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Bubble CPAP and oxygen for child pneumonia care in Malawi: a CPAP IMPACT time motion study
Kristen L Sessions1,2, Tisungane Mvalo3, Davie Kondowe3
1Mayo Clinic School of Medicine, 200 1st Street SW, Rochester, MN, USA. kristen.sessions@northwestern.edu.
Insights
Bubble continuous positive airway pressure (bCPAP) requires more healthcare worker time than nasal oxygen for childhood pneumonia in low-resource settings. This increased time burden during initiation and maintenance needs consideration for effective bCPAP implementation.
Area of Science:
- Pediatric critical care
- Global health interventions
- Respiratory support in children
Background:
- Bubble continuous positive airway pressure (bCPAP) is increasingly utilized in low-resource settings for treating childhood pneumonia.
- The time commitment for healthcare workers (HCWs) administering bCPAP is not well-documented, posing potential implementation challenges.
- This study addresses the need to quantify HCW time for bCPAP versus low-flow nasal oxygen in Malawi.
Purpose of the Study:
- To compare the time HCWs spend administering bCPAP versus low-flow nasal oxygen to children with severe pneumonia.
- To evaluate the time burden associated with bCPAP initiation and maintenance care.
- To inform the implementation strategies of bCPAP in resource-limited healthcare environments.
Main Methods:
- A randomized controlled trial (CPAP IMPACT) was conducted in a Malawian district hospital.
- Time-motion techniques were employed to observe HCW activities over four-hour blocks during bCPAP or oxygen therapy.
- Mean HCW time per patient at the bedside was calculated for both treatment arms during initiation and maintenance phases.
Main Results:
- Initiating bCPAP required an average of 34.71 minutes longer per patient compared to low-flow nasal oxygen (118.18 min vs. 83.47 min).
- Setup time for bCPAP equipment and nasal interface was significantly longer than for oxygen delivery systems.
- During maintenance, HCWs spent more time adjusting bCPAP compared to oxygen equipment (4.57 min vs. 1.52 min).
Conclusions:
- Implementing bCPAP in low-resource settings presents a greater HCW time burden compared to standard low-flow nasal oxygen therapy for pneumonia.
- The findings highlight the need for resource allocation and workflow adjustments to support bCPAP use.
- Effective bCPAP implementation requires acknowledging and planning for the increased demands on healthcare worker time.
Background:
In some low-resource settings bubble continuous positive airway pressure (bCPAP) is increasingly used to treat children with pneumonia. However, the time required for healthcare workers (HCWs) to administer bCPAP is unknown and may have implementation implications. This study aims to compare HCW time spent administering bCPAP and low-flow nasal oxygen care at a district hospital in Malawi during CPAP IMPACT (Improving Mortality for Pneumonia in African Children Trial).
Methods:
Eligible participants were 1-59 months old with WHO-defined severe pneumonia and HIV-infection, HIV-exposure, severe malnutrition, or hypoxemia and were randomized to either bCPAP or oxygen. We used time motion techniques to observe hospital care in four hour blocks during treatment initiation or follow up (maintenance). HCW mean time per patient at the bedside over the observation period was calculated by study arm.
Results:
Overall, bCPAP required an average of 34.71 min per patient more than low-flow nasal oxygen to initiate (bCPAP, 118.18 min (standard deviation (SD) 42.73 min); oxygen, 83.47 min (SD, 20.18 min), p < 0.01). During initiation, HCWs spent, on average, 12.45 min longer per patient setting up bCPAP equipment (p < 0.01) and 11.13 min longer per patient setting up the bCPAP nasal interface (p < 0.01), compared to oxygen equipment and nasal cannula set-up. During maintenance care, HCWs spent longer on average per patient adjusting bCPAP, compared to oxygen equipment (bCPAP 4.57 min (SD, 4.78 min); oxygen, 1.52 min (SD, 2.50 min), p = 0.03).
Conclusion:
Effective bCPAP implementation in low-resource settings will likely create additional HCW burden relative to usual pneumonia care with oxygen.
Trial Registration:
Clinicaltrials.gov NCT02484183 , June 29, 2015.
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