Cost analysis and critical success factors of the use of oxygen concentrators versus cylinders in sub-divisional hospitals in Fiji.

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.

Rural healthcare workers views on the introduction of solar power and oxygen concentrators in health facilities in Papua New Guinea: a qualitative study.

INTRODUCTION: A motivated, well supported rural health workforce is required to provide appropriate child health services to the rural population. This study explored the views of rural health workers in Papua New Guinea on the impact of a program to improve oxygen delivery systems and to provide reliable power to their health facilities. METHODS: A pre-tested, self-administered open question survey was carried out among rural health workers from 38 health facilities in which oxygen concentrators had been installed, including 30 with solar power. Thematic analysis was carried out on the responses. RESULTS: The program was highly appreciated. Benefits extended beyond the ability to treat children with a reliable source of oxygen. Participants reported the positive community response to improved patient care and avoiding patient referrals. They stressed their wish for further improvements in infrastructure and for continuing education. CONCLUSION: The program improved morale and job satisfaction. The views of rural health workers are important in assessing program effectiveness.

Assessment of portable oxygen concentrators in infants undergoing hypoxic challenge testing. A randomised controlled crossover trial.

AIM: Due to reduced PaO2 , aircrafts at cruising altitudes are pressurised to a cabin altitude of 2438 m, equivalent to breathing FiO2 0.15. Portable oxygen concentrators (POCs) are approved for onboard oxygen supply with lack of evidence, especially in infants. We assessed POCs (continuous-flow cPOC vs. pulsed-flow pPOC) under simulated altitude conditions performing Hypoxic Challenge Testing (HCT). METHODS: In a randomised controlled crossover trial, we included patients <1 year born prematurely. In incidents of hypoxia (SpO2  ≤ 85%), oxygen was administered through POC. In patients with a positive hypoxia reversal, HCT was repeated 24 hours later. If hypoxia occurred during the second testing, oxygen was given using the alternative POC. RESULTS: We randomised 26 patients; 22 patients received allocated intervention (4 dropped out). Mean gestational age 30.4 weeks, mean corrected age 38.2 weeks. Both POCs achieved immediate hypoxia reversal in all cases (SpO2 cPOC/pPOC 98%/99.4% (95%CI -2.91, 0.01)) without any adverse events. No significant difference was observed in patients with BPD. CONCLUSION: Both POCs generated sufficient oxygen to reverse HCT induced hypoxia. Although pPOCs are not recommended in paediatric age, our data suggest their effectiveness even in neonates without any associated adverse events. Future research on pPOCs safety is required to establish recommendations for their use.

Improving Breath Detection From Pulsed-Flow Oxygen Sources Using a New Nasal Interface.

BACKGROUND: Patients with COPD and other lung diseases are treated with long-term oxygen therapy (LTOT). Portable oxygen sources are required to administer LTOT while maintaining patient autonomy. Existing portable oxygen equipment has limitations that can hinder patient mobility. A novel nasal interface is presented in this study, aiming to enhance breath detection and triggering efficiency of portable pulsed-flow oxygen devices, thereby improving patient mobility and independence. METHOD: To examine the effectiveness of the new interface, 8 respiratory therapists participated in trials using different oxygen sources (tank with oxygen-conserving device, SimplyGo Mini portable oxygen concentrator [POC], and OxyGo NEXT POC) and breathing types (nasal and oral) while using either the new nasal interface or a standard cannula. Each trial was video recorded so participant breaths could be retroactively matched with a pulse/no-pulse response, and triggering success rates were calculated by dividing the number of oxygen pulses by the number of breaths in each trial. After each trial, volunteers were asked to rate their perceived breathing resistance. RESULTS: Nasal breathing consistently resulted in higher triggering success rates compared to oral breathing for pulsed-flow oxygen devices. POCs exhibited higher triggering success rates than did the oxygen tanks with conserving device. However, there were no significant differences in triggering success rates between the two POC models. The new nasal interface demonstrated improved triggering success rates compared to the standard cannula. Whereas the new nasal interface was associated with a slight increase in perceived breathing resistance during nasal breathing trials, participants reported manageable resistance levels when using the interface. CONCLUSIONS: This study demonstrates that the new nasal interface can improve triggering success rates of pulsed-flow oxygen devices during both nasal and oral breathing scenarios. Further research involving patient trials is recommended to understand the clinical implications of improved pulse triggering.

