Most downloaded biology preprints, all time
in category health systems and quality improvement
385 results found. For more information, click each entry to expand.
11,402 downloads medRxiv health systems and quality improvement
The 2019 Novel Coronavirus (COVID-19) has caused an acute shortage of personal protective equipment (PPE) globally as well as shortage in the ability to test PPE such as respirator fit testing. This limits not only the ability to fit PPE to medical practitioners, but also the ability to rapidly prototype and produce alternative sources of PPE as it is difficult to validate fit. At the George Washington University, we evaluated an easily sourced method of qualitative fit testing using a nebulizer or "atomizer" and a sodium saccharin solution in water. If aerosolized saccharin entered candidate masks due to poor fit or inadequate filtration, then a sweet taste was detected in the mouth of the user. This method was tested against previously fit tested Milwaukee N95 and 3D Printed Reusable N95 Respirator as a positive control. A Chinese sourced KN95, cotton cloth material, and surgical mask were tested as other masks of interest. Sensitivity testing was done with no mask prior to fit test. A sweet taste was detected for both the surgical mask and cotton cloth, demonstrating a lack of seal. However, there was no sweet taste detected for the Milwaukee N95, 3D Printed Reusable N95 Respirator, or Chinese KN95. These results demonstrate this could be a valuable methodology for rapid prototyping, evaluation, and validation of fit in a non-clinical environment for use in creation of PPE. This method should be not be used without confirmation in a formal qualitative or quantitative fit test but can be used to preserve those resources until developers are confident that potential new N95 comparable respirators will pass. We strongly suggest validation of masks and respirators with Occupational Safety and Health Administration (OSHA) approved fit testing prior to use in a clinical environment.
4,601 downloads medRxiv health systems and quality improvement
Following detection of the first few COVID-19 cases in early March, Bangladesh has stepped up its efforts to strengthen capacity of the healthcare system to avert a crisis in the event of a surge in the number of cases. This paper sheds light on the preparedness of the healthcare system by examining the spatial distribution of isolation beds across districts and divisions, forecasting the number of ICU units that may be required in the short term and analyzing the availability of frontline healthcare workers to combat the pandemic. As of May 2, COVID-19 cases have been found in 61 of the 64 districts in Bangladesh with Dhaka District being the epicenter. Seventy-one percent of the cases have been identified in 6 neighboring districts, namely, Dhaka, Narayanganj, Gazipur, Narsingdi, Munsiganj and Kishoreganj, which appear to form a spatial cluster. However, if one takes into account the population at risk, the prevalence appears to be highest in Dhaka, followed by Narayanganj, Gazipur, Kishorganj, Narsingdi and Munshiganj. These regions may therefore be flagged as the COVID-19 hotspots in Bangladesh. Among the eight divisions, prevalence is highest in Dhaka Division followed by Mymensingh. The number of cases per million exceeds the number of available isolation beds per million in the major hotspots indicating that there is a risk of the healthcare system becoming overwhelmed should the number of cases rise. This is especially true for Dhaka Division, where the ratio of COVID-19 patients to doctors appears to be alarmingly high. Mymensingh Division also has a disproportionately small number of doctors relative to the number of COVID-19 patients. Using second order polynomial regression, the analysis predicts that even if all ICU beds are allocated to COVID-19 patients, Bangladesh may run out of ICU beds soon after May 15, 2020. We conclude that in spite of a significant increase in hospital capacity during 2005-15 and a 57 % rise in the number of doctors during the same period, the healthcare system in Bangladesh and Dhaka Division in particular, may not be fully prepared to handle the COVID-19 crisis. Thus, further steps need to be taken to flatten the curve and improve healthcare capacity.
