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

Abstract

Objectives: To evaluate the effect of improved hospital oxygen systems on quality of care (QOC) for children with severe pneumonia, severe malaria, and diarrhoea with severe dehydration.

Design: Stepped-wedge cluster randomised trial (unblinded), randomised at hospital-level.

Setting: 12 hospitals in south-west Nigeria.

Participants: 7,141 children (aged 28 days to 14 years) admitted with severe pneumonia, severe malaria or diarrhoea with severe dehydration between January 2014 and October 2017.

Interventions: Phase 1 (pulse oximetry) introduced pulse oximetry for all admitted children. Phase 2 (full oxygen system) (i) standardised oxygen equipment package, (ii) clinical education and support, (iii) technical training and support, and (iv) infrastructure and systems support.

Outcome measures: We used quantitative QOC scores evaluating assessment, diagnosis, treatment, and monitoring practices against World Health Organization and Nigerian standards. We evaluated mean differences in QOC scores between study periods (baseline, oximetry, full oxygen system), using mixed-effects linear regression.

Results: 7,141 eligible participants; 6,893 (96.5%) had adequate data for analysis. Mean paediatric QOC score (maximum 6) increased from 1.64 to 3.00 (adjusted mean difference 1.39; 95% CI 1.08-1.69, p<0.001) for severe pneumonia and 2.81 to 4.04 (aMD 1.53; 95% CI 1.23-1.83, p<0.001) for severe malaria, comparing the full intervention to baseline, but did not change for diarrhoea with severe dehydration (aMD -0.12; 95% CI -0.46-0.23, p = 0.501). After excluding practices directly related to pulse oximetry and oxygen, we found aMD 0.23 for severe pneumonia (95% CI -0.02-0.48, p = 0.072) and 0.65 for severe malaria (95% CI 0.41-0.89, p<0.001) comparing full intervention to baseline. Sub-analysis showed some improvements (and no deterioration) in care processes not directly related to oxygen or pulse oximetry.

Conclusion: Improvements in hospital oxygen systems were associated with higher QOC scores, attributable to better use of pulse oximetry and oxygen as well as broader improvements in clinical care, with no negative distortions in care practices.

Trial registration: ACTRN12617000341325.

Fig 1. Participant inclusion in analysis, by diagnosis (all steps).

Fig 2. Crude QOC score total means (maximum six points) for severe pneumonia, severe malaria and diarrhoea with severe dehydration, by hospital and step.

Each cell contains the crude mean QOC score for a hospital during that step. For each of the three panels in this figure, the 12 hospitals are represented on the y-axis, whereas the steps of the trial are represented on the x-axis. The colour gradient extends from red (lowest score) through yellow to green (highest scores), providing a visual representation of change in scores over time. Blue spark-lines show the hospital- specific trend for easy reference. When the denominator to compute the cell rate is 0, cells are coloured in white. Data from November/December 2013 not available in step 1.