitted to the hospitals we studied. Results Our research explores gaps in hospital systems that result in lapses in effective, continuous care across the hospital journeys of patients in Tanzania and Kenya. We organise these factors according to the Systems Engineering Initiative for Patient Safety (SEIPS) approach to patient safety, which we extend to explore how these issues affect patients across the course of care. We discern three repeating, recursive phases we term Receive, Sustain, and Flow. We use this heuristic to show how gaps and weaknesses in service provision affect critically ill patients' hospital journeys. Conclusion Receive, Sustain, and Flow offers a heuristic for hospital management to identify and ameliorate limitations in human and technical resources for the care of the critically ill.
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Affiliation(s)
- Jacob McKnight
- Health Systems Collaborative, University of Oxford, Oxford, England, UK
| | | | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya
| | - Onesmus Onyango
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Elibariki Mkumbo
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - John Maiba
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Karima Khalid
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
- Department of Anaesthesia, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Mike English
- Health Systems Collaborative, University of Oxford, Oxford, England, UK
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Elvidge J, Hopkin G, Narayanan N, Nicholls D, Dawoud D. Diagnostics and treatments of COVID-19: two-year update to a living systematic review of economic evaluations. Front Pharmacol 2023; 14:1291164. [PMID: 38035028 PMCID: PMC10687367 DOI: 10.3389/fphar.2023.1291164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives: As the initial crisis of the COVID-19 pandemic recedes, healthcare decision makers are likely to want to make rational evidence-guided choices between the many interventions now available. We sought to update a systematic review to provide an up-to-date summary of the cost-effectiveness evidence regarding tests for SARS-CoV-2 and treatments for COVID-19. Methods: Key databases, including MEDLINE, EconLit and Embase, were searched on 3 July 2023, 2 years on from the first iteration of this review in July 2021. We also examined health technology assessment (HTA) reports and the citations of included studies and reviews. Peer-reviewed studies reporting full health economic evaluations of tests or treatments in English were included. Studies were quality assessed using an established checklist, and those with very serious limitations were excluded. Data from included studies were extracted into predefined tables. Results: The database search identified 8,287 unique records, of which 54 full texts were reviewed, 28 proceeded for quality assessment, and 15 were included. Three further studies were included through HTA sources and citation checking. Of the 18 studies ultimately included, 17 evaluated treatments including corticosteroids, antivirals and immunotherapies. In most studies, the comparator was standard care. Two studies in lower-income settings evaluated the cost effectiveness of rapid antigen tests and critical care provision. There were 17 modelling analyses and 1 trial-based evaluation. Conclusion: A large number of economic evaluations of interventions for COVID-19 have been published since July 2021. Their findings can help decision makers to prioritise between competing interventions, such as the repurposed antivirals and immunotherapies now available to treat COVID-19. However, some evidence gaps remain present, including head-to-head analyses, disease-specific utility values, and consideration of different disease variants. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021272219], identifier [PROSPERO 2021 CRD42021272219].
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Affiliation(s)
- Jamie Elvidge
- Science, Evidence and Analytics Directorate, National Institute for Health and Care Excellence, Manchester, United Kingdom
| | - Gareth Hopkin
- Science, Evidence and Analytics Directorate, National Institute for Health and Care Excellence, Manchester, United Kingdom
| | - Nithin Narayanan
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - David Nicholls
- Science, Evidence and Analytics Directorate, National Institute for Health and Care Excellence, Manchester, United Kingdom
| | - Dalia Dawoud
- Science, Evidence and Analytics Directorate, National Institute for Health and Care Excellence, Manchester, United Kingdom
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English M, Oliwa J, Khalid K, Onyango O, Willows TM, Mazhar R, Mkumbo E, Guinness L, Schell CO, Baker T, McKnight J. Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic. BMJ Glob Health 2023; 8:e013407. [PMID: 37918869 PMCID: PMC10626868 DOI: 10.1136/bmjgh-2023-013407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023] Open
Abstract
Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.
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Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Onesmus Onyango
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Tamara Mulenga Willows
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rosanna Mazhar
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, London, UK
- Centre for Global Development, London, UK
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Karolinska Institute, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacob McKnight
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Owoo C, Adhikari NKJ, Akinola O, Aryal D, Azevedo LC, Bacha T, Baelani JI, Baker T, Bartlett E, Bonney J, Convocar P, Dippenaar E, Dunser MW, Estenssoro E, Fowler R, Gore S, Guddu DK, Hashmi M, Hollong BG, Kabongo D, Kivlehan SM, King LL, Losonczy L, Lundeg G, McCurdy MT, Mer M, Misango D, Moll V, Murthy S, Pattnaik R, Petros S, Riviello E, Schell CO, Shrestha GS, Sultan M, Tefera M, Yim A, Tadesse AZ. The World Health Assembly resolution on integrated emergency, critical, and operative care for universal health coverage and protection from health emergencies: a golden opportunity to attenuate the global burden of acute and critical illness. Intensive Care Med 2023; 49:1223-1225. [PMID: 37578521 PMCID: PMC10556161 DOI: 10.1007/s00134-023-07176-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023]
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