Abstract
Background
Continuous positive airway pressure (CPAP) is a relatively low-cost technology which can improve outcome in neonatal and paediatric patients with respiratory distress. Prior work in a lower middle-income country demonstrated degradation of CPAP skills and knowledge after the initial training.
Aims
To determine if a training-of-trainers (ToT) curriculum can decrease gaps in skills and knowledge between first-generation (trained by a United States physician and nurse) and second-generation healthcare providers (trained by local trainers) in Kenya, and to describe the usage pattern, outcome and safety in patients who received CPAP following the trainings.
Methods
The first day of training entailed didactic and simulation sessions. On the second day participants were taught how to train others to use CPAP. First- and second-generation healthcare providers were tested on their skills and knowledge. Unpaired t-tests were used to test for equivalence. Prospective data on CPAP usage was collected following the initial trainings.
Results
37 first-generation healthcare providers (16 nurses; 21 physicians, medical/clinical officers) were trained as trainers and 40 second-generation healthcare providers (19 nurses, 21 physicians, medical/clinical officers) trained by first-generation healthcare providers were available for skills and knowledge testing. There were no statistically significant differences between first- and second-generation healthcare providers’ skills (90%, 95% CI 87–93 vs 89%, 95% CI 86–92) or knowledge scores (91%, 95% CI 88–93 vs 90%, 95% CI 88–93). A total of 1111 patients were placed on CPAP mostly by nurses (61%), prematurity/acute respiratory distress syndrome was the most common indication, nasal injury/bleeding (2%) was the most common reported adverse event, and the overall mortality rate was 24%.
Conclusion
The ToT model was successful, nurses initiated CPAP most commonly, prematurity with acute respiratory distress syndrome was the most common indication, and adverse events were uncommon.
Keywords: Continuous positive airway pressure, curriculum, infant, pneumonia, paediatrics
Introduction
Prematurity and pneumonia remain the leading killers of neonates and paediatric patients globally, with the majority of deaths occurring in low- and middle-income countries (LMIC) [1]. Continuous positive airway pressure (CPAP) is of relatively low cost and has been used for decades in high-income countries for premature neonates with acute respiratory distress syndrome (ARDS) and paediatric patients with respiratory infections. Emerging evidence also supports the safety and benefit of CPAP in LMIC [2–5]. Despite the increasing evidence, the technology has not been scaled up in LMIC.
One of the major barriers to scaling up CPAP is achieving successful training of healthcare providers in LMIC to use the technology safely and effectively while ensuring adequate training and institutional memory. Given the shortage of physicians in sub-Saharan Africa and other low- and middle-income regions of the world [6,7], it might be more feasible to train nurses to safely apply CPAP. A study has demonstrated significantly lower scores in skills and knowledge testing in healthcare providers in Ghana trained by their colleagues versus those trained by a United States (US) paediatric intensivist and nurse in the context of conducting a randomised controlled clinical trial measuring the impact of CPAP on paediatric mortality [8]. Specifically, Ghanaian healthcare providers trained by the US investigators for the clinical trial performed well on skills and knowledge testing versus healthcare providers trained by their Ghanaian colleagues after the clinical trial was complete. All training material was transferred to the local team but no formal training on how to effectively train others was provided. Thus, a training-of-trainers (ToT) programme targeting healthcare providers in LMIC was created [9]. The goal of a ToT model is to prepare instructors to present information effectively, respond to participant questions and lead activities which reinforce the learning [10]. The experience of introducing CPAP in 10 hospitals in Kenya, an LMIC with a neonatal mortality rate of 26.3/1000 births and an under-5 mortality rate of 70.7/1000 [11], using the previously described ToT curriculum [9] is reported. Additionally, the usage pattern, outcome and safety of patients who received CPAP after the training in the 10 hospitals is reported.
Methods
In July 2014, February 2015 and August 2015, a US paediatric critical care physician and registered nurse trained Kenyan doctors, medical officers, clinical officers and nurses from 10 different level 4 and 5 hospitals to be trainers (first generation) using previously described training materials [9]. Medical officers in Kenya are doctors who have undergone 5–6 years of undergraduate training in medicine and surgery followed by a 1-year internship training of which 3 months are spent in paediatric and neonatal units. Clinical officers are middle-level healthcare workers who have completed 3 years of medical training at a tertiary medical training college and a 1-year internship training programme including 3 months in paediatric and neonatal units. On completion of training they provide primary healthcare services and assist medical officers in providing inpatient care where there are few medical officers. Level 4 hospitals serve as referral centres for smaller medical facilities within the district and provide comprehensive medical and surgical services. Level 5 hospitals are referral centres for the district level 4 hospitals and can provide intensive care and specialist services. The average infant mortality rate in the 10 study hospitals is approximately 6.6%.