Economical synthesis of oxygen to combat the COVID-19 pandemic.

The whole world has been affected by the COVID-19 pandemic and oxygen demand is greater than ever, but the supply is expectedly short. People in need of this oxygen are not able to receive it, especially those who cannot afford it. In addition to these issues, the oxygen from production plants is not getting delivered to hospitals on a timely basis due to insufficient availability of tankers and cylinders. It is therefore crucial to enable access of oxygen beds and cylinders to the public by developing economical methods for medical oxygen generation. Conventional methods like oxygen concentrators, the Pressure Swing Adsorption (PSA) Technique and Air Separation Units (ASUs) are either too expensive, energy intensive or feasible only on a small scale. This indicates the need to exploit methods that have not been utilized fully yet, such as Integrated Energy Systems (IES). However, reducing the cost of a process is not enough. It needs to be scaled up to have a real impact on the situation at hand. Ion Transport Membranes (ITM) are promising in this aspect as they can produce large volumes of extremely high-purity oxygen at low costs. All these methods along with their economic aspects have been discussed and then compared to identify the most feasible one.

Saving oxygen when it was most needed.

Background: Oxygen is one of the most commonly prescribed drugs across the globe. The ongoing Covid-19 pandemic has put enormous burden on hospital infrastructure and oxygen demand. There is lack of knowledge among healthcare workers regarding optimal utilization of oxygen delivery devices, target oxygen saturations and adequate oxygen prescription. A quality improvement project was designed to optimize the oxygen usage in wards. Methods: A core team comprising one each of consultant, senior resident, junior resident and nursing officer was formed. Fish bone analysis was done to find deficiencies in the existing system and strategy was planned to overcome these deficiencies. The key intervention included education and training of staff, Formulation of Standard Operating Procedures, use of lower target oxygen saturation and use of oxygen concentrators. Results: The project was carried out for a very short period of 5 days, and a total of 180,000 liters of oxygen was saved. The use of oxygen concentrators increased from zero to 9.5% and thus reducing the load on central oxygen supply. Conclusion: The proper training and sensitization of health care workers can help in saving oxygen, which further helps in saving precious human life.

Medical Oxygen: A Lifesaving Drug During the COVID-19 Pandemic-Source and Distribution.

Oxygen is an essential lifesaving medicine used for several indications at all levels of health care. The COVID-19 pandemic and its recent second wave have resulted in a surge in demand for necessary resources, including trained staff, hospital beds, and medical supplies like oxygen. Limited availability of these resources resulted in added risk of adverse outcomes. Also, the widespread unregulated use of oxygen by the general public in household settings poses safety concerns. This review focuses on sources of medical oxygen like cryogenic oxygen plants, pressure swing adsorption, oxygen concentrators, and oxygen cylinders. Their specifications, storage, distribution within healthcare settings, regulation, and safety concerns have been considered. Resources needed for calculating oxygen demand, surge planning, identifying the suitable source, and distribution systems for different settings have been detailed. This review aims to help the hospital administrators, biomedical engineers, and clinicians plan and rationalize oxygen usage in low- and middle-income countries during the COVID-19 pandemic.

Response to oxygen therapy using oxygen concentrators run off solar power in children with respiratory distress in remote primary health facilities in Papua New Guinea.

Oxygen therapy reduces mortality and morbidity from hypoxaemia in children. There are no published studies assessing individual patient responses to oxygen when delivered by oxygen concentrators in primary healthcare facilities.Ours was a prospective observational study in remote health facilities over three years. A data recording form was used for children who required oxygen. Oxygen saturation (SpO2) was recorded before administration of oxygen, at 30 min and then daily. We assessed the primary diagnosis and the outcome.The common primary diagnoses needing oxygen were pneumonia: moderate (39%) and severe (37%). The median SpO2 before administration of oxygen in 913 patients was 80% (interquartile range [IQR] 66%-88%), and by five days, for the 121 patients who were recorded, SpO2 was 97% (IQR 93%-98%). Of the 745 patients with a recorded outcome, 99% had an uneventful recovery.We conclude that oxygen concentrators are effective in treating children in rural health facilities in Papua New Guinea.

