Journal of Emergency Medicine, Trauma and Acute Care - 1 - Qatar Health 2022 Conference abstracts, January 2022

Background: One of the most prevalent viruses among dialysis patients is Hepatitis C as it affects 8.4% of the dialysis patients in Qatar¹. It causes serious complications including end-stage liver disease. There is no available vaccine to protect against the transmission of the Hepatitis C virus (HCV). However, antiviral drugs lead to precious benefits including reducing the risk of morbidity/mortality, increasing life expectancy, and eventually nominating them for kidney transplant².

The Qatar National Plan for HCV control by 2020 was launched in December 2014. In 2017, the World Health Organization accepted to support the development and implementation of national multispectral policies and strategies for its prevention and control in Qatar³. The treatment of HCV in dialysis patients has been a challenge since its launch in 2020. Methods: This is a single-center cohort study, including a retrospective collection of data from 70 dialysis patients infected with Hepatitis C virus. 44 of them were treated with Ombitasvir 12.5 mg, Paritaprevir 75 mg, and Ritonavir 50 mg over 12 weeks and 12-week follow up period. As per all guidelines of the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), and the Asian Pacific Association for the Study of the Liver (APASL), sustained virological response indicates a patient has cured. Results: From the 70 HCV-positive patients, the 44 patients who received the 12-week treatments were cured (Figure 1). During the treatment phase, their biochemical values were normal (Figure 2). Conclusion: The outcome of the first phase treatment of Hepatitis C in dialysis patients is highly effective. Moreover, the successful HCV antiviral treatment will decrease the risk of infection transmission within dialysis patients and reduce the occurrence of complications occurring after kidney transplantation.

Background: Hamad General Hospital (HGH) Nephrology Department is the main provider for dialysis services in Qatar, serving almost 900 patients. The introduction of the COVID-19 vaccination is a crucial step in protecting End Stage Renal Disease (ESRD) patients who are vulnerable and prone to infections due to their immunocompromised status.¹ They are at high risk because they are unable to practice adequate safe physical distancing as the majority of them are dependent on others due to age and the medical condition.

During the first wave of the COVID 19 pandemic, the mortality rate was 20-30% among the dialysis population.² Several challenges were faced since February 2020 to manage and control COVID-19 infection in dialysis units. Vaccination is the most important preventive measure in facing COVID-19. Hence, a multidisciplinary team was formulated in March 2020 aiming to raise the patients and staff awareness of the importance of COVID-19 vaccination. Methods: The assessment of dialysis patients’ knowledge and educational needs was done by conducting multidisciplinary focus group activities, providing educational materials in many languages, education through hospital TV channels, WhatsApp group activities with patient educators, and direct education during physicians’ monthly dialysis assessment. Monitoring the compliance rate was done by monthly data collection and targeting non-compliant groups. Results: After the implementation of COVID-19 immunization strategic plan by the end of June 2021, 75% (666 patients) out of 884 dialysis patients were vaccinated (Figure 1). The current vaccination update for over 16-year-old in Qatar is 62.8% ³. Moreover, COVID-19 positive patients were properly managed since the beginning of 2020 by following Ministry of Public Health (MOPH) guidelines to control the spread among the dialysis population and the successful initiation of COVID-19 vaccination program (Figure 2). Conclusion: Continuous educational activities and awareness campaigns have increased COVID-19 immunization percentage among the dialysis population and probably contributed to saving lives.

Background: Patient-centered care is a concept focussing on meeting the specific health needs of patients as expressed by them. Patients Reported Experience Measures (PREM) is another concept associated with patient-centered care. PREM surveys capture information about the healthcare experience as perceived by patients.¹ Its importance lies in the incorporation of patient feedback into the clinical decisions and service evolution.² Dialysis patients play an important role in their treatment and their voice matters to provide proper care. PREM was first conducted in 2019 in our dialysis unit. In 2020, the COVID-19 impacted dialysis services and resulted in many challenges including staff shortage and deployment. Yet, the patients’ feedback was evaluated continuously and compared with previous years before the pandemic. Methods: A validated questionnaire from the National Health Service in London was used.³ It consisted of 7 questions covering demographics, dialysis options, patient portal, patient's relationship with the staff, teamwork, and traveling abroad. The survey involved 317 randomly selected patients who have been at least one year on dialysis. A comparison between 2019 and 2020 results was conducted using the chi-square test. Results: A drop in patients’ experience was observed in many survey components like education on dialysis, medication side effects, access to the patient portal, access to physicians and nurses from home (Figure 2). However, in other areas, some positive experiences remained unchanged like communication and knowledge among the staff.:Conclusion: Patients’ reported experience helps in the evaluation of health services. After exploring dialysis patients’ experiences, it was possible to identify what is going well and how COVID-19 impacted the patients’ perspectives. The PREM survey conducted in this work showed a significant decline in many parameters likely attributed to COVID-19 consequences including the staff shortages.