Briefly, the 2-day training session consisted of: Day 1, didactic lectures on respiratory physiology, indications, contraindications and monitoring followed by hands-on practice and simulation scenarios to learn how to place and maintain CPAP on neonatal and paediatric patients (8 hours); and Day 2, teaching participants how to train others through practice teaching sessions on the indications, contraindications, application and monitoring of paediatric patients on CPAP (4 hours) followed by placing CPAP on actual patients under the direct supervision of the US physician and nurse (4 hours). The training materials (PowerPoint slide presentation, CPAP Training Manual, two-page visual summary tool referred to as the CPAP Quick Guide, a detailed CPAP diagram demonstrating a complete set-up of CPAP, 10-min instructional video and training mannequins) were provided to the first-generation healthcare providers who were tasked with training their colleagues (second-generation) in their respective hospitals using the curriculum provided.
Providers were trained to wean CPAP in patients who achieved age-appropriate respiratory rates, lacked signs of respiratory distress and required no supplemental oxygen. Intravenous fluids and all other therapy were per local guidelines and standard of care. Patients with moderate-to-severe respiratory distress were not fed orally and nasogastric tubes were placed per local practice with close monitoring of gastric distention and emesis.
Skills and knowledge testing was performed after the first day of training the first-generation healthcare providers and approximately 6 months later for the second-generation healthcare providers. Eligible second-generation participants included those who had been trained by first-generation staff, had placed CPAP on at least one patient and were on site on one of the two days on which the testing took place. The skills evaluation consisted of direct observation of a participant setting up and applying CPAP on a simulation mannequin using a 15-item check list (Figure 1). Knowledge was evaluated with a 29-question, multiple-choice written examination (Figure 2) on indications, contraindications, set-up, application, monitoring and adverse events related to CPAP. Scores are presented as percentages with 95% confidence intervals.
Figure 1. Skills evaluation.
Figure 2. Knowledge evaluation.
Two DeVilbiss IntelliPAP (Somerset, PA, USA) CPAP machines, approximately 50 Hudson RCI nasal prongs (Durham, NC, USA) of various sizes, two pulse oximeters and supplies needed to apply CPAP (head wrap, rubber bands, safety pins) were provided to each hospital. The CPAP machines were set-up and locked to deliver five centimeters of water pressure. Oxygen, if indicated, was administered via the CPAP inspiratory limb from the available oxygen source at each hospital (oxygen concentrator, oxygen cylinder or wall oxygen). Humidification was provided through nasal saline drops to the nares as needed or through humidified oxygen. Data on demographics, diagnosis, duration, outcome and adverse events of patients placed on CPAP from 16 July 2014 to 31 March 2016 were entered onto a one-page case report form by the healthcare provider applying the CPAP. Adverse events related to the use of CPAP were recorded prospectively by the treating clinician. Aspiration pneumonia was reported if an episode of emesis was followed by worsening respiratory status, regardless of chest radiograph findings.
Approval was obtained from the Columbia University Institutional Review Board and the Kenya Medical Research Institute Ethical Review Board to evaluate the existing data from a programme evaluation project.
Statistical analysis
Skills and knowledge scores are presented as means with 95% confidence intervals and an unpaired t-test was used to test for equivalence between the groups. Eleven participants in each group are needed to detect an absolute difference of 10% with a power of 80%. Patient characteristics are reported as medians with interquartile (IQR) ranges.
Results
Thirty-seven first-generation healthcare providers (16 nurses and 21 physicians, medical/clinical officers) from eight level 4 hospitals and two level 5 hospitals were trained between July 2014 and August 2015 as CPAP trainers by the US physician and nurse. Forty second-generation healthcare providers (19 nurses and 21 physicians, medical/clinical officers) trained by first-generation healthcare providers were available for skills and knowledge testing.
First-generation healthcare providers scored 90% (95% CI 87–93) on the skills examination and 91% (95% CI 88–93) on the knowledge examination. Second-generation healthcare providers scored 89% (95% CI 86–92) on the skills examination and 90% (95% CI 88–93) on the knowledge examination. There were no statistically significant differences between the first-and second-generation healthcare providers’ skills or knowledge scores and no significant differences in scores between nurses and non-nurse healthcare providers (Table 1).
