1
|
Nowadly CD, Portillo DJ, Davis ML, Hood RL, De Lorenzo RA. The Use of Portable Oxygen Concentrators in Low-Resource Settings: A Systematic Review. Prehosp Disaster Med 2022; 37:1-8. [PMID: 35232523 DOI: 10.1017/s1049023x22000310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Portable oxygen concentrators (POCs) are medical devices that use physical means to separate oxygen from the atmosphere to produce concentrated, medical-grade gas. Providing oxygen to low-resources environments, such as austere locations, military combat zones, rural Emergency Medical Services (EMS), and during disasters, becomes expensive and logistically intensive. Recent advances in separation technology have promoted the development of POC systems ruggedized for austere use. This review provides a comprehensive summary of the available data regarding POCs in these challenge environments. METHODS PubMed, Google Scholar, and the Defense Technical Information Center were searched from inception to November 2021. Articles addressing the use of POCs in low-resource settings were selected. Three authors were independently involved in the search, review, and synthesis of the articles. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. RESULTS The initial search identified 349 articles, of which 40 articles were included in the review. A total of 724 study subjects were associated with the included articles. There were no Level I systematic reviews or randomized controlled trials. DISCUSSION Generally, POCs are a low-cost, light-weight tool that may fill gaps in austere, military, veterinary, EMS, and disaster medicine. They are cost-effective in low-resource areas, such as rural and high-altitude hospitals in developing nations, despite relatively high capital costs associated with initial equipment purchase. Implementation of POC in low-resource locations is limited primarily on access to electricity but can otherwise operate for thousands of hours without maintenance. They provide a unique advantage in combat operations as there is no risk of explosive if oxygen tanks are struck by high-velocity projectiles. Despite their deployment throughout the battlespace, there were no manuscripts identified during the review involving the efficacy of POCs for combat casualties or clinical outcomes in combat. Veterinary medicine and animal studies have provided the most robust data on the physiological effectiveness of POCs. The success of POCs during the coronavirus disease 2019 (COVID-19) pandemic highlights the potential for POCs during future mass-casualty events. There is emerging technology available that combines a larger oxygen concentrator with a compressor system capable of refilling small oxygen cylinders, which could transform the delivery of oxygen in austere environments if ruggedized and miniaturized. Future clinical research is needed to quantify the clinical efficacy of POCs in low-resource settings.
Collapse
Affiliation(s)
- Craig D Nowadly
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TexasUSA
| | - Daniel J Portillo
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TexasUSA
| | - Maxwell L Davis
- Department of Respiratory Therapy, Keesler Air Force Base, Biloxi, Mississippi, USA
| | - R Lyle Hood
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TexasUSA
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TexasUSA
| | - Robert A De Lorenzo
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TexasUSA
| |
Collapse
|
2
|
Mir F, Ali Nathwani A, Chanar S, Hussain A, Rizvi A, Ahmed I, Memon ZA, Habib A, Soofi S, Bhutta ZA. Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial. BMJ Open 2021; 11:e046158. [PMID: 34535473 PMCID: PMC8451312 DOI: 10.1136/bmjopen-2020-046158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh. METHODS AND ANALYSIS A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study. ETHICS AND DISSEMINATION Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT03588377.
Collapse
Affiliation(s)
- Fatima Mir
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Apsara Ali Nathwani
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Suhail Chanar
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Amjad Hussain
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Imran Ahmed
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Zahid Ali Memon
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Atif Habib
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Sajid Soofi
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | | |
Collapse
|
3
|
Howie SR, Ebruke BE, Gil M, Bradley B, Nyassi E, Edmonds T, Boladuadua S, Rasili S, Rafai E, Mackenzie G, Cheng YL, Peel D, Vives-Tomas J, Zaman SM. The development and implementation of an oxygen treatment solution for health facilities in low and middle-income countries. J Glob Health 2021. [PMID: 33274064 PMCID: PMC7698571 DOI: 10.7189/jgh.10.020425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Oxygen reduces mortality from severe pneumonia and is a vital part of case management, but achieving reliable access to oxygen is challenging in low and middle-income country (LMIC) settings. We developed and field tested two oxygen supply solutions suitable for the realities of LMIC health facilities. Methods A Health Needs Assessment identified a technology gap preventing reliable oxygen supplies in Gambian hospitals. We used simultaneous engineering to develop two solutions: a Mains-Power Storage (Mains-PS) system consisting of an oxygen concentrator and batteries connected to mains power, and a Solar-Power Storage (Solar-PS) system (with batteries charged by photovoltaic panels) and evaluated them in health facilities in The Gambia and Fiji to assess reliability, usability and costs. Results The Mains-PS system delivered the specified ≥85% (±3%) oxygen concentration in 100% of 1-2 weekly measurements over 12 months, which was available to 100% of hypoxaemic patients, and 100% of users rated ease-of-use as at least ‘good’ (90% very good or excellent). The Solar-PS system delivered ≥85% ± 3%) oxygen concentration in 100% of 1-2 weekly measurements, was available to 100% of patients needing oxygen, and 100% of users rated ease-of-use at least very good. Costs for the systems (in US dollars) were: PS$9519, Solar-PS standard version $20 718. The of oxygen for a standardised 30-bed health facility using 1.7 million litres of oxygen per year was: for cylinders 3.2 cents (c)/L in The Gambia and 6.8 c/L in Fiji, for the PS system 1.2 c/L in both countries, and for the Solar-PS system 1.5 c/L in both countries. Conclusions The oxygen systems developed and tested delivered high-quality, reliable, cost-efficient oxygen in LMIC contexts, and were easy to operate. Reliable oxygen supplies are achievable in LMIC health facilities like those in The Gambia and Fiji.