4,571 downloads medRxiv health systems and quality improvement
Michael D. Buck, Enzo Z. Poirier, Ana Cardoso, Bruno Frederico, Johnathan Canton, Sam Barrell, Rupert Beale, Richard Byrne, Simon Caidan, Margaret Crawford, Laura Cubitt, Steve Gamblin, Sonia Gandhi, Robert Goldstone, Paul R. Grant, Kiran Gulati, Steve Hindmarsh, Michael Howell, Michael Hubank, Rachael Instrell, Ming Jiang, George Kassiotis, Wei-Ting Lu, James I MacRae, Iana Martini, Davin Miller, David Moore, Eleni Nastouli, Jerome Nicod, Luke Nightingale, Jessica Olsen, Amin Oomatia, Nicola O'Reilly, Anett Rideg, Ok-Ryul Song, Amy Strange, Charles Swanton, Samra Turajlic, Philip A Walker, Mary Wu, Caetano Reis e Sousa, Crick COVID-19 Consortium
The ongoing pandemic of SARS-CoV-2 calls for rapid and cost-effective methods to accurately identify infected individuals. The vast majority of patient samples is assessed for viral RNA presence by RT-qPCR. Our biomedical research institute, in collaboration between partner hospitals and an accredited clinical diagnostic laboratory, established a diagnostic testing pipeline that has reported on more than 40,000 RT-qPCR results since its commencement at the beginning of April 2020. However, due to ongoing demand and competition for critical resources, alternative testing strategies were sought. In this work, we present a clinically-validated standard operating procedure (SOP) for high-throughput SARS- CoV-2 detection by RT-LAMP in 25 minutes that is robust, reliable, repeatable, sensitive, specific, and inexpensive.
4,111 downloads medRxiv health systems and quality improvement
Tamirat Moges, Workeabeba Abebe, Alemayehu Worku, Henok Tadele, Tewodros Haile, Damte Shimelis, Desalew Mekonin, Wondowossen Amogne, Ayalew Moges, Abebe Tamire, Rahel Argaw, Sewagegn Yeshiwas, Hyleyesus Adam, Asrat Dimtse, Wakgari Deressaw
Abstract Background: COVID-19, the disease caused by the new coronavirus SARS-CoV-2 is among the most obscure global pandemics resulting in diverse health and economic disruptions. It adversely affects the routine health care delivery and health service uptake by patients. However, its impact on care-seeking behavior is largely unknown in Ethiopia. Objective: This study was to determine the impact of the pandemic on the care-seeking behavior of patients with chronic health conditions at Tikur Anbessa Specialized Hospital in Addis Ababa. Methods: A cross-sectional hospital-based survey conducted between May and July 2020 on patients whose appointment was between March to June 2020. A sample of 750 patients was approached using phone calls and data collection was done using a pretested questionnaire. After cleaning, the data entered into the IBM SPSS software package for analysis. Results: A total of 644 patients with a median age of 25 years, and an M: F ratio of 1:1.01 was described with a response rate of 86%. A loss to follow-up missed medication and death occurred in 70%, 12%, and 1.3% of the patients respectively. In the multivariable logistic regression analysis, patients above 60 years old were more likely to miss follow-up (OR-23.28 (9.32-58.15), P<001). Patients who reported fear of COVID-19 at the hospital were 19 times more likely to miss follow-up (adjusted OR=19.32, 95% CI:10.73-34.79, P<0.001), while patients who reported transportation problems were 6.5 times more likely to miss follow-up (adjusted OR=6.11, 95% CI:3.06-12.17, P<0.001). Conclusions: COVID-19 pandemic affected the care-seeking behavior of patients with chronic medical conditions adversely and the impact was more pronounced among patients with severe disease, fear of COVID19, and transportation problems. Education on preventive measures of COVID-19, use of phone clinics, and improving chronic illness services at the local health institutions may reduce loss to follow-up among these patients.
3,864 downloads medRxiv health systems and quality improvement
The rapid spread of Coronavirus disease 2019 (COVID-19) presents China with a critical challenge. As normal capacity of the Chinese hospitals is exceeded, healthcare professionals struggling to manage this unprecedented crisis face the difficult question of how best to coordinate the medical resources used in highly separated locations. Responding rapidly to this crisis, the National Telemedicine Center of China (NTCC), located in Zhengzhou, Henan Province, has established the Emergency Telemedicine Consultation System (ETCS), a telemedicine-enabled outbreak alert and response network. ETCS is built upon a doctor-to-doctor (D2D) approach, in which health services can be accessed remotely through terminals across hospitals. The system architecture of ETCS comprises three major architectural layers: (1) telemedicine service platform layer, (2) telemedicine cloud layer, and (3) telemedicine service application layer. Our ETCS has demonstrated substantial benefits in terms of the effectiveness of consultations and remote patient monitoring, multidisciplinary care, and prevention education and training.
