How ready were hospitals to deliver EECC during the COVID-19 crisis?

Our studies in Kenya and Tanzania conducted in late 2020 and in 2021 found that hospitals were generally poorly prepared to cater to the basic needs of those with critical illness.9 10 Evaluations of equipment and the human and material resources for dealing with acute, severe illness highlighted considerable variability between hospitals in such inputs and were generally lacking in Tanzania. Even in better-resourced settings, there were major deficiencies in local organisational arrangements and clinical processes.10 For example, national referral hospitals described uniform triage processes within their emergency departments, but triaging systems in all hospitals’ wards and in the emergency departments of general hospitals were largely absent.9 10 Importantly, in both countries, even if hospitals had equipment and materials required to institute EECC, they typically lacked the management systems and routines for the proper deployment and use of these resources. For example, piped oxygen systems installed in some locations were often ‘present’ but not fully functional and staff abandoned them, reverting to older habits of relying on bottled oxygen. Worryingly, even in the midst of the COVID-19 pandemic, infection prevention and control measures remained weak. For example, in Kenya only two out of five facilities had protective face masks and aprons widely available, compounding wider problems of overcrowded, poorly maintained hospital buildings often with limited water provision.9 10 Our findings in Kenya and Tanzania are consistent with those from other low-resource settings.11

EECC requires that all staff are able to identify critical illness and provide the most basic immediate care that a critically ill patient would need. In Tanzania, personnel with any relevant training were available in the facilities on average less than 50% of the time.10 Skills deficits exacerbated substantial human resource shortages across both countries, particularly in more rural or smaller hospitals; they are a fundamental limitation to the proper treatment of the critically ill patients. Examples included 1 clinical officer (a form of non-physician clinician) attending to approximately 16 patients at one time, 1 nurse looking after 22 patients including some with critical illness and 1 doctor attending to 51 patients.9 Interestingly, such extreme staff to patient ratios could not be attributed to surges in COVID-19 admissions, as data actually suggest this did not occur.12 13 Not surprisingly, staff described frequently feeling‘overwhelmed’. The lack of skilled staff and high patient-to-clinician ratios emphasise the need to prioritise improving staffing as well as organisational processes, if facilities are to deliver effective EECC.11 14

Moving beyond resources: providing continued effective care

Effective management of critical illness including COVID-19 requires quality care sustained over hours or days. This includes periods spent in emergency departments, during transfers, during waits in diagnostic departments for investigations and sometimes prolonged periods spent in wards. The quality of continuous care, often reliant on nurses, has been much less well examined in low-resource settings, although some prior work suggests inadequacies.15 Our team used an approach based on following specific patient journeys in Kenya and Tanzania to examine this. This simple strategy highlighted how errors and dangerous delays were rooted in a lack of planning for providing even the basic forms of care encompassed in EECC uniformly across hospital settings.16 Inadequate organisational responses compounded the material and human resource shortages outlined above. For example, resulting in a critically ill patient with dangerously low oxygen saturation deteriorating due to delays in receiving timely care.16 Similarly, in departments such as pharmacy, laboratory and radiology, all suffering from personnel and material shortages, the delays in receiving diagnostic or therapeutic interventions compromised EECC. For example, resulting in extensive periods when critically ill patients were unobserved in reception areas. Patient journeys particularly highlighted the atomised nature of care in the hospitals we studied. In some cases, departments seemed to have an almost adversarial relationship, wanting to push out as many patients as possible while restricting new arrivals. These perpetual stresses combine to create a general sense of resignation and organisational norms that are likely to be highly resistant to positive change (a situation we describe as ‘arrested development’).9

Combining insights from patient journeys, formal interviews and direct observations allowed us to develop a broader conceptual understanding of the process challenges to delivery of quality EECC in Kenyan and Tanzanian hospitals. We propose it is helpful to think of three distinct areas of concern in any hospital location; how it receives, sustains and transfers any patient with critical illness. The receipt of patients into a facility or department was rarely well structured. For example, systems to identify that a patient waiting in a queue has probable sepsis and low blood pressure or other features of incipient or manifest critical illness were absent. Frequently, establishing the patient’s ability to pay was prioritised above such triage. Maintaining vigilance (monitoring and reassessment) even by assessing basic vital signs or monitoring ongoing treatment (eg, fluid or oxygen therapy) was often lacking. Worryingly, this was apparent during extended stays in wards as well as during shorter periods in emergency or other hospital departments. Although this often reflects staff shortages, functional systems for prioritising patients so that time is devoted to reassessment and care of the most ill were rare. Lastly, the flow of patients within and between departments was often problematic and reliant on family members if present. It could lead to long periods within a facility where critically ill patients could deteriorate while waiting to move to the next stage of care.16 In fact, issues as fundamental as a lack of any unified understanding of what comprises ‘critical illness’ among health workers also contribute to communication failures and suboptimal organisational processes.17 In sum, the absence of structured organisational systems means in many hospitals, the provision of EECC becomes contingent on the awareness, capacity and motivation of individuals to do what they consider best in very difficult circumstances.

