Identifying Constraints on Everyday Clinical Practice: Applying Work Domain Analysis to Emergency Department Care

BACKGROUND

Emergency departments (EDs) are complex socio-technical work systems that require staff to manage patients in an environment of fluctuating resources and demands. To better understand the purpose, and pressures and constraints for designing new ED facilities, we developed an abstraction hierarchy model as part of a work domain analysis (WDA) from the cognitive work analysis (CWA) framework. The abstraction hierarchy provides a model of the structure of the ED, encompassing the core objects, processes, and functions relating to key values and the ED's overall purpose.

METHODS

Reviews of relevant national and state policy, guidelines, and protocol documents applicable to care delivery in the ED were used to construct a WDA. The model was validated through focus groups with ED clinicians and subsequently validated using a series of WDA prompts.

RESULTS

The model shows that the ED system exhibits extremely interconnected and complex features. Heavily connected functions introduce vulnerability into the system with function performance determined by resource availability and prioritization, leading to a trade-off between time and safety priorities.

CONCLUSIONS

While system processes (e.g., triage, fast-track) support care delivery in ED, this delivery manifests in complex ways due to the personal and disease characteristics of patients and the dynamic state of the ED system. The model identifies system constraints that create tension in care delivery processes (e.g., electronic data entry, computer availability) potentially compromising patient safety.

APPLICATION

The model identified aspects of the ED system that could be leveraged to improve ED performance through innovative ED system design.

Effect of 3 Days of Oral Azithromycin on Young Children With Acute Diarrhea in Low-Resource Settings: A Randomized Clinical Trial

Importance

World Health Organization (WHO) guidelines do not recommend routine antibiotic use for children with acute watery diarrhea. However, recent studies suggest that a significant proportion of such episodes have a bacterial cause and are associated with mortality and growth impairment, especially among children at high risk of diarrhea-associated mortality. Expanding antibiotic use among dehydrated or undernourished children may reduce diarrhea-associated mortality and improve growth.

Objective

To determine whether the addition of azithromycin to standard case management of acute nonbloody watery diarrhea for children aged 2 to 23 months who are dehydrated or undernourished could reduce mortality and improve linear growth.

Design, Setting, and Participants

The Antibiotics for Children with Diarrhea (ABCD) trial was a multicountry, randomized, double-blind, clinical trial among 8266 high-risk children aged 2 to 23 months presenting with acute nonbloody diarrhea. Participants were recruited between July 1, 2017, and July 10, 2019, from 36 outpatient hospital departments or community health centers in a mixture of urban and rural settings in Bangladesh, India, Kenya, Malawi, Mali, Pakistan, and Tanzania. Each participant was followed up for 180 days. Primary analysis included all randomized participants by intention to treat.

Interventions

Enrolled children were randomly assigned to receive either oral azithromycin, 10 mg/kg, or placebo once daily for 3 days in addition to standard WHO case management protocols for the management of acute watery diarrhea.

Main Outcomes and Measures

Primary outcomes included all-cause mortality up to 180 days after enrollment and linear growth faltering 90 days after enrollment.

Results

A total of 8266 children (4463 boys [54.0%]; mean [SD] age, 11.6 [5.3] months) were randomized. A total of 20 of 4133 children in the azithromycin group (0.5%) and 28 of 4135 children in the placebo group (0.7%) died (relative risk, 0.72; 95% CI, 0.40-1.27). The mean (SD) change in length-for-age z scores 90 days after enrollment was -0.16 (0.59) in the azithromycin group and -0.19 (0.60) in the placebo group (risk difference, 0.03; 95% CI, 0.01-0.06). Overall mortality was much lower than anticipated, and the trial was stopped for futility at the prespecified interim analysis.

Conclusions and Relevance

The study did not detect a survival benefit for children from the addition of azithromycin to standard WHO case management of acute watery diarrhea in low-resource settings. There was a small reduction in linear growth faltering in the azithromycin group, although the magnitude of this effect was not likely to be clinically significant. In low-resource settings, expansion of antibiotic use is not warranted. Adherence to current WHO case management protocols for watery diarrhea remains appropriate and should be encouraged.

Trial Registration

ClinicalTrials.gov Identifier: NCT03130114.

BJS commission on surgery and perioperative care post-COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence.

METHODS

In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them.

RESULTS

BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training.

CONCLUSION

The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.

Prenatal diagnosis and planned peripartum care improve perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum in low-resource settings

OBJECTIVE

To report on the feasibility of establishing a regional prenatal referral network for critical congenital heart defects (CHDs) and its impact on perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum (TGA-IVS) in low-resource settings.

METHODS

This was a retrospective study of consecutive fetuses with a diagnosis of TGA-IVS between January 2011 and December 2019 in Kochi, Kerala, India. A regional network for prenatal diagnosis and referral of patients with critical CHDs was initiated in 2011. Pregnancy and early neonatal outcomes were reported. The impact of the timing of diagnosis (prenatal or after birth) on age at surgery, perinatal mortality and postoperative recovery was evaluated.

