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Care of the critically ill begins in the emergency medicine setting. Eur J Emerg Med 2024; 31:165-168. [PMID: 38635471 DOI: 10.1097/mej.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
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da Silva Ramos FJ, Freitas FGR, Machado FR. Boarding in the emergency department: challenges and mitigation strategies. Curr Opin Crit Care 2024; 30:239-245. [PMID: 38525875 DOI: 10.1097/mcc.0000000000001149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
PURPOSE OF REVIEW Herein, we conducted a review of the literature to better understand the issue of prolonged emergency department (ED) boarding by providing an overview of the current evidence on the available causes, consequences, and mitigation strategies. RECENT FINDINGS Severely ill patients awaiting transfer to intensive care units (ICU) imposes additional burdens on the emergency care team from both a clinical and management perspective. The reasons for prolonged ED boarding are multifactorial. ED boarding compromises patients' safety and outcomes, and is associated with increased team burnout and dissatisfaction. Mitigation strategies include the optimization of patients' flow, the establishment of resuscitative care units, deployment of mobile critical care teams, and improvements in training. Staffing adjustments, changes in hospital operations, and quality improvement initiatives are required to improve this situation, while active bed management and implementation of capacity command centers may also help. SUMMARY Considering the characteristics of healthcare systems, such as funding mechanisms, organizational structures, delivery models, access and quality of care, the challenge of ED boarding of critically ill patients requires a nuanced and adaptable approach. Solutions are complex but must involve the entirety of the hospital system, emergency department, staff adjustment, and education.
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Affiliation(s)
- Fernando J da Silva Ramos
- Intensive Care Department - Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
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Santesson I, Schell CO, Bjurling-Sjöberg P. Capability to identify and manage critical conditions: effects of an interprofessional training intervention. BMC MEDICAL EDUCATION 2024; 24:584. [PMID: 38807075 DOI: 10.1186/s12909-024-05567-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/16/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND The burden of critical illness is a global issue. Healthcare systems often fail to provide essential emergency and critical care for deteriorating patients, and the optimal strategy for ensuring safe care is not fully known. This study aimed to explore the capability to identify and manage critical conditions and to evaluate how an interprofessional training intervention that included theory as well as high-fidelity simulation (proACT) in the short and long term affected the capability. METHODS A questionnaire study was performed. A cross-sectional survey of all in-hospital nurses and physicians in a Swedish region (n538) and a longitudinal cohort of participants entering the proACT course during a six-month period (n99) were included. Descriptive and comparative statistics were generated. Additionally, qualitative content analysis was performed for free text answers. RESULTS The findings demonstrated that the intervention improved the individual healthcare professionals' competence with a sustained effect over time. The coverage of proACT trained staff increased from 13.2% to 26.5%, but no correlation was observed with workplace conditions that support safe care. Collaboration and workplace climate were perceived to be mainly positive, but for safer care, an overall need for improved competence and staffing was emphasized. CONCLUSIONS The present study confirms previously identified issues and the need for improvements in the care of critically ill patients in general hospital wards. It supports the notion that a training intervention, such as proACT, can increase the capability to identify and manage patients with critical conditions. All healthcare professions increased the competence. Hence, more effort is needed to enable staff of all professions to participate in such training. Studies of interventions cover higher number of trained staff in the setting are warranted to clarify whether the training can also improve workplace conditions that support safe care of deteriorating and critically ill patients.
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Affiliation(s)
- Ia Santesson
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, 631 88, Sweden
- Department of Patient Safety, Region Sörmland, Eskilstuna, 631 88, Sweden
| | - Carl Otto Schell
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, 631 88, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, 171 77, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, 611 88, Sweden
| | - Petronella Bjurling-Sjöberg
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, 631 88, Sweden.
- Department of Patient Safety, Region Sörmland, Eskilstuna, 631 88, Sweden.
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, 752 37, Sweden.
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Dünser MW, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B, Erblich R, Kalb S, Knöll M, Szasz J, Behringer W, Meier J. Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission. Wien Klin Wochenschr 2024:10.1007/s00508-024-02374-w. [PMID: 38755419 DOI: 10.1007/s00508-024-02374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.
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Affiliation(s)
- Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria.
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4020, Linz, Austria.
| | - Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Bruckner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Brunner
- Ambulance and Disaster Relief Services, Oberösterreichisches Rotes Kreuz, 4020, Linz, Austria
| | - Bernhard Eichler
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Romana Erblich
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Stephan Kalb
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Marius Knöll
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | | | - Wilhelm Behringer
- Department of Emergency Medicine, Vienna General Hospital, 1090, Vienna, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
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Fitzgerald E, Ciccone EJ, Mvalo T, Chiume M, Mgusha Y, Mkaliainga TB, Tilly AE, Chen J, Bell G, Crouse H, Robison JA, Eckerle M. Comprehensive assessment of pediatric acute and inpatient care at a tertiary referral hospital in Malawi: opportunities for quality improvement. BMJ Paediatr Open 2024; 8:e002404. [PMID: 38719563 PMCID: PMC11086186 DOI: 10.1136/bmjpo-2023-002404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/28/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the reduction in global under-5 mortality over the last decade, childhood deaths remain high. To combat this, there has been a shift in focus from disease-specific interventions to use of healthcare data for resource allocation, evaluation of performance and impact, and accountability. This is a descriptive analysis of data derived from a prospective cohort study describing paediatric admissions to a tertiary referral hospital in Malawi for the purpose of process evaluation and quality improvement. METHODS Using a REDCap database, we collected data for patients admitted acutely to Kamuzu Central Hospital, a tertiary referral centre in the central region. Data were collected from 17 123 paediatric inpatients from 2017 to 2020. RESULTS Approximately 6% of patients presented with either two or more danger signs or severely abnormal vital signs. Infants less than 6 months, who had the highest mortality rate, were also the most critically ill on arrival to the hospital. Sepsis was diagnosed in about 20% of children across all age groups. Protocols for the management of high-volume, lower-acuity conditions such as uncomplicated malaria and pneumonia were generally well adhered to, but there was a low rate of completion for labs, radiology studies and subspecialty consultations required to provide care for high acuity or complex conditions. The overall mortality rate was 4%, and 60% of deaths occurred within the first 48 hours of admission. CONCLUSION Our data highlight the need to improve the quality of care provided at this tertiary-level centre by focusing on the initial stabilisation of high-acuity patients and augmenting resources to provide comprehensive care. This may include capacity building through the training of specialists, implementation of clinical processes, provision of specialised equipment and increasing access to and reliability of ancillary services. Data collection, analysis and routine use in policy and decision-making must be a pillar on which improvement is built.
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Affiliation(s)
- Elizabeth Fitzgerald
- Department of Pediatrics, Division of Emergency Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Emily Jane Ciccone
- Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Tisungane Mvalo
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Yamikani Mgusha
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Alyssa Evelyn Tilly
- Divisions of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Jane Chen
- Institute for Global Health and Infectious Disease, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Griffin Bell
- Epidemiology, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Heather Crouse
- Department of Pediatrics, Division of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jeff A Robison
- Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michelle Eckerle
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Mwale D, Manda-Taylor L, Langton J, Likumbo A, van Hensbroek MB, Calis J, Janssens W, Pell C. The role of healthcare providers and caregivers in monitoring critically ill children: a qualitative study in a tertiary hospital, southern Malawi. BMC Health Serv Res 2024; 24:595. [PMID: 38714998 PMCID: PMC11077805 DOI: 10.1186/s12913-024-11050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. METHODS A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. RESULTS The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. CONCLUSION Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.
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Affiliation(s)
- Daniel Mwale
- Kamuzu University of Health Sciences, Blantyre, Malawi.
- Training Research Unit of Excellence, Blantyre, Malawi.
| | - Lucinda Manda-Taylor
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Training Research Unit of Excellence, Blantyre, Malawi
| | | | - Alice Likumbo
- Training Research Unit of Excellence, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
| | - Job Calis
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciencies, Blantyre, Malawi
| | - Wendy Janssens
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Economics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Khalid K, Schell CO, Oliwa J, English M, Onyango O, Mcknight J, Mkumbo E, Awadh K, Maiba J, Baker T. Hospital readiness for the provision of care to critically ill patients in Tanzania- an in-depth cross-sectional study. BMC Health Serv Res 2024; 24:182. [PMID: 38331742 PMCID: PMC10854052 DOI: 10.1186/s12913-024-10616-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and potential for reversibility. The burden of critical illness is high, especially in low- and middle-income countries. Critical care can be provided as Essential Emergency and Critical Care (EECC)- the effective, low-cost, basic care that all critically ill patients should receive in all parts of all hospitals in the world- and advanced critical care- complex, resource-intensive care usually provided in an intensive care unit. The required resources may be available in the hospital and yet not be ready in the wards for immediate use for critically ill patients. The ward readiness of these resources, although harder to evaluate, is likely more important than their availability in the hospital. This study aimed to assess the ward readiness for EECC and the hospital availability of resources for EECC and for advanced critical care in hospitals in Tanzania. METHODS An in-depth, cross-sectional study was conducted in five purposively selected hospitals by visiting all wards to collect data on all the required 66 EECC and 161 advanced critical care resources. We defined hospital-availability as a resource present in the hospital and ward-readiness as a resource available, functioning, and present in the right place, time and amounts for critically ill patient care in the wards. Data were analyzed to calculate availability and readiness scores as proportions of the resources that were available at hospital level, and ready at ward level respectively. RESULTS Availability of EECC resources in hospitals was 84% and readiness in the wards was 56%. District hospitals had lower readiness scores (less than 50%) than regional and tertiary hospitals. Equipment readiness was highest (65%) while that of guidelines lowest (3%). Availability of advanced critical care resources was 31%. CONCLUSION Hospitals in Tanzania lack readiness for the provision of EECC- the low-cost, life-saving care for critically ill patients. The resources for EECC were available in hospitals, but were not ready for the immediate needs of critically ill patients in the wards. To provide effective EECC to all patients, improvements are needed around the essential, low-cost resources in hospital wards that are essential for decreasing preventable deaths.
