The impact of pulse oximetry and Integrated Management of Childhood Illness (IMCI) training on antibiotic prescribing practices in rural Malawi: A mixed-methods study

Sylvies, Fiona; Nyirenda, Lucy; Blair, Alden; Baltzell, Kimberly

doi:10.1371/journal.pone.0242440

Cited by 9 publications

(8 citation statements)

References 24 publications

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“…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.…”

Section: Resultsmentioning

confidence: 99%

“…25 26 28 Staff should be given appropriate and ongoing training not just in the mechanics of pulse oximetry but also in its use in syndromic diagnosis and clinical management, thus building patient and caregiver trust in their clinical decision-making 23 26 28 29 32 41 42 ; largerscale benefits, such as better antibiotic stewardship may follow. 23 Fourth, pulse oximetry should not be rolled out in isolation if its full potential to improve the care of acutely febrile patients in LMICs is to be realised. Rather, it must be part of a systems approach incorporating reliable access to supplemental oxygen as well as strengthening of health infrastructure, sustainable provision of context-appropriate equipment and staff training, and continuous and comprehensive quality improvement.…”

Section: Discussionmentioning

confidence: 99%

“…When compared with IMCI alone, the addition of pulse oximetry increased the odds of reducing antibiotic prescription over sevenfold, despite only 30% of children in the intervention group having had SpO 2 measured. 23 Impact of pulse oximetry on patient outcomes Six studies assessed the impact of pulse oximetry on patient outcomes (table 3). The strength of the evidence presented in this section is low.…”

Section: Impact Of Pulse Oximetry On Diagnosismentioning

confidence: 99%

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

et al. 2021

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BackgroundAcute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such patients but is poorly detected by clinical examination. Therefore, including pulse oximetry in the assessment of acutely febrile patients may improve clinical outcomes in LMIC settings.MethodsWe systematically reviewed studies of any design comparing one group where pulse oximetry was used and at least one group where it was not. The target population was patients of any age presenting with acute febrile illness or associated syndromes in LMICs. Studies were obtained from searching PubMed, EMBASE, CABI Global Health, Global Index Medicus, CINAHL, Cochrane CENTRAL, Web of Science and DARE. Further studies were identified through searches of non-governmental organisation websites, snowballing and input from a Technical Advisory Panel. Outcomes of interest were diagnosis, management and patient outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 tool for Cluster Randomised Trials and Risk of Bias in Non-randomized Studies of Interventions tools, as appropriate.ResultsTen of 4898 studies were eligible for inclusion. Their small number and heterogeneity prevented formal meta-analysis. All studies were in children, eight only recruited patients with pneumonia, and nine were conducted in Africa or Australasia. Six were at serious risk of bias. There was moderately strong evidence for the utility of pulse oximetry in diagnosing pneumonia and identifying severe disease requiring hospital referral. Pulse oximetry used as part of a quality-assured facility-wide package of interventions may reduce pneumonia mortality, but studies assessing this endpoint were at serious risk of bias.ConclusionsVery few studies addressed this important question. In LMICs, pulse oximetry may assist clinicians in diagnosing and managing paediatric pneumonia, but for the greatest impact on patient outcomes should be implemented as part of a health systems approach. The evidence for these conclusions is not widely generalisable and is of poor quality.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Impact Of Pulse Oximetry On Diagnosismentioning

confidence: 99%

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

et al. 2021

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“…Perceived improved confidence in the clinical decision making of clinical officers and nurses after pulse oximetry and specialty-specific training has also been seen in Malawi among healthcare workers caring for children with suspected pneumonia. [ 20 ] However, education alone may not be enough to improve confidence and a thoughtful approach to setting and context and clinical role within the healthcare team need to be considered for future education capacity building initiatives. [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training

Peterson

Mattingly

Merrell

et al. 2022

BMC Health Serv Res

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Background Pulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists’ perioperative care and what, if any, capacity gaps remain. Methods We identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa > 0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care. Results Ten of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial. Conclusion Among a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.

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“…Several recent studies have demonstrated the utility of pulse oximetry in clinical decision‐making by identifying severely ill young children with community‐acquired pneumonia by primary health workers in sub‐Saharan Africa [ 13 , 14 , 15 ], as well as reducing likely inappropriate antibiotic prescription. Among the reasons for the latter are increased diagnostic confidence and improved management of patient and/or caregiver expectations through demonstration of objective physiological measurements [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

Modelling the cost‐effectiveness of pulse oximetry in primary care management of acute respiratory infection in rural northern Thailand

Chew

Greer

Tasak

et al. 2022

Tropical Med Int Health

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Objectives We aimed to determine the cost‐effectiveness of supplementing standard care with pulse oximetry among children <5 years with acute respiratory infection (ARI) presenting to 32 primary care units in a rural district (total population 241,436) of Chiang Rai province, Thailand, and to assess the economic effects of extending pulse oximetry to older patients with ARI in this setting. Methods We performed a model‐based cost‐effectiveness analysis from a health systems perspective. Decision trees were constructed for three patient categories (children <5 years, children 5–14 years, and adults), with a 1‐year time horizon. Model parameters were based on data from 49,958 patients included in a review of acute infection management in the 32 primary care units, published studies, and procurement price lists. Parameters were varied in deterministic sensitivity analyses. Costs were expressed in 2021 US dollars with a willingness‐to‐pay threshold per DALY averted of $8624. Results The annual direct cost of pulse oximetry, associated staff, training, and monitoring was $24,243. It reduced deaths from severe lower respiratory tract infections in children <5 years by 0.19 per 100,000 patients annually. In our population of 14,075 children <5 years, this was equivalent to 2.0 DALYs averted per year. When downstream costs such as those related to hospitalisation and inappropriate antibiotic prescription were considered, pulse oximetry dominated standard care, saving $12,757 annually. This intervention yielded smaller mortality gains in older patients but resulted in further cost savings, primarily by reducing inappropriate antibiotic prescriptions in these age groups. The dominance of the intervention was also demonstrated in all sensitivity analyses. Conclusions Pulse oximetry is a life‐saving, cost‐effective adjunct in ARI primary care management in rural northern Thailand. This finding is likely to be generalisable to neighbouring countries with similar disease epidemiology and health systems.

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The impact of pulse oximetry and Integrated Management of Childhood Illness (IMCI) training on antibiotic prescribing practices in rural Malawi: A mixed-methods study

Cited by 9 publications

References 24 publications

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

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

Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training

Modelling the cost‐effectiveness of pulse oximetry in primary care management of acute respiratory infection in rural northern Thailand

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