RESULTS

A total of 82 fetuses with TGA-IVS were included. Diagnosis typically occurred later on in gestation, at a median of 25 (interquartile range (IQR), 21-32) weeks. The majority (78.0%) of affected pregnancies resulted in live birth, most (84.4%) of which occurred in a specialist pediatric cardiac centers. Delivery in a specialist center, compared with delivery in a local maternity center, was associated with a significantly higher rate of surgical correction (98.1% vs 70.0%; P = 0.01) and overall lower neonatal mortality (3.7% vs 50%; P = 0.001). The proportion of cases undergoing arterial switch operation after prenatal diagnosis of TGA-IVS increased significantly, along with the prenatal detection rate, over the study period (2011-2015, 11.1% vs 2016-2019, 29.4%; P = 0.001). Median age at surgery was significantly lower in the prenatally diagnosed group than that in the postnatally diagnosed group (4 days (IQR, 1-23 days) vs 10 days (IQR, 1-91 days); P < 0.001). There was no significant difference in postoperative mortality (2.0% vs 3.6%; P = 0.49) between the two groups.

CONCLUSIONS

This study demonstrates the feasibility of creating a network for prenatal diagnosis and referral of patients with critical CHDs, such as TGA, in low-resource settings, that enables planned peripartum care in specialist pediatric cardiac centers and improved neonatal survival. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Availability of facility resources and services and infection-related maternal outcomes in the WHO Global Maternal Sepsis Study: a cross-sectional study

BACKGROUND

Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes.

METHODS

GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women's needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes.

FINDINGS

We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1·84 [95% CI 1·05-3·22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2·44 [1·02-5·85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities).

INTERPRETATION

While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes.

FUNDING

UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development.

Estimated Cost-effectiveness of Solar-Powered Oxygen Delivery for Pneumonia in Young Children in Low-Resource Settings

IMPORTANCE

Pneumonia is the leading cause of childhood mortality worldwide. Severe pneumonia associated with hypoxemia requires oxygen therapy; however, access remains unreliable in low- and middle-income countries. Solar-powered oxygen delivery (solar-powered O2) has been shown to be a safe and effective technology for delivering medical oxygen. Examining the cost-effectiveness of this innovation is critical for guiding implementation in low-resource settings.

OBJECTIVE

To determine the cost-effectiveness of solar-powered O2 for treating children in low-resource settings with severe pneumonia who require oxygen therapy.

DESIGN, SETTING, AND PARTICIPANTS

An economic evaluation study of solar-powered O2 was conducted from January 12, 2020, to February 27, 2021, in compliance with the World Health Organization Choosing Interventions That Are Cost-Effective (WHO-CHOICE) guidelines. Using existing literature, plausible ranges for component costs of solar-powered O2 were determined in order to calculate the expected total cost of implementation. The costs of implementing solar-powered O2 at a single health facility in low- and middle-income countries was analyzed for pediatric patients younger than 5 years who required supplemental oxygen.

EXPOSURES

Treatment with solar-powered O2.

MAIN OUTCOMES AND MEASURES

The incremental cost-effectiveness ratio (ICER) of solar-powered O2 was calculated as the additional cost per disability-adjusted life-year (DALY) saved. Sensitivity of the ICER to uncertainties of input parameters was assessed through univariate and probabilistic sensitivity analyses.

RESULTS

The ICER of solar-powered O2 was estimated to be $20 (US dollars) per DALY saved (95% CI, $2.83-$206) relative to the null case (no oxygen). Costs of solar-powered O2 were alternatively quantified as $26 per patient treated and $542 per life saved. Univariate sensitivity analysis found that the ICER was most sensitive to the volume of pediatric pneumonia admissions and the case fatality rate. The ICER was insensitive to component costs of solar-powered O2 systems. In secondary analyses, solar-powered O2 was cost-effective relative to grid-powered concentrators (ICER $140 per DALY saved) and cost-saving relative to fuel generator-powered concentrators (cost saving of $7120).

CONCLUSIONS AND RELEVANCE

The results of this economic evaluation suggest that solar-powered O2 is a cost-effective solution for treating hypoxemia in young children in low- and middle-income countries, relative to no oxygen. Future implementation should prioritize sites with high rates of pediatric pneumonia admissions and mortality. This study provides economic support for expansion of solar-powered O2 and further assessment of its efficacy and mortality benefit.

Development of a Resource Guide to Support the Engagement of Mental Health Providers and Patients With Digital Health Tools: Multimethod Study

BACKGROUND

As mental illness continues to affect 1 in 5 individuals, and the need for support has increased during the COVID-19 pandemic, the promise of digital mental health tools remains largely unrealized due to a lack of uptake by patients and providers. Currently, most efforts on supporting the uptake of digital mental health tools remain fragmented across organizations and geography. There is a critical need to synthesize these efforts in order to provide a coordinated strategy of supporting the adoption of digital mental health tools.

OBJECTIVE

The specific aim of this project is to develop a web-based resource document to support the engagement of mental health providers and patients in the use of digital mental health tools.

METHODS

The web-based resource was developed using a multimethod approach. A grey literature review was conducted in 2019 to identify relevant toolkits that are available in the public domain. This was supplemented with an environmental scan where individuals with expertise in the development, acquisition, implementation, and evaluation of digital mental health tools were invited to contribute additional tools or documents not identified in the grey literature search. An engagement workshop was held with stakeholders to explore how the resource document should be developed and delivered. These findings were collectively used to develop the final iteration of the resource document.

RESULTS

Based on a gray literature review and environmental scan with 27 experts, 25 resources were identified and included in the resource guide. These resources were developed for patients and providers by organizations from 5 countries. An engagement workshop was held with 14 stakeholders, and barriers related to cultural sensitivity, sustainability, and accessibility of the toolkit were identified. The final iteration of the resource document was developed by the research team using findings from the gray literature review, environmental scan, and engagement workshop. The contents of the 45-page resource guide are directed at mental health care providers, administrators, and patients (inclusive of families and caregivers).