Collapse
Affiliation(s)
- Stephen Rc Howie
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia.,Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| | - Bernard E Ebruke
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | | | | | - Ebrima Nyassi
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Timothy Edmonds
- Cure Kids New Zealand, Auckland, New Zealand.,Cure Kids Fiji, Suva, Fiji
| | | | | | - Eric Rafai
- Ministry of Health and Medical Services, Suva, Fiji
| | - Grant Mackenzie
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Basse, The Gambia.,Murdoch Children's Research Institute, Melbourne, Australia.,London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Joan Vives-Tomas
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Syed Ma Zaman
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia.,Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
4
|
McAllister S, Thorn L, Boladuadua S, Gil M, Audas R, Edmonds T, Rafai E, Hill PC, Howie SRC. Cost analysis and critical success factors of the use of oxygen concentrators versus cylinders in sub-divisional hospitals in Fiji. BMC Health Serv Res 2021; 21:636. [PMID: 34215232 PMCID: PMC8249838 DOI: 10.1186/s12913-021-06687-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/23/2021] [Indexed: 12/23/2022] Open
Abstract
Background Oxygen is vital in the treatment of illnesses in children and adults, yet is lacking in many low and middle-income countries health care settings. Oxygen concentrators (OCs) can increase access to oxygen, compared to conventional oxygen cylinders. We investigated the costs and critical success factors of OCs in three hospitals in Fiji, and extrapolated these to estimate the oxygen delivery cost to all Sub-Divisional hospitals (SDH) nationwide. Methods Data sources included key personnel interviews, and data from SDH records, Ministry of Health and Medical Services, and a non-governmental organisation. We used Investment Logic Mapping (ILM) to define key issues. An economic case was developed to identify the investment option that optimised value while incorporating critical success factors identified through ILM. A fit-for-purpose analysis was conducted using cost analysis of four short-listed options. Sensitivity analyses were performed by altering variables to show the best or worst case scenario. All costs are presented in Fijian dollars. Results Critical success factors identifed included oxygen availability, safety, ease of use, feasibility, and affordability. Compared to the status quo of having only oxygen cylinders, an option of having a minimum number of concentrators with cylinder backup would cost $434,032 (range: $327,940 to $506,920) over 5 years which would be 55% (range: 41 to 64%) of the status quo cost. Conclusion Introducing OCs into all SDHs in Fiji would reduce overall costs, while ensuring identified critical success factors are maintained. This study provides evidence for the benefits of OCs in this and similar settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06687-8.
Collapse
Affiliation(s)
- Susan McAllister
- Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand.
| | - Louise Thorn
- Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Sainimere Boladuadua
- Cure Kids Fiji, Suva, Fiji.,Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| | | | - Rick Audas
- Faculty of Medicine, Memorial University of Newfoundland, St John's, Canada
| | | | - Eric Rafai
- Ministry of Health and Medical Services, Suva, Fiji
| | - Philip C Hill
- Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Stephen R C Howie
- Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| |
Collapse
|
5
|
Howie SRC, Ebruke BE, Gil M, Bradley B, Nyassi E, Edmonds T, Boladuadua S, Rasili S, Rafai E, Mackenzie G, Cheng YL, Peel D, Vives-Tomas J, Zaman SMA. The development and implementation of an oxygen treatment solution for health facilities in low and middle-income countries. J Glob Health 2020; 10:020425. [DOI: 10.7189/jogh.10.020425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
6
|
Dauncey JW, Olupot-Olupot P, Maitland K. Healthcare-provider perceptions of barriers to oxygen therapy for paediatric patients in three government-funded eastern Ugandan hospitals; a qualitative study. BMC Health Serv Res 2019; 19:335. [PMID: 31126269 PMCID: PMC6534847 DOI: 10.1186/s12913-019-4129-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 04/29/2019] [Indexed: 11/17/2022] Open
Abstract
Background This study aimed to assess on-the-ground barriers to the provision of oxygen therapy for paediatric patients in three government-funded Eastern Ugandan district general hospitals (DGHs). Methods Site visits to DGHs during March 2017 involved semi-structured interviews with medical officers, clinical officers, paediatric nurses and non-clinical staff (n = 29). MAXQDA qualitative data software was used to assist with response analysis. Results The healthcare professionals reported that erratic electricity supplies, few and/or malfunctioning oxygen cylinders and concentrators, limited or no access to pulse oximetry, inadequate staffing and lack of continued professional training were key barriers to the delivery of oxygen therapy. Local populations were reportedly fearful of oxygen therapy and reluctant to consent for oxygen therapy to be administered to their children. Conclusion According to healthcare providers in three Eastern Ugandan DGHs, numerous barriers exist to oxygen therapy for paediatric patients. Healthcare professionals reported lack of facilities and training to effectively deliver oxygen therapy. Quality improvement work prioritising oxygen therapy in government-funded district general hospitals should focus on oxygen supply and delivery issues on a site-specific level and sensitizing communities to the potential benefits of oxygen.
Collapse
Affiliation(s)
- Jonathan W Dauncey
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.
| | - Peter Olupot-Olupot
- Department of Paediatrics, Mbale Regional Referral Hospital, Pallisa Road, PO Box 291, Mbale, Uganda.,Mbale Clinical Research Institute (MCRI), Plot 29-33 Pallisa Rd, P.O. Box 1966, Mbale, Uganda
| | - Kathryn Maitland
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,Mbale Clinical Research Institute (MCRI), Plot 29-33 Pallisa Rd, P.O. Box 1966, Mbale, Uganda.,KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, PO Box 230, Kilifi, Kenya
| |
Collapse
|
7
|
Calderon R, Morgan MC, Kuiper M, Nambuya H, Wangwe N, Somoskovi A, Lieberman D. Assessment of a storage system to deliver uninterrupted therapeutic oxygen during power outages in resource-limited settings. PLoS One 2019; 14:e0211027. [PMID: 30726247 PMCID: PMC6364892 DOI: 10.1371/journal.pone.0211027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 01/07/2019] [Indexed: 11/19/2022] Open
Abstract
Access to therapeutic oxygen remains a challenge in the effort to reduce pneumonia mortality among children in low- and middle-income countries. The use of oxygen concentrators is common, but their effectiveness in delivering uninterrupted oxygen is gated by reliability of the power grid. Often cylinders are employed to provide continuous coverage, but these can present other logistical challenges. In this study, we examined the use of a novel, low-pressure oxygen storage system to capture excess oxygen from a concentrator to be delivered to patients during an outage. A prototype was built and tested in a non-clinical trial in Jinja, Uganda. The trial was carried out at Jinja Regional Referral Hospital over a 75-day period. The flow rate of the unit was adjusted once per week between 0.5 and 5 liters per minute. Over the trial period, 1284 power failure episodes with a mean duration of 3.1 minutes (range 0.08 to 1720 minutes) were recorded. The low-pressure system was able to deliver oxygen over 56% of the 4,295 power outage minutes and cover over 99% of power outage events over the course of the study. These results demonstrate the technical feasibility of a method to extend oxygen availability and provide a basis for clinical trials.
