#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Variability in the use of pulse oximeters with children in Kenyan hospitals: A mixed-methods analysis


Autoři: Abigail J. Enoch aff001;  Mike English aff002;  ;  Gerald McGivern aff004;  Sasha Shepperd aff005
Působiště autorů: Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (former DPhil student) aff001;  KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya aff002;  Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom aff003;  Warwick Business School, University of Warwick, Coventry, United Kingdom aff004;  Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom aff005
Vyšlo v časopise: Variability in the use of pulse oximeters with children in Kenyan hospitals: A mixed-methods analysis. PLoS Med 16(12): e32767. doi:10.1371/journal.pmed.1002987
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1002987

Souhrn

Background

Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use.

Methods and findings

We analyzed admissions data recorded through Kenya’s Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN’s feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups.

Conclusions

There remain major challenges to implementing pulse oximetry—a cheap, decades old technology—into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized.

Klíčová slova:

Equipment – Hospitals – Kenya – Nurses – Oxygen – Pediatrics – Pneumonia – Procurement


Zdroje

1. World Health Organization. Manual on use of oxygen therapy in children. 2014.

2. Hanning CD, Alexander-Williams JM. Fortnightly review: pulse oximetry: a practical review. BMJ 1995;311:367.

3. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals. The Lancet 2016;388(10063):3027–3035.

4. Lozano JM. Epidemiology of hypoxaemia in children with acute lower respiratory infection [Oxygen Therapy in Children]. The international journal of tuberculosis and lung disease 2001;5(6):496–504. 11409574

5. Djelantik IG, Gessner BD, Sutanto A, Steinhoff M, Linehan M, Moulton LH, et al. Case fatality proportions and predictive factors for mortality among children hospitalized with severe pneumonia in a rural developing country setting. Journal of tropical pediatrics 2003;49(6):327–332. doi: 10.1093/tropej/49.6.327 14725409

6. Orimadegun A, Ogunbosi B, Orimadegun B. Hypoxemia predicts death from severe falciparum malaria among children under 5 years of age in Nigeria: the need for pulse oximetry in case management. African health sciences 2014;14(2):397–407. doi: 10.4314/ahs.v14i2.16 25320590

7. Lifebox. Value of a Lifebox. 2015; Available from: http://www.lifebox.org/safe-surgery/value-of-a-lifebox/. [cited 2019 Dec 7].

8. Peterson CL, Chen TP, Ansermino M, Dumont GA. Design and evaluation of a low-cost smartphone pulse oximeter. Sensors 2013;13(12):16882–16893. doi: 10.3390/s131216882 24322563

9. World Health Organization. WHO compendium of innovative health technologies for low-resource settings. 2015.

10. Ostfeld AE, Gaikwad AM, Khan Y, Arias AC. High-performance flexible energy storage and harvesting system for wearable electronics. Scientific Reports 2016;6:26122. doi: 10.1038/srep26122 27184194

11. Torfs T, Leonov V, Van Hoof C, Gyselinckx B. Body-Heat Powered Autonomous Pulse Oximeter. Sensors, 2006 IEEE 2006.

12. World Health Organization. Global pulse oximetry project: first international consultation meeting. Background document. 2008.

13. Feinmann J. Pulse oximeters for all. BMJ 2011;343.

14. McCollum ED, Bjornstad E, Preidis GA, Hosseinipour MC, Lufesi N. Multicenter study of hypoxemia prevalence and quality of oxygen treatment for hospitalized Malawian children. Transactions of the Royal Society of Tropical Medicine and Hygiene 2013;107(5):285–92. doi: 10.1093/trstmh/trt017 23584373

15. Ginsburg AS, Van Cleve WC, Thompson MIW, English M. Oxygen and Pulse Oximetry in Childhood Pneumonia: A Survey of Healthcare Providers in Resource-limited Settings. Journal of tropical pediatrics 2012;58(5):389–393. doi: 10.1093/tropej/fmr103 22170511

16. Ginsburg AS, Gerth-Guyette E, Mollis B, Gardner M, Chham S. Oxygen and pulse oximetry in childhood pneumonia: surveys of clinicians and student clinicians in Cambodia. Tropical Medicine and International Health 2014;19(5):537–544. doi: 10.1111/tmi.12291 24628874

17. Pham JC, Kelen GD, Pronovost PJ. National study on the quality of emergency department care in the treatment of acute myocardial infarction and pneumonia. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine 2007;14(10):856–863.