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Affiliation(s)
- Karima Khalid
- Department of Anaesthesia, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
- Ifakara Health Institute, Dar es Salaam, Tanzania.
- Department of Anaesthesia, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania.
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Jacquie Oliwa
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Onesmus Onyango
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacob Mcknight
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Khamis Awadh
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - John Maiba
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tim Baker
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Mitchell R, Fang W, Tee QW, O'Reilly G, Romero L, Mitchell R, Bornstein S, Cameron P. Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments? Acad Emerg Med 2024; 31:164-182. [PMID: 37803524 DOI: 10.1111/acem.14815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource-limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low- and middle-income country (LMIC) emergency departments (EDs). METHODS Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full-text review underwent risk-of-bias assessment using the Newcastle-Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE. RESULTS Among 10,394 articles identified through the search strategy, 58 underwent full-text review and 16 were included in the final synthesis. All utilized pre-/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators. CONCLUSIONS There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.
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Affiliation(s)
- Rob Mitchell
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wendy Fang
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Qiao Wen Tee
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Gerard O'Reilly
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | | | - Peter Cameron
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Njoki C, Simiyu N, Kaddu R, Mwangi W, Sulemanji D, Oduor P, Dona DG, Otieno D, Abonyo TT, Wangeci P, Kabanya T, Mutuku S, Kioko A, Muthoni J, Kamau PM, Beane A, Haniffa R, Dondorp A, Misango D, Pisani L, Waweru-Siika W. EPidemiology, clinical characteristics and Outcomes of 4546 adult admissions to high-dependency and intensive care units in Kenya (EPOK): a multicentre registry-based observational study. Crit Care Explor 2024; 6:e1036. [PMID: 38356864 PMCID: PMC7615640 DOI: 10.1097/cce.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Objective to describe clinical, management and outcome features of critically ill patients admitted to intensive care units (ICUs) and high dependency units (HDUs) in Kenya. Design prospective registry-based observational study. Setting three HDUs and eight ICUs in Kenya. Patients consecutive adult patients admitted between January 2021 and June 2022. Interventions none. Measurements and main results data was entered in a cloud based platform using a common data model. Study endpoints included case mix variables, management features and patient centred outcomes. Patients with Coronavirus disease 2019 (COVID-19) were reported separately. Of the 3892/4546 patients without COVID-19, 2445 patients (62.8%) were from HDUs and 1447 (37.2%) from ICUs. Patients had a median age of 53 years (interquartile range [IQR] 38-68), with HDU patients being older but with a lower severity (APACHE II 6 [3-9] in HDUs vs 12 [7-17] in ICUs; p<0.001). One out of four patients were postoperative with 604 (63.4%) receiving emergency surgery. Readmission rate was 4.8%. Hypertension and diabetes were prevalent comorbidities, with a 4.0% HIV/AIDS rate. Invasive mechanical ventilation (IMV) was applied in 3.4% in HDUs vs. 47.6% in ICUs (P<0.001), with a duration of 7 days (IQR 3-21). There was a similar use of renal replacement therapy (4.0% vs. 4.7%; P<0.001). Vasopressor use was infrequent while half of patients received antibiotics. Average length of stay was 2 days (IQR 1-5). Crude HDU mortality rate was 6.5% in HDUs versus 30.5% in the ICUs (P<0.001). Of the 654 COVID-19 admissions, most were admitted in ICUs (72.3%) with a 33.2% mortality. Conclusions We provide the first multicenter observational cohort study from an African ICU national registry. Distinct management features and outcomes characterise HDU from ICU patients. Study registration Clinicaltrials.gov (reference number NCT05456217, date of registration 07 Nov 2022).
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Affiliation(s)
- Carolyne Njoki
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
| | - Nabukwangwa Simiyu
- Department of Anesthesia and Intensive Care, Kisii Hospital, Kisii, Kenya
| | - Ronnie Kaddu
- Intensive Care Unit, Aga Khan Mombasa Hospital (AKM), Mombasa, Kenya
| | - Wambui Mwangi
- Intensive Care Unit, Nyeri County Hospital, Nyeri, Kenya
| | - Demet Sulemanji
- Department of Anesthesia and Intensive Care, MP Shah Hospital, Nairobi, Kenya
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
| | - Peter Oduor
- Department of Anesthesia and Intensive Care, Nakuru referral Hospital, Nakuru, Kenya
| | | | | | | | - Patricia Wangeci
- Department of Anesthesia and Intensive Care, Nakuru referral Hospital, Nakuru, Kenya
| | - Thomas Kabanya
- Intensive Care Unit, Nyeri County Hospital, Nyeri, Kenya
| | - Selina Mutuku
- Intensive Care Unit, Aga Khan Mombasa Hospital (AKM), Mombasa, Kenya
| | - Annastacia Kioko
- Department of Anesthesia and Intensive Care, Kisii Hospital, Kisii, Kenya
| | - Joy Muthoni
- Intensive Care Unit, Aga Khan Mombasa Hospital (AKM), Mombasa, Kenya
| | - Peter Mburu Kamau
- Department of Anesthesia and Intensive Care, MP Shah Hospital, Nairobi, Kenya
| | - Abigail Beane
- Nat Intensive Care Surveillance-MORU, Colombo, Sri Lanka
- Critical Care Society of Kenya, Nairobi, Kenya
| | - Rashan Haniffa
- Nat Intensive Care Surveillance-MORU, Colombo, Sri Lanka
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
| | - Arjen Dondorp
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
| | - David Misango
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
| | - Luigi Pisani
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
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Onyango OO, Willows TM, McKnight J, Schell CO, Baker T, Mkumbo E, Maiba J, Khalid K, English M, Oliwa JN. Third delay in care of critically ill patients: a qualitative investigation of public hospitals in Kenya. BMJ Open 2024; 14:e072341. [PMID: 38176878 PMCID: PMC10773318 DOI: 10.1136/bmjopen-2023-072341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVES Third delay refers to delays in delivering requisite care to patients after they arrive at a health facility. In low-resource care settings, effective triage and flow of care are difficult to guarantee. In this study, we aimed to identify delays in the delivery of care to critically ill patients and possible ways to address these delays. DESIGN This was an exploratory qualitative study using in-depth interviews and patient journeys. The qualitative data were transcribed and aggregated into themes in NVivo V.12 Plus using inductive and deductive approaches. SETTING This study was conducted in four secondary-level public Kenyan hospitals across four counties between March and December 2021. The selected hospitals were part of the Clinical Information Network. PARTICIPANTS Purposive sampling method was used to identify administrative and front-line healthcare providers and patients. We conducted 12 in-depth interviews with 11 healthcare workers and patient journeys of 7 patients. Informed consent was sought from the participants and maintained throughout the study. RESULTS We identified a cycle of suboptimal systems for care with adaptive mechanisms that prevent quality care to critically ill patients. We identified suboptimal systems for identification of critical illness, inadequate resources for continuity care and disruption of the flow of care, as the major causes of delays in identification and the initiation of essential care to critically ill patients. Our study also illuminated the contribution of inflexible bureaucratic non-clinical business-related organisational processes to third delay. CONCLUSION Eliminating or reducing delays after patients arrive at the hospital is a time-sensitive measure that could improve the care outcomes of critically ill patients. This is achievable through an essential emergency and critical care package within the hospitals. Our findings can help emphasise the need for standardised effective and reliable care priorities to maintain of care of critically ill patients.
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Affiliation(s)
| | - Tamara M Willows
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacob McKnight
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Muhimbili, Tanzania, United Republic Of
| | - Elibariki Mkumbo
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
| | - John Maiba
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
| | - Karima Khalid
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Department of Anaesthesia and Critical Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Mike English
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacquie N Oliwa
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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11
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McKnight J, Willows TM, Oliwa J, Onyango O, Mkumbo E, Maiba J, Khalid K, Schell CO, Baker T, English M. Receive, Sustain, and Flow: A simple heuristic for facilitating the identification and treatment of critically ill patients during their hospital journeys. J Glob Health 2023; 13:04139. [PMID: 38131357 PMCID: PMC10740342 DOI: 10.7189/jogh.13.04139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background Hospital patients can become critically ill anywhere in a hospital but their survival is affected by problems of identification and adequate, timely, treatment. This is issue of particular concern in lower middle-income countries' (LMICs) hospitals where specialised units are scarce and severely under-resourced. "Cross-sectional" approaches to improving narrow, specific aspects of care will not attend to issues that affect patients' care across the length of their experience. A simpler approach to understanding key issues across the "hospital journey" could help to deliver life-saving treatments to those patients who need it, wherever they are in the facility. Methods We carried out 31 narrative interviews with frontline health workers in five Kenyan and five Tanzanian hospitals from November 2020 to December 2021 during the COVID-19 pandemic and analysed using a thematic analysis approach. We also followed 12 patient hospital journeys, through the course of treatment of very sick patients admitted to the hospitals we studied. Results Our research explores gaps in hospital systems that result in lapses in effective, continuous care across the hospital journeys of patients in Tanzania and Kenya. We organise these factors according to the Systems Engineering Initiative for Patient Safety (SEIPS) approach to patient safety, which we extend to explore how these issues affect patients across the course of care. We discern three repeating, recursive phases we term Receive, Sustain, and Flow. We use this heuristic to show how gaps and weaknesses in service provision affect critically ill patients' hospital journeys. Conclusion Receive, Sustain, and Flow offers a heuristic for hospital management to identify and ameliorate limitations in human and technical resources for the care of the critically ill.
