COVID-19 Advanced Respiratory Care Educational Training Program for Healthcare Workers in Lesotho: An Observational Study

Objectives

To develop and implement a ‘Low Dose, High Frequency’ (LDHF) advanced respiratory care training program for COVID-19 care in Lesotho.

Design

Prospective pre-post training evaluation.

Setting

Lesotho has limited capacity in advanced respiratory care.

Participants

Physicians and nurses.

Interventions

Due to limited participation May-September 2020 the LDHF approach was modified into a traditional one-day offsite training November 2020 that reviewed respiratory anatomy and physiology, clinical principles for conventional oxygen, heated high flow nasal cannula, and non-invasive ventilation management. Basic mechanical ventilation principles were introduced.

Outcome measures

Participants completed a twenty-question multiple choice examination immediately before and after the one-day training. Paired t-tests were used to evaluate the difference in average participant pre- and post-training examination scores.

Results

Pre- and post-training examinations were completed by 46/53 (86.7%) participants, of whom 93.4% (n=43) were nurses. The overall mean pre-training score was 44.8% (standard deviation [SD], 12.4.%). Mean scores improved by an average of 23.7 percentage points (95% confidence interval [CI] 19.7, 27.6 percentage points, p<0.001) on the post-training examination to a mean score of 68.5% (SD, 13.6%). Performance on basic and advanced respiratory categories also improved by 17.7 (95% CI: 11.6, 23.8) and 25.6 percentage points (95% CI: 20.4, 30.8) (p<0.001). Likewise, mean examination scores increased on the post-training test, compared to pre-training, for questions related to respiratory management (29.6 percentage points (95% CI: 24.1, 35.0) and physiology (17.4 percentage points (95% CI: 12.0, 22.8).

Conclusions

A LDHF training approach was not feasible during this relatively early period of the COVID-19 pandemic in Lesotho. Despite clear knowledge gains the modest post-training examination scores coupled with limited physician engagement suggest healthcare workers require alternative educational strategies before higher advanced care like mechanical ventilation is implementable. Conventional and high flow oxygen are better aligned with post-training healthcare worker knowledge levels and rapid implementation.

Strengths and limitations of this study

• The training aimed to use a ‘Low Dose, High Frequency’ approach to improve the competence of doctors and nurses providing advanced respiratory care to severely ill COVID-19 patients during an emergency, pandemic African context with limited advanced respiratory care services.

• To provide a foundation for future implementation of invasive mechanical ventilation and more immediate application of conventional oxygen, heated high flow nasal cannula, and non-invasive ventilation, the training coupled pragmatic respiratory anatomy and physiology concepts to key clinical principles.

• Challenges in trainee participation and respiratory equipment availability necessitated modifications to the planned ‘Low Dose, High Frequency’ training strategy that reduced both the training duration and approach.

• This evaluation provides key lessons for future COVID-19 advanced respiratory care training approaches and the respiratory modalities best aligned with current healthcare worker expertise in Lesotho and likely other similar settings.