3,673 downloads medRxiv health systems and quality improvement
Jim Aitken, Karen Ambrose, Sam Barrell, Rupert Beale, Ganka Bineva-Todd, Dhruva Biswas, Richard Byrne, Simon Caidan, Peter Cherepanov, Laura Churchward, Graham Clark, Marg Crawford, Laura Cubitt, Vicky Dearing, Christopher Earl, Amelia Edwards, Chris Ekin, Efthymios Fidanis, Alessandra Gaiba, Steve Gamblin, Sonia Gandhi, Jacki Goldman, Robert Goldstone, Paul R. Grant, Maria Greco, Judith Heaney, Steve Hindmarsh, Catherine F Houlihan, Michael Howell, Michael Hubank, Debbie Hughes, Rachel Instrell, Deb Jackson, Mariam Jamal-Hanjani, Ming Jiang, Mark Johnson, Leigh Jones, Nnennaya Kanu, George Kassiotis, Stuart Kirk, Svend Kjaer, Andrew Levett, Lisa Levett, Marcel Levi, Wei-Ting Lu, James I MacRae, John Matthews, Laura McCoy, Catherine Moore, David Moore, Eleni Nastouli, Jerome Nicod, Luke Nightingale, Jessica Olsen, Nicola OReilly, Amar Pabari, Venizelos Papayannopoulos, Namita Patel, Nigel Peat, Marc Pollitt, Peter J. Ratcliffe, Caetano Reis e Sousa, Annachiara Rosa, Rachel Rosenthal, Chloe Roustan, Andrew Rowan, Gee Yen Shin, Daniel M. Snell, Ok-Ryul Song, Moria Spyer, Amy Strange, Charles Swanton, James M A Turner, Melanie Turner, Andreas Wack, Philip A Walker, Sophie Ward, Wai Keong Wong, Joshua Wright, Mary Wu
The emergence of the novel coronavirus SARS-CoV-2 has led to a pandemic infecting more than two million people worldwide in less than four months, posing a major threat to healthcare systems. This is compounded by the shortage of available tests causing numerous healthcare workers to unnecessarily self-isolate. We provide a roadmap instructing how a research institute can be repurposed in the midst of this crisis, in collaboration with partner hospitals and an established diagnostic laboratory, harnessing existing expertise in virus handling, robotics, PCR, and data science to derive a rapid, high throughput diagnostic testing pipeline for detecting SARS-CoV-2 in patients with suspected COVID-19. The pipeline is used to detect SARS-CoV-2 from combined nose-throat swabs and endotracheal secretions/ bronchoalveolar lavage fluid. Notably, it relies on a series of in-house buffers for virus inactivation and the extraction of viral RNA, thereby reducing the dependency on commercial suppliers at times of global shortage. We use a commercial RT-PCR assay, from BGI, and results are reported with a bespoke online web application that integrates with the healthcare digital system. This strategy facilitates the remote reporting of thousands of samples a day with a turnaround time of under 24 hours, universally applicable to laboratories worldwide.
3,617 downloads medRxiv health systems and quality improvement
Objectives: To determine the trend in mortality risk over time in people with severe COVID-19 requiring critical care (high intensive unit [HDU] or intensive care unit [ICU]) management. Methods: We accessed national English data on all adult COVID-19 specific critical care admissions from the COVID-19 Hospitalisation in England Surveillance System (CHESS), up to the 29th June 2020 (n=14,958). The study period was 1st March until 30th May, meaning every patient had 30 days of potential follow-up available. The primary outcome was in-hospital 30-day all-cause mortality. Hazard ratios for mortality were estimated for those admitted each week using a Cox proportional hazards models, adjusting for age (non-linear restricted cubic spline), sex, ethnicity, comorbidities, and geographical region. Results: 30-day mortality peaked for people admitted to critical care in early April (peak 29.1% for HDU, 41.5% for ICU). There was subsequently a sustained decrease in mortality risk until the end of the study period. As a linear trend from the first week of April, adjusted mortality risk decreased by 11.2% (adjusted HR 0.89 [95% CI 0.87 - 0.91]) per week in HDU, and 9.0% (adjusted HR 0.91 [95% CI 0.88 - 0.94]) in ICU. Conclusions: There has been a substantial mortality improvement in people admitted to critical care with COVID-19 in England, with markedly lower mortality in people admitted in mid-April and May compared to earlier in the pandemic. This trend remains after adjustment for patient demographics and comorbidities suggesting this improvement is not due to changing patient characteristics. Possible causes include the introduction of effective treatments as part of clinical trials and a falling critical care burden.