18. Jones M. The Oxygen Tissue Saturation (SPO2) Audit. Paediatric Research 2010;68:239.

19. Berkley JA, Brent A, Mwangi I, English M, Maitland K, Marsh K, et al. Mortality among Kenyan children admitted to a rural district hospital on weekends as compared with weekdays. Pediatrics 2004;114(6):1737–1738. doi: 10.1542/peds.2004-1263 15574646

20. English M, Ntoburi S, Wagai J, Mbindyo P, Opiyo N, Ayieko P, et al. An intervention to improve paediatric and newborn care in Kenyan district hospitals: understanding the context. Implementation Science 2009;4:42. doi: 10.1186/1748-5908-4-42 19627588

21. Graham HR, Bakare AA, Gray A, Ayede AI, Qazi S, McPake B, et al. Adoption of paediatric and neonatal pulse oximetry by 12 hospitals in Nigeria: a mixed-methods realist evaluation. BMJ Global Health 2018;3.

22. King C, Boyd N, Walker I, Zadutsa B, Baqui AH, Ahmed S, et al. Opportunities and barriers in paediatric pulse oximetry for pneumonia in low-resource clinical settings: a qualitative evaluation from Malawi and Bangladesh. BMJ Open 2018;8.

23. English M, Gathara D, Mwinga S, Ayieko P, Opondo C, Aluvaala J, et al. Adoption of recommended practices and basic technologies in a low-income setting. Archives of Disease in Children 2014;99:452–456.

24. Gachau S, Ayieko P, Gathara D, Mwaniki P, Ogero M, Akech S, et al. Does audit and feedback improve the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in Kenya. BMJ Global Health 2017;2.

25. Tuti T, Bitok M, Paton C, Makone B, Malla L, Muinga N, et al. Innovating to enhance clinical data management using non-commercial and open source solutions across a multi-center network supporting inpatient pediatric care and research in Kenya. Journal of the American Medical Informatics Association 2016;23(1):184–192. doi: 10.1093/jamia/ocv028 26063746

26. Irimu G, Ogero M, Mbevi G, Agweyu A, Akech S, Julius T, et al. Approaching quality improvement at scale: a learning health system approach in Kenya. Arch Dis Child 2018;103(11):1013–1019. doi: 10.1136/archdischild-2017-314348 29514814

27. World Health Organization. Countries: Kenya. Available from: http://www.who.int/countries/ken/en/. [cited 2017 Dec 8].

28. World Bank. Health expenditure per capita (current US$). Available from: https://data.worldbank.org/indicator/SH.XPD.PCAP?view=chart. [cited 2017 Dec 8].

29. World Health Organization. Global Health Observatory country views: Kenya statistics summary (2002-present). 2017; Available from: http://apps.who.int/gho/data/node.country.country-KEN. [cited 2017 Dec 8].

30. English M. Designing a theory-informed, contextually appropriate intervention strategy to improve delivery of paediatric services in Kenyan hospitals. Implementation Science 2013;8:39. doi: 10.1186/1748-5908-8-39 23537192

31. KPMG. Devolution of Healthcare Services in Kenya: Lessons learnt from other countries. 2013.

32. Wakaba M, Mbindyo P, Ochieng J, Kiriinya R, Todd J, Waudo A, et al. The public sector nursing workforce in Kenya: a county-level analysis. Human Resources for Health 2014;12:6. doi: 10.1186/1478-4491-12-6 24467776

33. English M, Irimu G, Nyamai R, Were F, Garner P, Opiyo N. Developing guidelines in low-income and middle-income countries: lessons from Kenya. Archives of Disease in Childhood 2017;102:846–851. doi: 10.1136/archdischild-2017-312629 28584069

34. English M, Wamae A, Nyamai R, Bevins B, Irimu G. Implementing locally appropriate guidelines and training to improve care of serious illness in Kenyan hospitals: a story of scaling-up (and down and left and right). Arch Dis Child 2011;96:285–290. doi: 10.1136/adc.2010.189126 21220265

35. Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. Thousand Oaks, CA: Sage; 2003.