Background: The D-dimer test has a diagnostic role in pulmonary embolism (PE) and deep vein thrombosis (DVT). In a low-risk patient with negative D-dimer, PE or DVT can safely be ruled out. This work aims at investigating whether the D-dimer has a similar role in cerebral vein thrombosis (CVT) diagnosis. Methods: A literature review was performed in PubMed, Google scholar, and BestBETs electronic resources to identify studies published from 1996 to July 2021 that assess D-dimer's diagnostic accuracy and report its sensitivity and specificity in CVT diagnosis. The AMSTAR tool was used to assess the quality of the included studies. Results: Out of 66 non-duplicated citations, 15 articles were relevant to our clinical question. Eight articles were included in one of the retrieved meta-analyses, and four articles were excluded during data collection because of unclear results. Two systematic reviews and meta-analyses^1,2 and one cohort study³ were included for the systematic review. The selection process is shown in Figure 1. The studies are reported with details of author, publication date, population details, and results are shown in Table 1. Most of the studies show that D–dimer has a high sensitivity which is estimated to be around 93% to 97% in CVT diagnosis. However, its sensitivity is affected by age, thrombus sizes, and the method used in D-dimer assay.

A review shows that more CVT extension and earlier presentation, prior to 2 weeks, were correlated with higher D-dimer levels. Unfortunately, most of the studies are not high-quality studies, with variable designs, population, and reference standard tests. The studies showed that D-dimer could help predict CVT in combination with risk factors and clinical presentation. Conclusion: Normal D-dimer only should not be used to exclude CVT. There is a probability of using D-dimer in CVT risk scoring and pre-imaging negotiation, and for that purpose, larger and higher-quality studies are needed.

Background: Clinical Pharmacists (CPs) have a vital role in the patient transition of care (TOC), including medication reconciliation and counseling upon admission, transfer, and discharge.¹ The Clinical Pharmacy Department at Al Wakra Hospital, Qatar, Hamad Medical Corporation (HMC), established a collaborative practice agreement with the Internal Medicine Department.² The post-discharge phone follow-up (PDPF) telehealth service aimed to maintain patient continuity of care post-discharge and ensure the safety and effectiveness of discharge medication therapy. This audit describes the implementation of a new TOC initiative. Methods: Criteria for PDPF service were developed and documented into a protocol. Patients discharged from medical wards with complex medication therapy or discharged without discharge medications counseling were contacted within 3 to 7 days from discharge. CPs provided phone medication reconciliation, counseling, lifestyle modification education, assessed medication adherence, and communicated identified medication errors to the primary physicians. Data collected from documented pharmacy interventions and PDPF service forms were used for descriptive analysis. Results: From December 2020 to March 2021, 429 patients met the inclusion criteria out of 1,117 discharged patients. CPs conducted more than 613 phone calls with an average of 15 minutes per patient. CPs reviewed 2,471 medications, found 638 pharmacy clinical interventions (Table 1), and approached more than 77 physicians. Out of the 276 patients who completed PDPF service (Figure 1), the average patients’ age was 52 years, 151 (51%) were females, and 85 (31%) were Qataris. Medication assessment by CPs revealed that 87% (n = 235) of the patients were adherent to medications, 20% (n = 56) were confused about discharge medication indications, and 13% (n = 30) experienced adverse drug reactions. Conclusion: There is no standardized or established TOC service utilizing telepharmacy; however, PDPF service expanded the clinical pharmacy role beyond the in-patient services.³ Our plan includes monitoring outcome-based parameters, including post-phone call readmissions rate, 60 days emergency visits, and patients’ satisfaction.