Table 1. Skills and knowledge scores as percentage correct.
| p-values | First generation, n = 37 | Second generation, n = 40 |
|---|---|---|
| Skills score, %: 0.31 | 90 | 89 |
| Nurses: 0.80 | 89, n = 16 | 89, n = 19 |
| Physicians, MO/CO: 0.26 | 91, n = 21 | 89, n = 21 |
| Knowledge score, %: 0.48 | 91 | 90 |
| Nurses: 0.37 | 92, n = 16 | 89, n = 19 |
| Physicians, MO/CO: 0.75 | 90, n = 21 | 92, n = 21 |
Mean scores presented and unpaired t-test used to compare groups. MO: medical officer; CO: clinical officer.
Altogether, 1111 patients were placed on CPAP during the evaluation period; 56% were male, median (IQR) age was 1 (0–46) day and median (IQR) weight 2.3 (1.6–4.4) kg. Most patients were in the newborn nursery with acute respiratory distress syndrome associated with prematurity (Table 2).
Table 2. Characteristics of 1111 patients.
| Male, 1111 patients, n (%) | 619 (56) |
| Age, days, median (IQR), 1080 patients | 1 (0-46) |
| Weight, kg, median (IQR), 1093 patients | 2.3 (1.6-4.4) |
| Diagnosis a, n (%) | |
| Prematurity/ARDSb | 623 (56) |
| Pneumonia | 296 (27) |
| Sepsis | 83 (8) |
| Birth asphyxia | 56 (5) |
| Respiratory distress NOS | 47 (4) |
| Asthma | 16 (1) |
| Aspiration | 11 (1) |
| Anaemia | 9 (1) |
| Pulmonary oedema | 6 (<1) |
| Malnutrition | 5 (<1) |
| Other unknown | 3 (<1) |
| Meningitis | 2 (<1) |
| Dehydration | 1 (<1) |
| Cardiac disorder | 1 (<1) |
| HIV infection | 1 (<1) |
| Location, n (%) | |
| Newborn nursery | 785 (71) |
| Paediatric wards | 305 (27) |
| Paediatric emergency | 9 (<1) |
| High-dependency unit | 6 (<1) |
| Surgical ward | 3 (<1) |
| Neonatal ICU | 2 (<1) |
| Paediatric ICU | 1 (<1) |
Patients may have had more than one diagnosis.
ARDS: acute respiratory distress syndrome. NOS: not otherwise specified.
In a majority of cases (61%), CPAP was initiated by nurses, median (IQR) duration of usage was 20 (9.7–35.5) hours and 72% of patients were discharged alive. The most common adverse event reported was nasal injuring/bleeding (2%) (Table 3). The overall mortality rate in the cohort was 24%. Children who died (269) were younger (2.1 vs 5.2 m) and weighed less (2.7 vs 4.2 kg) than those who survived (p < 0.001).
Table 3. CPAP usage, outcome and adverse events in 1111 patients.
| Healthcare provider applying CPAP | |
| Nurse | 677 (61) |
| Physician, medical/clinical officer | 427 (38) |
| Duration of CPAP, h, median (IQR) | 19.7 (9.7-35.5) |
| Outcome | |
| Alive/discharged home well | 796 (72) |
| Died | 269 (24) |
| Unknown | 33 (3) |
| Transferred to higher level facility | 9 (1) |
| Intubation | 4 (<1) |
| Diagnosis in patients who died (n = 269) a | |
| Prematurity/ARDS | 183 (68) |
| Pneumonia | 41 (15) |
| Sepsis | 19 (7) |
| Birth asphyxia | 17 (6) |
| Malaria | 10 (4) |
| Respiratory distress NOS | 10 (4) |
| Anaemia | 4 (2) |
| Pulmonary oedema | 3 (1) |
| Asthma | 1 (<1) |
| Meconium aspiration | 2 (<1) |
| Adverse events | |
| None | 1059 (95) |
| Nasal injury/bleeding | 27 (2) |
| Aspiration | 8 (1) |
| Vomiting | 5 (<1) |
| Abdominal distention | 5 (<1) |
| Eye injury | 3 (<1) |
| Unknown | 2 (<1) |
| Skin injury | 1 (<1) |
| Irritability | 1 (<1) |
| Pneumothorax | 0 |
Values expressed as number (percentage). Duration n = 1030.