CONCLUSIONS

The use of a multimethod approach led to the development of a resource guide that builds on existing evidence on digital mental health tools and was co-designed with stakeholders and end-users. The resource guide is now publicly available online for free and is being promoted through digital health and mental health websites. Future work should explore how this document can be integrated into clinical care delivery and pathways.

Pediatric Emergency and Critical Care Resources and Infrastructure in Resource-Limited Settings: A Multicountry Survey

OBJECTIVES

To describe the infrastructure and resources for pediatric emergency and critical care delivery in resource-limited settings worldwide.

DESIGN

Cross-sectional survey with survey items developed through literature review and revised following piloting.

SETTING

The electronic survey was disseminated internationally in November 2019 via e-mail directories of pediatric intensive care societies and networks and using social media.

PATIENTS

Healthcare providers who self-identified as working in resource-limited settings.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Results were summarized using descriptive statistics and resource availability was compared across World Bank country income groups. We received 328 responses (238 hospitals, 60 countries), predominantly in Latin America and Sub-Saharan Africa (n = 161, 67.4%). Hospitals were in low-income (28, 11.7%), middle-income (166, 69.5%), and high-income (44, 18.4%) countries. Across 174 PICU and adult ICU admitting children, there were statistically significant differences in the proportion of hospitals reporting consistent resource availability ("often" or "always") between country income groups (p < 0·05). Resources with limited availability in lower income countries included advanced ventilatory support, invasive and noninvasive monitoring, central venous access, renal replacement therapy, advanced imaging, microbiology, biochemistry, blood products, antibiotics, parenteral nutrition, and analgesic/sedative drugs. Seventy-seven ICUs (52.7%) were staffed 24/7 by a pediatric intensivist or anesthetist. The nurse-to-patient ratio was less than 1:2 in 71 ICUs (49.7%).

CONCLUSIONS

Contemporary data demonstrate significant disparity in the availability of essential and advanced human and material resources for the care of critically ill children in resource-limited settings. Minimum standards for essential pediatric emergency and critical care in resource-limited settings are needed.

Treating patients across European Union borders: An international survey in light of the coronavirus disease-19 pandemic

BACKGROUND

In light of the coronavirus disease-2019 (COVID-19) pandemic, how resources are managed and the critically ill are allocated must be reviewed. Although ethical recommendations have been published, strategies for dealing with overcapacity of critical care resources have so far not been addressed.

OBJECTIVES

Assess expert opinion for allocation preferences regarding the growing imbalance between supply and demand for medical resources.

DESIGN

A 10-item questionnaire was developed and sent to the most prominent members of the European Society of Anaesthesiology and Intensive Care (ESAIC).

SETTING

Survey via a web-based platform.

PATIENTS

Respondents were members of the National Anaesthesiologists Societies Committee and Council Members of the ESAIC; 74 of 80 (92.5%), responded to the survey.

MEASUREMENTS AND MAIN RESULTS

Responses were analysed thematically. The majority of respondents (83.8%), indicated that resources for COVID-19 were available at the time of the survey. Of the representatives of the ESAIC governing bodies, 58.9% favoured an allocation of excess critical care capacity: 69% wished to make them available to supraregional patients, whereas 30.9% preferred to keep the resources available for the local population. Regarding the type of distribution of resources, 35.3% preferred to make critical care available, 32.4% favoured the allocation of medical equipment and 32.4% wished to support both options. The majority (59.5%) supported the implementation of a central European institution to manage such resource allocation.

CONCLUSION

Experts in critical care support the allocation of resources from centres with overcapacity. The results indicate the need for centrally administered allocation mechanisms that are not based on ethically disputable triage systems. It seems, therefore, that there is wide acceptance and solidarity among the European anaesthesiological community that local medical and human pressure should be relieved during a pandemic by implementing national and international re-allocation strategies among healthcare providers and healthcare systems.

Analysis of Hospital Resource Availability and COVID-19 Mortality Across the United States

Although the impact of COVID-19 has varied greatly across the United States, there has been little assessment of hospital resources and mortality. We examine hospital resources and death counts among hospital referral regions from March 1 to July 26, 2020. This was an analysis of American Hospital Association data with COVID-19 data from the New York Times. Hospital-based resource availabilities were characterized per COVID-19 case. Death count was defined by monthly confirmed COVID-19 deaths. Geographic areas with fewer intensive care unit beds (incident rate ratio [IRR], 0.194; 95% CI, 0.076-0.491), nurses (IRR, 0.927; 95% CI, 0.888-0.967), and general medicine/surgical beds (IRR, 0.800; 95% CI, 0.696-0.920) per COVID-19 case were statistically significantly associated with an increased incidence rate of death in April 2020. This underscores the potential impact of innovative hospital capacity protocols and care models to create resource flexibility to limit system overload early in a pandemic.

