Most downloaded biology preprints, all time
in category health systems and quality improvement
163 results found. For more information, click each entry to expand.
9,000 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.
3,265 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 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.
3,058 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.
2,915 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.
2,856 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.
2,800 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.
2,695 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.
2,642 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.
2,423 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.
1,867 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.
1,645 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 Perrera, 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.
1,466 downloads medRxiv health systems and quality improvement
The SARS-CoV-2 virus has so far infected more than2.4 million people around the world, and its impact is being felt by all. Patients with airborne diseases such as Covid-19 should ideally be treated in negative pressure isolation rooms. However, due to the overwhelming demand for hospital beds, patients treated in general wards, hospital corridors, and makeshift hospitals. Adequate building ventilationin hospitals and public spaces is a crucial factor to contain the disease [1,2], to exit the current lockdown situation, and reduce the chance of subsequent waves of outbreaks. Lu et al.  reported an air-conditioner induced Covid-19 outbreak, by an asymptomatic patient, in a restaurant in Guangzhou, China, which exposes our vulnerability to future outbreaks linked to ventilation in public spaces. We demonstrate that displacement ventilation(either mechanical or naturalventilation), where air intakes are at low level and extracts are at high level, is a viable alternative to negative pressure isolation rooms, which are often not available on site in hospital wards and makeshift hospitals. Displacement ventilation produces negative pressure at the occupant level, which draws fresh air from outdoor, and positive pressure near the ceiling, which expels the hot and contaminated air out. We acknowledge that, in both developed and developing countries, many modern large structures lack the openings required for natural ventilation. This lack of openings can be supplemented by installing extract fans. We provide guidelines for such mechanically assisted-naturally ventilated makeshift hospitals, and public spaces such as supermarkets and essential public buildings
1,463 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.
1,271 downloads medRxiv health systems and quality improvement
Introduction: Coronavirus disease (COVID-19), a respiratory illness, first discovered in China in December 2019 has now spread to 213 countries or territories affecting millions across the globe. We received a request from National Health Systems Resource Centre, a public agency in India, for a Rapid Evidence Synthesis (RES) on community health workers (CHWs) for COVID-19 prevention and control. Methods: We searched PubMed, websites of ministries, public agencies, multilateral institutions, COVID-19 resource aggregators and pre-prints (without language restrictions) for articles on the role, challenges and enablers for CHWs in pandemics. Two reviewers screened the records independently with a third reviewer resolving disagreements. One reviewer extracted data in a consensus data extraction form with another reviewer cross-checking it. A framework on CHW performance in primary healthcare not specific to pandemic was used to guide data extraction and narrative analysis. Results: We retrieved 211 records and finally included 36 articles on the role, challenges and enablers for CHWs in pandemics. We found that CHWs play an important role in building awareness, countering stigma and maintaining essential primary healthcare service delivery. It is essential that CHWs are provided adequate Personal Protective Equipment (PPE) and appropriately trained in its usage in the early stages of the pandemic. Wide range of policies and guidance is required to ensure health systems functioning. A clear guidance for prioritizing essential activities, postponing non-essential ones and additional pandemic related activities is crucial. CHWs experience stigmatization, isolation and social exclusion. Psychosocial support, non-performance-based incentives, additional transport allowance, accommodation, child-support, awards and recognition programs have been used in previous pandemics. We also created inventories of resources with guiding notes for quick utility by decision makers on guidelines for health workers (n=24), self-isolation in the community (n=10) and information, education and counselling materials on COVID-19 (n=16). Conclusions: CHWs play a critical role in pandemics like COVID-19. It is important to ensure role clarity, training, supportive supervision, as well as their work satisfaction, health and well-being. There is a need for more implementation research on CHWs in pandemics like COVID-19.
1,202 downloads medRxiv health systems and quality improvement
Mark 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.
1,198 downloads medRxiv health systems and quality improvement
Background: Response to the COVID-19 pandemic calls for precision public health reflecting our improved understanding of who is the most vulnerable and their geographical location. We created three vulnerability indices to identify areas and people who require greater support while elucidating health inequities to inform emergency response in Kenya. Methods: Geospatial indicators were assembled to create three vulnerability indices; social (SVI), epidemiological (EVI) and a composite of the two (SEVI) resolved at 295 sub-counties in Kenya. SVI included nineteen indicators that affect the spread of disease; socio-economic inequities, access to services and population dynamics while EVI comprised five indicators describing comorbidities associated with COVID-19 severe disease progression. The indicators were scaled to a common measurement scale, spatially overlaid via arithmetic mean and equally weighted. The indices were classified into seven classes, 1-2 denoted low-vulnerability and 6-7 high-vulnerability. The population within vulnerabilities classes was quantified. Results: The spatial variation of each index was heterogeneous across Kenya. Forty-nine north-western and partly eastern sub-counties (6.9 m people) were highly vulnerable while 58 sub-counties (9.7 m people) in western and central Kenya were the least vulnerable for SVI. For EVI, 48 sub-counties (7.2 m people) in central and the adjacent areas and 81 sub-counties (13.2 m people) in northern Kenya were the most and least vulnerable respectively. Overall (SEVI), 46 sub-counties (7.0 m people) around central and south-eastern were more vulnerable while 81 sub-counties (14.4 m people) that were least vulnerable. Conclusion: The vulnerability indices created are tools relevant to the county, national government and stakeholders for prioritization and improved planning especially in highly vulnerable sub-counties where cases have not been confirmed. The heterogeneous nature of the vulnerability highlights the need to address social determinants of health disparities, strengthen the health system and establish programmes to cushion against the negative effects of the pandemic.