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Affiliation(s)
- Jacob McKnight
- Health Systems Collaborative, University of Oxford, Oxford, England, UK
| | | | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya
| | - Onesmus Onyango
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Elibariki Mkumbo
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - John Maiba
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Karima Khalid
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
- Department of Anaesthesia, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Mike English
- Health Systems Collaborative, University of Oxford, Oxford, England, UK
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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12
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Bartlett ES, Lim A, Kivlehan S, Losonczy LI, Murthy S, Lowsby R, Papali A, Raees M, Seth B, Cobb N, Brotherton J, Dippenaar E, Nepal G, Shrestha GS, Kuo SCE, Skrabal JR, Davis M, Lay C, Yi S, Jaung M, Chaffay B, Sefa N, Yang ML, Stephens PA, Rashed A, Benzoni N, Velasco B, Adhikari NK, Reynolds T. Critical care delivery across health care systems in low-income and low-middle-income country settings: A systematic review. J Glob Health 2023; 13:04141. [PMID: 38033248 PMCID: PMC10691174 DOI: 10.7189/jogh.13.04141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
Background Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higher rate of mortality from critical illness than high-income countries (HICs). There is a pressing need for improved critical care delivery in LLMICs to reduce this inequity. This systematic review aimed to characterise the range of critical care interventions and services delivered within LLMIC health care systems as reported in the literature. Methods A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles with human subjects describing at least one critical care intervention or service in an LLMIC setting published between 1 January 2008 and 1 January 2020. Results A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% on infants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of the care described (94%) was delivered in-hospital, with the remainder (6.2%) taking place in out-of-hospital care settings. Overall, 49% of critical care described was delivered outside of a designated intensive care unit. Specialist physicians delivered critical care in 60% of the included studies. Additional critical care was delivered by general physicians (40%), as well as specialist physician trainees (22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%), ambulance providers (3.3%) and respiratory therapists (3.1%). Conclusions This review represents a comprehensive synthesis of critical care delivery in LLMIC settings. Approximately 50% of critical care interventions and services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved in care delivery in the included studies, however generalist physicians were commonly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding critical care practice in LLMICs, demonstrating a paucity of interventional and cost-effectiveness studies. Future research is needed to understand better how to optimise critical care interventions, services, care delivery and costs in these settings. Registration PROSPERO CRD42019146802.
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Affiliation(s)
- Emily S Bartlett
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Andrew Lim
- Section of Critical Care Medicine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Sean Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Humanitarian Initiative, Cambridge, Massachuesetts, USA
| | - Lia I Losonczy
- Department of Emergency Medicine, Department of Anaesthesia and Critical Care Medicine, George Washington University Medical Center, Washington, District of Columbia, USA
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Lowsby
- Department of Critical Care Medicine, Department of Emergency Medicine, Mid Cheshire Hospitals National health Service Foundation Trust, Cheshire, UK
| | - Alfred Papali
- Pulmonary and Critical Care Medicine, Atrium Health, Pineville, North Carolina, USA
| | - Madiha Raees
- Division of Critical Care Medicine, Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Natalie Cobb
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Jason Brotherton
- Department of Internal Medicine and Paediatrics, Africa Inland Church Kijabe Hospital, Kijabe Kenya
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Gaurav Nepal
- Ministry of Health and Population, Kathmandu, Nepal
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Shih-Chiang E Kuo
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J Ryan Skrabal
- Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA
| | - Margaret Davis
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Cappi Lay
- Department of Neurosurgery, Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Sojung Yi
- Stanford University, Stanford, California, USA
| | - Michael Jaung
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Brandon Chaffay
- Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA
| | - Nana Sefa
- Department of Emergency Medicine, Department of Critical Care, Medstar Washington Hospital Center, Washington, District of Columbia, USA
| | - Marc Lc Yang
- Accident and Emergency Medicine, The Chinese University of Hong Kong Faculty of Medicine, Hong Kong
| | - P Andrew Stephens
- Department of Emergency Medicine, Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amir Rashed
- Albert Einstein College of Medicine, New York, New York, USA
| | - Nicole Benzoni
- Critical Care Medicine, Virginia Mason Franciscan Health, Silverdale, Washington, USA
| | - Bernadett Velasco
- Department of Emergency Medicine, East Avenue Medical Center, Quezon City, National Capital Region, Philippines
| | - Neill Kj Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Teri Reynolds
- Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
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English M, Oliwa J, Khalid K, Onyango O, Willows TM, Mazhar R, Mkumbo E, Guinness L, Schell CO, Baker T, McKnight J. Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic. BMJ Glob Health 2023; 8:e013407. [PMID: 37918869 PMCID: PMC10626868 DOI: 10.1136/bmjgh-2023-013407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023] Open
Abstract
Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.
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Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Onesmus Onyango
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Tamara Mulenga Willows
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rosanna Mazhar
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, London, UK
- Centre for Global Development, London, UK
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Karolinska Institute, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacob McKnight
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Connolly E, Kasomekera N, Sonenthal PD, Nyirenda M, Marsh RH, Wroe EB, Scott KW, Bukhman A, Minyaliwa T, Katete M, Banda G, Mukherjee J, Rouhani SA. Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study. BMC Health Serv Res 2023; 23:1062. [PMID: 37798681 PMCID: PMC10557270 DOI: 10.1186/s12913-023-10014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. METHODS This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. RESULTS From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. CONCLUSION Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.
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Affiliation(s)
- Emilia Connolly
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi.
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
- Division of Hospital Medicine, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Noel Kasomekera
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
- Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Paul D Sonenthal
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Brigham & Women's Hospital, Division of Pulmonary & Critical Care, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Mulinda Nyirenda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
- University of Malawi College of Medicine, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Regan H Marsh
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
| | - Emily B Wroe
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Division of Global Health Equity, 75 Francis St, Boston, MA, 02115, USA
| | - Kirstin W Scott
- Department of Emergency Medicine, University of Washington, Seattle, USA
| | - Alice Bukhman
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
| | - Tadala Minyaliwa
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Martha Katete
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Grace Banda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
| | - Joia Mukherjee
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Shada A Rouhani
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
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15
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Owoo C, Adhikari NKJ, Akinola O, Aryal D, Azevedo LC, Bacha T, Baelani JI, Baker T, Bartlett E, Bonney J, Convocar P, Dippenaar E, Dunser MW, Estenssoro E, Fowler R, Gore S, Guddu DK, Hashmi M, Hollong BG, Kabongo D, Kivlehan SM, King LL, Losonczy L, Lundeg G, McCurdy MT, Mer M, Misango D, Moll V, Murthy S, Pattnaik R, Petros S, Riviello E, Schell CO, Shrestha GS, Sultan M, Tefera M, Yim A, Tadesse AZ. The World Health Assembly resolution on integrated emergency, critical, and operative care for universal health coverage and protection from health emergencies: a golden opportunity to attenuate the global burden of acute and critical illness. Intensive Care Med 2023; 49:1223-1225. [PMID: 37578521 PMCID: PMC10556161 DOI: 10.1007/s00134-023-07176-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023]
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16
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Schell CO, Wellhagen A, Lipcsey M, Kurland L, Bjurling-Sjöberg P, Stålsby Lundborg C, Castegren M, Baker T. The burden of critical illness among adults in a Swedish region-a population-based point-prevalence study. Eur J Med Res 2023; 28:322. [PMID: 37679836 PMCID: PMC10483802 DOI: 10.1186/s40001-023-01279-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Patients with critical illness have a high risk of mortality. Key decision-making in the health system affecting the outcomes of critically ill patients requires epidemiological evidence, but the burden of critical illness is largely unknown. This study aimed to estimate the prevalence of critical illness in a Swedish region. Secondary objectives were to estimate the proportion of hospital inpatients who are critically ill and to describe the in-hospital location of critically ill patients. METHODS A prospective, multi-center, population-based, point-prevalence study on specific days in 2017-2018. All adult (> 18 years) in-patients, regardless of admitting specially, in all acute hospitals in Sörmland, and the patients from Sörmland who had been referred to university hospitals, were included. Patients in the operating theatres, with a psychiatric cause of admission, women in active labor and moribund patients, were excluded. All participants were examined by trained data collectors. Critical illness was defined as "a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and a potential for reversibility". The presence of one or more severely deranged vital signs was used to classify critical illness. The prevalence of critical illness was calculated as the number of critically ill patients divided by the number of adults in the region. RESULTS A total of 1269 patients were included in the study. Median age was 74 years and 50% of patients were female. Critical illness was present in 133 patients, resulting in an adult population prevalence of critical illness per 100,000 people of 19.4 (95% CI 16.4-23.0). The proportion of patients in hospital who were critically ill was 10.5% (95% CI 8.8-12.3%). Among the critically ill, 125 [95% CI 94.0% (88.4-97.0%)] were cared for in general wards. CONCLUSIONS The prevalence of critical illness was higher than previous, indirect estimates. One in ten hospitalized patients were critically ill, the large majority of which were cared for in general wards. This suggests a hidden burden of critical illness of potential public health, health system and hospital management significance.