Background: For some time, paramedics and nurses of the National Ambulance Service in Qatar provided outpatient parenteral antimicrobial therapy (OPAT) to patients with the support of Family Physicians. Like in many other countries of the Middle East, there is a high prevalence of antimicrobial resistance which makes treating infectious conditions challenging. Methods: This is a retrospective cohort study of patients referred to the Ambulance Service – Mobile Healthcare Service from a public hospital acute facility for OPAT over 6 months in 2015. The study's primary aim is to determine whether the OPAT service had comparable outcomes to international reports with respect to unplanned hospital visits for acute care within 30 days of OPAT referral. A secondary aim of this work is to determine the effect of body fluid culture results on that outcome by comparing subgroups within the OPAT population, and the documentation of prevalence and types of antimicrobial resistance. Results: Between the 1^st of March and the 30^th of August 2015, 232 OPAT referrals were received. The most common referral diagnoses are reported in Table 1. Within 30 days of OPAT referral, 24.1% - 30.7% of patients required an unplanned hospital visit. This is at the high end of the range reported internationally for OPAT services.^1,2 Patients with resistant bacterial infections isolated from body fluid cultures experienced the worst outcomes. The prevalence of significant drug resistance among OPAT referrals was 28.0%, mostly extended-spectrum β-lactamase (ESBL) production. Conclusion: OPAT can be provided in the community.³ The rate of return to hospital for acute care within 30 days of OPAT referral was relatively high, however much of this can be accounted for by patients with resistant infections. They had worse outcomes than patients with non-resistant infections or those treated on an empiric basis. The prevalence of antimicrobial resistance was comparable with other recent Middle Eastern reports.

Background: Labour analgesia blocks the aggravated sympathetic overactivity due to labor pains in preeclampsia.¹ Performing regional anesthesia in obese parturients with severe scoliosis poses challenges due to technical difficulties and alterations in epidural space.²Case presentation: A 24-year-old primigravida (40 weeks, weight 111kg, Body Mass Index 41) presented to our emergency department with mild contractions and hypertension (156/110mmHg, proteinuria 3+). Systemic examination and laboratory tests including platelets were normal. Airway assessment showed Mallampati class 3. No prior Pulmonary Function Test or cardiologic evaluation was done. Xray of the abdomen showed altered thoracolumbar lordosis with double curve scoliosis (Figure 1). The thoracolumbar scoliosis was convex to left with cobb's angle 65° (severe >40°) and cervicothoracic scoliosis was convex to right (cobb's angle 40°). She was started on labetalol infusion, and the anesthesiologist was paged for labor analgesia. Using ultrasound guidance, the epidural space was reached at 8 cm, in a sitting position by orienting the needle towards the convexity of curvature in L3, L4 interspace. 10 ml 0.125% levobupivacaine with Fentanyl 2 mcg/ml was given as bolus and Patient Controlled Epidural Analgesia infusion started at 6 ml/hr, bolus 10 ml and lockout interval 20 minutes. The patient reported pain relief within 15 to 20 minutes and remained pain-free during her vaginal delivery keeping her blood pressure (BP) almost in a normal range. Findings/Recommendations: Working epidurals provide pain relief, minimize BP aggravations, and can be extended to provide anesthesia if a caesarean is needed.¹ This improves the uteroplacental blood flow and neonatal outcome. Epidurals mitigate the exaggerated cardiovascular response to intubation during difficult airway management in obese patients with Pregnancy Induced Hypertension (PIH). Conclusion: Epidural analgesia controls BP during labor in PIH. Ultrasound-guided technique is a highly reliable technique, especially in difficult cases like scoliosis.³ In scoliosis, neuraxial procedures warrant careful titration of drugs due to reduced subarachnoid space.

