Solar-powered oxygen, quality improvement and child pneumonia deaths: a large-scale effectiveness study

Abstract

BackgroundPneumonia is the largest cause of child deaths in low-income countries. Lack of availability of oxygen in small rural hospitals results in avoidable deaths and unnecessary and unsafe referrals.MethodWe evaluated a programme for improving reliable oxygen therapy using oxygen concentrators, pulse oximeters and sustainable solar power in 38 remote health facilities in nine provinces in Papua New Guinea. The programme included a quality improvement approach with training, identification of gaps, problem solving and corrective measures. Admissions and deaths from pneumonia and overall paediatric admissions, deaths and referrals were recorded using routine health information data for 2–4 years prior to the intervention and 2–4 years after. Using Poisson regression we calculated incidence rates (IRs) preintervention and postintervention, and incidence rate ratios (IRR).ResultsThere were 18 933 pneumonia admissions and 530 pneumonia deaths. Pneumonia admission numbers were significantly lower in the postintervention era than in the preintervention era. The IRs for pneumonia deaths preintervention and postintervention were 2.83 (1.98–4.06) and 1.17 (0.48–1.86) per 100 pneumonia admissions: the IRR for pneumonia deaths was 0.41 (0.24–0.71, p<0.005). There were 58 324 paediatric admissions and 2259 paediatric deaths. The IR for child deaths preintervention and postintervention were 3.22 (2.42–4.28) and 1.94 (1.23–2.65) per 100 paediatric admissions: IRR 0.60 (0.45–0.81, p<0.005). In the years postintervention period, an estimated 348 lives were saved, at a cost of US$6435 per life saved and over 1500 referrals were avoided.ConclusionsSolar-powered oxygen systems supported by continuous quality improvement can be achieved at large scale in rural and remote hospitals and health care facilities, and was associated with reduced child deaths and reduced referrals. Variability of effectiveness in different contexts calls for strengthening of quality improvement in rural health facilities.Trial registration numberACTRN12616001469404.

The impact of pulse oximetry on diagnosis, management and outcomes of acute febrile illness in low-income and middle-income countries: a systematic review

“…All studies enrolled children aged <15 years. Six studies included, but not exclusively, patients <2 months old [23][24][25][26][27][28] ; another enrolled only those in this age group. 29 Seven studies included patients aged 2 months to ≤5 years, 23-28 30-32 and only two included children >5 years and adolescents.…”

Oxygen systems and quality of care for children with pneumonia, malaria and diarrhoea: Analysis of a stepped-wedge trial in Nigeria

“…In Papua New Guinea (PNG), Duke et al suggested that the most probable explanation for the observed 35% mortality reduction for children admitted to hospital with pneumonia is “the improved system and better quality of care that accompanies such a system” [ 3 , 6 ]. Following this rationale, subsequent work in Laos and remote clinics in the PNG highlands introduced improved oxygen systems alongside other clinical education and quality improvement activities—not only addressing pneumonia and oxygen therapy, but also many other important aspects of hospital care for children [ 6 , 8 ]. These programs reported substantial mortality benefits for children with pneumonia, and the PNG program also documented substantial benefits for children overall [ 6 , 8 ].…”

“…Following this rationale, subsequent work in Laos and remote clinics in the PNG highlands introduced improved oxygen systems alongside other clinical education and quality improvement activities—not only addressing pneumonia and oxygen therapy, but also many other important aspects of hospital care for children [ 6 , 8 ]. These programs reported substantial mortality benefits for children with pneumonia, and the PNG program also documented substantial benefits for children overall [ 6 , 8 ].…”

“…Effective oxygen systems are an important element of quality hospital care and are critical for achieving good clinical outcomes for patients with severe pneumonia [1,2]. Improvements in hospital oxygen systems have been shown to reduce inpatient child mortality from pneumonia by 35-58%, yet oxygen access for patients remains poor in many low-and middle-income countries (LMICs) [3][4][5][6][7][8]. The COVID-19 pandemic has further highlighted the importance of improving hospital oxygen systems, and the fatal consequences of deficient systems, pushing oxygen access higher onto the global health agenda [9,10].…”

“…Findings from previous oxygen improvement programs suggest that clinical impacts are more significant if oxygen is approached as part of a more comprehensive quality improvement program [ 3 , 6 , 8 ]. Authors postulated that improvements in oxygen systems may have contributed to broader improvements in structures and processes of care, thereby enabling the oxygen improvement program to achieve more substantial reductions in mortality, than would have been possible with a narrower approach to oxygen systems [ 3 , 6 ].…”