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Affiliation(s)
- Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden.
- Department of Medicine, Nyköping Hospital, Sörmland Region, Nyköping, Sweden.
| | - Andreas Wellhagen
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Anaesthesia and Intensive Care, Nyköping Hospital, Sörmland Region, Nyköping, Sweden
| | - Miklós Lipcsey
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - Lisa Kurland
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Emergency Medicine, Örebro University, Örebro University Hospital, Örebro, Sweden
| | - Petronella Bjurling-Sjöberg
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- Department of Patient Safety, Region Sörmland, Eskilstuna, Sweden
| | | | - Markus Castegren
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology (FyFa), Karolinska Institutet, Stockholm, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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17
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Oliwa JN, Mazhar RJ, Serem G, Khalid K, Amoth P, Kiarie H, Warfa O, Schell CO, Baker T, English M, Mcknight J. Policies and resources for strengthening of emergency and critical care services in the context of the global COVID-19 pandemic in Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000483. [PMID: 37399177 DOI: 10.1371/journal.pgph.0000483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/19/2023] [Indexed: 07/05/2023]
Abstract
Critical illnesses cause several million deaths annually, with many of these occurring in low-resource settings like Kenya. Great efforts have been made worldwide to scale up critical care to reduce deaths from COVID-19. Lower income countries with fragile health systems may not have had sufficient resources to upscale their critical care. We aimed to review how efforts to strengthen emergency and critical care were operationalised during the pandemic in Kenya to point towards how future emergencies should be approached. This was an exploratory study that involved document reviews, and discussions with key stakeholders (donors, international agencies, professional associations, government actors), during the first year of the pandemic in Kenya. Our findings suggest that pre-pandemic health services for the critically ill in Kenya were sparse and unable to meet rising demand, with major limitations noted in human resources and infrastructure. The pandemic response saw galvanised action by the Government of Kenya and other agencies to mobilise resources (approximately USD 218 million). Earlier efforts were largely directed towards advanced critical care but since the human resource gap could not be reduced immediately, a lot of equipment remained unused. We also note that despite strong policies on what resources should be available, the reality on the ground was that there were often critical shortages. While emergency response mechanisms are not conducive to addressing long-term health system issues, the pandemic increased global recognition of the need to fund care for the critically ill. Limited resources may be best prioritised towards a public health approach with focus on provision of relatively basic, lower cost essential emergency and critical care (EECC) that can potentially save the most lives amongst critically ill patients.
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Affiliation(s)
- Jacquie Narotso Oliwa
- Department of Health Systems & Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya
| | - Rosanna Jeffries Mazhar
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Oxford, United Kingdom
| | - George Serem
- Department of Health Systems & Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Karima Khalid
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Patrick Amoth
- Office of the Director General, Ministry of Health, Nairobi, Kenya
| | - Helen Kiarie
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya
| | - Osman Warfa
- Office of the Director General, Ministry of Health, Nairobi, Kenya
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Internal Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mike English
- Department of Health Systems & Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Oxford, United Kingdom
| | - Jacob Mcknight
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Oxford, United Kingdom
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Spencer SA, Adipa FE, Baker T, Crawford AM, Dark P, Dula D, Gordon SB, Hamilton DO, Huluka DK, Khalid K, Lakoh S, Limbani F, Rylance J, Sawe HR, Simiyu I, Waweru-Siika W, Worrall E, Morton B. A health systems approach to critical care delivery in low-resource settings: a narrative review. Intensive Care Med 2023; 49:772-784. [PMID: 37428213 PMCID: PMC10354139 DOI: 10.1007/s00134-023-07136-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023]
Abstract
There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.
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Affiliation(s)
- Stephen A Spencer
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Tim Baker
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Queen Marys University of London, London, UK
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Paul Dark
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
| | - Dingase Dula
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Stephen B Gordon
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - David Oliver Hamilton
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | | | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sulaiman Lakoh
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Felix Limbani
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Jamie Rylance
- Health Care Readiness Unit, World Health Organisation, Geneva, Switzerland
| | - Hendry R Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ibrahim Simiyu
- Liverpool School of Tropical Medicine, Liverpool, UK
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Eve Worrall
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ben Morton
- Liverpool School of Tropical Medicine, Liverpool, UK.
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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Willows TM, Oliwa J, Onyango O, Mkumbo E, Maiba J, Schell CO, Baker T, McKnight J. COVID-19 and unintended steps towards further equity in global health research. BMJ Glob Health 2023; 8:e011888. [PMID: 37328283 PMCID: PMC10276961 DOI: 10.1136/bmjgh-2023-011888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/29/2023] [Indexed: 06/18/2023] Open
Abstract
There was, and possibly still is, potential for COVID-19 to disrupt power inequities and contribute to positive transformation in global health research that increases equity. While there is consensus about the need to decolonise by transforming global health, and a roadmap outlining how we could approach it, there are few examples of steps that could be taken to transform the mechanics of global health research. This paper contributes lessons learnt from experiences and reflections of our diverse multinational team of researchers involved in a multicountry research project. We demonstrate the positive impact on our research project of making further steps towards improving equity within our research practices. Some of the approaches adopted include redistributing power to researchers from the countries of interest at various stages in their career, by involving the whole team in decisions about the research; meaningfully involving the whole team in research data analysis; and providing opportunities for all researchers from the countries of interest to voice their perspectives as first authors in publications. Although this approach is consistent with how research guidance suggests research should be run, in reality it does not often happen in this way. The authors of this paper hope that by sharing our experience, we can contribute towards discussions about the processes required to continue developing a global health sector that is equitable and inclusive.
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Affiliation(s)
- Tamara Mulenga Willows
- Tropical Medicine and Global Health, University of Oxford Medical Sciences Division, Oxford, UK
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Onesmus Onyango
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Elibariki Mkumbo
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Tanzania
| | - John Maiba
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Tim Baker
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Tanzania
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Jacob McKnight
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
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Lee JS, Godard A. A humanitarian's perspective of critical care in conflict zones. Intensive Care Med 2023; 49:685-688. [PMID: 37041368 PMCID: PMC10089819 DOI: 10.1007/s00134-023-07042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/16/2023] [Indexed: 04/13/2023]
Affiliation(s)
- James S Lee
- Medical Department, Médecins Sans Frontières-Operational Centre Brussels, Brussels, Belgium.
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
| | - Aurélie Godard
- Medical Department, Médecins Sans Frontières-Operational Centre Paris, Paris, France
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21
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Shah HA, Baker T, Schell CO, Kuwawenaruwa A, Awadh K, Khalid K, Kairu A, Were V, Barasa E, Baker P, Guinness L. Cost Effectiveness of Strategies for Caring for Critically Ill Patients with COVID-19 in Tanzania. PHARMACOECONOMICS - OPEN 2023:10.1007/s41669-023-00418-x. [PMID: 37178434 PMCID: PMC10181924 DOI: 10.1007/s41669-023-00418-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The resources for critical care are limited in many settings, exacerbating the significant morbidity and mortality associated with critical illness. Budget constraints can lead to choices between investing in advanced critical care (e.g. mechanical ventilators in intensive care units) or more basic critical care such as Essential Emergency and Critical Care (EECC; e.g. vital signs monitoring, oxygen therapy, and intravenous fluids). METHODS We investigated the cost effectiveness of providing EECC and advanced critical care in Tanzania in comparison with providing 'no critical care' or 'district hospital-level critical care' using coronavirus disease 2019 (COVID-19) as a tracer condition. We developed an open-source Markov model ( https://github.com/EECCnetwork/POETIC_CEA ) to estimate costs and disability-adjusted life-years (DALYs) averted, using a provider perspective, a 28-day time horizon, patient outcomes obtained from an elicitation method involving a seven-member expert group, a normative costing study, and published literature. We performed a univariate and probabilistic sensitivity analysis to assess the robustness of our results. , RESULTS EECC is cost effective 94% and 99% of the time when compared with no critical care (incremental cost-effectiveness ratio [ICER] $37 [-$9 to $790] per DALY averted) and district hospital-level critical care (ICER $14 [-$200 to $263] per DALY averted), respectively, relative to the lowest identified estimate of the willingness-to-pay threshold for Tanzania ($101 per DALY averted). Advanced critical care is cost effective 27% and 40% of the time, when compared with the no critical care or district hospital-level critical care scenarios, respectively. CONCLUSION For settings where there is limited or no critical care delivery, implementation of EECC could be a highly cost-effective investment. It could reduce mortality and morbidity for critically ill COVID-19 patients, and its cost effectiveness falls within the range considered 'highly cost effective'. Further research is needed to explore the potential of EECC to generate even greater benefits and value for money when patients with diagnoses other than COVID-19 are accounted for.
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Affiliation(s)
| | - Tim Baker
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | | | - Khamis Awadh
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Karima Khalid
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Angela Kairu
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Vincent Were
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lorna Guinness
- Center for Global Development, London, UK.
- Global Health Economics Centre, London School of Hygiene and Tropical Medicine, London, UK.