Introduction: Nearly 98% of women in developed nations benefit from antenatal services.^1,2 In Qatar, all pregnant women are provided with antenatal care services at primary and secondary care facilities. If indicated, they are referred or transferred to tertiary care hospitals.³ However, it was noted that a significant number of women opted not to avail of these services. This study is conducted to assess the prevalence of women with no/poor antenatal care and their neonatal outcomes. Methods: A retrospective chart review was conducted at a secondary care hospital. All women (n = 5,796) who gave birth in the year 2018 were included. Prevalence of women with poor/no antenatal care was noted. Neonatal outcomes of 248 women with poor antenatal care (Group A) were compared with 298 randomly selected women with antenatal care (Group B). Statistical analysis was performed with the MedCalc online software. Results: The prevalence of women with poor and no antenatal care was 12.54%. The prevalence of preterm birth was 23.79% versus 4.39% in Groups A and B; respectively (OR-6.79, 95% CI-3.62 to 12.73, P < 0.001). Large for dates and small for dates babies were observed in 14.92% versus 3.38% (OR-1.14 95% CI-0.67 to 1.92, P>0.05) and 12.5% versus 11.15% (OR-5.01, 95% CI-2.44 to 10.31, P < 0.001) in Groups A and B; respectively. Neonatal admissions at birth were 12.10% versus 6.76% (OR-1.89, 95% CI-1.05 to 3.44, P < 0.05) in Groups A and B. Higher prevalence of intrauterine fetal deaths was also noted in women with poor/no antenatal care with 3.32% versus 0.34% (OR-12.49, 95% CI-1.55 to 100.6, P < 0.05) (Figure 1, Table 1). Conclusion: A higher prevalence of women with poor antenatal care was noted as compared to data from developed nations. Poor neonatal outcomes were observed in these women. This study identified the need for future studies to determine why some women are not using maternity services in Qatar.

Background: Poor knowledge and attitude of postpartum complication (KAPC) among women delays their management and increases Maternal Mortality Ratio (MMR).¹ MMR in Lebanon increased from 24 deaths per 100,000 live births in 2005 to 29 in 2017.² This study aims to assess the perceived KAPC of Lebanese women and how it differs according to their level of education and age groups, in different regions in Lebanon. Methods: This community-based cross-sectional study was conducted among 500 women aged 17-50 years old from 2018 to 2020 regardless of having children or not. A questionnaire was developed, and its internal validity was found to be within the acceptable range (Richard's Kurdson = 0.75). The questionnaire was translated from English to Arabic and administered for data gathering through face-to-face interviews. Chi-square and ANOVA were applied to identify the statistical difference. A confidence interval of 95% was reported, and statistical significance was declared at p < 0.05. Results: The majority of women who regarded proteins and dairy products as essential are those living in Beirut [p = 0.020] [0.019]. Women who attended university demonstrated more knowledge of alarming urinary tract infection symptoms than those who attended secondary or high school level [p = 0.05]. Females living in Beirut knew better about deep vein thrombosis symptoms than those living in the South and Nabatieh [p = 0.047] (Table 1). Regarding the best method for breast emptying, 64.8% of women aged 36-50 chose continuous suckling compared to 47.2% of females aged 18-25 year-old (Table 2). Conclusion: KAPC among Lebanese women is distinct from one complication to another, and this is influenced directly or inversely by mainly the effect of the Lebanese geographical regions and educational level. Therefore, an awareness campaign must be implemented at several levels, targeting the most distant regions, especially the rural ones like Beqaa, and vulnerable age groups, particularly the young.

Background: Early ambulation is considered as one of the post-operative interventions in Enhanced Recovery After Surgery protocol and women could be ambulated anytime from 6-8 hours post-surgery.¹ Early ambulation benefits patients by reducing the risk of deep vein thrombosis, improving breastfeeding rate, promoting better diet and nutrition, and improving their satisfaction.² A retrospective baseline data collection from December 2019 to February 2020 showed that only 6-7% of women were ambulated within 24 hours of surgery in the Obstetrics and Gynecology inpatient unit of Al Khor Hospital. Methods: A Quality Improvement (QI) project was conducted to deliver early ambulation in post-cesarean women using QI methodology from the 1^st of March, 2020 to the 31^st of July, 2021 with the aim to ambulate 100% of the women who underwent Lower Segment Caesarean Section (LSCS) within 12 hours of surgery. Patients received pre-and post-operative patient education, were reassessed by a physician within 6 hours post-surgery, and started oral intake. Women were assisted for post-surgery ambulation as required. They were offered multimodal analgesia to minimize the use of opioids and to enable them to mobilize without falling. Results: Results have suggested that 96% of women were ambulated within 12 hours of surgery at the end of the improvement cycle 1 and 100% of the women were ambulated by the 31^st of December, 2020 (Figure 1). Using opioids for pain relief during this period was reduced (Figure 2). Early oral intake increased from 17% to 92% and breastfeeding rate within 24 hours post-surgery increased from 25% to 85% by December, 2020. No fall incidences during ambulation were reported. The QI project is still under monitoring for evaluation of its sustainability. Conclusion: Early ambulation enables new mothers to mobilize within 12 hours of surgery and helps reduce the use of opioid drugs for pain, and increases compliance to breastfeeding and early oral intake.

