Improving oxygen therapy for children and neonates in secondary hospitals in Nigeria: study protocol for a stepped-wedge cluster randomised trial

Abstract

BackgroundOxygen is a life-saving, essential medicine that is important for the treatment of many common childhood conditions. Improved oxygen systems can reduce childhood pneumonia mortality substantially. However, providing oxygen to children is challenging, especially in small hospitals with weak infrastructure and low human resource capacity.Methods/designThis trial will evaluate the implementation of improved oxygen systems at secondary-level hospitals in southwest Nigeria. The improved oxygen system includes: a standardised equipment package; training of clinical and technical staff; infrastructure support (including improved power supply); and quality improvement activities such as supportive supervision. Phase 1 will involve the introduction of pulse oximetry alone; phase 2 will involve the introduction of the full, improved oxygen system package. We have based the intervention design on a theory-based analysis of previous oxygen projects, and used quality improvement principles, evidence-based teaching methods, and behaviour-change strategies.We are using a stepped-wedge cluster randomised design with participating hospitals randomised to receive an improved oxygen system at 4-month steps (three hospitals per step). Our mixed-methods evaluation will evaluate effectiveness, impact, sustainability, process and fidelity. Our primary outcome measures are childhood pneumonia case fatality rate and inpatient neonatal mortality rate. Secondary outcome measures include a range of clinical, quality of care, technical, and health systems outcomes. The planned study duration is from 2015 to 2018.DiscussionOur study will provide quality evidence on the effectiveness of improved oxygen systems, and how to better implement and scale-up oxygen systems in resource-limited settings. Our results should have important implications for policy-makers, hospital administrators, and child health organisations in Africa and globally.Trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN12617000341325. Retrospectively registered on 6 March 2017.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-017-2241-8) contains supplementary material, which is available to authorized users.

Adoption of paediatric and neonatal pulse oximetry by 12 hospitals in Nigeria: a mixed-methods realist evaluation

“…The Nigeria Oxygen Implementation project evaluation includes quantitative impact evaluation, process and technical evaluations, and mixed-methods assessment of programme theories using realist evaluation 21. This paper focuses on a realist evaluation of oximetry adoption in the 12 participating hospitals.…”

“…We conducted this study in 12 secondary-level hospitals in seven urban areas of south-west Nigeria between 1 January 2014 and 30 April 2017 (which coincided with a national economic recession26). These hospitals included government and mission hospitals of varying sizes, selected to be representative of secondary health facilities that admitted children 12 21. Hospitals were typically fee-paying, staffed by doctors and nurses (variable paediatric expertise), well stocked with medications but had poor power supply and oxygen availability (table 1, additional details in online supplementary appendix 1).…”

“…We introduced oximetry into the paediatric and newborn wards of 12 Nigerian hospitals, as part of the Nigeria Oxygen Implementation project, a stepped-wedge trial seeking to improve the provision of oxygen to children and newborns 21. We derived our overall programme theory from our realist review of 20 oxygen therapy projects from 15 countries 13.…”

Using intermittent pulse oximetry to guide neonatal oxygen therapy in a low-resource context

“…The study hospitals were also participating in an oxygen improvement project, and had already improved their oxygen practices substantially prior to this study. In the 2 years prior to this study, all three hospitals had adopted pulse oximetry into routine practice, and installed oxygen delivery systems that enabled them to more easily and accurately provide oxygen to patients (including 0-2 LPM flowmeters, nasal prongs, oxygen concentrators and reliable power supply) 16 17. Unpublished data show that the introduction of pulse oximetry did improve the quality of oxygen care in our study hospitals (personal correspondence, Dr Hamish Graham, January 2019).…”

“…We did not provide additional refresher training or reminders, as we intended to evaluate routine care. Staff had previously received training and supportive supervision on pulse oximetry and the oxygen protocol in November 2015 16 17. The oxygen protocol recommended using pulse oximetry for every neonate admitted to the nursery, and commencement of oxygen therapy if any SpO 2 reading was <90%.…”