Collapse
Affiliation(s)
- Ryan Calderon
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Melissa C. Morgan
- Department of Pediatrics, University of California San Francisco, San Francisco, California, United States of America
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- Maternal, Adolescent, Reproductive, and Child Health Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mark Kuiper
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Harriet Nambuya
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Nicholas Wangwe
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Akos Somoskovi
- Intellectual Ventures Global Good Fund, Bellevue, Washington, United States of America
| | - Daniel Lieberman
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
- * E-mail:
| |
Collapse
|
8
|
Duke T, Hwaihwanje I, Kaupa M, Karubi J, Panauwe D, Sa'avu M, Pulsan F, Prasad P, Maru F, Tenambo H, Kwaramb A, Neal E, Graham H, Izadnegahdar R. Solar powered oxygen systems in remote health centers in Papua New Guinea: a large scale implementation effectiveness trial. J Glob Health 2018; 7:010411. [PMID: 28567280 PMCID: PMC5441450 DOI: 10.7189/jogh.07.010411] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pneumonia is the largest cause of child deaths in Papua New Guinea (PNG), and hypoxaemia is the major complication causing death in childhood pneumonia, and hypoxaemia is a major factor in deaths from many other common conditions, including bronchiolitis, asthma, sepsis, malaria, trauma, perinatal problems, and obstetric emergencies. A reliable source of oxygen therapy can reduce mortality from pneumonia by up to 35%. However, in low and middle income countries throughout the world, improved oxygen systems have not been implemented at large scale in remote, difficult to access health care settings, and oxygen is often unavailable at smaller rural hospitals or district health centers which serve as the first point of referral for childhood illnesses. These hospitals are hampered by lack of reliable power, staff training and other basic services. METHODS We report the methodology of a large implementation effectiveness trial involving sustainable and renewable oxygen and power systems in 36 health facilities in remote rural areas of PNG. The methodology is a before-and after evaluation involving continuous quality improvement, and a health systems approach. We describe this model of implementation as the considerations and steps involved have wider implications in health systems in other countries. RESULTS The implementation steps include: defining the criteria for where such an intervention is appropriate, assessment of power supplies and power requirements, the optimal design of a solar power system, specifications for oxygen concentrators and other oxygen equipment that will function in remote environments, installation logistics in remote settings, the role of oxygen analyzers in monitoring oxygen concentrator performance, the engineering capacity required to sustain a program at scale, clinical guidelines and training on oxygen equipment and the treatment of children with severe respiratory infection and other critical illnesses, program costs, and measurement of processes and outcomes to support continuous quality improvement. CONCLUSIONS This study will evaluate the feasibility and sustainability issues in improving oxygen systems and providing reliable power on a large scale in remote rural settings in PNG, and the impact of this on child mortality from pneumonia over 3 years post-intervention. Taking a continuous quality improvement approach can be transformational for remote health services.
Collapse
Affiliation(s)
- Trevor Duke
- Center for International Child Health, University of Melbourne and MCRI, Melbourne, Australia.,School of Medicine and Health Sciences, University of PNG, Taurama Campus, NCD, Papua New Guinea
| | - Ilomo Hwaihwanje
- Goroka General Hospital, Eastern Highlands Province, Goroka, Papua New Guinea
| | - Magdalynn Kaupa
- Mt Hagen General Hospital, Western Highlands, Mount Hagen, Papua New Guinea
| | - Jonah Karubi
- Mt Hagen General Hospital, Western Highlands, Mount Hagen, Papua New Guinea
| | | | - Martin Sa'avu
- Mendi Hospital, Southern Highlands Province, Mendi, Papua New Guinea
| | - Francis Pulsan
- School of Medicine and Health Sciences, University of PNG, Taurama Campus, NCD, Papua New Guinea
| | | | - Freddy Maru
- AusTrade Pacific, Port Moresby, Papua New Guinea
| | - Henry Tenambo
- Health Facilities Branch, National Department of Health, Papua New Guinea
| | - Ambrose Kwaramb
- Health Facilities Branch, National Department of Health, Papua New Guinea
| | - Eleanor Neal
- Center for International Child Health, University of Melbourne and MCRI, Melbourne, Australia
| | - Hamish Graham
- Center for International Child Health, University of Melbourne and MCRI, Melbourne, Australia
| | | |
Collapse
|
9
|
Bradley BD, Light JD, Ebonyi AO, N'Jai PC, Ideh RC, Ebruke BE, Nyassi E, Peel D, Howie SRC. Implementation and 8-year follow-up of an uninterrupted oxygen supply system in a hospital in The Gambia. Int J Tuberc Lung Dis 2018; 20:1130-4. [PMID: 27393551 PMCID: PMC4937752 DOI: 10.5588/ijtld.15.0889] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
SETTING: A 42-bed hospital operated by the Medical Research Council (MRC) Unit in The Gambia. OBJECTIVE: To devise, test and evaluate a cost-efficient uninterrupted oxygen system in the MRC Hospital. DESIGN: Oxygen cylinders were replaced with oxygen concentrators as the primary source of oxygen. An uninterruptable power supply (UPS) ensured continuity of power. Hospital staff were trained on the use of the new system. Eight years post-installation, an analysis of concentrator maintenance needs and costs was conducted and user feedback obtained to assess the success of the system. RESULTS: The new system saved at least 51% of oxygen supply costs compared to cylinders, with savings likely to have been far greater due to cylinder leakages. Users indicated that the system is easier to use and more reliable, although technical support and staff training are still needed. CONCLUSION: Oxygen concentrators offer long-term cost savings and an improved user experience compared to cylinders; however, some technical support and maintenance are needed to upkeep the system. A UPS dedicated to oxygen concentrators is an appropriate solution for settings where power interruptions are frequent but short in duration. This approach can be a model for health systems in settings with similar infrastructure.