Background: The majority of patients living in a Long-Term Care Unit (LTCU) have limited mobility.¹ Prolonged immobilization results in functional decline and increases the risk of other complications.² It was observed that there is a lack of a structured, evidence-based mobility program using mobility protocols and guidelines. As per a 6-weeks baseline data collection, out of the 36 patients in Rumailah Hospital's LTCU-2, 40% were bedbound and only 60% of them were engaged in any kind of “Out Of Bed Therapeutic Activities” (OOBTA) as of November 2020.The project aimed to increase patients’ participation in OOBTA from 60% to 80% by December 2021. Methods: A Mobility Task Force (MTF) was formed from a Multi-disciplinary Team (MDT). The Institute for Healthcare Improvement (IHI) Model of Improvement was utilized. A Cause and Effect Diagram with multi-disciplinary input identified potential causes limiting mobility and supported possible solutions for testing in a series of Plan-Do-Study-Act (PDSA) cycles (Figure 1). Each specialty evaluated and provided appropriate OOBTA based on their level of care. Results: This project helped the unit to promote a culture³ of early and safe patient mobility as shown by increased participation in OOBTA and zero falls, no pressure injuries, etc. As a result, it helped the unit to attain more than 80% of patient participation in OOBTA during their hospital stay (Figure 2). The team observed good multidisciplinary collaboration and engagement in developing this mobility program. Conclusion: Promoting early mobility is a cultural change that improved patients’ participation in OOBTA from 60% to 80% from July 2021, five months ahead of our target date and despite the COVID-19 pandemic situation.

Background: Early assisted patient discharge has been implemented in Qatar since 2014 through the introduction of a Mobile Healthcare Service (MHS) with family physicians, nurses, and paramedics doing home visits¹. Studies have explored the effect of Ramadan on Muslims, but findings have been variable^2,3. This research aims to study and quantify any effects of the Holy month of Ramadan, and other important Muslim Religious events, on MHS operations. Methods: Operational data was gathered and analyzed for the weeks of Ramadan, Eid Festivals, and ‘Normal’ working weeks, over 10 months in 2015, using descriptive statistics. Results: 5,863 interventions were extracted and grouped by time durations. The number of interactions per day ranged from 1 to 38, with the median gradually increasing throughout the duration of this study. Ramadan showed an average of 19 visits/day; Eid al Fitr: 16 visits/day; Eid al Adha: 20 visits/day. During Ramadan, call numbers often returned to zero at some point between 16:00-19:00 hrs, which corresponded to Iftar (breaking fast). There are outlying values in the weekly distribution, including a high number on the Sunday of Eid al Adha when many employees returned to work. Conclusion: Despite several possible confounding factors, Ramadan and other Holy events and holidays appear to affect the MHS demand. Although not statistically significant, a decrease in workload over the duration of Ramadan and Eid al Fitr was noticed. There is an approximately tri-modal distribution of interactions across all days, presumably reflecting the high proportion of patients requiring Intra-Venous antibiotics at set intervals and the effect of meal breaks. There is a marked dip between 11:00-12:00 hrs on Fridays, likely corresponding to Friday prayers. However, it is not clear how generalizable the observations are to other similar services in the Gulf countries or other Muslim populations.