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Mekontso Dessap A, Richard JCM, Baker T, Godard A, Carteaux G. Technical Innovation in Critical Care in a World of Constraints: Lessons from the COVID-19 Pandemic. Am J Respir Crit Care Med 2023; 207:1126-1133. [PMID: 36716353 PMCID: PMC10161748 DOI: 10.1164/rccm.202211-2174cp] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
The COVID-19 crisis was characterized by a massive need for respiratory support, which has unfortunately not been met globally. This situation mimicked those which gave rise to critical care in the past. Since the polio epidemic in the 50's, the technological evolution of respiratory support has enabled health professionals to save the lives of critically-ill patients worldwide every year. However, much of the current innovation work has turned around developing sophisticated, complex, and high-cost standards and approaches whose resilience is still questionable upon facing constrained environments or contexts, as seen in resuscitation work outside intensive care units, during pandemics, or in low-income countries. Ventilatory support is an essential life-saving tool for patients with respiratory distress. It requires an oxygen source combined to a ventilatory assistance device, an adequate monitoring system, and properly trained caregivers to operate it. Each of these elements can be subject to critical constraints, which we can no longer ignore. The innovation process should incorporate them as a prima materia, whilst focusing on the core need of the field using the concept of frugal innovation. Having a universal access to oxygen and respiratory support, irrespective of the context and constraints, necessitates: i) developing cost-effective, energy-efficient, and maintenance-free oxygen generation devices; ii) improving the design of non-invasive respiratory devices (for example, with oxygen saving properties); iii) conceiving fully frugal ventilators and universal monitoring systems; iv) broadening ventilation expertise by developing end-user training programs in ventilator assistance. The frugal innovation approach may give rise to a more resilient and inclusive critical care system. This paradigm shift is essential for the current and future challenges.
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Affiliation(s)
- Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé de Créteil, IMRB, GRC CARMAS, Université Paris-Est Créteil, Créteil, France
- INSERM U955, Créteil, France
| | - Jean-Christophe Marie Richard
- Vent’Lab, Medical ICU, Angers University Hospital, University of Angers, Angers, France
- Med2Lab, Air Liquide Medical Systems, Antony, France
| | - Tim Baker
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Global Public Health, Karolinska Institute, Stockholm, Sweden
- Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom; and
| | - Aurélie Godard
- Médecins Sans Frontières – Centre Opérationel Paris, Paris, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé de Créteil, IMRB, GRC CARMAS, Université Paris-Est Créteil, Créteil, France
- INSERM U955, Créteil, France
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23
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Mumo E, Agutu NO, Moturi AK, Cherono A, Muchiri SK, Snow RW, Alegana VA. Geographic accessibility and hospital competition for emergency blood transfusion services in Bungoma, Western Kenya. Int J Health Geogr 2023; 22:6. [PMID: 36973723 PMCID: PMC10041813 DOI: 10.1186/s12942-023-00327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Estimating accessibility gaps to essential health interventions helps to allocate and prioritize health resources. Access to blood transfusion represents an important emergency health requirement. Here, we develop geo-spatial models of accessibility and competition to blood transfusion services in Bungoma County, Western Kenya. METHODS Hospitals providing blood transfusion services in Bungoma were identified from an up-dated geo-coded facility database. AccessMod was used to define care-seeker's travel times to the nearest blood transfusion service. A spatial accessibility index for each enumeration area (EA) was defined using modelled travel time, population demand, and supply available at the hospital, assuming a uniform risk of emergency occurrence in the county. To identify populations marginalized from transfusion services, the number of people outside 1-h travel time and those residing in EAs with low accessibility indexes were computed at the sub-county level. Competition between the transfusing hospitals was estimated using a spatial competition index which provided a measure of the level of attractiveness of each hospital. To understand whether highly competitive facilities had better capacity for blood transfusion services, a correlation test between the computed competition metric and the blood units received and transfused at the hospital was done. RESULTS 15 hospitals in Bungoma county provide transfusion services, however these are unevenly distributed across the sub-counties. Average travel time to a blood transfusion centre in the county was 33 min and 5% of the population resided outside 1-h travel time. Based on the accessibility index, 38% of the EAs were classified to have low accessibility, representing 34% of the population, with one sub-county having the highest marginalized population. The computed competition index showed that hospitals in the urban areas had a spatial competitive advantage over those in rural areas. CONCLUSION The modelled spatial accessibility has provided an improved understanding of health care gaps essential for health planning. Hospital competition has been illustrated to have some degree of influence in provision of health services hence should be considered as a significant external factor impacting the delivery, and re-design of available services.
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Affiliation(s)
- Eda Mumo
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Geomatic Engineering and Geospatial Information System (GEGIS), Jomo Kenyatta University of Agriculture and Technology (JKUAT), Nairobi, Kenya
| | - Nathan O. Agutu
- Department of Geomatic Engineering and Geospatial Information System (GEGIS), Jomo Kenyatta University of Agriculture and Technology (JKUAT), Nairobi, Kenya
| | - Angela K. Moturi
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Anitah Cherono
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Samuel K. Muchiri
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Robert W. Snow
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Victor A. Alegana
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
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24
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Agulnik A. Management of septic shock in children with cancer-Common challenges and research priorities. J Pediatr (Rio J) 2023; 99:101-104. [PMID: 36706794 PMCID: PMC10031354 DOI: 10.1016/j.jped.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN.
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Guinness L, Kairu A, Kuwawenaruwa A, Khalid K, Awadh K, Were V, Barasa E, Shah H, Baker P, Schell CO, Baker T. Essential emergency and critical care as a health system response to critical illness and the COVID19 pandemic: what does it cost? COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:15. [PMID: 36782287 PMCID: PMC9923646 DOI: 10.1186/s12962-023-00425-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 01/27/2023] [Indexed: 02/15/2023] Open
Abstract
Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, effective, low-cost, life-saving care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in Tanzania and Kenya.The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.The costs per patient day of EECC is estimated to be 1 USD, 11 USD and 33 USD in Tanzania and 2 USD, 14 USD and 37 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13 USD and 294 USD in Tanzania and USD 17 USD and 345 USD in Kenya for severe and critical COVID-19 patients, respectively.EECC is a novel approach for providing the essential care to all critically ill patients. The low costs and lower tech approach inherent in delivering EECC mean that EECC could be provided to many and suggests that prioritizing EECC over ACC may be a rational approach when resources are limited.
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Affiliation(s)
- Lorna Guinness
- Center for Global Development, Great Peter House, Abbey Gardens, Great College St, London, SW1P 3SE, UK. .,Global Health Economics Centre, London School of Hygiene and Tropical Medicine, London, UK.
| | - Angela Kairu
- grid.33058.3d0000 0001 0155 5938Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - August Kuwawenaruwa
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Dar es Salaam, Tanzania
| | - Karima Khalid
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Dar es Salaam, Tanzania ,grid.25867.3e0000 0001 1481 7466Muhimbili University of Health and Allied Sciences, Dar Es Salaam, United Republic of Tanzania
| | - Khamis Awadh
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Dar es Salaam, Tanzania
| | - Vincent Were
- grid.33058.3d0000 0001 0155 5938Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine Barasa
- grid.33058.3d0000 0001 0155 5938Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Hiral Shah
- Center for Global Development, Great Peter House, Abbey Gardens, Great College St, London, SW1P 3SE UK
| | - Peter Baker
- Center for Global Development, Great Peter House, Abbey Gardens, Great College St, London, SW1P 3SE UK
| | - Carl Otto Schell
- grid.4714.60000 0004 1937 0626Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden ,grid.8993.b0000 0004 1936 9457Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden ,Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Dar es Salaam, Tanzania ,grid.25867.3e0000 0001 1481 7466Muhimbili University of Health and Allied Sciences, Dar Es Salaam, United Republic of Tanzania ,grid.4714.60000 0004 1937 0626Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden ,grid.8991.90000 0004 0425 469XDepartment of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Mkumbo E, Willows TM, Onyango O, Khalid K, Maiba J, Schell CO, Oliwa J, McKnight J, Baker T. Same label, different patients: Health-workers' understanding of the label 'critical illness'. FRONTIERS IN HEALTH SERVICES 2023; 3:1105078. [PMID: 36811083 PMCID: PMC7614203 DOI: 10.3389/frhs.2023.1105078] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Background During the course of patients' sickness, some become critically ill, and identifying them is the first important step to be able to manage the illness. During the course of care provision, health workers sometimes use the term 'critical illness' as a label when referring to their patient's condition, and the label is then used as a basis for communication and care provision. Their understanding of this label will therefore have a profound impact on the identification and management of patients. This study aimed to determine how Kenyan and Tanzanian health workers understand the label 'critical illness'. Methods A total of 10 hospitals-five in Kenya and five in Tanzania-were visited. In-depth interviews were conducted with 30 nurses and physicians from different departments in the hospitals who had experience in providing care for sick patients. We conducted a thematic analysis of the translated and transcribed interviews, synthesized findings and developed an overarching set of themes which captured healthcare workers' understandings of the label 'critical illness'. Results Overall, there does not appear to be a unified understanding of the label 'critical illness' among health workers. Health workers understand the label to refer to patients in four thematic ways: (1) those in a life-threatening state; (2) those with certain diagnoses; (3) those receiving care in certain locations; and (4) those in need of a certain level of care. Conclusion There is a lack of a unified understanding about the label 'critical illness' among health workers in Tanzania and Kenya. This potentially hampers communication and the selection of patients for urgent life-saving care. A recently proposed definition, "a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility", could be useful for improving communication and care.