From Hospital to Home: An Intensive Transitional Care Management Intervention for Patients with COVID-19.

Implementing emergency department (ED) and hospital patient throughput management coupled with at-home medical and tele-management upon discharge may increase surge capacity during national emergencies and pandemics. This novel intensive transitional care management (ITCM) intervention presents the opportunity to optimize hospital bed capacity through prevention of inpatient admissions for patients who could be discharged home safely with appropriate in-home medical support and tele-management. This observational cohort intervention was conducted between April 7, 2020 and April 30, 2020, at the 4 largest inpatient facilities of RWJBarnabas Health System in New Jersey. The intervention group included a convenience sample of 192 patients who were evaluated in the ED, monitored in the observation unit, or admitted to the hospital with a diagnosis of mild-to-moderate COVID-19 infection. Their outcomes were compared to a matched comparison group of 593 patients who were admitted with the same COVID-19-related diagnosis and severity. The primary outcome was the reduction in inpatient days as a result of the intervention that included provision of at-home oxygen supplementation therapy, expanded home care services, and tele-management sessions. Secondary outcomes were re-encounters with the health system in the ED, observation unit, or inpatient readmissions. A total of 481.6 hospital patient days were avoided for 78 patients who had been discharged from the ED or observation unit stays. Secondary analysis included hospital readmission rates. The ITCM intervention demonstrated a feasible strategy for improving throughput of patients with COVID-19, resulting in increased hospital bed capacity.

Our experience of 200 patients: usage and maintenance of long-term oxygen therapy and non-invasive ventilation devices at home.

OBJECTIVE: To evaluate the patients' attitudes about the devices, of which they use for long-term respiratory support at home. METHOD: 200 consecutive patients were questioned about the treatment and devices of respiratory support at home by face to face questionnaire. Their records were taken from the archives of Social Security Agency. RESULTS: 123 (61.5%) of the patients were men and 77 (38.5%) were women. The mean age was 65.8 ± 11.9 (15-92) years. The most frequently prescribed device was oxygen concentrator and BIPAP was the one that follows. The most common indications were hypoxic and hypercapnic respiratory failure due to COPD. The devices were prescribed by the state university hospitals, most commonly. The average daily oxygen usage duration was 16.3 ± 3.1 hours, the average duration was 7.4 ± 3.1 hours, for BIPAP. Twenty one (11.4%) of the patients, who were treated with LTOT, stated that they were taking oxygen less than 15 hours a day. Higher education levels of the patients was correlated with the higher rates of visiting the companies - that they bought the devices- both for information about and control of the devices (p=0.002). The rate of visiting companies/firms was significantly higher in patients, who use BIPAP and respiratory support combined with it (p=0.010). Twenty three (47.9%) of the 48 patients, who notified that their devices were impaired, waited for repairment by the firm, 20 (41.6%) investigated special repair facilities and the rest (10.5%) rented a new device. CONCLUSION: Effective and continuous technical maintenance support must be provided to the patients, who are treated with long-term respiratory support at home.

Improving paediatric and neonatal care in rural district hospitals in the highlands of Papua New Guinea: a quality improvement approach.