1,177 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.
1,161 downloads medRxiv health systems and quality improvement
Oilson A. Gonzatto, Diego C. Nascimento, Cibele Maria Russo, Marcos Jardel Henriques, Caio Paziani Tomazella, Maristela Oliveira Santos, Denis Neves, Diego Assad, Rafaela Guerra, Evelyn Keise Bertazo, Jose Alberto Cuminato, Francisco Louzada
Background: Many challenges lie ahead for COVID-19, not only related to the acceleration of the pandemic, but also to the prediction of the hospital's personal protective equipment to accommodate the explosive demand. Due to the situation of uncertainty, the hospital administration encourages the excess stock of these materials, causing excess products in some hospitals, but shortages in others. Although three main factors limit the number of patients seen at a hospital: the number of beds available, the number of equipment, and, above all, the number of health professionals available at the hospital, per shift. Objective: In this scenario, a challenge is to build an easy-to-use computational tool to predict the demand for personal protective equipment in hospitals during the COVID-19 pandemic, with updating in real-time. Methods: We propose naive statistical modeling, which combines historical data on the consumption of personal protective equipment by hospitals, current protocols for their uses and epidemiological data related to the disease, in order to build predictive models for the demand for personal protective equipment in Brazilian hospitals during the pandemic. We then embed our modeling in a tool that can provide the safety stock for a particular hospital. Results: Our tool presents forecasts of consumption/demand for personal protective equipment over time, indicating the moment when the hospital reaches maximum consumption, the estimate of how long it will work in this state, and when it will leave it. Conclusion: With our forecasting, a hospital may have estimated, based on its stock levels and possible new purchases, its needs related to a specific personal protective equipment, which allows for the adoption of strategies to control and keep the stock at safety levels to the demand. As a direct consequence, it enables interchange and cooperation between hospitals, aiming to maximize the care during the pandemic.
1,149 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
1,088 downloads medRxiv health systems and quality improvement
Sulaiman Somani, Felix Richter, Valentin Fuster, Jessica De Freitas, Nidhi Naik, Keith Sigel, Mount Sinai Covid Informatics Center (MSCIC), Erwin P. Boettinger, Matthew Levin, Zahi Fayad, Allan C Just, Alexander Charney, Shan Zhao, Benjamin S Glicksberg, Anuradha Lala, Girish Nadkarni
Background: Data on patients with coronavirus disease 2019 (COVID-19) who return to hospital after discharge are scarce. Characterization of these patients may inform post-hospitalization care. Methods and Findings: Retrospective cohort study of patients with confirmed SARS-CoV-2 discharged alive from five hospitals in New York City with index hospitalization between February 27th-April 12th, 2020, with follow-up of [≥]14 days. Significance was defined as P<0.05 after multiplying P by 125 study-wide comparisons. Of 2,864 discharged patients, 103 (3.6%) returned for emergency care after a median of 4.5 days, with 56 requiring inpatient readmission. The most common reason for return was respiratory distress (50%). Compared to patients who did not return, among those who returned there was a higher proportion of COPD (6.8% vs 2.9%) and hypertension (36% vs 22.1%). Patients who returned also had a shorter median length of stay (LOS) during index hospitalization (4.5 [2.9,9.1] vs. 6.7 [3.5, 11.5] days; Padjusted=0.006), and were less likely to have required intensive care on index hospitalization (5.8% vs 19%; Padjusted=0.001). A trend towards association between absence of in-hospital anticoagulation on index admission and return to hospital was also observed (20.9% vs 30.9%, Padjusted=0.064). On readmission, rates of intensive care and death were 5.8% and 3.6%, respectively. Conclusions: Return to hospital after admission for COVID-19 was infrequent within 14 days of discharge. The most common cause for return was respiratory distress. Patients who returned had higher proportion of COPD and hypertension with shorter LOS on index hospitalization, and a trend towards lower rates of in-hospital treatment-dose anticoagulation. Future studies should focus on whether these comorbid conditions, longer LOS and anticoagulation are associated with reduced readmissions.
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