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Affiliation(s)
- Elibariki Mkumbo
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania,Correspondence: Elibariki Mkumbo,
| | - Tamara Mulenga Willows
- Health Systems Collaborative, Department of Tropical Medicine and Global Health University of Oxford Health, Oxford, United Kingdom
| | - Onesmus Onyango
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Karima Khalid
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania,Department of Anaesthesia, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - John Maiba
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden,Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden,Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacob McKnight
- Health Systems Collaborative, Department of Tropical Medicine and Global Health University of Oxford Health, Oxford, United Kingdom
| | - Tim Baker
- Department of Health Systems, Ifakara Health Institute, Dar es Salaam, Tanzania,Department of Anaesthesia, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Diagnostic, Management, and Research Considerations for Pediatric Acute Respiratory Distress Syndrome in Resource-Limited Settings: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S148-S159. [PMID: 36661443 DOI: 10.1097/pcc.0000000000003166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Diagnosis of pediatric acute respiratory distress syndrome (PARDS) in resource-limited settings (RLS) is challenging and remains poorly described. We conducted a review of the literature to optimize recognition of PARDS in RLS and to provide recommendations/statements for clinical practice and future research in these settings as part of the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included studies related to precipitating factors for PARDS, mechanical ventilation (MV), pulmonary and nonpulmonary ancillary treatments, and long-term outcomes in children who survive PARDS in RLS. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Seventy-seven studies were identified for full-text extraction. We were unable to identify any literature on which to base recommendations. We gained consensus on six clinical statements (good practice, definition, and policy) and five research statements. Clinicians should be aware of diseases and comorbidities, uncommon in most high-income settings, that predispose to the development of PARDS in RLS. Because of difficulties in recognizing PARDS and to avoid underdiagnosis, the PALICC-2 possible PARDS definition allows exclusion of imaging criteria when all other criteria are met, including noninvasive metrics of hypoxemia. The availability of MV support, regular MV training and education, as well as accessibility and costs of pulmonary and nonpulmonary ancillary therapies are other concerns related to management of PARDS in RLS. Data on long-term outcomes and feasibility of follow-up in PARDS survivors from RLS are also lacking. CONCLUSIONS To date, PARDS remains poorly described in RLS. Clinicians working in these settings should be aware of common precipitating factors for PARDS in their patients. Future studies utilizing the PALICC-2 definitions are urgently needed to describe the epidemiology, management, and outcomes of PARDS in RLS.
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Leidinger A, Zuckerman SL, Feng Y, He Y, Chen X, Cheserem B, Gerber LM, Lessing NL, Shabani HK, Härtl R, Mangat HS. Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania. J Neurosurg Spine 2023; 38:503-511. [PMID: 36640104 DOI: 10.3171/2022.11.spine22763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings. METHODS This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated. RESULTS Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively. CONCLUSIONS Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.
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Affiliation(s)
- Andreas Leidinger
- 1Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Scott L Zuckerman
- 2Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yueqi Feng
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | - Yitian He
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | - Xinrui Chen
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | | | | | - Noah L Lessing
- 6School of Medicine, University of Maryland, Baltimore, Maryland
| | - Hamisi K Shabani
- 7Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania; and
| | - Roger Härtl
- 8Neurology and Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Halinder S Mangat
- 9Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center, Kansas City, Kansas
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Bedwell GJ, Dias P, Hahnle L, Anaeli A, Baker T, Beane A, Biccard BM, Bulamba F, Delgado-Ramirez MB, Dullewe NP, Echeverri-Mallarino V, Haniffa R, Hewitt-Smith A, Hoyos AS, Mboya EA, Nanimambi J, Pearse R, Pratheepan AP, Sunguya B, Tolppa T, Uruthirakumar P, Vengadasalam S, Vindrola-Padros C, Stephens TJ. Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study. Anesth Analg 2022; 135:1217-1232. [PMID: 36005395 DOI: 10.1213/ane.0000000000006113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Provision of timely, safe, and affordable surgical care is an essential component of any high-quality health system. Increasingly, it is recognized that poor quality of care in the perioperative period (before, during, and after surgery) may contribute to significant excess mortality and morbidity. Therefore, improving access to surgical procedures alone will not address the disparities in surgical outcomes globally until the quality of perioperative care is addressed. We aimed to identify key barriers to quality perioperative care delivery for 3 "Bellwether" procedures (cesarean delivery, emergency laparotomy, and long-bone fracture fixation) in 5 low- and middle-income countries (LMICs). METHODS Ten hospitals representing secondary and tertiary facilities from 5 LMICs were purposefully selected: 2 upper-middle income (Colombia and South Africa); 2 lower-middle income (Sri Lanka and Tanzania); and 1 lower income (Uganda). We used a rapid appraisal design (pathway mapping, ethnography, and interviews) to map out and explore the complexities of the perioperative pathway and care delivery for the Bellwether procedures. The framework approach was used for data analysis, with triangulation across different data sources to identify barriers in the country and pattern matching to identify common barriers across the 5 LMICs. RESULTS We developed 25 pathway maps, undertook >30 periods of observation, and held >40 interviews with patients and clinical staff. Although the extent and impact of the barriers varied across the LMIC settings, 4 key common barriers to safe and effective perioperative care were identified: (1) the fragmented nature of the care pathways, (2) the limited human and structural resources available for the provision of care, (3) the direct and indirect costs of care for patients (even in health systems for which care is ostensibly free of charge), and (4) patients' low expectations of care. CONCLUSIONS We identified key barriers to effective perioperative care in LMICs. Addressing these barriers is important if LMIC health systems are to provide safe, timely, and affordable provision of the Bellwether procedures.
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Affiliation(s)
- Gillian J Bedwell
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Priyanthi Dias
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Lina Hahnle
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Tim Baker
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Abi Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Fred Bulamba
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Martha B Delgado-Ramirez
- Departments of Clinical Epidemiology and Biostatistics.,Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Nilmini P Dullewe
- Post Basic School of Nursing, Colombo, Sri Lanka.,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | | | - Rashan Haniffa
- Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Adam Hewitt-Smith
- Elgon Centre for Health, Research and Innovation, Mbale' Uganda.,Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Alejandra Sanin Hoyos
- Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Erick A Mboya
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juliana Nanimambi
- Department of Anaesthesia and Critical Care, Faculty of Health Sciences, Busitema University, Mbale, Uganda.,Elgon Centre for Health, Research and Innovation, Mbale' Uganda
| | - Rupert Pearse
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Anton Premadas Pratheepan
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Jaffna Teaching Hospital, Jaffna, Sri Lanka
| | - Bruno Sunguya
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Timo Tolppa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Powsiga Uruthirakumar
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | | | | | - Timothy J Stephens
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Kazibwe J, Shah HA, Kuwawenaruwa A, Schell CO, Khalid K, Tran PB, Ghosh S, Baker T, Guinness L. Resource use, availability and cost in the provision of critical care in Tanzania: a systematic review. BMJ Open 2022; 12:e060422. [PMID: 36414306 PMCID: PMC9684998 DOI: 10.1136/bmjopen-2021-060422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania. DESIGN This is a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES Medline, Embase and Global Health databases were searched covering the period 2010 to 17 November 2020. ELIGIBILITY CRITERIA We included studies that reported on forms of critical care offered, critical care services offered and/or costs and resources used in the provision of care in Tanzania published from 2010. DATA EXTRACTION AND SYNTHESIS Quality assessment of the articles and data extraction was done by two independent researchers. The Reference Case for Estimating the Costs of Global Health Services and Interventions was used to assess quality of included studies. A narrative synthesis of extracted data was conducted. Costs were adjusted and reported in 2019 US$ and TZS using the World Bank GDP deflators. RESULTS A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: intensive care unit (ICU) delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. Paediatric critical care equipment was more scarce than equipment for adults. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (eg, oxygen, personal protective equipment), services and human resources were identified as inputs to specific critical care services in Tanzania. CONCLUSION There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilisation and costs across specialties and hospitals of different level in low/middle-income countries like Tanzania to inform planning, priority setting and budgeting for critical care services. PROSPERO REGISTRATION NUMBER CRD42020221923.
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Affiliation(s)
- Joseph Kazibwe
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Hiral A Shah
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Center for Global Development, Washington, DC, USA
| | - August Kuwawenaruwa
- Health System Impact Evaluation and Policy Unit, Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Karima Khalid
- Department of Anaesthesia and Critical Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Phuong Bich Tran
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Srobana Ghosh
- Global Health Department, Center for Global Development, Washington, DC, USA
| | - Tim Baker
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Department of Emergency Medicine, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Lorna Guinness
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Center for Global Development, Washington, DC, USA
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31
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Argent AC, Ranjit S, Peters MJ, Andre-von Arnim AVS, Chisti MJ, Jabornisky R, Musa NL, Kissoon N. Factors to be Considered in Advancing Pediatric Critical Care Across the World. Crit Care Clin 2022; 38:707-720. [PMID: 36162906 DOI: 10.1016/j.ccc.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This article reviews the many factors that have to be taken into account as we consider the advancement of pediatric critical care (PCC) in multiple settings across the world. The extent of PCC and the range of patients who are cared for in this environment are considered. Along with a review of the ongoing treatment and technology advances in the PCC setting, the structures and systems required to support these services are also considered. Finally the question of how PCC can be made sustainable in a volatile world with the impacts of global crises such as climate change is addressed.
