Improving effective coverage of medical-oxygen services for neonates and children in health facilities in Uganda: a before-after intervention study.

BACKGROUND: Medical oxygen services are essential for the care of acutely unwell patients. We aimed to assess the effects of a multilevel, multicomponent health-system intervention on hypoxaemia detection, oxygen therapy, and mortality among neonates and children attending level IV health centres and hospitals in Uganda. METHODS: For this before-after intervention study, we included children who attended paediatric or neonatal wards of 24 level IV health centres and seven general or regional referral hospitals in the Busoga and North Buganda regions of Uganda between June 1, 2020, and June 30, 2022. All neonates younger than 1 month and children aged 1 month to 14 years were eligible for inclusion. We excluded neonates who were not sick but stayed in the maternity ward for routine postnatal care. The intervention involved clinical training, mentorship, and supportive supervision; provision of pulse oximeters and cylinder-based oxygen sources; biomedical-capacity support; and support to develop and disseminate oxygen supply strategies, oxygen therapy guidelines, and lists of essential oxygen supplies. Trained research assistants extracted individual patient data from case notes using a standardised electronic data collection form. Data were collected on health-facility details, age, sex, clinical signs and symptoms, admission diagnoses, pulse oximetry readings, oxygen therapy details, and final patient outcome. The primary outcome was the proportion of admitted neonates and children with a pulse oximetry oxygen saturation reading documented in their patient case notes on day 1 of health-facility admission (ie, pulse oximetry coverage). We used mixed-effects logistic regression to evaluate the effect of the intervention. FINDINGS: We obtained data on 71 997 eligible neonates and children admitted to 31 participating health facilities; the primary analysis included 10 001 patients in the pre-intervention period (ie, June 1 to Oct 30, 2020) and 51 329 patients in the post-intervention period (ie, March 1, 2021, to June 30, 2022). Because 1356 patients had missing data for sex, 4365 (46·7%) of 9347 in the pre-intervention group and 22 831 (46·2%) of 49 410 in the post-intervention group were female; 4982 (53·3%) in the pre-intervention group and 26 579 (53·8%) in the post-intervention group were male. The proportion of neonates and children with pulse oximetry at admission increased from 2365 (23·7%) of 10 001 in the pre-intervention period to 45 029 (87·7%) of 51 328 in the post-intervention period. Adjusted analysis indicated greater likelihood of a patient receiving pulse oximetry during the post-intervention period compared with the pre-intervention period (adjusted odds ratio 40·10, 95% CI 37·38-42·93; p<0·0001). INTERPRETATION: Large-scale improvements in hospital oxygen services are achievable and have the potential to improve clinical outcomes. Governments should be encouraged to develop national oxygen plans and focus investment on interventions that have been shown to be effective, including the introduction of pulse oximetry into routine hospital care and clinical and biomedical mentoring and support. FUNDING: Bill & Melinda Gates Foundation and ELMA Philanthropies. TRANSLATIONS: For the Luganda and Lusoga translations of the abstract see Supplementary Materials section.

Real-Time Digital Feedback Device and Simulated Newborn Ventilation Quality.

OBJECTIVES: Effective bag-valve-mask ventilation is critical for reducing perinatal asphyxia-related neonatal deaths; however, providers often fail to achieve and maintain effective ventilation. The Augmented Infant Resuscitator (AIR) attaches to bag-valve-masks and provides visual feedback on air leaks, blocked airways, harsh breaths, and improper ventilatory rates. We evaluated the effect of this real-time-digital feedback on ventilation quality and the effective determination of airway integrity in a randomized controlled study in Uganda and the United States. METHODS: Birth attendants trained in newborn resuscitation were randomized to receive either real-time AIR device feedback (intervention) or no feedback (control) during ventilation exercises. Intervention-arm participants received a 2-minute orientation on interpreting AIR feedback using a single-page iconography chart. All participants were randomly assigned to 3 blinded ventilation scenarios on identical-appearing manikins with airways that were either normal, significantly leaking air, or obstructed. RESULTS: We enrolled 270 birth attendants: 77.8% from Uganda and 22.2% from the United States. Birth attendants receiving AIR feedback achieved effective ventilation 2.0 times faster: intervention mean 13.8s (95% confidence interval 10.6-17.1) versus 27.9s (21.6-34.3) for controls (P < .001). The duration of effective ventilation was 1.5 times longer: intervention mean 72.1s (66.7-77.5) versus 47.9s (41.6-54.2) for controls (P < .001). AIR feedback was associated with significantly more accurate and faster airway condition assessment (intervention mean 43.7s [40.5-47.0] versus 55.6s [51.6-59.6]). CONCLUSIONS: Providers receiving real-time-digital AIR device feedback achieved effective ventilation significantly faster, maintained it longer, and determined airway condition faster and more accurately than providers in the control group.

Hypoxaemia prevalence and management among children and adults presenting to primary care facilities in Uganda: A prospective cohort study.

Hypoxaemia (low blood oxygen) is common among hospitalised patients, increasing the odds of death five-fold and requiring prompt detection and treatment. However, we know little about hypoxaemia prevalence in primary care and the role for pulse oximetry and oxygen therapy. This study assessed the prevalence and management of hypoxaemia at primary care facilities in Uganda. We conducted a cross sectional prevalence study and prospective cohort study of children with hypoxaemia in 30 primary care facilities in Uganda, Feb-Apr 2021. Clinical data collectors used handheld pulse oximeters to measure blood oxygen level (SpO2) of all acutely unwell children, adolescents, and adults. We followed up a cohort of children aged under 15 years with SpO2<93% by phone after 7 days to determine if the patient had attended another health facility, been admitted, or recovered. Primary outcome: proportion of children under 5 years of age with severe hypoxaemia (SpO2<90%). Secondary outcomes: severe (SpO2<90%) and moderate hypoxaemia (SpO2 90-93%) prevalence by age/sex/complaint; number of children with hypoxaemia referred, admitted and recovered. We included 1561 children U5, 935 children 5-14 years, and 3284 adolescents/adults 15+ years. Among children U5, the prevalence of severe hypoxaemia was 1.3% (95% CI 0.9 to 2.1); an additional 4.9% (3.9 to 6.1) had moderate hypoxaemia. Performing pulse oximetry according to World Health Organization guidelines exclusively on children with respiratory complaints would have missed 14% (3/21) of severe hypoxaemia and 11% (6/55) of moderate hypoxaemia. Hypoxaemia prevalence was low among children 5-14 years (0.3% severe, 1.1% moderate) and adolescents/adults 15+ years (0.1% severe, 0.5% moderate). A minority (12/27, 44%) of severely hypoxaemic patients were referred; 3 (12%) received oxygen. We followed 87 children aged under 15 years with SpO2<93%, with complete data for 61 (70%), finding low rates of referral (6/61, 10%), hospital attendance (10/61, 16%), and admission (6/61, 10%) with most (44/61, 72%) fully recovered at day 7. Barriers to referral included caregiver belief it was unnecessary (42/51, 82%), cost (8/51, 16%), and distance or lack of transport (3/51, 6%). Hypoxaemia is common among acutely unwell children under five years of age presenting to Ugandan primary care facilities. Routine pulse oximetry has potential to improve referral, management and clinical outcomes. Effectiveness, acceptability, and feasibility of pulse oximetry and oxygen therapy for primary care should be investigated in implementation trials, including economic analysis from health system and societal perspectives.