Collapse
Affiliation(s)
- B D Bradley
- Centre for Global Engineering and Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada
| | - J D Light
- Engineering Science, University of Toronto, Toronto, Ontario, Canada
| | - A O Ebonyi
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - P C N'Jai
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - R C Ideh
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - B E Ebruke
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - E Nyassi
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - D Peel
- Ashdown Consultants, Hartfield, UK
| | - S R C Howie
- Centre for Global Engineering and Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada; Medical Research Council Unit The Gambia, Fajara, The Gambia, Department of Paediatrics, University of Auckland, Auckland, Centre for International Health, University of Otago, Dunedin, New Zealand
| |
Collapse
|
10
|
Graham HR, Ayede AI, Bakare AA, Oyewole OB, Peel D, Gray A, McPake B, Neal E, Qazi S, Izadnegahdar R, Falade AG, Duke T. Improving oxygen therapy for children and neonates in secondary hospitals in Nigeria: study protocol for a stepped-wedge cluster randomised trial. Trials 2017; 18:502. [PMID: 29078810 PMCID: PMC5659007 DOI: 10.1186/s13063-017-2241-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 10/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxygen is a life-saving, essential medicine that is important for the treatment of many common childhood conditions. Improved oxygen systems can reduce childhood pneumonia mortality substantially. However, providing oxygen to children is challenging, especially in small hospitals with weak infrastructure and low human resource capacity. METHODS/DESIGN This trial will evaluate the implementation of improved oxygen systems at secondary-level hospitals in southwest Nigeria. The improved oxygen system includes: a standardised equipment package; training of clinical and technical staff; infrastructure support (including improved power supply); and quality improvement activities such as supportive supervision. Phase 1 will involve the introduction of pulse oximetry alone; phase 2 will involve the introduction of the full, improved oxygen system package. We have based the intervention design on a theory-based analysis of previous oxygen projects, and used quality improvement principles, evidence-based teaching methods, and behaviour-change strategies. We are using a stepped-wedge cluster randomised design with participating hospitals randomised to receive an improved oxygen system at 4-month steps (three hospitals per step). Our mixed-methods evaluation will evaluate effectiveness, impact, sustainability, process and fidelity. Our primary outcome measures are childhood pneumonia case fatality rate and inpatient neonatal mortality rate. Secondary outcome measures include a range of clinical, quality of care, technical, and health systems outcomes. The planned study duration is from 2015 to 2018. DISCUSSION Our study will provide quality evidence on the effectiveness of improved oxygen systems, and how to better implement and scale-up oxygen systems in resource-limited settings. Our results should have important implications for policy-makers, hospital administrators, and child health organisations in Africa and globally. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12617000341325 . Retrospectively registered on 6 March 2017.
Collapse
Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Department of Paediatrics, University College Hospital, Ibadan, Nigeria.
| | - Adejumoke I Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Oladapo B Oyewole
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Eleanor Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Shamim Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
| |
Collapse
|
11
|
Graham H, Tosif S, Gray A, Qazi S, Campbell H, Peel D, McPake B, Duke T. Providing oxygen to children in hospitals: a realist review. Bull World Health Organ 2017; 95:288-302. [PMID: 28479624 PMCID: PMC5407252 DOI: 10.2471/blt.16.186676] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To identify and describe interventions to improve oxygen therapy in hospitals in low-resource settings, and to determine the factors that contribute to success and failure in different contexts. METHODS Using realist review methods, we scanned the literature and contacted experts in the field to identify possible mechanistic theories of how interventions to improve oxygen therapy systems might work. Then we systematically searched online databases for evaluations of improved oxygen systems in hospitals in low- or middle-income countries. We extracted data on the effectiveness, processes and underlying theory of selected projects, and used these data to test the candidate theories and identify the features of successful projects. FINDINGS We included 20 improved oxygen therapy projects (45 papers) from 15 countries. These used various approaches to improving oxygen therapy, and reported clinical, quality of care and technical outcomes. Four effectiveness studies demonstrated positive clinical outcomes for childhood pneumonia, with large variation between programmes and hospitals. We identified factors that help or hinder success, and proposed a practical framework depicting the key requirements for hospitals to effectively provide oxygen therapy to children. To improve clinical outcomes, oxygen improvement programmes must achieve good access to oxygen and good use of oxygen, which should be facilitated by a broad quality improvement capacity, by a strong managerial and policy support and multidisciplinary teamwork. CONCLUSION Our findings can inform practitioners and policy-makers about how to improve oxygen therapy in low-resource settings, and may be relevant for other interventions involving the introduction of health technologies.
Collapse
Affiliation(s)
- Hamish Graham
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Shidan Tosif
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Amy Gray
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Shamim Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Harry Campbell
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland
| | | | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Trevor Duke
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| |
Collapse
|
12
|
Nyende S, Conroy A, Opoka RO, Namasopo S, Kain KC, Mpimbaza A, Bhargava R, Hawkes M. Solar-powered oxygen delivery: study protocol for a randomized controlled trial. Trials 2015; 16:297. [PMID: 26156116 PMCID: PMC4496955 DOI: 10.1186/s13063-015-0814-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 06/22/2015] [Indexed: 12/16/2022] Open
Abstract
Background Pneumonia is a leading cause of childhood mortality globally. Oxygen therapy improves survival in children with pneumonia, yet its availability remains limited in many resource-constrained settings where most deaths occur. Solar-powered oxygen delivery could be a sustainable method to improve oxygen delivery in remote areas with restricted access to a supply chain of compressed oxygen cylinders and reliable electrical power. Methods/Design This study is a randomized controlled trial (RCT). Solar-powered oxygen delivery systems will be compared to a conventional method (oxygen from cylinders) in patients with hypoxemic respiratory illness. Enrollment will occur at two sites in Uganda: Jinja Regional Referral Hospital and Kambuga District Hospital. The primary outcome will be the length of hospital stay. Secondary study endpoints will be mortality, duration of supplemental oxygen therapy (time to wean oxygen), proportion of patients successfully oxygenated, delivery system failure, cost, system maintenance and convenience. Discussion The RCT will provide useful data on the feasibility and noninferiority of solar-powered oxygen delivery. This technological innovation uses freely available inputs, the sun and the air, to oxygenate children with pneumonia, and can be applied “off the grid” in remote and/or resource-constrained settings where most pneumonia deaths occur. If proven successful, solar-powered oxygen delivery systems could be scaled up and widely implemented for impact on global child mortality. Trial registration Clinicaltrials.gov registration number NCT0210086 (date of registration: 27 March, 2014)
Collapse
Affiliation(s)
- Saleh Nyende
- Department of Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda.