36. Tuti T, Bitok M, Malla L, Paton C, Muinga N, Gathara D, et al. Improving documentation of clinical care within a clinical information network: an essential initial step in efforts to understand and improve care in Kenyan hospitals. BMJ Global Health 2016;1.

37. World Health Organization. Children: reducing mortality. Fact sheet. 2017; Available from: http://www.who.int/mediacentre/factsheets/fs178/en/. [cited 2017 Nov 22].

38. van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate Imputation by Chained Equations in R. Journal of Statistical Software 2011;45(3).

39. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science 2009;4:50. doi: 10.1186/1748-5908-4-50 19664226

40. Fishbein M, Yzer MC. Using Theory to Design Effective Health Behavior Interventions. Communication Theory 2003;13(2):164–183.

41. Fishbein M, Ajzen I. Predicting and Changing Behavior: The Reasoned Action Approach: Psychology Press, Taylor & Francis Group; 2010.

42. Ayieko P, Ogero M, Makone B, Julius T, Mbevi G, Nyachiro W, et al. Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network. Archives of Disease in Childhood 2016;101:223–229. doi: 10.1136/archdischild-2015-309269 26662925

43. Gray AZ, Morpeth M, Duke T, Peel D, Winter C, Satvady M, et al. Improved oxygen systems in district hospitals in Lao PDR: a prospective field trial of the impact on outcomes for childhood pneumonia and equipment sustainability. BMJ Paediatrics Open 2017;1:e000083. doi: 10.1136/bmjpo-2017-000083 29637121

44. Weber MW, Mulholland EK. Pulse oximetry in developing countries. The Lancet 1998;351(9115):1589.

45. Crede S, Van der Merwe B, Hutchinson J, Woods D, Karlen W, Lawn J. Where do pulse oximeter probes break?. Journal of clinical monitoring and computing 2014;28(3):309–314. doi: 10.1007/s10877-013-9538-2 24420339

46. Malkin R, Keane A. Evidence-based approach to the maintenance of laboratory and medical equipment in resource-poor settings. Medical & biological engineering & computing 2010;48(7):721–726.

47. McGivern G, Nzinga J, English M. ‘Pastoral practices’ for quality improvement in a Kenyan clinical network. Social science & medicine 2017;195:115–122.

48. Nzinga J, McGivern G, English M. Examining clinical leadership in Kenyan public hospitals through the distributed leadership lens. Health Policy Plan 2018;33(Suppl 2):ii27–ii34. doi: 10.1093/heapol/czx167 30053035

49. Mwakyusa S, Wamae A, Wasunna A, Were F, Esamai F, Ogutu B, et al. Implementation of a structured paediatric admission record for district hospitals in Kenya–results of a pilot study. BMC International Health and Human Rights 2006;6(9).

50. Cheung A, Weir M, Mayhew A, Kozloff N, Brown K, Grimshaw J. Overview of systematic reviews of the effectiveness of reminders in improving healthcare professional behavior. Systematic Reviews 2012;1(36).

51. Flodgren G, Hall AM, Goulding L, Eccles MP, Grimshaw JM, Leng GC, et al. Tools developed and disseminated by guideline producers to promote the uptake of their guidelines. Cochrane Database of Systematic Reviews 2016(8). Art. No.: CD010669. doi: 10.1002/14651858.CD010669.pub2 27546228

52. Pantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS, et al. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2017(9). Art. No.: CD011086.

53. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2012(6). Art. No.: CD000259. doi: 10.1002/14651858.CD000259.pub3 22696318

54. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger P, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 2009;360:491–499. doi: 10.1056/NEJMsa0810119 19144931

55. Spector JM, Agrawal P, Kodkany B, Lipsitz S, Lashoher A, Dziekan G, et al. Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program. PLoS ONE 2012;7(5):e35151. doi: 10.1371/journal.pone.0035151 22615733

56. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Quality & Safety 2014;23:299–318.

57. Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness. BMC Health Services Research 2011;11(211).