SARS-CoV 2 Infection (Covid-19) and Cardiovascular Disease in Africa: Health Care and Socio-Economic Implications

The current pandemic of SARS-COV 2 infection (Covid-19) is challenging health systems and communities worldwide. At the individual level, the main biological system involved in Covid-19 is the respiratory system. Respiratory complications range from mild flu-like illness symptoms to a fatal respiratory distress syndrome or a severe and fulminant pneumonia. Critically, the presence of a pre-existing cardiovascular disease or its risk factors, such as hypertension or type II diabetes mellitus, increases the chance of having severe complications (including death) if infected by the virus. In addition, the infection can worsen an existing cardiovascular disease or precipitate new ones. This paper presents a contemporary review of cardiovascular complications of Covid-19. It also specifically examines the impact of the disease on those already vulnerable and on the poorly resourced health systems of Africa as well as the potential broader consequences on the socio-economic health of this region.

Comparison of Preclinical Properties of Several Available Antivenoms in the Search for Effective Treatment of Vipera ammodytes and Vipera berus Envenoming

Snakebites are a relatively rare medical emergency in Europe. In more than half of the annual cases caused by Vipera ammodytes, Vipera berus, and Vipera aspis, immunotherapy with animal-derived antivenom is indicated. Among eight products recently identified as available against European medically relevant species, only Zagreb antivenom, Viperfav, and ViperaTAb have been used almost exclusively for decades. Zagreb antivenom comprises V. ammodytes-specific F(ab')₂ fragments. Viperfav is a polyspecific preparation based on F(ab')₂ fragments against V. aspis, V. berus, and V. ammodytes venoms. ViperaTAb contains Fab fragments against the venom of V. berus. In 2014 the production of Zagreb antivenom was discontinued. Additionally, in the period of 2017 to 2018 a shortage of Viperfav occurred. Due to a lack of the product indicated for the treatment of V. ammodytes bites, other antivenoms were implemented into clinical practice without comparative assessment of their eligibility. The aim of our work was to identify a high-quality antivenom that might ensure the successful treatment of V. ammodytes and V. berus bites at the preclinical level. Differentiation between bites from these two species is difficult and unreliable in clinical practice, so the availability of a unique antivenom applicable in the treatment of envenoming caused by both species would be the most advantageous for Southeastern Europe. Zagreb antivenom, Viperfav, and ViperaTAb, as well as Viper venom antitoxin for V. berus envenoming and the in-development Inoserp Europe, which was designed to treat envenoming caused by all medically important European snakes, were comparatively tested for the first time. Emphasis was placed on their physicochemical properties, primarily purity and aggregate content, as well as their in vivo protective efficacies. As Zagreb antivenom is no longer available on the European market, Viperfav is the highest-quality product currently available and the only antivenom whose neutralisation potency against V. ammodytes and V. berus venoms was above regulatory requirements.

Review of economic analysis of available interventions on idiopathic short stature: A protocol for systematic review and meta-analysis

BACKGROUND

Idiopathic short stature (ISS) causes a high economic burden worldwide. As part of a research project that synthesizes economic evidence for Korean medicine treatment of ISS, we describe the methods that will be used for the comprehensive review of articles that analyze health-related economic evaluation for available interventions for ISS using a systematic review methodology.

METHODS

Eight electronic English, Korean, and Chinese databases will be searched from their inception until December 2020 to identify studies on the economic evaluation of available interventions on ISS, without language, study design, or publication status restrictions. From the included studies, the effectiveness, utility, and cost data will be collected as the outcome measures by two researchers independently. Descriptive analysis of individual studies will be conducted. If it is judged that the interventions and outcomes of the included studies are sufficiently homogeneous, we will attempt a quantitative synthesis through meta-analysis using Review Manager version 5.4 software (Cochrane, London, UK).

RESULTS

This study will summarize the evidence regarding the economic evaluation of available interventions for ISS.

CONCLUSIONS

The findings of this review will help clinicians and patients in evidence-based decision-making in clinical settings and help policy makers develop effective policies and distribute resources based on the available evidence.

Surgical and Trauma Capacity Assessment in Rural Haryana, India

Background

Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified.

Objective

The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools.

Methods

The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively.

Findings

Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures.

Conclusions

Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.

Nursing resources and patient outcomes in intensive care units: A protocol for systematic review and meta-analysis

BACKGROUND

As nursing resources is directly related to patient outcomes in the intensive care unit setting, identifying factors related to nursing resources at various levels could contribute to improving those outcomes. This study aims to determine the association of nursing resources with outcomes of intensive care unit patients.

METHOD

This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Protocols. Chinese electronic Database (Chinese Biomedical Literature Database, Wanfang, and China National Knowledge Infrastructure) and international electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) will be searched for all relevant published articles, with no restrictions on the year of publication or language. Study selection, data collection and assessment of study bias will be conducted independently by a pair of independent reviewers. The Newcastle-Ottawa Scale tool will be used for the risk of bias assessment. The Grading of Recommendations Assessment Development and Evaluation system will be used to assess the quality of evidence. The statistical analysis of this meta-analysis will be calculated by Review manager version 5.3.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

The findings of this systematic review will provide a high-quality synthesis of latest evidence and provide a basis for assessing the association of nursing resources on patients' outcomes in intensive care units.

TRIAL REGISTRATION NUMBER

10.17605/OSF.IO/9FNEX.