3,546 downloads medRxiv health systems and quality improvement
Compared to other coronaviruses, COVID-19 has a longer incubation period and features asymptomatic infection at a high rate (>25%). Therefore, early detection of infection is the key to early isolation and treatment. Direct detection of the virus itself has advantages over indirect detection. Currently, the most sensitive and commercially validated method for COVID-19 testing is RT-qPCR, designed to detect amplified virus-specific RNA. Reliable testing has proven to be a bottleneck in early diagnosis of virus infection in all countries dealing with the pandemic. Significant performance and quality issues with available testing kits have caused confusion and serious health risks. In order to provide better understanding of the Quality and performance of COVID-19 RNA detection kits on the market, we designed a system to evaluate the specificity (quantitation), sensitivity (LOD) and robustness of the kits using positive RNA and pseudovirus controls based on COVID-19 genomic sequence. We evaluated 8 Nucleic Acid qPCR Kits approved in China, some of which are also approved in the US and EU. Our study showed that half of these 8 kits lack 1:1 linear relationship for virus RNA copy: qPCR signal. Of the 4 with linear response, 2 demonstrated sensitivity at 1 Copy viral RNA/Reaction, suitable for early detection of virus infection. Furthermore, we established the best RNA extraction, handling and qPCR procedures allowing highly sensitive and consistent performance using BGI qPCR kits. Our study provides an effective method to assess and compare performance quality of all COVID-19 nucleic acid testing kits, globally.
3,195 downloads medRxiv health systems and quality improvement
Purpose: Staff perception of safety must be frequently measured to achieve a positive safety culture. There are several active and reactive methods to use to measure safety cultures such as near-miss occurrence and safety questionnaires. The safety attitudes questionnaire tool was used to measure safety culture. This tool is widely used in literature and among researchers and has been used and validated in middle eastern cultures. Methods: A cross sectional study was conducted using anonymous and random sampling. I surveyed all ICU staff working in all the adult ICUs in two of the major hospitals in the eastern province of Saudi Arabia. The short version of the Safety Attitudes Questionnaire was used to assess participants' attitudes towards safety culture. The study involved all healthcare providers working in Adult ICU. Results: The study occurred over a three week period in March 2019. A total of 82 completed questionnaires were returned which represented a response rate of 82%. On average, the domain that scored the highest number of positive responses was Job satisfaction with 68.5% followed by teamwork climate 67.8. A statistically significant difference was found between the mean SAQ score and the educational level of the participants. Participants with bachelors degrees scored a mean of 50.17 compared to participants hold diploma degrees who scored a mean of 68.81 (P=0.02). Moreover a significant difference was found between the mean SAQ score and participants' specialties (P=0.04). In addition 79.2% of the respondents did not report any incidents in the last 12 months. Conclusions: The result of the study shows an unsatisfying level of safety culture among healthcare staff in ICUs. The importance of this study is to establish a baseline for safety climate in these hospitals and specifically ICUs.
2,943 downloads medRxiv health systems and quality improvement
Coronavirus disease 2019 (COVID-19) is a disease triggered by SARS-CoV-2 infection, which is related in the most recent pandemic situation, significantly affecting health and economic systems. In this study we assessed the death rate associated to COVID-19 in Brazil and the United States of America (USA) to estimate the probability of Brazil becoming the next pandemic epicenter. We equated data between Brazil and USA obtained through the Worldometer website (www.worldometer.info). Epidemic curves from Brazil and USA were associated and regression analysis was undertaken to predict the Brazilian death rate regarding COVID-19 in June. In view of data from April 9th 2020, death rates in Brazil follow a similar exponential increase to USA (r=0.999; p<0.001), estimating 64,310 deaths by June 9th 2020. In brief, our results demonstrated that Brazil follows an analogous progression of COVID-19 deaths cases when compared to USA, signifying that Brazil could be the next global epicenter of COVID-19. We highlight public strategies to decrease the COVID-19 outbreak.