| | - Andrea Conroy
- Department of Medicine, University of Toronto, Toronto, Canada.
| | - Robert Opika Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda.
| | - Sophie Namasopo
- Department of Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda.
| | - Kevin C Kain
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda. .,Institute of Medical Sciences, University of Toronto, Toronto, Canada. .,Sandra A. Rotman Laboratories, McLaughlin-Rotman Centre for Global Health, Toronto, Canada. .,McLaughlin Centre for Molecular Medicine, Toronto, Canada. .,Tropical Disease Unit, Toronto General Hospital, Toronto, Canada.
| | | | - Ravi Bhargava
- Department of Diagnostic Imaging, University of Alberta, Edmonton, Canada.
| | - Michael Hawkes
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, Canada.
| |
Collapse
|
13
|
Bradley BD, Chow S, Nyassi E, Cheng YL, Peel D, Howie SRC. A retrospective analysis of oxygen concentrator maintenance needs and costs in a low-resource setting: experience from The Gambia. HEALTH AND TECHNOLOGY 2015. [DOI: 10.1007/s12553-015-0094-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
14
|
|
15
|
Duke T, Peel D, Graham S, Howie S, Enarson PM, Jacobson R. Oxygen concentrators: a practical guide for clinicians and technicians in developing countries. ACTA ACUST UNITED AC 2013; 30:87-101. [DOI: 10.1179/146532810x12637745452356] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
16
|
Catto AG, Zgaga L, Theodoratou E, Huda T, Nair H, Arifeen SE, Rudan I, Duke T, Campbell H. An evaluation of oxygen systems for treatment of childhood pneumonia. BMC Public Health 2011; 11 Suppl 3:S28. [PMID: 21501446 PMCID: PMC3231901 DOI: 10.1186/1471-2458-11-s3-s28] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Oxygen therapy is recommended for all of the 1.5 - 2.7 million young children who consult health services with hypoxemic pneumonia each year, and the many more with other serious conditions. However, oxygen supplies are intermittent throughout the developing world. Although oxygen is well established as a treatment for hypoxemic pneumonia, quantitative evidence for its effect is lacking. This review aims to assess the utility of oxygen systems as a method for reducing childhood mortality from pneumonia. METHODS Aiming to improve priority setting methods, The Child Health and Nutrition Research Initiative (CHNRI) has developed a common framework to score competing interventions into child health. That framework involves the assessment of 12 different criteria upon which interventions can be compared. This report follows the proposed framework, using a semi-systematic literature review and the results of a structured exercise gathering opinion from experts (leading basic scientists, international public health researchers, international policy makers and representatives of pharmaceutical companies), to assess and score each criterion as their "collective optimism" towards each, on a scale from 0 to 100%. RESULTS A rough estimate from an analysis of the literature suggests that global strengthening of oxygen systems could save lives of up to 122,000 children from pneumonia annually. Following 12 CHNRI criteria, the experts expressed very high levels of optimism (over 80%) for answerability, low development cost and low product cost; high levels of optimism (60-80%) for low implementation cost, likelihood of efficacy, deliverability, acceptance to end users and health workers; and moderate levels of optimism (40-60%) for impact on equity, affordability and sustainability. The median estimate of potential effectiveness of oxygen systems to reduce the overall childhood pneumonia mortality was ~20% (interquartile range: 10-35%, min. 0%, max. 50%). However, problems with oxygen systems in terms of affordability, sustainability and impact on equity are noted in both expert opinion scores and on review. CONCLUSION Oxygen systems are likely to be an effective intervention in combating childhood mortality from pneumonia. However, a number of gaps in the evidence base exist that should be addressed to complete the investment case and research addressing these issues merit greater funding attention.
Collapse
Affiliation(s)
- Alastair G Catto
- Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
| | - Lina Zgaga
- Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
| | - Evropi Theodoratou
- Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
| | - Tanvir Huda
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Harish Nair
- Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
- Public Health Foundation of India, New Delhi, India
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Igor Rudan
- Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
- Croatian Centre for Global Health, University of Split Medical School, Split, Croatia
| | - Trevor Duke
- Centre for International Child Health, Melbourne University Department of Paediatrics, Royal Children's Hospital, Parkville, 3052, Victoria, Australia
| | - Harry Campbell
- Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
| |
Collapse
|
17
|
Howie SRC, Hill S, Ebonyi A, Krishnan G, Njie O, Sanneh M, Jallow M, Stevens W, Taylor K, Weber MW, Njai PC, Tapgun M, Corrah T, Mulholland K, Peel D, Njie M, Hill PC, Adegbola RA. Meeting oxygen needs in Africa: an options analysis from the Gambia. Bull World Health Organ 2011; 87:763-71. [PMID: 19876543 DOI: 10.2471/blt.08.058370] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Accepted: 04/06/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare oxygen supply options for health facilities in the Gambia and develop a decision-making algorithm for choosing oxygen delivery systems in Africa and the rest of the developing world. METHODS Oxygen cylinders and concentrators were compared in terms of functionality and cost. Interviews with key informants using locally developed and adapted WHO instruments, operational assessments, cost-modelling and cost measurements were undertaken to determine whether oxygen cylinders or concentrators were the better choice. An algorithm and a software tool to guide the choice of oxygen delivery system were constructed. FINDINGS In the Gambia, oxygen concentrators have significant advantages compared to cylinders where power is reliable; in other settings, cylinders are preferable as long as transporting them is feasible. Cylinder costs are greatly influenced by leakage, which is common, whereas concentrator costs are affected by the cost of power far more than by capital costs. Only two of 12 facilities in the Gambia were found suitable for concentrators; at the remaining 10 facilities, cylinders were the better option. CONCLUSION Neither concentrators nor cylinders are well suited to every situation, but a simple options assessment can determine which is better in each setting. Nationally this would result in improved supply and lower costs by comparison with conventional cylinders alone, although ensuring a reliable supply would remain a challenge. The decision algorithm and software tool designed for the Gambia could be applied in other developing countries.
