Providing Oxygen to Children in Hospitals: A Realist review/Administration D'oxygene Aux Enfants Dans Les Hopitaux: Un Examen realiste/Proporcionar Oxigeno a Ninos En Hospitals: Una Revision Realista

By Graham, Hamish; Tosif, Shidan et al. | Bulletin of the World Health Organization, April 2017 | Go to article overview

Providing Oxygen to Children in Hospitals: A Realist review/Administration D'oxygene Aux Enfants Dans Les Hopitaux: Un Examen realiste/Proporcionar Oxigeno a Ninos En Hospitals: Una Revision Realista


Graham, Hamish, Tosif, Shidan, Gray, Amy, Qazi, Shamim, Campbell, Harry, Peel, David, McPakee, Barbara, Duke, Trevor, Bulletin of the World Health Organization


Introduction

Oxygen is an essential medical therapy that has been saving lives for over 100 years. (1) Oxygen therapy is used not only for pneumonia and other primary lung diseases but also many other conditions that result in hypoxaemia, such as sepsis, severe malaria, status epilepticus, trauma, obstetric and neonatal conditions (respiratory distress, apnoea, asphyxia, sepsis), surgical care and anaesthesia. A systematic review estimated that, globally, hypoxaemia affects about 13% of children admitted to hospital with pneumonia, about 20% of sick neonates and 10-15% of children admitted with conditions such as malaria, meningitis or convulsions. (2) Given that hypoxaemia is a major risk factor for death, (2,3) oxygen therapy is important for improving child health outcomes.

Effective oxygen therapy requires prompt and accurate detection of hypoxaemia and appropriate administration of oxygen, combined with good clinical evaluation and management of the underlying condition. (4) Improvements in the technology and affordability of pulse oximetry--the standard method for detecting hypoxaemia--are enhancing its accessibility for hospitals in low-resource settings. (1) Oxygen may be supplied by oxygen cylinders, oxygen concentrators or larger oxygen plants, each of which have unique advantages and disadvantages, particularly when used in hot, humid or dusty environments. (1,5) The World Health Organization (WHO) has produced guidelines on the clinical use of oxygen (6-8) and oxygen equipment. (9)

Despite these advances, the availability of pulse oximetry and oxygen supplies remains limited in regions of the world where they are most needed. (10) Furthermore, workforce limitations and health-system failures limit the ability to maintain, sustain or effectively use oxygen even when it is available. (1) A solution to this must be multifaceted, and is likely to be context-specific.

We aimed to identify and describe interventions to improve oxygen therapy in hospitals in low-resource settings, and to determine the factors that contribute to the success or failure of interventions in different contexts.

Methods

We used a realist review approach (11) to study not only whether oxygen therapy interventions work, but also how and why complex programmes work in particular contexts and settings. Realist review is a theory-driven systematic review method that involves identifying key mechanistic theories about how projects might work, searching the evidence about project implementation and impact (including variability between contexts), and then testing the evidence with respect to the theories. (11-14) Our review was prospectively registered on the PROSPERO register of systematic reviews (CRD42015032405).

Identification of theories

We made a preliminary scan of the literature to identify potential theories to explain how improved oxygen therapy systems could impact on clinical outcomes. This resulted in a list of candidate theories, each describing a mechanism through which the intervention influences particular outcomes in particular contexts. We consulted key experts and stakeholders, including interviewing the authors of five large-scale oxygen therapy projects. Interviews were recorded and transcribed for accuracy, but were not formally analysed and were used only to assist in identifying emerging themes.

Search strategy

We made a systematic search of online databases (MEDLINE*, Embase', CINAHL, AIM, LILACS, the Index Medicus for the Eastern Mediterranean Region, the Index Medicus for South-East Asia Region, the Western Pacific Region Index Medicus, CAB Global Health, Health Systems Evidence, PubMed[R] (for e-publications) and Google Scholar (first 500 citations)) on 10 August 2016. We searched variations of keywords "child", "oxygen concentrator", "oxygen cylinder", "oxygen therapy", "oxygen delivery", "oxygen administration" and "developing country" (MEDLINE[R] search; Box 1). …

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Providing Oxygen to Children in Hospitals: A Realist review/Administration D'oxygene Aux Enfants Dans Les Hopitaux: Un Examen realiste/Proporcionar Oxigeno a Ninos En Hospitals: Una Revision Realista
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