2,792 downloads medRxiv health systems and quality improvement
Susan Swedo, David M. Baguley, Damiaan Denys, Laura J. Dixon, Mercede Erfanian, Alessandra Fioretti, Pawel J. Jastreboff, Sukhbinder Kumar, M. Zachary Rosenthal, Romke Rouw, Daniela Schiller, Julia Simner, Eric A. Storch, Steven Taylor, Kathy R. Vander Werff, Sylvina Mullins Raver
Misophonia is a disorder of decreased tolerance to specific sounds or their associated stimuli that has been characterized using different language and methodologies. The absence of a common understanding or foundational definition of misophonia hinders progress in research to understand the disorder and develop effective treatments for individuals suffering from misophonia. From June 2020 through January 2021, a project was conducted to determine whether a committee of experts with diverse expertise related to misophonia could develop a consensus definition of misophonia. An expert committee used a modified Delphi method to evaluate candidate definitional statements that were identified through a systematic review of the published literature. Over four rounds of iterative voting, revision, and exclusion, the committee made decisions to include, exclude, or revise these statements in the definition based on the currently available scientific and clinical evidence. A definitional statement was included in the final definition only after reaching consensus at 80% or more of the committee agreeing with its premise and phrasing. The results of this rigorous consensus-building process were compiled into a final definition of misophonia that is presented here. This definition will serve as an important step to bring cohesion to the growing field of researchers and clinicians who seek to better understand and support individuals experiencing misophonia.
2,772 downloads medRxiv health systems and quality improvement
Introduction The COVID-19 pandemic will test the capacity of health systems worldwide. Health systems will need surge capacity to absorb acute increases in caseload due to the pandemic. We assessed the capacity of the Kenyan health system to absorb surges in the number of people that will need hospitalization and critical care because of the COVID-19. Methods We assumed that 2% of the Kenyan population get symptomatic infection by SARS-Cov-2 based on modelled estimates for Kenya and determined the health system surge capacity for COVID-19 under three transmission curve scenarios, 6, 12, and 18 months. We estimated four measures of hospital surge capacity namely: 1) hospital bed surge capacity 2) ICU bed surge capacity 3) Hospital bed tipping point, and 5) ICU bed tipping point. We computed this nationally and for all the 47 county governments. Results The capacity of Kenyan hospitals to absorb increases in caseload due to COVID-19 is constrained by the availability of oxygen, with only 58% of hospital beds in hospitals with oxygen supply. There is substantial variation in hospital bed surge capacity across counties. For example, under the 6 months transmission scenario, the percentage of available general hospital beds that would be taken up by COVID-19 cases varied from 12% Tharaka Nithi county, to 145% in Trans Nzoia county. Kenya faces substantial gaps in ICU beds and ventilator capacity. Only 22 out of the 47 counties have at least 1 ICU unit. Kenya will need an additional 1,511 ICU beds and 1,609 ventilators (6 months transmission curve) to 374 ICU beds and 472 ventilators (18 months transmission curve) to absorb caseloads due to COVID-19.
2,500 downloads medRxiv health systems and quality improvement
Background: Non-pharmacological interventions were introduced based on modelling studies which suggested that the English National Health Service (NHS) would be overwhelmed by the COVID-19 pandemic. In this study, we describe the pattern of bed occupancy across England during the first wave of the pandemic, January 31st to June 5th 2020. Methods: Bed availability and occupancy data was extracted from daily reports submitted by all English secondary care providers, between 27-Mar and 5-June. Two thresholds (85% as per Royal College of Emergency Medicine and 92% as per NHS Improvement) were applied as thresholds for safe occupancy. Findings: At peak availability, there were 2711 additional beds compatible with mechanical ventilation across England, reflecting a 53% increase in capacity, and occupancy never exceeded 62%. A consequence of the repurposing of beds meant that at the trough, there were 8.7% (8,508) fewer general and acute (G&A) beds across England, but occupancy never exceeded 72%. The closest to (surge) capacity that any trust in England reached was 99.8% for general and acute beds. For beds compatible with mechanical ventilation there were 326 trust-days (3.7%) spent above 85% of surge capacity, and 154 trust-days (1.8%) spent above 92%. 23 trusts spent a cumulative 81 days at 100% saturation of their surge ventilator bed capacity (median number of days per trust = 1 [range: 1 to 17]). However, only 3 STPs (aggregates of geographically co-located trusts) reached 100% saturation of their mechanical ventilation beds. Interpretation: Throughout the first wave of the pandemic, an adequate supply of all bed-types existed at a national level. Due to an unequal distribution of bed utilization, many trusts spent a significant period operating above safe occupancy thresholds, despite substantial capacity in geographically co-located trusts; a key operational issue to address in preparing for a potential second wave. Funding: This study received no funding.
