Essential Emergency and Critical Care as a health system response to critical illness and the COVID19 pandemic: What does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, low-cost care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in low resource settings with Kenya and Tanzania as case studies.

The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.

The costs per patient day of EECC is estimated to be 1.01 USD, 10.83 USD and 32.84 USD in Tanzania and 1.76 USD, 14.86 USD and 37.43 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13.11 USD and 17.33 USD for severe and 297.30 USD and 369.64 USD for critical COVID-19 patients in Tanzania and Kenya, respectively.

EECC, an approach of providing the essential care to all critically ill patients, is low-cost. The components of EECC are basic and universal and, when assessed against the existing gaps in critical care coverage and costs of advanced critical care, suggest that it should be a priority area of investment for health systems around the globe.

On prioritising global health’s triple crisis of sepsis, COVID-19 and antimicrobial resistance: a mixed-methods study from Malawi

Sepsis causes 20% of global deaths, particularly among children and vulnerable populations living in developing countries. This study investigated how sepsis is prioritised in Malawi’s health system to inform health policy. In this mixed-methods study, twenty multisectoral stakeholders were qualitatively interviewed and asked to quantitatively rate the likelihood of sepsis-related medium-term policy outcomes being realised. Respondents indicated that sepsis is not prioritised in Malawi due to a lack of local sepsis-related evidence and policies. However, they highlighted strong linkages between sepsis and maternal health, antimicrobial resistance and COVID-19, which are already existing national priorities, and offers opportunities for sepsis researchers as policy entrepreneurs. To address the burden of sepsis, we recommend that funding should be channelled to the generation of local evidence, evidence uptake, procurement of resources and treatment of sepsis cases, development of appropriate indicators for sepsis, adherence to infection prevention and control measures, and antimicrobial stewardship.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-saharan Africa: a Co-creation Consensus Approach

Background:

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi-consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa as well as to implement the checklist in health institutions in four African countries.

Method:

The AMS checklist tool was developed using a modified Delphi approach to achieve local, expert consensus on items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, and Ghana were invited to review, score and comment on items from a published, global AMS checklist. Following their feedback, eight items were re-phrased and 25 new items added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites.

Findings:

The final tool comprised 54 items. Across the 14 sites, the checklist consistently showed improvements for all AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). Elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions.

Conclusion:

Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. The study extends existing AMS materials for low and middle-income countries and provides empirical evidence for successful use in practice.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

A mixed methods study to assess the impact of COVID-19 on maternal, newborn, child Health and nutrition in fragile and conflict-affected settings

Background: The impacts of COVID-19 are unprecedented globally. The pandemic is reversing decades of progress in maternal, newborn, child health and nutrition (MNCHN), including fragile and conflict-affected settings (FCAS) whose populations were already facing challenges in accessing basic health and nutrition services. This study aimed to investigate the collateral impact of COVID-19 on funding, services and MNCHN outcomes in FCAS, as well as adaptations used in the field to continue activities.

Methods: A scoping review of peer-reviewed and grey literature published between

1st March 2020 – 31st January 2021 was conducted and analysed using a narrative synthesis approach. 39 remote semi-structured key informant interviews with humanitarian actors and donor staff within 12 FCAS were conducted between October 2020 and February 2021. Thematic analysis was undertaken independently by two researchers on interview transcripts and supporting documents provided by key informants, and triangulated with literature review findings.

Results: Funding for MNCHN has been reduced or suspended with increase in cost of continuing the same activities, and diversion of MNCHN funding to COVID-19 activities. Disruption in supply and demand of interventions was reported across different settings which, despite data evidence still being missing, points towards likely increased maternal and child morbidity and mortality. Some positive adaptations including use of technology and decentralisation of services have been reported, however overall adaptation strategies have been insufficient to equitably meet additional challenges posed by the pandemic, and have not been evaluated for their effectiveness.

Conclusions: COVID-19 is further exacerbating negative women’s and children’s health outcomes in FCAS. Increased funding is urgently required to re-establish MNCHN activities which have been deprioritised or halted. Improved planning to sustain routine health services and enable surge planning for emergencies with focus on the community/service users throughout adaptations is vital for improved MNCHN outcomes in FCAS.

Surviving the Struggle of COVID-19: Practical Recommendations for Pediatric/Adult Cardiology and Cardiac Surgical Programs in Resource-Limited Settings: a Review

Introduction: The primary aim of this systematic review is to provide perioperative strategies to help restore or preserve cardiovascular services under threat from financial and personnel constraints imposed by the coronavirus disease 2019 (COVID-19) pandemic.
Methods: The Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials/CCTR, and Google Scholar were systematically searched using the search terms “(cardiac OR cardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus OR SARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)”. Additionally, the webpages of relevant medical
societies, including the World Federation Society of Anesthesiologists, the Cardiothoracic Surgery Network, and the Society of Thoracic Surgeons, were screened for relevant information.
Results: Whereas cardiac surgery and cardiology practices were reduced by 50–75% during the pandemic, mortality of patients with COVID-19 increased significantly. Healthcare workers are among those at high risk of infection with COVID-19.
Conclusion: Hospitals must provide maximum protective equipment and training on how to use it to healthcare workers for their mutual protection. Triage management of patients — which accounts for patient’s clinical status and risk-factor profile relatable to which services are available during the COVID-19 pandemic — is recommended. A strict reorganization of the hospital resources including preoperative, intraoperative, and postoperative detailed protective measures is necessary to reduce probability of vector contamination, to protect patients and the cardiovascular teams, and to permit safe resumption of cardiological and cardiac surgical activity.