BACKGROUND: In developing countries such as Papua New Guinea (PNG), district hospitals play a vital role in clinical care, training health-care workers, implementing immunization and other public health programmes and providing necessary data on disease burdens and outcomes. Pneumonia and neonatal conditions are a major cause of child admission and death in hospitals throughout PNG. Oxygen therapy is an essential component of the management of pneumonia and neonatal conditions, but facilities for oxygen and care of the sick newborn are often inadequate, especially in district hospitals. Improving this area may be a vehicle for improving overall quality of care. METHOD: A qualitative study of five rural district hospitals in the highlands provinces of Papua New Guinea was undertaken. A structured survey instrument was used by a paediatrician and a biomedical technician to assess the quality of paediatric care, the case-mix and outcomes, resources for delivery of good-quality care for children with pneumonia and neonatal illnesses, existing oxygen systems and equipment, drugs and consumables, infection-control facilities and the reliability of the electricity supply to each hospital. A floor plan was drawn up for the installation of the oxygen concentrators and a plan for improving care of sick neonates, and a process of addressing other priorities was begun. RESULTS: In remote parts of PNG, many district hospitals are run by under-resourced non-government organizations. Most hospitals had general wards in which both adults and children were managed together. Paediatric case-loads ranged between 232 and 840 patients per year with overall case-fatality rates (CFR) of 3-6% and up to 15% among sick neonates. Pneumonia accounts for 28-37% of admissions with a CFR of up to 8%. There were no supervisory visits by paediatricians, and little or no continuing professional development of staff. Essential drugs were mostly available, but basic equipment for the care of sick neonates was often absent or incomplete. Infection control measures were inadequate in most hospitals. Cylinders were the major source of oxygen for the district hospitals, and logistical problems and large indirect costs meant that oxygen was under-utilized. There were multiple electricity interruptions, but hospitals had back-up generators to enable the use of oxygen concentrators. After 6 months in each of the five hospitals, high-dependency care areas were planned, oxygen concentrators installed, staff trained in their use, and a plan was set out for improving neonatal care. INTERPRETATION: If MGD-4 targets for child health are to be met, reducing neonatal mortality and deaths from pneumonia will have to include better quality services in district hospitals. Establishing better oxygen supplies with a systems approach can be a vehicle for addressing other areas of quality and safety in district hospitals.

Oxygen saturations of medical inpatients in a Malawian hospital: cross-sectional study of oxygen supply and demand.

Oxygen is a World Health Organisation listed essential drug yet provision of oxygen in developing countries often fails to meet demand. The aim of this study was to evaluate the need for supplementary oxygen against oxygen delivery capacity at a large teaching hospital in Malawi. A cross-sectional study of all adult medical inpatients and assessment of oxygen provision over a 24-hour period was conducted. 144 patients were included in the study, 14 of whom met local and international criteria for oxygen therapy (oxygen saturations of <90%). Four were receiving oxygen. Of the 8 oxygen concentrators available, only 4 were functional. In conclusion, we identified a need for oxygen that was greater than the supply.

Usinas concentradoras de oxigênio: evolução da fração inspirada de oxigênio e repercussões no paciente anestesiado em sistema com absorvedor de CO2: estudo piloto / Oxygen concentrators: evolution of inspired concentration of oxygen and repercussions in an anesthetized patient with CO2 absorber system: pilot study

JUSTIFICATIVA E OBJETIVOS: A Resolução 1.355/92 do Conselho Federal de Medicina aprovou os padrões mínimos para instalação e funcionamento das usinas concentradoras de oxigênio (P.S.A.) e recomendou que os hospitais universitários fizessem análise prospectiva, permitindo o aperfeiçoamento do sistema, o que motivou a realização deste estudo piloto, cujo objetivo foi estudar a viabilidade clínica do uso do oxigênio proveniente das P.S.A., por meio da análise da variação da concentração de oxigênio no fluxo de gás fresco e da fração inspirada de oxigênio. MÉTODO: Estudo observacional, 30 pacientes ASA I, submetidos a cirurgias do abdome superior, utilizando-se sistema com absorvedor de CO2 e fluxo de gases frescos (FGF) de O(2)93 500 mL.min-1. Foram avaliadas as variáveis peso, idade, tipo e tempo dos procedimentos cirúrgicos; fração inspirada e expirada do CO2 (FiCO2, P ET CO2); fração inspirada O2 (FiO2) e concentração O2 (O2ent) do FGF. As variáveis P ET CO2, FiO2 e O2ent foram medidas após a intubação e a cada 10 minutos até o final da anestesia. Os resultados foram submetidos a tratamento estatístico, considerando-se significativo p < 0,05. RESULTADOS: A FiCO2 apresentou valor igual a zero em todos os pacientes e momentos estudados, mas ocorreu diminuição significativa da P ET CO2 no correr do tempo. As variáveis O2ent e FiO2 apresentaram tendências similares ao longo do tempo (p = 0,1283) e a variável O2ent apresentou médias superiores (p < 0,001); houve evolução das médias de O2ent e FiO2 (p < 0,05). CONCLUSÕES: Este estudo verificou que o uso de oxigênio proveniente de P.S.A., dentro das condições propostas para o experimento, mostrou ser seguro e induziu aumento progressivo da concentração de O(2)93 ofertada no FGF e da FiO2.