2,453 downloads medRxiv health systems and quality improvement
Max Denning, Ee Teng Goh, Alasdair Scott, Guy Martin, Sheraz Markar, Kelsey Flott, Sam Mason, Jan Przybylowicz, Melanie Almonte, Jonathan Clarke, Jasmine Winter Beatty, Swathikan Chidambaram, Seema Yalamanchili, Benjamin Tan, Abhiram Kanneganti, Viknesh Sounderajah, Mary Wells, Sanjay Purkayastha, James Kinross
Introduction Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and in turn patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. Methods The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK teaching hospital during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. Results Significant increased were seen in SAQ scores of doctors and 'other clinical staff', there was no change in the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40-49 years, non-white ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13), non-disclosed ethnicity (-0.11), nursing role (-0.15), and support (0.29) persisted to significance. A significant decrease (p<0.003) was seen in error reporting after the onset of the Covid-19 pandemic. Discussion This is the first study to report SAQ during Covid-19 and compare with baseline. Differences in SAQ scores were observed during Covid-19 between professional groups and compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics.
2,152 downloads medRxiv health systems and quality improvement
ABSTRACT Objectives The overall objectives of this rapid scoping review are to (a) synthesize the common triggers of stress, burnout, and depression faced by women in health care during the COVID-19 pandemic, and (b) identify individual-, organizational-, and systems-level interventions that can support the well-being of women HCWs during a pandemic. Design This scoping review is registered on Open Science Framework (OSF) and was guided by the JBI guide to scoping reviews and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension to scoping reviews. A systematic search of literature databases (Medline, EMBASE, CINAHL, PsycInfo and ERIC) was conducted from 2003 until June 12, 2020. Two reviewers independently assessed full-text articles according to predefined criteria. Interventions We included review articles and primary studies that reported on stress, burnout, and depression in HCWs; that primarily focused on women; and that included the percentage or number of women included. All English language studies from any geographical setting where COVID-19 has affected the population were reviewed. Primary and secondary outcome measures Studies reporting on mental health outcomes (e.g., stress, burnout, and depression in HCWs), interventions to support mental health well-being were included. Results Of the 2,803 papers found, 31 were included. The triggers of stress, burnout and depression are grouped under individual-, organizational-, and systems-level factors. There is a limited amount of evidence on effective interventions that prevents anxiety, stress, burnout and depression during a pandemic. Conclusions Our preliminary findings show that women HCWs are at increased risk for stress, burnout, and depression during the COVID-19 pandemic. These negative outcomes are triggered by individual level factors such as lack of social support; family status; organizational factors such as access to personal protective equipment or high workload; and systems-level factors such as prevalence of COVID-19, rapidly changing public health guidelines, and a lack of recognition at work. Keywords Coronavirus, COVID-19, women in health care, stress, burnout, depression
2,087 downloads medRxiv health systems and quality improvement
Mark J. Siedner, John D. Kraemer, Mark J Meyer, Guy Harling, Thobeka Mngomezulu, Patrick Gabela, Siphephelo Dlamini, Dickman Gareta, Nomathamsanqa Majozi, Nothando Ngwenya, Zahra Reynolds, Janet Seeley, Emily Wong, Collins Iwuji, Maryam Shahmanesh, Willem Hanekom, Kobus Herbst
Objectives Public health interventions designed to interrupt COVID-19 transmission could have deleterious impacts on primary healthcare access. We sought to identify whether implementation of the nationwide lockdown (shelter-in-place) order in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN). Design Prospective, longitudinal cohort study Setting Data were analyzed from the Africa Health Research Institute Health and Demographic Surveillance System, which includes prospective data capture of clinic visits at eleven primary healthcare clinics in northern KwaZulu-Natal Participants A total of 36,291 individuals made 55,545 clinic visits during the observation period. Exposure of Interest We conducted an interrupted time series analysis with regression discontinuity methods to estimate changes in outpatient clinic visitation from 60 days before through 35 days after the lockdown period. Outcome Measures Daily clinic visitation at ambulatory clinics. In stratified analyses we assessed visitation for the following sub-categories: child health, perinatal care and family planning, HIV services, non-communicable diseases, and by age and sex strata. Results We found no change in total clinic visits/clinic/day from prior to and during the lockdown (-6.9 visits/clinic/day, 95%CI -17.4, 3.7) or trends in clinic visitation over time during the lockdown period (-0.2, 95%CI -3.4, 3.1). We did detect a reduction in child healthcare visits at the lockdown (-7.2 visits/clinic/day, 95%CI -9.2, -5.3), which was seen in both children <1 and children 1-5. In contrast, we found a significant increase in HIV visits immediately after the lockdown (8.4 visits/clinic/day, 95%CI 2.4, 14.4). No other differences in clinic visitation were found for perinatal care and family planning, non-communicable diseases, or among adult men and women. Conclusions In rural KZN, the ambulatory healthcare system was largely resilient during the national-wide lockdown order. A major exception was child healthcare visitation, which declined immediately after the lockdown but began to normalize in the weeks thereafter. Future work should explore efforts to decentralize chronic care for high-risk populations and whether catch-up vaccination programs might be required in the wake of these findings.