Analysing the trends in breast surgery practice during COVID-19 pandemic: A comparative study with the Pre-COVID era

The emergence of coronavirus disease 2019 (COVID-19) pandemic has crippled the healthcare systems all over the world. Cancer treatment is indispensable and disruption in its provision can lead to unanticipated consequences. No local data exists that has quantified the impact of COVID-19 pandemic on breast cancer surgery in a lower middle-income country (LMIC), therefore, the present retrospective comparative cohort study is directed to determine the trends in breast surgery operative volumes and its outcomes at our institution in Pakistan.

Materials and methods
Data was collected retrospectively from Pre-COVID-19 and COVID-19 era to determine impact of the current pandemic on breast cancer management practices and outcomes.

Results
Cohort results showed a decline in the number of surgeries during COVID-19 era. A total 149 cases were operated during study period vs. 231 during same Pre-COVID-19 i.e. a 35.5% drop in cancer surgeries. In early COVID-19 time frame, only 4 patients had breast reconstruction, 12 out of 149 (8.05%) surgical candidates were identified having positive COVID-19 status preoperatively and one ASA class 3 patient caught COVID-19 post-surgery and succumbed to virus.

Conclusion
Pandemic has a negative effect on cancer management in a LMIC with compromised access and care of cancer patients.

Surgical Management During the COVID-19 Era at a Private Tertiary Care Hospital of Karachi, Pakistan: A Cross-Sectional Study

Background
The coronavirus disease 2019 (COVID-19), declared a pandemic in March 2020, has affected the entire healthcare system, including the surgical practice. Guidelines for the management of surgical patients during this COVID-19 era need to be established to provide timely yet safe surgical care. In this study, we aimed to evaluate the outcomes of the COVID-19 testing algorithm established for surgery patients presenting to a tertiary care hospital in Karachi, Pakistan, and to compare the outcomes among patients who underwent elective versus emergency surgery.

Methodology
This is a cross-sectional study conducted at a tertiary care hospital in Pakistan to apply and assess the outcomes of the COVID-19 testing algorithm established for patients presenting for surgery. We included all patients who underwent any surgery from May to October 2020. The total sample size was 6,846. The data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY, USA). The categorical variables were assessed using the chi-square or Fisher’s exact test. A p-value of <0.05 was considered significant.

Results
A total of 6,846 surgeries were performed from May 1 to October 31, 2020. In total, 74% of the surgeries were elective procedures. We observed that a significantly higher proportion of emergency surgery patients tested positive for COVID-19 (4.2%) compared to elective surgery patients (25/5,063, 0.5%). A higher proportion of surgeries were performed in September (1,437, 21%) and October (1,445, 21%) while the lowest number of surgeries were performed in May (625, 9.1%). From week one to week five, a higher proportion of emergency surgeries were performed (32%) compared to elective surgeries (25%). Only 1.9% of the patients who were undergoing surgery were COVID-19 positive, with the highest number of COVID-19 cases presenting in June. Overall, 74.7% of the COVID-19-positive patients underwent emergency surgeries.

Conclusions
The timely establishment of well-defined guidelines for surgical management during the pandemic allowed us to provide timely and effective surgical care to patients with the priority of minimizing the spread of COVID-19 and preventing unnecessary deferral of surgeries.

Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations

Objective
A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need.

Design
A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care.

Results
Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.

Conclusions
A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Impact of COVID-19 on Cardiovascular Disease Presentation, Emergency Department Triage and Inpatient Cardiology Services in a Low- to Middle-Income Country – Perspective from a Tertiary Care Hospital of Pakistan

Aims: To identify the changes in cardiovascular disease presentation, emergency room triage and inpatient diagnostic and therapeutic pathways.

Methods: We conducted a retrospective cohort study at the Aga Khan University Hospital, Karachi. We collected data for patients presenting to the emergency department with cardiovascular symptoms between March–July 2019 (pre-COVID period) and March–July 2020 (COVID period). The comparison was made to quantify the differences in demographics, clinical characteristics, admission, diagnostic and therapeutic procedures, and in-hospital mortality between the two periods.

Results: Of 2976 patients presenting with cardiac complaints to the emergency department (ED), 2041(69%) patients presented during the pre-COVID period, and 935 (31%) patients presented during the COVID period. There was significant reduction in acute coronary syndrome (ACS) (8% [95% CI 4–11], p < 0.001) and heart failure (↓6% [95% CI 3–8], p < 0.001). A striking surge was noted in Type II Myocardial injury (↑18% [95% CI 20–15], p < 0.001) during the pandemic. There was reduction in cardiovascular admissions (coronary care unit p < 0.01, coronary step-down unit p = 0.03), cardiovascular imaging (p < 0.001), and procedures (percutaneous coronary intervention p = 0.04 and coronary angiography p = 0.02). No significant difference was noted in mortality (4.7% vs. 3.7%). The percentage of patients presenting from rural areas declined significantly during the COVID period (18% vs. 14%, p = 0.01). In the subgroup analysis of sex, we noticed a falling trend of intervention performed in females during the COVID period (8.2% male vs. 3.3 % female). Conclusions: This study shows a significant decline in patients presenting with Type I myocardial infarction (MI) and a decrease in cardiovascular imaging and procedures during the COVID period. There was a significant increase noted in Type II MI.