Selecting Instruments for Measuring the Clinical Learning Environment of Medical Education: A 4-Domain Framework

Learning environments shape the experiences of learners and practitioners, making them an important component of program evaluation. However, educators find it challenging to decide whether to measure clinical learning environments with existing instruments or to design their own new instrument and, if using an existing instrument, which to choose. To assist educators with these decisions, the authors compared clinical learning environment instruments based on their characteristics, underlying constructs, and degree to which items reflect 4 domains (personal, social, organizational, material) from a recently developed model for conceptualizing learning environments in the health professions. Building on 3 prior literature reviews as well as a literature search, the authors identified 6 clinically oriented learning environment instruments designed for medical education. They collected key information about each instrument (e.g., number of items and subscales, conceptual frameworks, operational definitions of the learning environment) and coded items from each instrument according to the 4 domains. The 6 instruments varied in number of items, underlying constructs, subscales, definitions of clinical learning environment, and domain coverage. Most instruments focused heavily on the organizational and social domains and less on the personal and material domains (half omitted the material domain entirely). The variations in these instruments suggest that educators might consider several guiding questions. How will they define the learning environment and which theoretical lens is most applicable (e.g., personal vitality, sociocultural learning theory)? What aspects or domains of the learning environment do they most wish to capture (e.g., personal support, social interactions, organizational culture, access to resources)? How comprehensive do they want the instrument to be (and correspondingly how much time do they expect people to devote to completing the instrument and how frequently)? Whose perspective do they wish to evaluate (e.g., student, resident, fellow, attending, team, patient)? Each of these considerations is addressed.

An Observational Laboratory-Based Assessment of SARS-CoV-2 Molecular Diagnostics in Benin, Western Africa

Information on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread in Africa is limited by insufficient diagnostic capacity. Here, we assessed the coronavirus disease (COVID-19)-related diagnostic workload during the onset of the pandemic in the central laboratory of Benin, Western Africa; characterized 12 SARS-CoV-2 genomes from returning travelers; and validated the Da An RT-PCR-based diagnostic kit that is widely used across Africa. We found a 15-fold increase in the monthly laboratory workload due to COVID-19, dealt with at the cost of routine activities. Genomic surveillance showed near-simultaneous introduction of distinct SARS-CoV-2 lineages termed A.4 and B.1, including the D614G spike protein variant potentially associated with higher transmissibility from travelers from six different European and African countries during March-April 2020. We decoded the target regions within the ORF1ab and N genes of the Da An dual-target kit by MinION-based amplicon sequencing. Despite relatively high similarity between SARS-CoV-2 and endemic human coronaviruses (HCoVs) within the ORF1ab target domain, no cross-detection of high-titered cell culture supernatants of HCoVs was observed, suggesting high analytical specificity. The Da An kit was highly sensitive, detecting 3.2 to 9.0 copies of target-specific in vitro transcripts/reaction. Although discrepant test results were observed in low-titered clinical samples, clinical sensitivity of the Da An kit was at least comparable to that of commercial kits from affluent settings. In sum, virologic diagnostics are achievable in a resource-limited setting, but unprecedented pressure resulting from COVID-19-related diagnostics requires rapid and sustainable support of national and supranational stakeholders addressing limited laboratory capacity.IMPORTANCE Months after the start of the COVID-19 pandemic, case numbers from Africa are surprisingly low, potentially because the number of SARS-CoV-2 tests performed in Africa is lower than in other regions. Here, we show an overload of COVID-19-related diagnostics in the central laboratory of Benin, Western Africa, with a stagnating average number of positive samples irrespective of daily sample counts. SARS-CoV-2 genomic surveillance confirmed a high genomic diversity in Benin introduced by travelers returning from Europe and other African countries, including early circulation of the D614G spike mutation associated with potentially higher transmissibility. We validated a widely used RT-PCR kit donated by the Chinese Jack Ma Foundation and confirmed high analytical specificity and clinical sensitivity equivalent to tests used in affluent settings. Our assessment shows that although achievable in an African setting, the burden from COVID-19-related diagnostics on national reference laboratories is very high.

The Pandemic's Toll-A Case for Clinician Support

Healthcare providers perform lifesaving work in unusually stressful work environments due to the challenges and related risks of battling the unprecedented COVID-19 pandemic. The potential personal and professional toll is substantial. This article describes how one healthcare facility benefited from existing peer support resources to address workforce well-being, ensuring that resources were available to support workforce resilience throughout the protracted COVID response.

Imagining and Preparing for the Aftermath of the COVID-19 Pandemic: A Justification for Taking Caring Responsibilities into Consideration when Allocating Scarce Resources

Various models have been used to "emplot" our collective experience of the COVID-19 pandemic, including the epidemiological curve, threshold models, and narrative. Drawing on a threshold model that was designed to frame resource-allocation decisions in clinical care, I offer an ethical justification for taking caring responsibilities into consideration in such decisions during pandemics. My basic argument is that we should prioritize the survival of patients with caring responsibilities for similar reasons we should prioritize the survival of healthcare professionals. More generally, the pandemic reveals the fundamental importance of informal care and affords an opportunity to raise questions of justice relating to it.

Between Crisis and Convention: How Should We Address Contingency?

The Covid-19 pandemic has brought about renewed conversation about equality and equity in the distribution of medical resources. Much of the recent conversation has focused on creating and implementing policies in times of crisis when resources are exhausted. Depending on how the pandemic develops, some communities may implement crisis measures, but many health care facilities are currently experiencing shortages of staff and materials even if the facilities have not implemented crisis standards. There is a need for shared conversation about equality and equity in these times of contingency between conventional and crisis medicine. To respond well to these challenges, I recommend that institutions rely on policy, professional education, and ethics consultation. As is the case with crisis policies, creating contingency policies requires that health care professionals decide on how, specifically, to achieve equity. A policy is only as effective as its implementation; therefore, institutions should invest in context-specific education on contingency policies. Finally, ethics consultation should be available for questions that contingency policies cannot address.