Background: A significant number of offshore operations are carried out by Qatargas (QG) employees and contractors in multiple offshore locations, hence, people acutely ill require costly and risky Medical Evacuation (Medevac) undertaken by helicopter or boat.¹ This study aims to evaluate the impact of offshore fitness to work on reducing the number of preventable medevacs in QG compared to other oil and gas offshore organizations. Methods: This is a retrospective review of medevac data (2018-2020) in Qatargas offshore locations concerning the total yearly population. Employees’ records, human resource data, and medical screening data were used as a dominator for the population. It included analysis of pre-employment medical examination, periodic medical examination, medical screening programs, occupational vaccination, and fitness to return to work programs. Results: During the 3 years, 10 medevacs occurred for a total of 13,376 workers, resulting in a rate of 0.74 medevac cases per 1000 workers (Figure 1). This rate is remarkable compared to similar studies in other oil and gas offshore industries (4.97/1000²; 4/1000³). In addition, we have evaluated retrospectively the medical records of the medevac cases to identify those due to a medical reason (not injuries/trauma). Among the 6 medical cases, 1 worker had a pre-existing medical condition. Another finding was that the average age of the 3 medical medevac cases due to suspicious chest pain was 57 years old. All medevacs were male workers, mostly because of illnesses (60%) rather than trauma (40%) (Figure 2). Conclusion: This study provides a new benchmark medevac rate (0.74/1000). A robust fitness to work in an offshore program with the adequate implementation of other preventative measures (e.g., vaccination) is effective in reducing the number of preventable medical medevacs from offshore remote locations and hence, reducing the cost of both medevacs and lost working hours.

Background: Quality improvement has been well documented in various industries to improve safety and processes.¹ However, limited research has taken place within the pre-hospital sector in this regard. Various factors can be attributed to the delivery of effective services. Studies often investigate customer/patient perception and often sideline the importance of employee perception.² This study evaluates Qatar's Hamad Medical Corporation Ambulance Service (HMCAS) staffs’ perception on service delivery to patients they treat and transport. Methods: An online survey was designed and distributed to HMCAS staff working within the emergency section (N = 750). A 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) was used. The SERVQUAL model consisting of 5 dimensions (RATER): Reliability, Assurance, Tangibility, Empathy, and Responsiveness was used.³ Two variables with the highest perception score were regarded as the drivers of service quality. A negative gap score (perception minus expectation) was used as the basis for the study recommendations. Results: As per the required calculated sample size to achieve a 95% confidence interval, 255 questionnaires were completed. Respondents were 79% Ambulance Paramedics, 18% supervisors, and 3% managers. The weights of each dimension's variables were calculated to obtain perception and expectation scores. Descriptive statistics and gap scores of the survey responses are presented in Table 1 for the two variables of each dimension. None of the gap scores were found to be statistically significant. The proposed recommendations generated from this study are presented in Table 2. Conclusion: A standardized staff quality perception tool can assist in identifying potentially missed quality-related service issue(s). In this study, the SERVQUAL model was easily adapted and applied to the pre-hospital Emergency Medical Service setting in Qatar and proved useful in identifying service delivery proponents needing attention. Overall and reassuringly, the staff believes that they provide quality service to their patients.

Background: The lack of healthcare quality management poses significant legal and financial implications^1,2. A proactive approach to systems improvement seems warranted and reasonable. It is not clear if current quality control measures are perceived by patients. The study aims to understand if any correlation exists in this respect in the context of patients using the Hamad Medical Corporation Ambulance Service in Qatar. Methods: A survey was distributed to adult patients transported by the Ambulance Service's emergency division to the Hamad General Hospital's See and Treat unit in Doha (n = 255). The patients had to be free from serious injury/illness, fully conscious, and with re-collection of the service received. The original SERVQUAL model³ consisting of 5 dimensions (Reliability/Assurance/Tangibility/Empathy/Responsiveness) was modified and a 6^th dimension (Quality Control) was added. The Spearman's rank correlation was used to test the strength between quality control (QC) and service quality responses. Results: The mean age was 33.46 years ( ± 9.62). Patients’ continent of origin distribution is presented in Table 1. The QC dimension was correlated with that of the SERVQUAL dimensions presented in Table 2. Most of the SERQUAL dimensions had strong correlations with QC. Interestingly, there was a weak correlation between Assurance/QC and a moderate correlation between Tangibility/QC. The results seem to be driven by providing service within promised timeframes, access to care, and patients’ perception of ambulance staff's willingness to help. Conclusion: An awareness of the variables with strong correlations is indicative of the significant impact QC measures have and the associated perception of importance held by patients. This study sheds light on the importance of evaluating quality processes and limiting internal costs. The number of patients by continent of origin did not enable valid statistical tests based on that variable. The Ambulance Service's QC measures appear to maintain favorable patients’ perceptions of services received.