58. World Health Organization. Oxygen therapy for children: a manual for health workers. 2016.

59. Jensen LA, Onyskiw JE, Prasad NG. Meta-analysis of arterial oxygen saturation monitoring by pulse oximetry in adults. Heart & lung: the journal of critical care 1998;27(6):387–408.

60. Blaisdell CJ, Goodman S, Clark K, Casella JF, Loughlin GM. Pulse Oximetry Is a Poor Predictor of Hypoxemia in Stable Children With Sickle Cell Disease. Arch Pediatr Adolesc Med 2000;154:900–903. doi: 10.1001/archpedi.154.9.900 10980793

61. Chan ED, Chan MM, Chan MM. Pulse oximetry: Understanding its basic principles facilitates appreciation of its limitations. Respiratory medicine 2013;107:789–799. doi: 10.1016/j.rmed.2013.02.004 23490227

62. Langley R, Cunningham S. How Should Oxygen Supplementation Be Guided by Pulse Oximetry in Children: Do We Know the Level?. Frontiers in Pediatrics 2016;4(138).

63. Olive S. Using pulse oximetry to assess oxygen levels. Nursing times 2016;112(16):12. 27295798

64. World Health Organization. Pulse oximetry training manual. 2011.

65. Nabwire J, Namasopo S, Hawkes M. Oxygen Availability and Nursing Capacity for Oxygen Therapy in Ugandan Paediatric Wards. Journal of tropical pediatrics 2017:fmx033.

66. Fouzas S, Politis P, Skylogianni E, Syriopoulou T, Priftis KN, Chatzimichael A, et al. Knowledge on Pulse Oximetry Among Pediatric Health Care Professionals: A Multicenter Survey. Pediatrics 2010;126(3):e657–e662. doi: 10.1542/peds.2010-0849 20679299

67. Seeley M, McKenna L, Hood K. Graduate nurses’ knowledge of the functions and limitations of pulse oximetry. Journal of Clinical Nursing 2015;24(23–24):3538–3549. doi: 10.1111/jocn.13008 26419943

68. Choudhry NK, Fletcher RH, Soumerai SB. Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Annals of Internal Medicine 2005;142(4):260–273. doi: 10.7326/0003-4819-142-4-200502150-00008 15710959

69. McDonald R, Waring J, Harrison S, Walshe K, Boaden R. Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors’ and nurses’ views. BMJ Quality and Safety 2005;14(4):290–294.

70. Maitland K, Kiguli S, Opoka RO, Olupot-Olupot P, Engoru C, Njuguna P, et al. Children’s Oxygen Administration Strategies Trial (COAST): A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia. Wellcome Open Research 2017;11(2).

71. Enoch AJ, English M, Shepperd S. Does pulse oximeter use impact health outcomes? A systematic review. Archives of Disease in Childhood 2015;101:694–700. doi: 10.1136/archdischild-2015-309638 26699537

72. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science 2011;6:42. doi: 10.1186/1748-5908-6-42 21513547

73. May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science 2009;4:29. doi: 10.1186/1748-5908-4-29 19460163

74. Sedgwick P. Non-response bias versus response bias. BMJ 2014;348:g2573.

Štítky
Interní lékařství

Článek vyšel v časopise

PLOS Medicine


2019 Číslo 12
Nejčtenější tento týden
Nejčtenější v tomto čísle
Kurzy

Zvyšte si kvalifikaci online z pohodlí domova

Aktuální možnosti diagnostiky a léčby litiáz
nový kurz
Autoři: MUDr. Tomáš Ürge, PhD.

Střevní příprava před kolonoskopií
Autoři: MUDr. Klára Kmochová, Ph.D.

Závislosti moderní doby – digitální závislosti a hypnotika
Autoři: MUDr. Vladimír Kmoch

Aktuální možnosti diagnostiky a léčby AML a MDS nízkého rizika
Autoři: MUDr. Natália Podstavková

Jak diagnostikovat a efektivně léčit CHOPN v roce 2024
Autoři: doc. MUDr. Vladimír Koblížek, Ph.D.

Všechny kurzy
Přihlášení
Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.

Přihlášení

Nemáte účet?  Registrujte se

#ADS_BOTTOM_SCRIPTS#