BACKGROUND AND OBJECTIVES: Resolution 1355/92 of the Conselho Federal de Medicina approved minimal standards for the installation and operation of oxygen concentrators (PSA) and recommended University Hospitals to undertake a prospective analysis in order to improve the system. It motivated this pilot study whose objective was to determine the clinical viability of using PSA oxygen by analyzing the variation in oxygen concentration in the fresh gas flow (FGF) outlet and in the inspired concentration of oxygen. METHODS: An observational study with 30 patients, ASA I, undergoing upper abdominal surgeries using a CO2 absorber system and fresh gas flow (FGF) O(2)93 at 500 mL.min-1. Weight, age, type and duration of the surgery, inspired and expired fraction of CO2 (FiCO2, P ET CO2); inspired fraction of O2 (FiO2); and O2 concentration (O2ent) in the FGF. The following parameters were measured after intubation and every 10 minutes until the end of the procedure: P ET CO2, FiO2, and O2. Results underwent statistical analysis and p < 0.05 was considered significant. RESULTS: The inspired fraction of carbon dioxide was equal to zero in all patients and moments of the study, but there was a significant reduction in P ET CO2 with time. The variables O2ent and FiO2 had similar tendencies with time (p = 0.1283), but the variable O2ent presented higher means (p < 0.001); evolution of mean O2ent and FiO2 was observed (p < 0.05). CONCLUSIONS: This study demonstrated that the use of PSA oxygen, within the conditions proposed for the experiment, is safe and induced a progressive increase in O(2)93 in the FGF and of FiO2.

JUSTIFICATIVA Y OBJETIVOS: La Resolución 1355/92, del Conselho Federal de Medicina aprobó los estándares mínimos para la instalación y el funcionamiento de las fábricas concentradoras de oxígeno (P.S.A.) y recomendó que los Hospitales Universitarios hiciesen un análisis prospectivo, permitiendo el perfeccionamiento del sistema, lo que motivó la realización de este estudio piloto, cuyo objetivo fue el de estudiar la viabilidad clínica del uso del oxígeno proveniente de las P.S.A., por medio del análisis de la variación de la concentración de oxígeno en el flujo de gas fresco y de la fracción inspirada de oxígeno. MÉTODO: Estudio de observación, 30 pacientes ASA I, sometidos a cirugías del abdomen superior, utilizando sistema con absorvedor de CO2 y flujo de gases frescos (FGF) de O(2)93 500 mL.min-1. Se evaluaron las variables peso, edad, tipo y tiempo de los procedimientos quirúrgicos; fracción inspirada y expirada del CO2 (FiCO2, P ET CO2); fracción inspirada O2 (FiO2) y concentración O2 (O2ent) del FGF. Las variables P ET CO2, FiO2 y O2 ent fueron medidas después de la intubación y a cada 10 minuto hasta el final de la anestesia. Los resultados fueron sometidos a tratamiento estadístico, considerándose significativo p < 0,05. RESULTADOS: La FiCO2 presentó un valor igual a cero en todos los pacientes y momentos estudiados, pero ocurrió una disminución significativa de la P ET CO2 en el transcurso del tiempo. Las variables O2ent y FiO2 presentaron tendencias similares a lo largo del tiempo (p = 0,1283), siendo que la variable O2 ent presentó medias superiores (p < 0,001); hubo evolución de las medias de O2 ent y FiO2 (p < 0,05). CONCLUSIONES: Este estudio verificó que el uso de oxígeno proveniente de P.S.A., dentro de las condiciones propuestas para el experimento, mostró ser seguro e indujo un aumento progresivo de la concentración de O(2)93 ofertada en el FGF y de la FiO2.