Background: Across the world, the COVID-19 pandemic is causing unprecedented human and economic losses. The availability of safe and effective vaccines against the virus is instrumental in saving lives. Supply chain readiness is key to efficiently deliver vaccines to the target populations.¹ To control temperature excursions and equipment breakdowns with an upgraded cold chain system with the latest technology suitable in a hot country are challenging. Methods: Primary Health Care Corporation (PHCC) institutionalized a continuous temperature monitoring system using a specific Temperature Monitoring Device (TMD) called a Digital Data Logger (DDL) mounted on cold chain medical equipment like pharmaceutical refrigerators, freezers, and the pre-qualified iceboxes of the World Health Organization (WHO). The DDL devices were affixed to the medical equipment to monitor the temperature and are supported by sound alarm when there are temperature excursions. Results: PHCC Cold Chain Management Ecosystem (Figure 1) involves vaccine vials stored in pharmaceutical refrigerators with a temperature range between 2°C to 8°C and freezers with a temperature range between -10°C to -30°C and WHO prequalified iceboxes for short periods of transportation.² The DDL has a set point temperature measuring limit, measuring interval, and delay time (Table 1) defined for temperature monitoring.³

PHCC Bio-Medical Engineering Department has successfully institutionalized a 24-hour/7 day a week Cold Chain Management System across 27 PHCC health centers. Moreover, a Cold Chain Management System was arranged in an offsite facility within a short period of 72 hours at the Qatar National Convention Centre where the Covid-19 Mass Vaccination Program administered 650,000 doses over 4 months with Zero Wastage of Vaccines attributed to any temperature excursions. Conclusion: PHCC can rapidly deliver healthcare cold chain management solutions under any circumstances. To leverage economies of scale and utilize emerging technology, PHCC has envisioned a plan to migrate the cold chain medical equipment 24/7 temperature monitoring based on cloud services in 2022.

Background: Paramedics need a range of medications that are stored in bags for easy transportation to the patient's side and are exposed to temperature variations, especially in a hot country like Qatar¹. The thermal stability of some medications was examined in previous studies^2,3. Methods: A safe and practical solution had to be found and should be approved by the Production committee to investigate the thermal stability of a range of 13 medications over different periods of time (Table 1). Results: Six medication bags have been specially prepared with the drug samples presented in Table 1. While one data logger was fixed to the metal net divider at the back of the rapid response vehicle, each bag contained a radio-frequency identification (RFID) tag for tracing, two data loggers to measure the temperature and humidity every 10 minutes over a 3 to 12-month period, and an initial total of 15 drug samples (Table 1). The bags have been labeled “For research purpose” and placed at the back of rapid response vehicles (Figure 1). At collection times, 3 samples of each medication will be removed for analysis and replaced by new samples. Similarly, data loggers will be collected and replaced with new ones. As per Qatar Ambulance Service's standard operating procedures, paramedics are required to always keep their medication bag with them when they leave their vehicle for a break or to treat a patient, but for practical and safety reasons it will not be the case with the research samples. Although this means that the research bags will have less exposure to the outdoor environment, they will still be subjected to temperature variation in case the vehicle is parked without air conditioning¹. The collected samples will be kept at 4°C until analyzed by high-performance liquid chromatography. Conclusion: Based on the findings of this study, the results may have a significant impact on how some of the drugs are handled in the pre-hospital setting, especially, possible modification of the recommended expiration date specified by manufacturers to ensure patient safety.

Background: 0.9% sodium chloride (NaCl) fluid bags are commonly stored in ambulances. Despite that the ambulances normally use air-conditioning during operational shifts, NaCl bags are exposed to deviations from the controlled environmental conditions that could affect their integrity^1,2, as all ambulances are not constantly in use. Although stress tests performed in a laboratory Binder Convection Oven³ showed that NaCl maintained its stability, these findings need to be validated. This study aims to develop a protocol to evaluate the thermal stability of NaCl under real-life conditions in Qatar. Methods: Key aspects were considered to subject the research samples to the routine environmental conditions under which NaCl bags are stored in ambulances. The study bags are used for research purposes only, thus should not be used on patients (to avoid hindering the work of paramedics) and need to be tested after various exposure durations. Results: The agreed-upon study protocol is to be replicated on 5 ambulances over 12 months and includes 4 collection cycles of three 500 mL NaCl study bags and three 10 ml NaCl vials following different exposure durations (Table 1). Hence, 12 NaCl bags and 12 vials marked “for research-use-only” will be stored in a locked cabinet in the ambulance patient compartment alongside a temperature and humidity data logger taking measurements every 30 minutes (Figure 1). Control samples will be stored under manufacturer's recommended conditions. Following each collection cycle from the 5 ambulances and controls, samples will be stored at 4°C and protected from light until being visually inspected (for discoloration, turbidity, bulging), diluted, and tested using ion-exchange chromatography to measure sodium and chloride levels. Conclusion: This study performed under real-life conditions will help determine the effect of exposure to actual ambulance operational conditions on NaCl bags and may have a significant impact on how they are handled in the prehospital setting in countries with a hot/arid climate.

