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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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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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English M, Aluvaala J, Maina M, Duke T, Irimu G. Quality of inpatient paediatric and newborn care in district hospitals: WHO indicators, measurement, and improvement. Lancet Glob Health 2023; 11:e1114-e1119. [PMID: 37236212 DOI: 10.1016/s2214-109x(23)00190-0] [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] [Received: 10/30/2022] [Revised: 03/02/2023] [Accepted: 04/03/2023] [Indexed: 05/28/2023]
Abstract
Poor-quality paediatric and neonatal care in district hospitals in low-income and middle-income countries (LMICs) was first highlighted more than 20 years ago. WHO recently developed more than 1000 paediatric and neonatal quality indicators for hospitals. Prioritising these indicators should account for the challenges in producing reliable process and outcome data in these settings, and their measurement should not unduly narrow the focus of global and national actors to reports of measured indicators. A three-tier, long-term strategy for the improvement of paedicatric and neonatal care in LMIC district hospitals is needed, comprising quality measurement, governance, and front-line support. Measurement should be better supported by integrating data from routine information systems to reduce the future cost of surveys. Governance and quality management processes need to address system-wide issues and develop supportive institutional norms and organisational culture. This strategy requires governments, regulators, professions, training institutions, and others to engage beyond the initial consultation on indicator selection, and to tackle the pervasive constraints that undermine the quality of district hospital care. Institutional development must be combined with direct support to hospitals. Too often the focus of indicator measurement as an improvement strategy is on reporting up to regional or national managers, but not on providing support down to hospitals to attain quality care.
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Affiliation(s)
- Mike English
- Kenya Medical Research Institute-Wellcome Programme, Nairobi, Kenya; Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jalemba Aluvaala
- Kenya Medical Research Institute-Wellcome Programme, Nairobi, Kenya; Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Michuki Maina
- Kenya Medical Research Institute-Wellcome Programme, Nairobi, Kenya
| | - Trevor Duke
- Intensive Care Unit, Royal Melbourne Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Grace Irimu
- Kenya Medical Research Institute-Wellcome Programme, Nairobi, Kenya; Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Faulkenberry JG, Luberti A, Craig S. Electronic health records, mobile health, and the challenge of improving global health. Curr Probl Pediatr Adolesc Health Care 2022; 52:101111. [PMID: 34969611 DOI: 10.1016/j.cppeds.2021.101111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Technology continues to impact healthcare around the world. This provides great opportunities, but also risks. These risks are compounded in low-resource settings where errors in planning and implementation may be more difficult to overcome. Global Health Informatics provides lessons in both opportunities and risks by building off of general Global Health. Global Health Informatics also requires a thorough understanding of the local environment and the needs of low-resource settings. Forming effective partnerships and following the lead of local experts are necessary for sustainability; it also ensures that the priorities of the local community come first. There is an opportunity for partnerships between low-resource settings and high income areas that can provide learning opportunities to avoid the pitfalls that plague many digital health systems and learn how to properly implement technology that truly improves healthcare.
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Affiliation(s)
- J Grey Faulkenberry
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia.
| | - Anthony Luberti
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia
| | - Sansanee Craig
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia
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English M, Ogola M, Aluvaala J, Gicheha E, Irimu G, McKnight J, Vincent CA. First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality. Arch Dis Child 2021; 106:326-332. [PMID: 33361068 PMCID: PMC7982941 DOI: 10.1136/archdischild-2020-320630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.
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Affiliation(s)
- Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK .,Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Edith Gicheha
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Kenya Paediatric Research Consortium, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya,Kenya Paediatric Research Consortium, Nairobi, Kenya
| | - Jacob McKnight
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
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