Collapse
Affiliation(s)
- Stephen R C Howie
- Bacterial Diseases Programme, Medical Research Council Laboratories, Banjul, Gambia.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Foran M, Ahn R, Novik J, Tyer-Viola L, Chilufya K, Katamba K, Burke T. Prevalence of undiagnosed hypoxemia in adults and children in an under-resourced district hospital in Zambia. Int J Emerg Med 2010; 3:351-6. [PMID: 21373304 PMCID: PMC3047821 DOI: 10.1007/s12245-010-0241-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 09/06/2010] [Indexed: 11/30/2022] Open
Abstract
Background In adequately resourced clinical environments, diagnosis of hypoxemia via pulse oximetry is routine. Unfortunately, pulse oximetry is rarely utilized in under-resourced hospitals in developing countries. Aim The prevalence of undiagnosed hypoxemia among adults and children with illnesses other than pneumonia in these environments remains poorly described. Methods This cross-sectional analysis of the prevalence of hypoxemia was conducted in Kapiri Mposhi, Zambia, at the 60-bed District Hospital, which serves a population of 320,000. The resting room air oxygen saturations of two consecutive samples of all adult and pediatric inpatients were measured in December 2008 and March 2009 using handheld pulse oximetry. Hypoxemia was defined as resting room air SpO2 less than 90%. Results A total of 192 patients were enrolled: 68 young children (<5 years old), 15 older children (5–17 years old), and 109 adults (≥18 years old). Five young children (7%), 0 older children (0%), and 10 adults (9%) were hypoxemic. No hypoxemic patients were receiving oxygen therapy at the time of diagnosis. Pneumonia, tuberculosis, and malnutrition were the most common conditions among those with hypoxemia. Oximetry data changed clinical management in all observed cases of hypoxemia and several cases of normoxemia, leading to application of supplemental oxygen, initiation of further diagnostic testing, prolongation of inpatient stay, or expedited discharge home. Conclusions Undiagnosed hypoxemia is present among inpatients at this district hospital in rural Zambia with high prevalence in both adults and young children. These results support routine screening for hypoxemia in similar facilities in both age groups. Further investigation is warranted into the clinical impact and cost-effectiveness of pulse oximetry, provision of oxygen concentrators, and training on their use in developing countries.
Collapse
Affiliation(s)
- Mark Foran
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
- 5 Emerson Place, Suite 101, Boston, MA 02114 USA
| | - Roy Ahn
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph Novik
- Department of Emergency Medicine, Bellevue Hospital, New York University School of Medicine, New York, NY USA
| | - Lynda Tyer-Viola
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Kennedy Chilufya
- Kapiri District Hospital, Kapiri Mposhi, Central Province Zambia
| | - Kasseba Katamba
- Kapiri District Hospital, Kapiri Mposhi, Central Province Zambia
| | - Thomas Burke
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| |
Collapse
|
19
|
Ashraf H, Mahmud R, Alam NH, Jahan SA, Kamal SM, Haque F, Salam MA, Gyr N. Randomized controlled trial of day care versus hospital care of severe pneumonia in Bangladesh. Pediatrics 2010; 126:e807-15. [PMID: 20855397 DOI: 10.1542/peds.2009-3631] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE A randomized controlled trial compared day care versus hospital care management of pneumonia. METHODS Children 2 to 59 months of age with severe pneumonia received either day care, with antibiotic treatment, feeding, and supportive care from 8:00 am to 5:00 pm, or hospital care, with similar 24-hour treatment. RESULTS In 2006-2008, 360 children were assigned randomly to receive either day care or hospital care; 189 (53%) had hypoxemia, with a mean±SD oxygen saturation of 93±4%, which increased to 99±1% after oxygen therapy. The mean±SD durations of day care and hospital care were 7.1±2.3 and 6.5±2.8 days, respectively. Successful management was possible for 156 (87.7% [95% confidence interval [CI]: 80.9%-90.9%]) of 180 children in the day care group and 173 (96.1% [95% CI: 92.2%-98.1%]) of 180 children in the hospital care group (P=.001). Twenty-three children in the day care group (12.8% [95% CI: 8.7%-18.4%] and 4 children in the hospital care group (2.2% [95% CI: 0.9%-5.6%] required referral to hospitals (P<.001). During the follow-up period, 22 children in the day care group (14.1% [95% CI: 9.5%-20.4%]) and 11 children in the hospital care group (6.4% [95% CI: 3.6%-11%]) required readmission to hospitals (P=.01). The estimated costs per child treated successfully at the clinic and the hospital were US$114 and US$178, respectively. CONCLUSION Severe childhood pneumonia without severe malnutrition can be successfully managed at day care clinics, except for children with hypoxemia who require prolonged oxygen therapy.
Collapse
Affiliation(s)
- Hasan Ashraf
- International Centre for Diarrhoeal Disease Research, Bangladesh, Clinical Sciences Division, 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
|
21
|
The prevalence of hypoxaemia among ill children in developing countries: a systematic review. THE LANCET. INFECTIOUS DISEASES 2009; 9:219-27. [PMID: 19324294 DOI: 10.1016/s1473-3099(09)70071-4] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hypoxaemia is a common complication of childhood infections, particularly acute lower respiratory tract infections. In pneumonia-a disease that disproportionately impacts developing countries, and accounts for more than two million deaths of children worldwide-hypoxaemia is a recognised risk factor for death, and correlates with disease severity. Hypoxaemia also occurs in severe sepsis, meningitis, common neonatal problems, and other conditions that impair ventilation and gas exchange or increase oxygen demands. Despite this, hypoxaemia has been overlooked in worldwide strategies for pneumonia control and reducing child mortality. Hypoxaemia is also often overlooked in developing countries, mainly due to the low accuracy of clinical predictors and the limited availability of pulse oximetry for more accurate detection and oxygen for treatment. In this Review of published and unpublished studies of acute lower respiratory tract infection, the median prevalence of hypoxaemia in WHO-defined pneumonia requiring hospitalisation (severe and very severe classifications) was 13%, but prevalence varied widely. This corresponds to at least 1.5 to 2.7 million annual cases of hypoxaemic pneumonia presenting to health-care facilities. Many more people do not access health care. With mounting evidence of the impact that improved oxygen systems have on mortality due to acute respiratory infection in limited-resource health-care facilities, there is a need for increased awareness of the burden of hypoxaemia in childhood illness.