Patients may have had more than one diagnosis. NOS: not otherwise specified.
Discussion
The 2-day training-of-trainers curriculum was effective in ensuring adequate second-generation training. Specifically, unpaired t-tests showed no difference in skills or knowledge scores between healthcare providers trained by US personnel to be trainers (first-generation) and the healthcare providers trained by the local Kenyan trainers (second-generation).The new training curriculum closed the gap in knowledge and skills between first-and second-generation healthcare providers in a previous study of a 1-day training session [8]. It is speculated that the provision of multi-modality training material (visual, auditory and kinaesthetic) to first-generation healthcare providers allowed them the flexibility to address the different learning needs of their colleagues (second-generation healthcare providers). Both formal teaching sessions and on-the job-training could be used, depending on the particular setting and needs of specific learners. By empowering the local trainers (first-generation) with comprehensive material, summary tools and fundamental teaching skills, they were able to successfully train their colleagues (second-generation) in the indications, application and monitoring of CPAP for neonatal and paediatric patients. The addition of the 2nd day of training focusing on how to train others using the training material provided was indeed sufficient to ensure that adequate knowledge and skills were transferred between the generations of healthcare providers. It is more cost-effective to train trainers in LMIC than to rely on a physician and nurse from a high-income country continuing to return.
There were no major differences in scores between nurses and physicians/medical officers/clinical officers which is critical given the shortage of physicians in LMIC. The 2-day training can be undertaken on site, alleviating the need for travel and off-site accommodation of clinical staff. All training material is open-access [9] for use by other organisations and institutions.
Acute respiratory distress syndrome in neonatal prematurity was the most common indication for CPAP. Bubble CPAP has been used for decades as standard care for neonates and, given the high morbidity and mortality associated with prematurity, it is not unexpected that healthcare providers focused their efforts on them. In this cohort, the mortality rate was extremely high (24%). This may be secondary to clinicians applying CPAP to the sickest neonatal patients because of the limited number of available CPAP machines. Given their overall poor outcome and limited availability of CPAP machines, some institutions avoid the use of CPAP in neonates <1 kg. Providers were trained to wean CPAP in patients who achieved age-appropriate respiratory rates, lacked signs of respiratory distress and required no supplemental oxygen. Thus, a sick patient requiring CPAP for a long time would prevent other patients from receiving it. To maximize the use of resources, further studies are needed to better determine the patients who will derive optimal benefit from CPAP.
In this cohort, nurses initiated CPAP most frequently and adverse events were minimal. Given the shortage of physicians in many LMIC [6,7], nurse-driven protocols are the most feasible. Empowering non-physician healthcare providers such as nurses and clinical officers to initiate CPAP independently of a physician’s order using specific guidelines may expedite placement of the potentially life-saving device on children suffering from acute respiratory distress. The median duration of CPAP usage was less than a day, similar to that in a previous study in Ghana [5].
This study has several limitations. The skills and knowledge evaluations have not been validated but have been used in five LMIC (Ghana, Kenya, Rwanda, Honduras, Cambodia) to document clinical competency [9]. It is possible that the knowledge and skills assessment does not reflect the clinical effectiveness of placing and monitoring CPAP on actual patients. Few second-generation healthcare providers were available for testing owing to high turnover rates of medical staff, frequent transfer to other government health facilities, scheduled leave and clinical responsibilities, which might have biased the results. It is possible that second-generation clinicians who were more comfortable with CPAP were more willing to be assessed on knowledge and skills than second-generation clinicians who were less comfortable using CPAP, thus biasing the results. It is not known which teaching tools the first-generation healthcare providers used to train their colleagues (most trainers verbally reported the CPAP Quick Guide and training mannequin) or how many first- versus second-generation healthcare providers placed CPAP. Two CPAP machines were provided at each site which might have limited the number of patients placed on CPAP during the observational period. It is not known how many patients failed weaning or died after CPAP was weaned off.
To conclude, the training-of-trainers curriculum was successful in transferring skills and knowledge of CPAP between first- and second-generation healthcare providers in a low-income country and it was demonstrated that nurses, clinical officers and physicians can safely apply and monitor CPAP following a standardised protocol. There was no statistically significant difference in performance between the two cohorts after training by US trainers versus the local Kenyan trainers. Further follow-up is needed to determine if CPAP skills and knowledge are retained longitudinally and beyond first- and second-generation training. The curriculum could be incorporated into formal medical education in medical and nursing schools. Additionally, further studies are needed to determine definitively which specific populations will benefit most from CPAP, given the limited resources in many LMIC.