Background: In the pre-hospital context, paramedics carry medications in multi-compartment medication bags. However, these medications are occasionally subjected to temperature and humidity variations as they are being carried around by paramedics during their operational duties.^1,2 To develop a protocol to investigate medications’ stability inside these bags, a pilot study was needed to build a basic understanding of the temperature and humidity variations within both vehicles and bags and to guide the development of such a protocol. Methods: Data loggers, pre-programmed to record temperature and humidity every 5 minutes, were inserted inside two operational rapid-response vehicles and their respective medication bags for two full days (16-17/09/2020) when the outside temperature ranged from 30 to 40°C and the humidity ranged from 39% to 74%.³ Following this, 4 data loggers were installed for one month inside 4 different medication bags (28/09/2020-28/10/2020) in similar operational vehicles when the outside temperature ranged from 23 to 42°C and the humidity ranged from 18% to 80%.³ Logging data were extracted using special software (ElitechLog V6.0.3). Results: For the two-day study, temperature and humidity recordings were obtained (Figure 1). The mean (SD) temperature differences between both medication bags and their respective vehicles were -1.04°C (3.01) and 0.09°C (2.64).

Variations above and below the mean temperature difference were found to be random, and within the 3 sigma control limits, which demonstrates the stability and predictability of these temperature differences. Data from the one-month study showed similar recorded ranges (Figure 2). Conclusion: The findings illustrate that temperature readings inside air-conditioned vehicles and their respective medication bag were very similar in the context of Qatar. Therefore, it is possible and feasible to depend on recordings from either of them alone. These results will guide the development of a protocol for a future research project investigating drugs’ stability inside medication bags.

Background: Normal saline 0.9 % (NS) is the most widespread crystalloid used as a life-saving intravenous (IV) fluid.¹ NS contains sodium and chloride in equal concentrations and is subject to thermal stress conditions while stored and transported by clinicians in the pre-hospital environment.² This study aimed to investigate the effect of high-temperature exposure on NS bags used by the Hamad Medical Corporation Ambulance Service in Qatar. Methods: Five-hundred mL polyolefin NS soft bags (Qatar-Pharma, BN:1929013008) were divided into 4 groups of 24 each and stored at constant temperature (22, 50, or 70°C), or subjected to a temperature of 70°C for 8 hours followed by 22°C for 16 hours repeatedly over 28 days. Inspection and chromatographic analysis of the bags was performed at 0, 12, 24, 48, and 72 hours in the 72-hour study, and at 1, 2, 3, and 4 weeks in the 28-day study. Results: NS bags slightly bulged at 50°C and significantly bulged at 70°C or in the long experiment with temperature variation (Figure 1). During the exposure period, there was no discoloration, turbidity, or leaching of plastic components observed in the NS fluid. The pH readings were 5.59 ± 0.08 (22°C-Control sample), 5.73 ± 0.04 (50°C), 5.86 ± 0.02 (70°C), and 5.79 ± 0.03 following prolonged temperature variation. The sodium and chloride levels for the short-term study ranged from 100.2 ± 0.26% to 107.9 ± 0.75% and from 99.04 ± 0.76 to 102.11 ± 1.71%, and for the long-term study they ranged from 101.93 ± 0.90% to 111.27 ± 2.61 and from 99.05 ± 0.94% to 110.95 ± 1.63%; respectively (Figure 2) in comparison to manufacturer stated concentrations. Conclusion: There was no evidence to suggest that the NS fluid inside the PO bags is physically and chemically different when exposed up to 28 days to 50°C, 70°C, and prolonged temperature variations compared to 22°C. These simulated conditions are subject to further testing under real-life pre-hospital care emergency conditions in a hot country.