Collapse
|
22
|
Duke T, Wandi F, Jonathan M, Matai S, Kaupa M, Saavu M, Subhi R, Peel D. Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea. Lancet 2008; 372:1328-33. [PMID: 18708248 DOI: 10.1016/s0140-6736(08)61164-2] [Citation(s) in RCA: 188] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND In rural hospitals of developing countries, oxygen supplies are poor and detection of hypoxaemia is difficult. Oxygen concentrators and pulse oximeters might help to manage the disease; however, use of such technology in developing countries needs comprehensive assessment. We studied the effect of an improved oxygen system on death rate in children with pneumonia in Papua New Guinea. METHODS We installed an improved oxygen system in five hospitals in Papua New Guinea, and assessed its use in more than 11 000 children with pneumonia (2001-07) and compared case-fatality rates. Admissions between January, 2001, and December, 2004, formed the pre-intervention group, and those between July, 2005, and October, 2007, formed the post-intervention group. Oxygen concentrators and pulse oximeters were introduced in the five hospitals, and a protocol for detection of hypoxaemia and clinical use of oxygen was supplied. All children admitted had their oxygen saturation measured; if it was less than 90%, oxygen was delivered via nasal prongs at a starting flow rate of 0.5-1 L/min. We recorded all costs associated with the establishment and maintenance of this system. The study was approved by the Medical Research Advisory Committee of Papua New Guinea, number MRAC 04.02. FINDINGS Before the use of this system, 356 of 7161 children admitted in the five hospitals for pneumonia died (case-fatality rate 4.97% [95% CI 4.5-5.5]), whereas 133 of 4130 children died in the 27 months after the introduction of the system (3.22% [2.7-3.8]). After the improved system was introduced, the risk of death for a child with pneumonia was 35% lower than was that before the project began (risk ratio 0.65 [0.52-0.78], p<0.0001). Mortality rates varied between hospitals. The estimated costs of this system were US$51 per patient treated, US$1673 per life saved, and US$50 per disability-adjusted life-year (DALY) averted. INTERPRETATION Pulse oximetry and oxygen concentrators can alleviate oxygen shortages, reduce mortality, and improve quality of care for children with pneumonia in developing countries. The cost-effectiveness of this system compared favourably with that of other public-health interventions. FUNDING The Papua New Guinea National Department of Health; WHO, Papua New Guinea and Western Pacific Regional Office; AirSep corporation, Buffalo, NY, USA; the Ross Trust, VIC, Australia; AusAID; Jacques Gostelli, Switzerland; and a grant from the University of Melbourne.
Collapse
Affiliation(s)
- Trevor Duke
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia.
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Enarson P, La Vincente S, Gie R, Maganga E, Chokani C. Implementation of an oxygen concentrator system in district hospital paediatric wards throughout Malawi. Bull World Health Organ 2008; 86:344-8. [PMID: 18545736 DOI: 10.2471/blt.07.048017] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Accepted: 02/27/2008] [Indexed: 11/27/2022] Open
Abstract
PROBLEM Hypoxaemia in children with severe or very severe pneumonia is a reliable predictor of mortality, yet oxygen was not available in most paediatric wards in Malawi. APPROACH The Child Lung Health Programme in Malawi made oxygen available by supplying oxygen concentrators and essential supplies to 22 district and 3 regional hospitals' paediatric wards. Five key steps were taken to introduce concentrators: (1) develop a curriculum and training materials; (2) train staff on use and maintenance; (3) retrain electromedical departments on maintenance and repair; (4) conduct training once concentrators arrived in the country; and (5) distribute concentrators once staff had been trained. LOCAL SETTING The paediatric wards in 3 regional and 22 government district hospitals and 3 regional electromedical engineering departments in Malawi. RELEVANT CHANGES Main changes were: (1) provision of a source of oxygen in every paediatric ward in all district hospitals; (2) training of electrical engineering and health personnel in the use, maintenance and repair of oxygen concentrators; and (3) setting-up of high-dependency rooms or areas for severely ill children where oxygen is administered. LESSONS LEARNED It is feasible to implement an oxygen system using concentrators throughout a low-income country. Oxygen delivery requires trained staff with necessary equipment and supplies. Regular maintenance and supervision are essential to ensure optimal utilization.
Collapse
Affiliation(s)
- Penny Enarson
- International Union Against Tuberculosis and Lung Disease, Paris, France.
| | | | | | | | | |
Collapse
|
24
|
Graham SM, English M, Hazir T, Enarson P, Duke T. Challenges to improving case management of childhood pneumonia at health facilities in resource-limited settings. Bull World Health Organ 2008; 86:349-55. [PMID: 18545737 PMCID: PMC2647436 DOI: 10.2471/blt.07.048512] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Accepted: 02/01/2008] [Indexed: 11/27/2022] Open
Abstract
Effective case management is an important strategy to reduce pneumonia-related morbidity and mortality in children. Guidelines based on sound evidence are available but are used variably. This review outlines current guidelines for childhood pneumonia management in the setting where most child pneumonia deaths occur and identifies challenges for improved management in a variety of settings and different "at-risk" groups. These include appropriate choice of antibiotic, clinical overlap with other conditions, prompt and appropriate referral for inpatient care, and management of treatment failure. Management of neonates, and of HIV-infected or severely malnourished children is more complicated. The influence of co-morbidities on pneumonia outcome means that pneumonia case management must be integrated within strategies to improve overall paediatric care. The greatest potential for reducing pneumonia-related deaths in health facilities is wider implementation of the current guidelines built around a few core activities: training, antibiotics and oxygen. This requires investment in human resources and in equipment for the optimal management of hypoxaemia. It is important to provide data from a variety of epidemiological settings for formal cost-effectiveness analyses. Improvements in the quality of case management of pneumonia can be a vehicle for overall improvements in child health-care practices.