A flexible method for optimising sharing of healthcare resources and demand in the context of the COVID-19 pandemic

As the number of cases of COVID-19 continues to grow, local health services are at risk of being overwhelmed with patients requiring intensive care. We develop and implement an algorithm to provide optimal re-routing strategies to either transfer patients requiring Intensive Care Units (ICU) or ventilators, constrained by feasibility of transfer. We validate our approach with realistic data from the United Kingdom and Spain. In the UK, we consider the National Health Service at the level of trusts and define a 4-regular geometric graph which indicates the four nearest neighbours of any given trust. In Spain we coarse-grain the healthcare system at the level of autonomous communities, and extract similar contact networks. Through random search optimisation we identify the best load sharing strategy, where the cost function to minimise is based on the total number of ICU units above capacity. Our framework is general and flexible allowing for additional criteria, alternative cost functions, and can be extended to other resources beyond ICU units or ventilators. Assuming a uniform ICU demand, we show that it is possible to enable access to ICU for up to 1000 additional cases in the UK in a single step of the algorithm. Under a more realistic and heterogeneous demand, our method is able to balance about 600 beds per step in the Spanish system only using local sharing, and over 1300 using countrywide sharing, potentially saving a large percentage of these lives that would otherwise not have access to ICU.

Implementing active surveillance for TB-The views of managers in a resource limited setting, South Africa

BACKGROUND

The achievement of the World Health Organization's END TB goals will depend on the successful implementation of strategies for early diagnosis and retention of patients on effective therapy until cure. An estimated 150,000 cases are missed annually in South Africa. It is necessary to look at means for identifying these missed cases. This requires the implementation of active surveillance for TB, a policy adopted by the National Department of Health.

AIM

To explore the views of managers of the TB program on the implementation of active surveillance for TB in the resource constrained setting of the Eastern Cape, South Africa.

METHODS

A descriptive, explorative, thematically analysed qualitative study based on 10 semi-structured interviews of managers of the TB program. Interviews were transcribed verbatim and analysed using the framework method and Atlas-ti.

RESULTS

Active case finding of people attending health facilities was the dominant approach, although screening by community health workers (CHWs) was available. Both government and non-government organisations employed CHWs to screen door to door and sometimes as part of campaigns or community events. Some CHWs focused only on contact tracing or people that were non-adherent to TB treatment. Challenges for CHWs included poor coordination and duplication of services, failure to investigate those identified in the community, lack of transport and supportive supervision as well as security issues. Successes included expanding coverage by government CHW teams, innovations to improve screening, strategies to improve CHW capability and attention to social determinants.

CONCLUSION

A multifaceted facility- and community-based approach was seen as ideal for active surveillance. More resources should be targeted at strengthening teams of CHWs, for whom this would be part of a comprehensive and integrated service in a community-orientated primary care framework, and community engagement to strengthen community level interventions.

COVID-19: Adaptation of a model to predicting healthcare resources needs in Valle del Cauca, Colombia

BACKGROUND

Valle del Cauca is the region with the fourth-highest number of COVID-19 cases in Colombia (>50,000 on September 7, 2020). Due to the lack of anti-COVID-19 therapies, decision-makers require timely and accurate data to estimate the incidence of disease and the availability of hospital resources to contain the pandemic.

METHODS

We adapted an existing model to the local context to forecast COVID-19 incidence and hospital resource use assuming different scenarios: (1) the implementation of quarantine from September 1st to October 15th (average daily growth rate of 2%); (2-3) partial restrictions (at 4% and 8% growth rates); and (4) no restrictions, assuming a 10% growth rate. Previous scenarios with predictions from June to August were also presented. We estimated the number of new cases, diagnostic tests required, and the number of available hospital and intensive care unit (ICU) beds (with and without ventilators) for each scenario.

RESULTS

We estimated 67,700 cases by October 15th when assuming the implementation of a quarantine, 80,400 and 101,500 cases when assuming partial restrictions at 4% and 8% infection rates, respectively, and 208,500 with no restrictions. According to different scenarios, the estimated demand for reverse transcription-polymerase chain reaction tests ranged from 202,000 to 1,610,600 between September 1st and October 15th. The model predicted depletion of hospital and ICU beds by September 20th if all restrictions were to be lifted and the infection growth rate increased to 10%.

CONCLUSION

Slowly lifting social distancing restrictions and reopening the economy is not expected to result in full resource depletion by October if the daily growth rate is maintained below 8%. Increasing the number of available beds provides a safeguard against slightly higher infection rates. Predictive models can be iteratively used to obtain nuanced predictions to aid decision-making.

Measuring geographical disparities in England at the time of COVID-19: results using a composite indicator of population vulnerability

OBJECTIVES

The growth of COVID-19 infections in England raises questions about system vulnerability. Several factors that vary across geographies, such as age, existing disease prevalence, medical resource availability and deprivation, can trigger adverse effects on the National Health System during a pandemic. In this paper, we present data on these factors and combine them to create an index to show which areas are more exposed. This technique can help policy makers to moderate the impact of similar pandemics.

DESIGN

We combine several sources of data, which describe specific risk factors linked with the outbreak of a respiratory pathogen, that could leave local areas vulnerable to the harmful consequences of large-scale outbreaks of contagious diseases. We combine these measures to generate an index of community-level vulnerability.