2,050 downloads medRxiv health systems and quality improvement
Massimo Micocci, Adam Gordon, Mikyung Kelly Seo, Joy A Allen, Kerrie Davies, Dan Lasserson, Carl Thompson, Karen Spilsbury, Cyd Akrill, Ros Heath, Anita Astle, Claire Sharpe, Rafael Perera, Gail Hayward, Peter Buckle
Introduction Reliable rapid testing on COVID-19 is needed in care homes to reduce the risk of outbreaks and enable timely care. Point-of-care testing (POCT) in care homes could provide rapid actionable results. This study aimed to examine the usability and test performance of point of care polymerase chain reaction (PCR) for COVID-19 in care homes. Methods Point-of-care PCR for detection of SARS-COV2 was evaluated in a purposeful sample of four UK care homes. Test agreement with laboratory real-time PCR and usability and use errors were assessed. Results Point of care and laboratory polymerase chain reaction (PCR) tests were performed on 278 participants. The point of care and laboratory tests returned uncertain results or errors for 17 and 5 specimens respectively. Agreement analysis was conducted on 256 specimens. 175 were from staff: 162 asymptomatic; 13 symptomatic. 69 were from residents: 59 asymptomatic; 10 symptomatic. Asymptomatic specimens showed 83.3% (95% CI: 35.9%-99.6%) positive agreement and 98.7% negative agreement (95% CI: 96.2%-99.7%), with overall prevalence and bias-adjusted kappa (PABAK) of 0.965 (95% CI: 0.932-0.999). Symptomatic specimens showed 100% (95% CI: 2.5%-100%) positive agreement and 100% negative agreement (95% CI: 85.8%-100%), with overall PABAK of 1. No usability-related hazards emerged from this exploratory study. Conclusion Applications of point-of-care PCR testing in care homes can be considered with appropriate preparatory steps and safeguards. Agreement between POCT and laboratory PCR was good. Further diagnostic accuracy evaluations and in-service evaluation studies should be conducted, if the test is to be implemented more widely, to build greater certainty on this initial exploratory analysis.
2,019 downloads medRxiv health systems and quality improvement
Objective The purpose of this analysis was to describe national critical care capacity shortages for 52 African countries and to outline needs for each country to adequately respond to the COVID-19 pandemic. Methods A modified SECIR compartment model was used to estimate the number of severe COVID-19 cases at the peak of the outbreak. Projections of the number of hospital beds, ICU beds, and ventilators needed at outbreak peak were generated for four scenarios (if 30, 50, 70, or 100% of patients with severe COVID-19 symptoms seek health services) assuming that all people with severe infections would require hospitalization, that 4.72% would require ICU admission, and that 2.3% would require mechanical ventilation. Findings Across the 52 countries included in this analysis, the average number of severe COVID-19 cases projected at outbreak peak was 138 per 100,000 (SD: 9.6). Comparing current national capacities to estimated needs at outbreak peak, we found that 31of 50 countries (62%) do not have a sufficient number of hospital beds per 100,000 people if 100% of patients with severe infections seek out health services and assuming that all hospital beds are empty and available for use by patients with COVID-19. If only 30% of patients seek out health services then 10 of 50 countries (20%) do not have sufficient hospital bed capacity. The average number of ICU beds needed at outbreak peak across the 52 included countries ranged from 2 per 100,000 people (SD: 0.1) when 30% of people with severe COVID-19 infections access health services to 6.5 per 100,000 (SD: 0.5) assuming 100% of people seek out health services. Even if only 30% of severely infected patients seek health services at outbreak peak, then 34 of 48 countries (71%) do not have a sufficient number of ICU beds per 100,000 people to handle projected need. Only four countries (Cabo Verde, Egypt, Gabon, and South Africa) have a sufficient number of ventilators to meet projected national needs if 100% of severely infected individuals seek health services assuming all ventilators are functioning and available for COVID-19 patients, while 35 other countries require two or more additional ventilators per 100,000 people.