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Affiliation(s)
- Andrew C Argent
- Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Suchitra Ranjit
- Pediatric ICU, Apollo Children's Hospital, 15, Shafee Mhd Road, Chennai 600006, India
| | - Mark J Peters
- University College London Great Ormond Street Institute of Child Health, London, WC1N 3JH, UK; Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, WC1N 1EH, UK
| | - Amelie von Saint Andre-von Arnim
- Department of Pediatrics, Division of Pediatric Critical Care, University of Washington, Seattle Children's, 4800 Sand Point Way NorthEast, Seattle, WA 98105, USA; Department of Global Health, University of Washington, Seattle Children's, 4800 Sand Point Way NorthEast, Seattle, WA 98105, USA
| | - Md Jobayer Chisti
- ARI Ward, Dhaka Hospital, Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Roberto Jabornisky
- Universidad Nacional Del Nordeste, Argentina. Pediatric Intensive Care Unit (Hospital Juan Pablo II and Hospital Olga Stuky) Argentina, Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, LARed Network, Universidad Nacional Del Nordeste, 1420 Mariano Moreno, Corrientes 3400, Argentina
| | - Ndidiamaka L Musa
- Paediatric Critical Care, University of Washington, 4800 Sand Point Way NorthEast, Seattle, WA 98105, USA
| | - Niranjan Kissoon
- British Columbia Children's Hospital and The University of British Columbia, Vancouver, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
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Buowari DY, Owoo C, Gupta L, Schell CO, Baker T. Essential Emergency and Critical Care: A Priority for Health Systems Globally. Crit Care Clin 2022; 38:639-656. [PMID: 36162903 DOI: 10.1016/j.ccc.2022.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided, and the potential for reversibility. An estimated 45 million adults become critically ill each year. While some are treated in emergency departments or intensive care units, most are cared for in general hospital wards. We outline a priority for health systems globally: the first-tier care that all critically ill patients should receive in all parts of all hospitals: Essential Emergency and Critical Care. We describe its relation to other specialties and care and opportunities for implementation.
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Affiliation(s)
- Dabota Yvonne Buowari
- Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Along East West Road, Alakahia, Port Harcourt, Rivers State 23401, Nigeria
| | - Christian Owoo
- Department of Anaesthesia, University of Ghana Medical School, College of Health Sciences, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Department of Anaesthesia, Korle Bu Teaching Hospital, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Ghana Infectious Disease Centre, Kwabenya, Ga East, Municipal Hospital, GE-255-9501 (PQ47+FGV), Accra, Ghana; University of Ghana Medical Centre, Indian Ocean Link, University of Ghana, GA-337-6980 (JRJ7+WJP) Accra, Ghana
| | - Lalit Gupta
- Department of Anaesthesia and Critical Care, Maulana Azad Medical College, 2 Bahadur Shah Zafar Marg, New Delhi 110002, India
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Sveavägen entré 9 Mälarsjukhuset, Eskilstuna, 631 88 Sweden; Department of Medicine, Nyköping Hospital, Nyköping 61185, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, United Nations Road, Dar es Salaam, P.O. Box 65001, Tanzania; Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; Ifakara Health Institute, 5 Ifakara Street, Plot 463 Mikocheni, Dar es Salaam, P.O. Box 78 373, Tanzania.
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Kwizera A, Sendagire C, Kamuntu Y, Rutayisire M, Nakibuuka J, Muwanguzi PA, Alenyo-Ngabirano A, Kyobe-Bosa H, Olaro C. Building Critical Care Capacity in a Low-Income Country. Crit Care Clin 2022; 38:747-759. [PMID: 36162908 PMCID: PMC9507099 DOI: 10.1016/j.ccc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Critical illness is common throughout the world and is associated with high costs of care and resource intensity. The Corona virus disease 2019 (COVID-19) pandemic created a sudden surge of critically ill patients, which in turn led to devastating effects on health care systems worldwide and more so in Africa. This narrative report describes how an attempt was made at bridging the existing gaps in quality of care for critically ill patients at national and regional levels for COVID and the postpandemic era in a low income country.
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Affiliation(s)
- Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University, College of Health Sciences, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda,Corresponding author
| | - Cornelius Sendagire
- Department of Anaesthesia and Critical Care, Makerere University, College of Health Sciences, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | - Yewande Kamuntu
- Clinton Health Access Initiative, Plot 8a, Moyo Close, P O Box 2191, Kampala, Uganda
| | - Meddy Rutayisire
- Department of Anaesthesia and Critical Care, Makerere University, College of Health Sciences, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | - Jane Nakibuuka
- Department of Medicine, Intensive Care Unit, Mulago National Referral Hospital, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | - Patience A. Muwanguzi
- Department of Nursing, College of Health Sciences, Makerere University, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | | | - Henry Kyobe-Bosa
- Ministry of Health, Plot 6 Lourdel Road, P O Box 2191, Wandegeya, Kampala, Uganda,Uganda Peoples Defense Forces, Chwa II Road, Mbuya , P O Box 2191, Kampala, Uganda,Kellogg College, University of Oxford, 60-62 Banbury Road, Park Town, Oxford OX2 6PN, United Kingdom
| | - Charles Olaro
- Ministry of Health, Plot 6 Lourdel Road, P O Box 2191, Wandegeya, Kampala, Uganda
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Kayambankadzanja RK, Schell CO, Gerdin Wärnberg M, Tamras T, Mollazadegan H, Holmberg M, Alvesson HM, Baker T. Towards definitions of critical illness and critical care using concept analysis. BMJ Open 2022; 12:e060972. [PMID: 36606666 PMCID: PMC9445819 DOI: 10.1136/bmjopen-2022-060972] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE As 'critical illness' and 'critical care' lack consensus definitions, this study aimed to explore how the concepts' are used, describe their defining attributes, and propose potential definitions. DESIGN AND METHODS We used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O'Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts' defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents. RESULTS Nine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, 'a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility', and of critical care as, 'the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.' CONCLUSION The concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.
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Affiliation(s)
- Raphael Kazidule Kayambankadzanja
- Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Carl Otto Schell
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Internal Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Martin Gerdin Wärnberg
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Tamras
- Internal Medicine, Södertälje Hospital, Stockholm, Sweden
| | | | - Mats Holmberg
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Centre of Interprofessional Collaboration within Emergency care, Linnaeus University, Växjö, Sweden
- Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden
| | | | - Tim Baker
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Cox M, Sharma D, Phillips G, Mitchell R, Herron LM, Brolan CE, O'Reilly G, Körver S, Kendino M, Poloniati P, Kafoa B. Lessons from the frontline: Documenting the pandemic emergency care experience from the Pacific region - Infrastructure and equipment. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 25:100516. [PMID: 35818575 PMCID: PMC9259041 DOI: 10.1016/j.lanwpc.2022.100516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background The COVID-19 pandemic highlighted challenges for all health systems worldwide. This research aimed to explore the impact of COVID-19 across the Pacific especially with regards to emergency care (EC) and clinicians' preparations and responses. Methods A collaboration of Australia and Pacific researchers conducted prospective qualitative research over 18 months of the pandemic. In this three phase study data were gathered from Emergency Clinicians and stakeholders through online support forums, in-depth interviews and focus groups. A phenomenological methodological approach was employed to explore the lived experience of participants. This paper discusses the findings of the study regarding the EC building block of 'Infrastructure and Equipment.' Findings Pre-existing infrastructure and equipment were not sufficient to help control the pandemic. Adequate space and correct equipment were essential needs for Pacific Island emergency clinicians, with donations, procurement and local ingenuity required for suitable, sustainable supplies and facilities. Adequate personal protective equipment (PPE) conferred a sense of security and increased Health Care Workers willingness to attend to patients. Interpretation Investing in adequate infrastructure and appropriate equipment is crucial for an effective response to the COVID-19 pandemic. The sustainability of such investments in the Pacific context is paramount for ongoing EC and preparation for future surge responses and disasters. Funding Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.
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Affiliation(s)
- Megan Cox
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- The Sutherland Hospital, Sydney, NSW, Australia
- NSW Ambulance, Sydney, Australia
| | | | - Georgina Phillips
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Rob Mitchell
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency & Trauma Centre, Alfred Health, Melbourne, Australia
| | - Lisa-Maree Herron
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Claire E. Brolan
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Centre for Policy Futures, Faculty of Humanities and Social Sciences, The University of Queensland, Brisbane, Australia
| | - Gerard O'Reilly
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency & Trauma Centre, Alfred Health, Melbourne, Australia
| | - Sarah Körver
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | - Berlin Kafoa
- Public Health Division, Secretariat of the Pacific Community, Suva, Fiji
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Mitchell R, O'Reilly G, Herron LM, Phillips G, Sharma D, Brolan CE, Körver S, Kendino M, Poloniati P, Kafoa B, Cox M. Lessons from the frontline: The value of emergency care processes and data to pandemic responses across the Pacific region. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 25:100515. [PMID: 35818576 PMCID: PMC9259010 DOI: 10.1016/j.lanwpc.2022.100515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Emergency care (EC) addresses the needs of patients with acute illness and injury, and has fulfilled a critical function during the COVID-19 pandemic. 'Processes' (e.g. triage) and 'data' (e.g. surveillance) have been nominated as essential building blocks for EC systems. This qualitative research sought to explore the impact of the pandemic on EC clinicians across the Pacific region, including the contribution of EC building blocks to effective responses. Methods The study was conducted in three phases, with data obtained from online support forums, key informant interviews and focus group discussions. There were 116 participants from more than 14 Pacific Island Countries and Territories. A phenomenological approach was adopted, incorporating inductive and deductive methods. The deductive thematic analysis utilised previously identified building blocks for Pacific EC. This paper summarises findings for the building blocks of 'processes' and 'data'. Findings Establishing triage and screening capacity, aimed at assessing urgency and transmission risk respectively, were priorities for EC clinicians. Enablers included support from senior hospital leaders, previous disaster experience and consistent guidelines. The introduction of efficient patient flow processes, such as streaming, proved valuable to emergency departments, and checklists and simulation were useful implementation strategies. Some response measures impacted negatively on non-COVID patients, and proactive approaches were required to maintain 'business as usual'. The pandemic also highlighted the value of surveillance and performance data. Interpretation Developing effective processes for triage, screening and streaming, among other areas, was critical to an effective EC response. Beyond the pandemic, strengthening processes and data management capacity will build resilience in EC systems. Funding Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.
