key: cord-0703653-6ro374gw authors: Sanders, J. E.; Chakare, T.; Mapota-Masoabi, L.; Ranyali-Otubanjo, M.; Ramokhele, M. M.; Rozario, A.; McCollum, E. D. title: National hospital readiness for COVID-19 in Lesotho: Evidence for oxygen ecosystem strengthening date: 2021-04-30 journal: nan DOI: 10.1101/2021.04.27.21256199 sha: 78257ad28e3cbca22a84f6d585151e754c870ba0 doc_id: 703653 cord_uid: 6ro374gw The COVID-19 pandemic continues to challenge healthcare systems globally. To understand hospital capacity, including critical oxygen capacity, a pragmatic assessment of all public hospitals in Lesotho was made in July 2020 (baseline), with follow-up in December 2020. We developed a qualitative hospital services questionnaire modeled on the World Health Organization COVID-19 assessment tool and converted answers into quantitative ordinal variables. At baseline we found all 12 domains had areas demonstrating preparedness and weakness. Key baseline gaps within infection prevention and control were lack of a dedicated team, and insufficient personal protective equipment and space for donning and doffing. Substantial limitations were noted in hypoxemia diagnosis and treatment; information management and care coordination pathways were also suboptimal. Our baseline findings may reflect uneven early pandemic care quality. Targeted follow-up after five months revealed marked improvement in the availability of pulse oximetry, oxygen capacity, and heated high flow nasal cannula devices. The global pandemic caused by SARS-CoV-2, the novel virus responsible for COVID-19 disease, has impacted health systems at all levels. Sub-Saharan African countries were affected later in the pandemic's first wave, with peak infections recorded during July 2020 1 . A second wave was experienced during the festive season from December 2020 to January 2021. Lesotho, a nation of two million people in southern Africa, confirmed its first COVID-19 case on May 13, 2020. As of March 3, 2021, a total of 10,521 cases have been confirmed, with 305 deaths 2 . Lesotho's health system is comparable to other African countries with a foundation of nurse-led primary healthcare delivered from community-based clinics. Each of Lesotho's ten administrative districts has at least one secondary-level hospital, which is physician-led and generally lacks higher care. The national tertiary care hospital in Maseru, the capital, is the only government hospital offering intensive care. In response to the pandemic, all districtlevel hospitals established COVID-19 isolation wards and the Ministry of Health designated two district hospitals as COVID-19 Treatment Centres with inpatient services dedicated to suspected or confirmed cases ( Figure 1 ). There are few publications to date from sub-Saharan African countries on COVID-19 national hospital readiness and oxygen availability [3] [4] [5] [6] . To better understand COVID-19 hospital capacity and remaining gaps during the first pandemic wave in July 2020, we conducted a rapid, pragmatic baseline assessment of all public hospitals using an adapted World Health Organization (WHO) COVID-19 hospital assessment tool. We then completed a focused reassessment of the national oxygen ecosystem during the second pandemic wave in December 2020. This is a cross-sectional study of hospital readiness using a researcher-administered questionnaire with additional longitudinal follow-up of the oxygen ecosystem. We developed a questionnaire focused on hospital services to reflect the WHO 'Rapid Hospital Readiness Checklist' tool, designed to assist hospital managers in evaluating current and future facility capacities for COVID-19 surges 7 . Questions were grouped into 12 domains: 1) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Management, 12) Transport. Assessment options were qualitative and included "Yes or usually", "Sometimes" and "No or rarely" answers. Answers were converted into quantitative ordinal variables. "Yes or usually" scored one point, "Sometimes" 0.5 points, and "No or rarely" zero points. We supplemented the isolation ward and severe disease management domains with information on the hospital oxygen ecosystem including pulse oximeter, oxygen, and advanced respiratory care availability. We described the distribution of each domain using standard summary statistics and explored post hoc whether there were differences between hospitals by domain using the Kruskal Wallis test. The questionnaire is included as a supplemental appendix. Using The McNemar chi-square test we assessed for any differences in the proportion of hospitals at baseline and follow-up having pulse oximetry at triage and in the isolation ward, and oxygen in the isolation ward. We also analyzed the difference in mean patient-adjusted oxygen capacity per hospital at baseline and follow-up using paired t-tests. Patient-adjusted oxygen capacity per hospital was defined as the number of patients that can be simultaneously treated with oxygen per hospital. Jhpiego Lesotho, a Johns Hopkins University affiliate, is supporting the Lesotho Ministry of Health COVID-19 response to scale-up case management and respiratory care at hospitals with USAID funding. All 16 secondary-level hospitals in Lesotho, including the two COVID-19 Treatment Centres, were visited in person by Jhpiego personnel (JS, MMR) during July 2020 with follow-up in December 2020 to reassess the oxygen ecosystem. Hospital leadership, Medical Superintendents and Managers of Hospital Nursing Services, were the primary responders with support from administrators, human resource managers, pharmacists, and COVID-19 focal persons. When possible, we verified qualitative answers with in-person checks. Constructive feedback was provided to hospital teams. The survey was conducted in collaboration with Ministry of Health of Lesotho. Consent was not required as Johns Hopkins University Institutional Review Board and Lesotho National Health Research Ethics Committee classified this activity as non-human subjects research. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256199 doi: medRxiv preprint The sponsors had no role in the design, implementation, analyses, interpretation, write up, or decision to publish. The corresponding authors had access to all data and assume responsibility for the manuscript. All 12 surveyed domains had areas demonstrating preparedness and weakness (Table 1 ). Our post hoc exploratory analysis found no statistical differences between hospitals within any of the 12 domains. (Table 1) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 30, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256199 doi: medRxiv preprint centralized system, including long delays. Ten facilities reported waiting overnight for ambulances. Oxygen Ecosystem -Baseline in July 2020 (Table 2 and Supplemental Appendix 2): The diagnosis and oxygen treatment of hypoxemia, a peripheral oxyhemoglobin saturation (SpO2) <94%, was limited at all hospitals (Table 2) At the time of our baseline assessment of national hospital readiness, Lesotho was in the midst of the peak of its first pandemic wave in July 2020. Our baseline results show inconsistent readiness across all domains interrogated, which likely reflected -to some extent -the quality of COVID-19 hospital care provided during an intense pandemic period. Given the respiratory pathophysiology of SARS-CoV-2, the severe human resource constraints of the Lesotho healthcare system 8 , and the national care pathway designed to centralize COVID-19 hospital resources and expertise at treatment centres, we identified gaps in the hospital oxygen ecosystem as not only the most urgent and feasible to address, but also the most likely to optimize patient outcomes in preparation for subsequent pandemic waves. Our targeted follow-up of the oxygen ecosystem in December 2020 revealed important progress in pulse oximetry availability, oxygen capacity, and the arrival of heated high flow nasal cannula devices and expanded access to non-invasive ventilation for severe COVID-19 patients. An estimated 19% of symptomatic patients will be hypoxemic, and delivery of supplemental oxygen to patients with severe confirmed or suspected COVID-19 disease is one of the key components to reducing mortality 9,10 . Yet, our baseline July 2020 assessment revealed the limited capacity to diagnose and manage hypoxemia in Lesotho. Most hospitals only had capacity to provide oxygen to one or two patients simultaneously, with the potential for supply to become quickly depleted for extended periods. Our survey did not identify any coordinated systems at the hospital or national level to manage scarce oxygen resources. As Lesotho has stable electricity, concentrators are preferred over cylinders for hypoxemic patients responsive to low oxygen amounts. Cylinders are large, heavy, difficult to transport, and contain finite amounts of oxygen; they are ideally used as a back-up to concentrators. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256199 doi: medRxiv preprint Thus, Lesotho's relative lack of concentrators and reliance on cylinders necessitated closer monitoring and greater resources to ensure uninterrupted supply. We also observed that even when sufficient quantities of cylinders were present, the regulators required to titrate the cylinder's oxygen flow were unavailable. Oxygen cylinders cannot be used without an appropriately fitted regulator. Despite notable progress in oxygen availability, we do not know if the observed increase is sufficient to meet future demand. Calculating the estimated burden of severe disease and corresponding oxygen needs is beyond the scope of this analysis. Neither pulse oximetry nor vital sign monitors with oximetry functionality were available in one-third of Lesotho's public hospitals at baseline. It has been well established that providers relying only on clinical acumen to prescribe oxygen do so inaccurately, resulting in the misuse of precious oxygen supplies and high proportions of hypoxemic patients failing to receive a potentially life-saving treatment 11,12 . In preparation for possible surges in the COVID-19 pandemic as well as future epidemics, an organized national oxygen system predicated on pulse oximetry and oxygen concentrators was urgently needed in Lesotho. The Ministry of Health, in collaboration with development partners, was able to rapidly address baseline oxygen equipment shortages for severe COVID-19 disease management. Pulse oximeters were procured and distributed to facilities for use in the diagnosis and monitoring of hypoxemia. Priority was given to procurement of oxygen concentrators, including those with higher flow rates, for provision of supplemental oxygen. An oxygen plant was also completed and opened to support refilling of oxygen cylinders utilized at the Treatment Centres although procurement of cylinder regulators has remained a challenge. Higher levels of respiratory care can now be supported using heated high-flow nasal cannula and non-invasive partial pressure ventilation devices. Effective implementation of both oxygen and higher levels of respiratory care will rely upon ongoing collaboration and human resource capacity building within hospitals and the larger health system. There are three key limitations to this work. First, this survey was conducted crosssectionally, and the status of supply chains and stock management are time sensitive. We attempted to account for this through the use of a graded scoring system that recognized . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256199 doi: medRxiv preprint partial implementation of interventions and inconsistencies. Second, this survey was based upon self-reporting and given its urgency and our own resource limitations we could not verify all responses. However, our questions were addressed to personnel in the best position to be informed and all respondents were encouraged to consult others. Despite our efforts to optimize reporting accuracy, these results should be interpreted within this context. Lastly, we were unable to follow-up all domains although our baseline assessment identified gaps that would benefit from follow-up. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256199 doi: medRxiv preprint World Health Organization Coronavirus Disease (COVID-19) Dashboard How Prepared Is Africa for the COVID-19 Pandemic Response? The Case of Ethiopia Sub-Saharan Africa preparedness and response to the COVID-19 pandemic: A perspective of early career African scientists Oxygen supplies and COVID-19 mortality in Africa. The Lancet. Respiratory medicine Equipment for COVID-19 Case Management Malawi Facility Survey Report. Seattle: PATH World Health Organization Rapid hospital readiness checklist We offer our sincere thanks to Ministry of Health and Christian Health Association of Lesotho leadership and personnel for active participation in the survey. The authors declare no conflicts of interest.