SETTING

91 Clinical Commissioning Groups (CCGs) in England.

MAIN OUTCOME MEASURES

We merge 15 measures spatially to generate an index of community-level vulnerability. These measures cover prevalence rates of high-risk diseases; proxies for the at-risk population density; availability of staff and quality of healthcare facilities.

RESULTS

We find that 80% of CCGs that score in the highest quartile of vulnerability are located in the North of England (24 out of 30). Here, vulnerability stems from a faster rate of population ageing and from the widespread presence of underlying at-risk diseases. These same areas, especially the North-East Coast areas of Lancashire, also appear vulnerable to adverse shocks to healthcare supply due to tighter labour markets for healthcare personnel. Importantly, our index correlates with a measure of social deprivation, indicating that these communities suffer from long-standing lack of economic opportunities and are characterised by low public and private resource endowments.

CONCLUSIONS

Evidence-based policy is crucial to mitigate the health impact of pandemics such as COVID-19. While current attention focuses on curbing rates of contagion, we introduce a vulnerability index combining data that can help policy makers identify the most vulnerable communities. We find that this index is positively correlated with COVID-19 deaths and it can thus be used to guide targeted capacity building. These results suggest that a stronger focus on deprived and vulnerable communities is needed to tackle future threats from emerging and re-emerging infectious disease.

[To what extent Africa can limit the impact of the COVID-19 pandemic?]

Suite au déclenchement de la pandémie COVID-19 et aux alertes lancées par l’Organisation mondiale de la santé, l’attention s’est concentrée depuis plusieurs mois sur l’Afrique en tant que zone gravement menacée par la pandémie. Un grand nombre de pays africains, en particulier ceux à revenu faible et moyen seraient confrontés au risque de débordement de leurs systèmes de santé déjà fragiles, souffrant de la limitation des ressources de soins et de la disponibilité des moyens de base. Pour mieux gérer cette crise multidimensionnelle, l’enjeu va au-delà de la mise à niveau des infrastructures de santé publique, il s’agit aussi de savoir comment anticiper et agir activement sur les facteurs susceptibles de limiter la propagation du SRAS-CoV2 pour amortir le choc de cette pandémie sur le continent. Certains de ces facteurs sont naturels et non maîtrisables (climat, géographie…), mais beaucoup d’autres seraient à la portée des gouvernements et des populations africaines tels que les facteurs socioculturels, audiovisuels et même politiques.

Impact of the COVID-19 pandemic on hospital emergency departments: results of a survey of departments in 2020 - the Spanish ENCOVUR study

OBJECTIVES

To estimate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the organization of Spanish hospital emergency departments (EDs). To explore differences between Spanish autonomous communities or according to hospital size and disease incidence in the area.

MATERIAL AND METHODS

Survey of the heads of 283 EDs in hospitals belonging to or affiliated with Spain's public health service. Respondents evaluated the pandemic's impact on organization, resources, and staff absence from work in March and April 2020. Assessments were for 15-day periods. Results were analyzed overall and by autonomous community, hospital size, and local population incidence rates.

RESULTS

A total of 246 (87%) responses were received. The majority of the EDs organized a triage system, first aid, and observation wards; areas specifically for patients suspected of having COVID-19 were newly set apart. The nursing staff was increased in 83% of the EDs (with no subgroup differences), and 59% increased the number of physicians (especially in large hospitals and locations where the COVID-19 incidence was high). Diagnostic tests for the severe acute respiratory syndrome coronavirus 2 were the resource the EDs missed most: 55% reported that tests were scarce often or very often. Other resources reported to be scarce were FPP2 and FPP3 masks (38% of the EDs), waterproof protective gowns (34%), and space (32%). More than 5% of the physicians, nurses, or other emergency staff were on sick leave 20%, 19%, and 16% of the time. These deficiencies were greatest during the last half of March, except for tests, which were most scarce in the first 15 days. Large hospital EDs less often reported that diagnostic tests were unavailable. In areas where the COVID-19 incidence was higher, the EDs reported higher rates of staff on sick leave. Resource scarcity differed markedly by autonomous community and was not always associated with the incidence of COVID-19 in the population.

CONCLUSION

The COVID-19 pandemic led to organizational changes in EDs. Certain resources became scarce, and marked differences between autonomous communities were detected.

Predicted COVID-19 fatality rates based on age, sex, comorbidities and health system capacity

Early reports suggest the fatality rate from COVID-19 varies greatly across countries, but non-random testing and incomplete vital registration systems render it impossible to directly estimate the infection fatality rate (IFR) in many low- and middle-income countries. To fill this gap, we estimate the adjustments required to extrapolate estimates of the IFR from high-income to lower-income regions. Accounting for differences in the distribution of age, sex and relevant comorbidities yields substantial differences in the predicted IFR across 21 world regions, ranging from 0.11% in Western Sub-Saharan Africa to 1.07% for high-income Asia Pacific. However, these predictions must be treated as lower bounds in low- and middle-income countries as they are grounded in fatality rates from countries with advanced health systems. To adjust for health system capacity, we incorporate regional differences in the relative odds of infection fatality from childhood respiratory syncytial virus. This adjustment greatly diminishes but does not entirely erase the demography-based advantage predicted in the lowest income settings, with regional estimates of the predicted COVID-19 IFR ranging from 0.37% in Western Sub-Saharan Africa to 1.45% for Eastern Europe.