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Affiliation(s)
- Rob Mitchell
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency & Trauma Centre, Alfred Hospital, Melbourne, Australia
| | - Gerard O'Reilly
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency & Trauma Centre, Alfred Hospital, Melbourne, Australia
| | - Lisa-Maree Herron
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Georgina Phillips
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Deepak Sharma
- Emergency Department, Colonial War Memorial Hospital, Suva, Fiji
| | - Claire E. Brolan
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Centre for Policy Futures, Faculty of Humanities and Social Sciences, The University of Queensland, Brisbane, Australia
| | - Sarah Körver
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mangu Kendino
- Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | | | - Berlin Kafoa
- Public Health Division, Secretariat of the Pacific Community, Suva, Fiji
| | - Megan Cox
- Faculty of Medicine and Health, The University of Sydney; NSW, Australia
- The Sutherland Hospital, NSW, Australia
- NSW Ambulance, Sydney, Australia
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37
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Kariuki-Barasa I, Adam MB. Living on the Edge of Possibility. Crit Care Clin 2022; 38:853-863. [DOI: 10.1016/j.ccc.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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38
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Biccard BM, Baker T, Mabedi D, Waweru-Siika W. The State of Critical Care Provision in Low-Resource Environments. Anesth Analg 2022; 134:926-929. [PMID: 35427266 DOI: 10.1213/ane.0000000000005885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Bruce M Biccard
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Observatory, South Africa
| | - Tim Baker
- Department of Emergency Medicine. Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Delia Mabedi
- Department of Anaesthesia and Intensive Care, Zomba Central Hospital, Zomba, Malawi
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39
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Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-COVID-19 condition by a Delphi consensus. THE LANCET INFECTIOUS DISEASES 2022; 22:e102-e107. [PMID: 34951953 PMCID: PMC8691845 DOI: 10.1016/s1473-3099(21)00703-9] [Citation(s) in RCA: 865] [Impact Index Per Article: 432.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 12/13/2022]
Abstract
People with COVID-19 might have sustained postinfection sequelae. Known by a variety of names, including long COVID or long-haul COVID, and listed in the ICD-10 classification as post-COVID-19 condition since September, 2020, this occurrence is variable in its expression and its impact. The absence of a globally standardised and agreed-upon definition hampers progress in characterisation of its epidemiology and the development of candidate treatments. In a WHO-led Delphi process, we engaged with an international panel of 265 patients, clinicians, researchers, and WHO staff to develop a consensus definition for this condition. 14 domains and 45 items were evaluated in two rounds of the Delphi process to create a final consensus definition for adults: post-COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset, with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction, and generally have an impact on everyday functioning. Symptoms might be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms might also fluctuate or relapse over time. A separate definition might be applicable for children. Although the consensus definition is likely to change as knowledge increases, this common framework provides a foundation for ongoing and future studies of epidemiology, risk factors, clinical characteristics, and therapy.
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Affiliation(s)
- Joan B Soriano
- Hospital Universitario de la Princesa, Servicio de Neumología, Madrid, Spain; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Srinivas Murthy
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Canada
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40
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Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-COVID-19 condition by a Delphi consensus. THE LANCET. INFECTIOUS DISEASES 2022. [PMID: 34951953 DOI: 10.1016/s1473-3099(21)00703-9/attachment/ef4fd06b-88fa-4a0c-b837-dcfee13e82d7/mmc1.pdf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
People with COVID-19 might have sustained postinfection sequelae. Known by a variety of names, including long COVID or long-haul COVID, and listed in the ICD-10 classification as post-COVID-19 condition since September, 2020, this occurrence is variable in its expression and its impact. The absence of a globally standardised and agreed-upon definition hampers progress in characterisation of its epidemiology and the development of candidate treatments. In a WHO-led Delphi process, we engaged with an international panel of 265 patients, clinicians, researchers, and WHO staff to develop a consensus definition for this condition. 14 domains and 45 items were evaluated in two rounds of the Delphi process to create a final consensus definition for adults: post-COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset, with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction, and generally have an impact on everyday functioning. Symptoms might be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms might also fluctuate or relapse over time. A separate definition might be applicable for children. Although the consensus definition is likely to change as knowledge increases, this common framework provides a foundation for ongoing and future studies of epidemiology, risk factors, clinical characteristics, and therapy.
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Affiliation(s)
- Joan B Soriano
- Hospital Universitario de la Princesa, Servicio de Neumología, Madrid, Spain; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Srinivas Murthy
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Canada
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41
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Branson RD. Pandemic Surge, Well-Intended Responses, and Unintended Consequences. Respir Care 2022; 67:272-273. [PMID: 35078901 PMCID: PMC9993942 DOI: 10.4187/respcare.09929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Richard D Branson
- Department of Surgery Division of Trauma and Critical Care University of Cincinnati Cincinnati, OhioEditor-in-Chief Respiratory Care
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42
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Sonenthal PD, Nyirenda M, Kasomekera N, Marsh RH, Wroe EB, Scott KW, Bukhman A, Connolly E, Minyaliwa T, Katete M, Banda-Katha G, Mukherjee JS, Rouhani SA. The Malawi emergency and critical care survey: A cross-sectional national facility assessment. EClinicalMedicine 2022; 44:101245. [PMID: 35072017 PMCID: PMC8762065 DOI: 10.1016/j.eclinm.2021.101245] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/16/2021] [Accepted: 12/08/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage. METHODS We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility. FINDINGS A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021). INTERPRETATION This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts. FUNDING Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.
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Affiliation(s)
- Paul D. Sonenthal
- Brigham and Women's Hospital, Division of Pulmonary and Critical Care Medicine, 75 Francis St, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
- Corresponding author at: Brigham and Women's Hospital, Division of Pulmonary and Critical Care Medicine, 75 Francis St, Boston, MA 02115, USA.
| | - Mulinda Nyirenda
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Centre, P.O. Box 95, Blantyre, Malawi
- University of Malawi College of Medicine, Private Bag 360 Blantyre 3, Chichiri, Malawi
| | - Noel Kasomekera
- Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Regan H. Marsh
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Emily B. Wroe
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
- Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis St, Boston, MA 02115, USA
| | - Kirstin W. Scott
- University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Alice Bukhman
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Emilia Connolly
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | | | - Martha Katete
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Grace Banda-Katha
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Centre, P.O. Box 95, Blantyre, Malawi
| | - Joia S. Mukherjee
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
| | - Shada A. Rouhani
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
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Abstract
This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient—these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single “best” care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country’s current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient’s geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.
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44
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Bjorklund A, Slusher T, Day LT, Yola MM, Sleeth C, Kiragu A, Shirk A, Krohn K, Opoka R. Pediatric Critical Care in Resource Limited Settings-Lessening the Gap Through Ongoing Collaboration, Advancement in Research and Technological Innovations. Front Pediatr 2021; 9:791255. [PMID: 35186820 PMCID: PMC8851601 DOI: 10.3389/fped.2021.791255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/21/2021] [Indexed: 12/02/2022] Open
Abstract
Pediatric critical care has continued to advance since our last article, "Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned" was written just 3 years ago. In that article, we reviewed the history, current state, and gaps in level of care between low- and middle-income countries (LMICs) and high-income countries (HICs). In this article, we have highlighted recent advancements in pediatric critical care in LMICs in the areas of research, training and education, and technology. We acknowledge how the COVID-19 pandemic has contributed to increasing the speed of some developments. We discuss the advancements, some lessons learned, as well as the ongoing gaps that need to be addressed in the coming decade. Continued understanding of the importance of equitable sustainable partnerships in the bidirectional exchange of knowledge and collaboration in all advancement efforts (research, technology, etc.) remains essential to guide all of us to new frontiers in pediatric critical care.
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Affiliation(s)
- Ashley Bjorklund
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States.,Global Pediatric Program, Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Tina Slusher
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States.,Global Pediatric Program, Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Louise Tina Day
- Maternal and Newborn Health Group, Department of Infectious Disease Epidemiology, London School Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Clark Sleeth
- Department of Pediatrics, Tenwek Hospital, Bomet, Kenya
| | - Andrew Kiragu
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States.,Global Pediatric Program, Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States.,Childrens Hospital of Minnesota, Minneapolis, MN, United States
| | - Arianna Shirk
- Department of Pediatrics, Africa Inland Church Kijabe Hospital, Kijabe, Kenya
| | - Kristina Krohn
- Global Pediatric Program, Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States.,Department of Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Robert Opoka
- Department of Pediatrics, Makerere University, Kampala, Uganda
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