Collapse
Affiliation(s)
- Stephen M Graham
- Centre for International Child Health, University Department of Paediatrics, Royal Children's Hospital, Melbourne, Australia.
| | | | | | | | | |
Collapse
|
25
|
Matai S, Peel D, Wandi F, Jonathan M, Subhi R, Duke T. Implementing an oxygen programme in hospitals in Papua New Guinea. ACTA ACUST UNITED AC 2008; 28:71-8. [PMID: 18318953 DOI: 10.1179/146532808x270716] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
In Papua New Guinea (PNG), the most common cause of death among children under 5 years of age is pneumonia. Children with severe pneumonia need antibiotics and oxygen but oxygen shortages are common owing to the cost and complex logistics of transporting it in cylinders. Detection of hypoxaemia using clinical signs can be difficult, especially in highly pigmented children in whom cyanosis is difficult to recognise. Pulse oximetry is the most reliable, non-invasive way of detecting hypoxaemia. However, most hospitals in PNG do not have pulse oximetry. We proposed that the installation of a reliable, sufficient and cheap supply of oxygen in hospitals coupled with the use of pulse oximetry would make a significant difference to child survival rates in PNG. Oxygen concentrators, which extract oxygen from ambient air, were installed in the children's wards of five hospitals during 2005. Pulse oximeters were also introduced to enable better detection of hypoxaemia. This paper describes the technical aspects of this programme: the equipment used and the rationale behind choosing it, the installation, commissioning and testing processes. The ongoing training of clinical and engineering staff as well as two follow-up evaluations are described.
Collapse
Affiliation(s)
- Sens Matai
- National Department of Health, School of Medicine & Health Sciences, University of PNG, Papua New Guinea
| | | | | | | | | | | |
Collapse
|
26
|
Howie SRC, Hill SE, Peel D, Sanneh M, Njie M, Hill PC, Mulholland K, Adegbola RA. Beyond good intentions: lessons on equipment donation from an African hospital. Bull World Health Organ 2008; 86:52-6. [PMID: 18235890 DOI: 10.2471/blt.07.042994] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Accepted: 06/25/2007] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE In 2000, a referral hospital in the Gambia accepted a donation of oxygen concentrators to help maintain oxygen supplies. The concentrators broke down and were put into storage. A case study was done to find the reasons for the problem and to draw lessons to help improve both oxygen supplies and the success of future equipment donations. METHODS A technical assessment of the concentrators was carried out by a biomedical engineer with relevant expertise. Semi-structured interviews were undertaken with key informants, and content analysis and inductive approaches were applied to construct the history of the episode and the reasons for the failure. FINDINGS Interviews confirmed the importance of technical problems with the equipment. They also revealed that the donation process was flawed, and that the hospital did not have the expertise to assess or maintain the equipment. Technical assessment showed that all units had the wrong voltage and frequency, leading to overheating and breakdown. Subsequently a hospital donations committee was established to oversee the donations process. On-site biomedical engineering expertise was arranged with a nongovernmental organization (NGO) partner. CONCLUSION Appropriate donations of medical equipment, including oxygen concentrators, can be of benefit to hospitals in resource-poor settings, but recipients and donors need to actively manage donations to ensure that the donations are beneficial. Success requires planning, technical expertise and local participation. Partners with relevant skills and resources may also be needed. In 2002, WHO produced guidelines for medical equipment donations, which address problems that might be encountered. These guidelines should be publicized and used.
Collapse
Affiliation(s)
- Stephen R C Howie
- Bacterial Diseases Programme, Medical Research Council Laboratories, Banjul, the Gambia.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
Approximately 20 years ago, the international community embarked on a project to bring health care to everyone by the year 2000 featuring, among other things, technologies that were known to be effective and economical. It was largely a failure. In fact, health care deteriorated in many of the target nations. Problems such as public mistrust, lack of spare parts, lack of required consumables, lack of reliable power and water, lack of public infrastructure such as roads, lack of technical expertise, and other problems plague health care technology in the developing world. Biomedical engineers are just beginning to quantify and address the barriers to technology unique to the developing world. This article reviews the barriers, both real and perceived, to the introduction of health care technology with a main focus on health care technology in hospitals.
Collapse
Affiliation(s)
- Robert A Malkin
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708, USA.
| |
Collapse
|
28
|
Abstract
A survey of the anaesthetic services in rural Tanzania was carried out in an area of 67500 km2 and population of 4 million in order to assess the quality of anaesthesia and the major obstacles to good practice. Lack of draw-over vaporizers, Ayre's T-pieces, and a supply of oxygen were found to be the major obstacles to safe practice in this area of Africa.
Collapse
Affiliation(s)
- E Kimaro
- Department of Anaesthesia, Bugando Medical Centre, Mwanza, Tanzania
| | | |
Collapse
|
29
|
|
30
|
Shankar KB, Moseley HS, Mushlin PS, Hallsworth RA, Fakoory M, Walrond ER. Anaesthesia in Barbados. Can J Anaesth 1997; 44:559-68. [PMID: 9161753 DOI: 10.1007/bf03011947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To describe the anaesthesia services in Barbados: to present the major challenges confronting the Anaesthesia Department of the government-owned Queen Elizabeth Hospital (QEH): and to describe the Department's approaches to optimise safety and cost-effectiveness of anaesthesia at QEH. SOURCE OF INFORMATION Authors (KBS, HSLM, RAH), who collectively provided more than 50 yr of anaesthesia at QEH; the Dean (ERW) of the University of West Indies Medical School (Barbados campus); archives of Barbados; and records of QEH. PRINCIPAL FINDINGS The government of Barbados provides modern health care services to all of its citizens, primarily at QEH. Barbados, however, has tight financial constraints, infrastructural limitations, and a bureaucratic administration that predispose QEH's Anaesthesia Department to unexpected depletions of drugs and disposable supplies, sporadic shortages of personnel and functioning equipment, and occasional quality assurance problems. To deal with such problems, the Anaesthesia Department has implemented several pro-active measures: establishing an audit system to prevent depletion of imported drugs and supplies: training local personnel to maintain equipment: purchasing an oxygen concentrator to reduce oxygen costs: decreasing nitrous oxide use (expensive in Barbados): and initiating its own quality and safety standards. CONCLUSION Continuous delivery of high quality, cost-effective anaesthesia care requires thoughtful planning by administrators and judicious resource allocations. Health care administrators and clinical departments need to work together closely to establish a framework that enables departments to play a major role in determining how the institution's limited financial resources are best allocated to meet the departmental priorities.
Collapse
Affiliation(s)
- K B Shankar
- Department of Anaesthesia, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | | | | | | | | |
Collapse
|