Efforts to improve care for the critically ill patients: the global and national response

Concerned by the catastrophic potential of COVID-19, countries had to act. With rich countries’ ICUs flooded with patients early in the pandemic, initial global attention focused on how to rapidly scale up advanced respiratory support in low-resource settings.18 The result was national governments, multilateral agencies and private philanthropy urgently sourcing and distributing equipment such as ventilators.19 20 Unfortunately, in our opinion, this response ignored prior information from existing health facility readiness assessments and research.3 6 21 While it was true that Kenya and Tanzania had very few ventilators, it was also known they had an extreme shortage of medical, nursing and other specially trained personnel able to manage ventilated patients.20 22 Seconding personnel from another hospital area to address gaps in the critical care workforce and attempting to upskill them with extensive virtual training risked more pronounced workforce deficits elsewhere. This actually threatens provision of EECC more widely, especially as emergency hiring programmes to increase staffing levels were typically short-lived.20

Recognition that attention had to be paid to apparently basic forms of care for critically ill patients with COVID-19 rather than advanced respiratory support was slow. In our facility surveys, sometimes many months after the onset of the pandemic, access to oxygen remained low.9 10 Indeed, it took many months for the focus of global support to shift to improving access to medical oxygen, a critically important agenda known to have been neglected for many years.23 Even now though, the focus is on solving the ‘hardware’ or equipment issues and training. The logical simplicity that one can solve the problem of acute care by providing oxygen and other basic materials belies the challenges faced by health systems. Attempts to strengthen overall staffing levels and organisational processes remain neglected. This challenge is compounded by the interpretation of health facility assessment or readiness surveys (including the Service Availability and Readiness Assessment tools). These identify hospitals that completely lack essential inputs, but they do not provide any real sense of whether a hospital and its staff have the minimum functional level of inputs combined with needed individual and organisational capabilities to provide safe, effective care.9 10 16 24 Training specialist ICU staff will not paper over the much wider cracks in the availability of well-trained general nurses and clinicians that undermines delivery of quality care to the critically ill patients and all others in need. Moreover, specialist professionals often champion the needs in their specific field of expertise, leaving few to champion prioritisation of more basic forms of care such as EECC as a foundational approach.7 25

Our team also examined the potential cost-effectiveness of improving care for critical illness in low-resource settings and specifically improving coverage of EECC. These studies suggest that EECC can be both low cost-effective and highly cost-effective. In Tanzania and Kenya, the cost of current advanced critical care conducted in ICUs with specialised staff, facilities and technologies is nearly ten times than that of EECC.26 In Tanzania, preliminary analysis has found that the probability of EECC provision being cost-effective is greater than 95% while more advanced critical care is not cost-effective based on commonly used thresholds.26–29 While these estimates provide a good benchmark, they have limitations; observational studies on the clinical effectiveness of EECC are not yet available. However, a focus on delivering quality EECC at scale would also promote equity, making it a priority for inclusion in universal health coverage strategies.30

Our findings highlight the foundational quality challenge of delivering the right care, at the right time to the right individual across all parts of hospitals at scale.1–5 This is not simply a problem of providing the right equipment or materials nor of providing the right life-support training to build workforce competence, although these are needed. Saving lives threatened by critical illness requires us to tackle wider system challenges.31 These include prioritising the care that can impact most patients and lead to the best outcomes with the fewest resources. Improving general patient to staff ratios is needed as we create leaders with the knowledge, technical and importantly service management skills to oversee the structural and cultural organisational changes that are needed to sustain quality care throughout hospital journeys. This vital service improvement capability is often neglected in low-resource health systems. However, the response to severe COVID-19 was a reminder of the carefully planned and continuous work required to redesign and improve services (figure 2). The COVID-19 pandemic revealed major gaps in policy and planning in all countries and inadequacies in supply chains, staffing, technologies and financing to support these in most. The global response aimed to tackle some of these, often temporarily in the case of human resources, but paid much less attention to developing the skilled service improvement and implementation work that must span multiple facility locations, teams and processes that are essential to achieve the changes our findings indicate are needed (figure 2). To be effective, these much needed system changes requires people who can negotiate and manage complex-dependent and context-dependent challenges. These include the high levels of psychological distress and burnout in the workforce that threaten quality care, particularly in low-resource settings.32 While leadership from emergency and critical care specialists is likely to be important, does currently offered specialist training in critical care build these much needed skills?

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Figure 2

Changing complex health systems at scale is hugely challenging. For simplicity, we present the broad efforts required to introduce EECC and more advanced levels of critical care in health facilities employing the familiar input, process, output or outcome framing. Key inputs are often seen as complicated but quite logical; however, these need to well beyond provision of technologies and should be supported by careful planning and financing as improvement efforts may well require rethinking of service provision and sustained supply of resources and equipment maintenance. The process of change is often reduced to a focus on new guidelines and skills training around new technologies but is much more complex. Process changes may involve adaptation to each specific context and may result in new ways to organise services (eg, allocation of specific spaces to the critically ill patients), new health worker roles and new information needs or resources (eg, new patient charts or handover tools). Attention must be paid to these dynamic and emergent processes that will require local leaders to take on change management roles if systems are to achieve better patient, staff and system outcomes including the improved teamwork that facilitates adoption and effective use of any new technologies.

In summary, our multidisciplinary team found that hospitals in Kenya and Tanzania, as in other low-resource settings, may have some of the essential resources they need to offer EECC. Although each study has limitations, and even a set of studies cannot claim to be a full and accurate representation of complex systems, taken together our work indicates that we need to go beyond considering EECC as a package of life-saving interventions and think of it as a continuous process. Considered this way, EECC is almost a state of mind requiring a form of systemic vigilance and response, while ensuring the care that is most needed is prioritised first. High-income countries have invested over decades in personnel and their skills, improvements in tools and organisational processes. In some places, this even includes dedicated ‘floor level’ management to promote timely action. These system responses are almost completely absent in Kenya and Tanzania. They must be carefully developed alongside efforts to tackle basic infrastructure and resource gaps. Addressing only the problem of technical inputs by offering training and technologies without addressing system challenges seems little more than building sandcastles on a beach and ignoring the reality of the incoming tide.