Funding
The study was supported by the General Electric Foundation/Assist International [reference: CPAP Kenya]; General Electric Foundation [KENYA CPAP].
Footnotes
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Bernard Olayo is a public health specialist and an entrepreneur from Kenya. He is the founder of the Center for Public Health and Development, a non-profit which has designed and developed two successful social enterprises – MediQuip Global (biomedical equipment repair and maintenance solutions) and Hewa Tele (a public-private venture delivering affordable oxygen in remote areas). He has over 14 years of experience managing complex public health programs in resource-limited settings in 15 countries across the globe. He is also a technical team member on several World Bank projects, primarily as a technical advisor to a number of ministries of health.
Caroline Kendi Kirigia is a public health practitioner with training as a clinical officer, in project management, and a Masters in public health. Her 13 years of work experience ranges from HIV and TB prevention, care and treatment and team leadership with the University of California San Francisco and the Kenya Medical Research Institute’s FACES programme to supporting the development of continuous quality improvement systems with HealthStrat and the Center for Public Health and Development in Kenya where she currently works in programmes. Her current work covers her interest areas of mental health, maternal health, newborn and child health.
Jacquie Narotso Oliwa is a paediatrician, clinical epidemiologist, lecturer and a research fellow working on improving case detection of TB in children. She has 10 years of experience in medical education as a trainer for Paediatric TB, paediatric HIV Comprehensive Care Course; Paediatric TB; Paediatric Life support courses. She teaches child health and research methods at the University of Nairobi and has worked in health systems research collaborating with the Kenyan Ministry of Health and government hospitals in various quality improvement projects, pragmatic clinical observational studies trials and conducting systematic reviews.
Odero Nicholas Agai is a Consultant Paediatrician and Child Health Specialist with 10 years hands-on experience both in the public and private sectors. He is also affiliated to The Centre for Public Health and Development, Kenya where he is a consultant and is actively involved in training of health care workers on innovative technology that are designed to reduce neonatal and childhood morbidity and mortality.
Marilyn Morris is a graduate of Tufts University School of Medicine and the Columbia University Mailman School of Public Health. Her academic focus centers on the ethics and regulation of biomedical research. She is particularly interested in the challenges of conducting research involving children and research involving critically ill individuals.
Megan Benckert is a Registered Nurse, graduate of University of Virginia with a Bachelor’s of Science in Nursing, Emory University with a Master’s in Public Health and Nursing Leadership and Fordham University Advanced Diploma in Humanitarian Assistance. She has worked as a nurse in a Surgical Trauma ICU in Atlanta Georgia, Nursing Activity Manager with Médecins Sans Frontières completing 6 mission in South Sudan, Tanzania and Bangladesh and as Senior Program Officer with Columbia University School of Public Health in Ghana, Kenya, Rwanda, Cambodia and Honduras. She is passionate about humanitarian work, nursing and critical care.
Steve Adudans is a Kenyan born, UK trained public health and infectious disease specialist with over 10 years global experience. He received his doctor of medicine and surgery training at the University of Nairobi and post-graduate training Infectious Diseases training at the London School of Hygiene and Tropical Medicine (LSHTM). He is the Executive Director for Center for Public Health and Development (CPHD), a hybrid not-for profit and for-profit organization leading in mitigation of neglected maternal and child health areas in SSA. At CPHD, he provides leadership on technical program development and implementation and policy advocacy with host government agencies.
Florence Murila is an expert Peadiatrician and Senior Lecturer at the University of Nairobi in the Department of Paediatrics & Child Health. She has published extensively in the field of Paediatics and has been a consultant to the Ministry of Health, World Health Organization and UNICEF on child survival programs. She is active in the Kenya Peadiatric Association and Kenya Medical Association and has given multiple lectures and workshops on the use of CPAP.
Patrick T. Wilson is an Assistant Professor of Pediatrics and Population and Family Health at Columbia University Medical Center. He is board certified in Pediatrics, Pediatric Infectious Diseases and Pediatric Critical Care Medicine and has a Diploma in Tropical Medicine from the Case Western Center for Global Health and a Master of Public Health in International Health from Johns Hopkins University. Dr. Wilson’s research expertise is in the impact of non-invasive ventilation in critically ill pediatric patients living in low- and middle-income countries.
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