Audit of Clinical Care Received by COVID-19 Patients Treated at a Tertiary Care Hospital of Nepal in 2021.

Like the world over, Nepal was also hard hit by the second wave of COVID-19. We audited the clinical care provided to COVID-19 patients admitted from April to June 2021 in a tertiary care hospital of Nepal. This was a cohort study using routinely collected hospital data. There were 620 patients, and most (458, 74%) had severe illness. The majority (600, 97%) of the patients were eligible for admission as per national guidelines. Laboratory tests helping to predict the outcome of COVID-19, such as D-dimer and C-reactive protein, were missing in about 25% of patients. Nearly all (>95%) patients with severe disease received corticosteroids, anticoagulants and oxygen. The use of remdesivir was low (22%). About 70% of the patients received antibiotics. Hospital exit outcomes of most (>95%) patients with mild and moderate illness were favorable (alive and discharged). Among patients with severe illness, about 25% died and 4% were critically ill, needing further referral. This is the first study from Nepal to audit and document COVID-19 clinical care provision in a tertiary care hospital, thus filling the evidence gap in this area from resource-limited settings. Adherence to admission guidelines was excellent. Laboratory testing, access to essential drugs and data management needs to be improved.

Experiences of COVID-19 patients admitted in a government infectious disease hospital in Nepal and its implications for health system strengthening: A qualitative study.

INTRODUCTION: The COVID-19 pandemic has affected the health systems in many ways. It has put unprecedented strain on health systems worldwide and exposed gaps in public health infrastructure. A health system comprises all institutions and resources working towards improving and maintaining health. Among the different aspects of health system strengthening, a patient's experiences and expectations play a crucial role in determining how well the health facilities function. This study aims to explore health system strengthening's implications based on experiences and feedback provided by COVID-19 patients admitted to a government tropical and infectious disease hospital in Nepal. METHODS: In this qualitative study, we collected the voluntary handwritten feedback by the admitted COVID-19 patients to document the feedback and experiences from a book, maintained by the hospital. We performed thematic content analysis using the World Health Organization's six building blocks of health system as a theoretical framework which included service delivery, health workforce, information, leadership and governance, financing, and access to medicines. RESULTS: Most patients in this study had positive experiences on service delivery and health workforce. Some also highlighted the gaps in infrastructure, cleanliness, and hygiene. Many suggested positive experiences on other dimensions of the health system such as financing, governance and leadership, and access to medicines reflected upon by the patients' thankfulness to the hospital and the government for the treatment they received. The responses also reflected the inter-connectedness between the different building blocks of health system. CONCLUSION: This study approached a unique way to strengthen the health system by exploring patients' feedback, which suggested an overall positive impression on most building blocks of health system. However, it also highlighted certain gaps in infrastructure, cleanliness, and hygiene. It reinforces the hospital management and government's role to continue its efforts to strengthen the health system.

Clinical Mortality Review of COVID-19 Patients at Sukraraj Tropical and Infectious Disease Hospital, Nepal; A Retrospective Study.

Coronavirus Disease 2019 (COVID-19) has challenged the health system worldwide, including the low and middle income countries like Nepal. In view of the rising number of infections and prediction of multiple waves of this disease, mortalities due to COVID-19 need to be critically analyzed so that every possible effort could be made to prevent COVID-19 related mortalities in future. Main aim of this research was to study about the mortalities due to COVID-19 at a tertiary level hospital, in Nepal. This was a retrospective, observational study that included all inpatients from Sukraraj Tropical and Infectious Disease Hospital, who were reverse transcriptase polymerase chain reaction positive for SARS-COV-2 and died during hospital stay from January 2020 till January 2021. Medical records of the patients were evaluated. Out of 860 total admissions in a year, there were 50 mortalities in the study center. Out of 50 mortalities, majority were males (76%) with male to female ratio of 3.17:1. Most were above 65 years of age (72%) and had two or more comorbidities (64%). The most common comorbidities among the patients who had died during hospital stay were hypertension (58%) followed by diabetes mellitus (50%) and chronic obstructive airway disease (24%). The median duration from the symptom onset to death was 18 days, ranged from the minimum of 2 days till maximum of 39 days. D-dimer was found to be >1 mg/L in 58% cases and ferritin was >500 ng/ml in 42% patients at presentation. A total of 42% patients had thrombocytopenia, 80% patients had lymphocytopenia and 60% had Neutrophil to Lymphocyte ratio >11.75 with the mean NLR of 18.38. Of total mortalities, 16% patients also showed microbiological evidence of secondary infection; Male gender, age more than 65 years, multiple comorbidities with lymphocytopenia, elevated Neutrophil lymphocyte ratio and elevated inflammatory markers were risk factors found in majority of mortalities in our study. These findings could be utilized for early triage and risk assessment in COVID-19 patients so that aggressive treatment strategies could be employed at the earliest to reduce mortalities due to COVID-19 in future.

Persistent Symptoms in Post-COVID-19 Patients Attending Follow-Up OPD at Sukraraj Tropical and Infectious Disease Hospital (STIDH), Kathmandu, Nepal.

The long-term effects of COVID-19 among survivors is a matter of concern. This research aimed to study persistent symptoms in post-COVID-19 patients attending a follow-up clinic at a tertiary care hospital in Nepal. All patients, presenting to the outpatient clinic during the study duration of six weeks, with history of positive reverse transcriptase- polymerase chain reaction for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) at least two weeks prior to presentation, were included. The duration of follow-up ranged from 15 till 150 days with the mean duration of 28 days after diagnosis of COVID-19. Of 118 patients, 43 (36.4%) had a history of mild COVID-19, 15 (12.8%) had moderate, and 60 (50.8%) had severe. At the time of presentation, 97 (82.2%) patients reported that they had at least one persistent/new symptom beyond two weeks from the diagnosis of COVID-19. Dyspnea, fatigue, chest heaviness, and cough were the commonest persistent complaints in 48 (40.7%), 39 (33.1%), 33 (28%), and 32 (27.1%) patients, respectively. The findings in our study highlight the need for extended monitoring of post-COVID-19 patients following discharge, in order to understand and mitigate long-term implications of the disease.

Bell's palsy as a possible neurological complication of COVID-19: A case report.

COVID-19 has been associated with several neurological complications. We presented a case of Bell's palsy as a possible neurological complication of COVID-19 infection. Further research should be conducted to clarify the association, correlation, or causality between COVID-19 and neuroimmunological diseases.