1,978 downloads medRxiv health systems and quality improvement
ObjectivesThe aim of this review was to analyse the implementation and impact of remote home monitoring models (virtual wards) during COVID-19, identifying their main components, processes of implementation, target patient populations, impact on outcomes, costs and lessons learnt. The review will be kept live through regular updates. DesignThe review was designed as a living systematic review to capture a rapidly evolving evidence base. We used the Preferred Reporting Items for Systematic Reviews and Meta- Analysis (PRISMA) statement. SettingThe review included remote home monitoring models led by primary and secondary care across seven countries. Participants17 examples of remote home monitoring models were included in the review. Main outcome measuresImpact of remote home monitoring on virtual length of stay, escalation, Emergency department attendance/reattendance, admission/readmission and mortality. ResultsThe primary aim of the remote home monitoring models was the early identification of deterioration for patients self-managing COVID-19 symptoms at home. Most models were led by secondary care. Broad criteria for the eligible patient population were used and confirmation of COVID-19 was not required (in most cases). Monitoring was carried via online platforms, paper-based systems with telephone calls or (less frequently) through wearable sensors. We could not reach conclusions regarding patient safety and the identification of early deterioration due to lack of standardised reporting across articles and missing data. None of the articles reported any form of economic analysis, beyond how the resources were used. ConclusionsThe review pointed to variability in the implementation of the models, in relation to healthcare sector, monitoring approach and selected outcome measures. Lack of standardisation on reporting prevented conclusions on the impact of remote home monitoring on patient safety or early escalation during COVID-19. Future research should focus on staff and patient experiences of care and potential inequalities in patients access to these models. Attention needs to be paid to the processes used to implement these models, the evaluation of their impact on patient outcomes through the use of comparators, the use of risk-stratification tools, and cost-effectiveness of the models and their sustainability. Protocol registrationThe review protocol was published on PROSPERO (CRD: 42020202888).
1,891 downloads medRxiv health systems and quality improvement
Carl Otto Schell, Karima Khalid, Alexandra Wharton-Smith, Jacquie Narotso Oliwa, Hendry Robert Sawe, Nobhojit Roy, Alex Sanga, John C Marshall, Jamie Rylance, Claudia Hanson, Raphael Kayambankadzanja,, Lee A Wallis, Maria Jirwe, Tim Baker, the EECC Collaborators
BackgroundGlobally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients can be overlooked in health systems. Essential and Emergency Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low-cost and low-complexity for the identification and timely treatment of critically ill patients across all medical specialities. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. MethodsA Delphi process was conducted to seek consensus (>90% agreement) among a diverse panel of global clinical experts. The panel was asked to iteratively rate proposed treatments and actions based on previous guidelines and the WHOs Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent, user-friendly, and feasible EECC package of clinical processes plus a list of hospital resource requirements. ResultsThe 272 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 hospital readiness requirements. The essential diagnosis-specific care of critically ill COVID-19 patients has an additional 7 clinical processes and 9 hospital readiness requirements. ConclusionThe study has specified the content of the essential emergency and critical care that should be provided to all critically ill patients. Implementation of EECC could be an effective strategy to reduce preventable deaths worldwide. As critically ill patients have high mortality rates in all hospital settings, especially where trained staff or resources are limited, even small improvements would have a large impact on survival. EECC has a vital role in the effective scale-up of oxygen and other care for critically ill patients in the COVID-19 pandemic. Policy makers should prioritise EECC, increase its coverage in hospitals, and include EECC as a component of universal health coverage.
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