A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis.

Methods

We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days.

Results

We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs.

Conclusion

Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04482-8) contains supplementary material, which is available to authorized users.

Resource use and direct medical costs of acute respiratory illness in the UK based on linked primary and secondary care records from 2001 to 2009

Background

Previous studies have shown that influenza is associated with a substantial healthcare burden in the United Kingdom (UK), but more studies are needed to evaluate the resource use and direct medical costs of influenza in primary care and secondary care.

Methods

A retrospective observational database study in the UK to describe the primary care and directly-associated secondary care resource use, and direct medical costs of acute respiratory illness (ARI), according to age, and risk status (NCT Number: 01521416). Patients with influenza, ARI or influenza-related respiratory infections during 9 consecutive pre-pandemic influenza peak seasons were identified by READ codes in the linked Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) dataset. The study period was from 21st January 2001 to 31st March 2009.

Results

A total of 156,193 patients had ≥1 general practitioner (GP) episode of ARI, and a total of 82,204 patients received ≥1 GP prescription, at a mean of 2.5 (standard deviation [SD]: 3.0) prescriptions per patient. The total cost of GP consultations and prescriptions equated to £462,827 per year per 100,000 patients. The yearly cost of prescribed medication for ARI was £319,732, at an estimated cost of £11,596,350 per year extrapolated to the UK, with 40% attributable to antibiotics. The mean cost of hospital admissions equated to a yearly cost of £981,808 per 100,000 patients. The total mean direct medical cost of ARI over 9 influenza seasons was £21,343,445 (SD: £10,441,364), at £136.65 (SD: £66.85) per case.

Conclusions

Extrapolating to the UK population, for pre-pandemic influenza seasons from 2001 to 2009, the direct medical cost of ARI equated to £86 million each year. More studies are needed to assess the costs of influenza disease to help guide public health decision-making for seasonal influenza in the UK.

Working conditions in a mental health institution: An exploratory study of professional nurses in Limpopo province, South Africa

BACKGROUND

Professional nurses are responsible for the provision of care, treatment and rehabilitation of all mental healthcare users (MHCUs) in the institutions for mental healthcare. However, professional nurses find themselves in difficult circumstances under which they must provide quality healthcare services to MHCUs.

OBJECTIVES

The study explored and described the challenges experienced by the professional nurses working in a mental healthcare institution in Limpopo province of South Africa.

METHOD

A qualitative approach was used to explore and describe the challenges faced by professional nurses working in a mental healthcare institution. The study was conducted from July 2016 to December 2016. Purposive sampling was used to select participants. Data were obtained through individual in-depth interviews with professional nurses between the ages of 26 and 50 years. Data collection continued until data saturation, which occurred after interviewing 18 participants. Tech's open coding method was used to analyse data in this study.

RESULTS

Four themes emerged from data analysis, namely: inadequate safety measures, inadequate resources, impact of high workload and shortage of staff. The themes were further sub-divided into sub-themes.

CONCLUSION

The study revealed several challenges that professional nurses face in mental healthcare institutions which might be a barrier to the provision of quality healthcare. Conducive working environments should be established to enable professional health nurses to provide quality nursing care, thereby promoting the health of MHCUs.

Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic

Hospitals have severely curtailed the performance of nonurgent surgical procedures in anticipation of the need to redeploy healthcare resources to meet the projected massive medical needs of patients with coronavirus disease 2019 (COVID-19). Surgical treatment of non-COVID-19 related disease during this period, however, still remains necessary. The decision to proceed with medically necessary, time-sensitive (MeNTS) procedures in the setting of the COVID-19 pandemic requires incorporation of factors (resource limitations, COVID-19 transmission risk to providers and patients) heretofore not overtly considered by surgeons in the already complicated processes of clinical judgment and shared decision-making. We describe a scoring system that systematically integrates these factors to facilitate decision-making and triage for MeNTS procedures, and appropriately weighs individual patient risks with the ethical necessity of optimizing public health concerns. This approach is applicable across a broad range of hospital settings (academic and community, urban and rural) in the midst of the pandemic and may be able to inform case triage as operating room capacity resumes once the acute phase of the pandemic subsides.

Does communicable diseases (including COVID-19) may increase global poverty risk? A cloud on the horizon

Coronavirus epidemic can push millions of people in poverty. The shortage of healthcare resources, lack of sanitation, and population compactness leads to an increase in communicable diseases, which may increase millions of people add in a vicious cycle of poverty. The study used the number of factors that affect poverty incidence in a panel of 76 countries for a period of 2010-2019. The dynamic panel GMM estimates show that the causes of death by communicable diseases, chemical-induced carbon and fossil fuel combustion, and lack of access to basic hand washing facilities menace to increase poverty headcounts, whereas, an increase in healthcare expenditures substantially decreases poverty headcounts across countries. Further, the results show the U-shaped relationship between economic growth and poverty headcounts, as economic growth first decreases and later increase poverty headcount due to rising healthcare disparities among nations. The causality estimates show that lack of access to basic amenities lead to increase of communicable diseases including COVID-19 whereas chemical-induced carbon and fossil fuel emissions continue to increase healthcare expenditures and economic growth in a panel of selected countries. The rising healthcare disparities, regional conflicts, and public debt burden further 'hold in the hand' of communicable diseases that push millions of people in the poverty trap.