Nationwide survey on resource availability for implementing current sepsis guidelines in Mongolia

Out-of-hospital deaths in Mongolia: a nationwide cohort study on the proportion, causes, and potential impact of emergency and critical care services

Background

Little is known about the proportion and causes of out-of-hospital deaths in Mongolia. In this study, we aimed to determine the proportion and causes of out-of-hospital deaths in Mongolia during a six-month observation period before the COVID-19 pandemic.

Methods

In a retrospective study, the Mongolian National Death Registry was screened for all deaths occurring from 01 to 06/2020. The proportion and causes of out-of-hospital deaths, causes of out-of-hospital deaths likely treatable by emergency/critical care interventions, as well as sex, regional and seasonal differences in the proportion and causes of out-of-hospital deaths were determined. The primary endpoint was the proportion and causes of out-of-hospital death in children and adults. Descriptive statistical methods, the Fisher's Exact, multirow Chi2-or Mann-Whitney-U-rank sum tests were used for data analysis.

Findings

Five-thousand-five-hundred-fifty-three of 7762 deaths (71.5%) occurred outside of a hospital. The proportion of out-of-hospital deaths was lower in children than adults (39.3% vs. 74.8%, p < 0.001). Trauma, chronic neurological diseases, lower respiratory tract infections, congenital birth defects, and neonatal disorders were the causes of out-of-hospital deaths resulting in most years of life lost in children. In adults, chronic heart diseases, trauma, liver cancer, poisonings, and self-harm caused the highest burden of premature mortality. The proportion of out-of-hospital deaths did not differ between females and males (70.5% vs. 72.2%, p = 0.09). The proportion (all, p < 0.001; adults, p < 0.001; children, p < 0.001) and causes (adults, p < 0.001; children, p < 0.001) of out-of-hospital deaths differed between Mongolian regions and Ulaanbaatar. The proportion of out-of-hospital deaths was higher during winter than spring/summer months (72.3% vs. 69.9%, p = 0.03). An expert panel estimated that 49.3% of out-of-hospital deaths were likely treatable by emergency/critical care interventions.

Interpretation

With regional and seasonal variations, about 75% of Mongolian adults and 40% of Mongolian children died outside of a hospital. Heart diseases, trauma, cancer, and poisonings resulted in most years of life lost. About half of the causes of out-of-hospital deaths could be treated by emergency/critical care interventions.

Funding

Institutional funding.

A 2-Phase Survey to Assess a Facility's Readiness for Pediatric Essential Emergency and Critical Care in Resource-Limited Settings: A Literature Review and Survey Development

OBJECTIVE

Infectious diseases, including pneumonia, malaria, and diarrheal diseases, are the leading causes of death in children younger than 5 years worldwide. The vast majority of these deaths occur in resource-limited settings where there is significant variation in the availability and type of human, physical, and infrastructural resources. The ability to identity gaps in healthcare systems that may hinder their ability to deliver care is an important step to determining specific interventions for quality improvement. Our study objective was to develop a comprehensive, digital, open-access health facility survey to assess facility readiness to provide pediatric critical care in resource-limited settings (eg, low- and lower middle-income countries).

METHODS

A literature review of existing facility assessment tools and global guidelines was conducted to generate a database of survey questions. These were then mapped to one of the following 8 domains: hospital statistics, services offered, operational flow, facility infrastructure, staff and training, medicines and equipment, diagnostic capacity, and quality of clinical care. A 2-phase survey was developed and an iterative review process of the survey was undertaken with 12 experts based in low- and middle-income countries. This was built into the REDCap Mobile Application for electronic data capture.

RESULTS

The literature review process yielded 7 facility assessment tools and 7 global guidelines for inclusion. After the iterative review process, the final survey consisted of 11 sections with 457 unique questions in the first phase, "environmental scan," focusing on the infrastructure, availability, and functionality of resources, and 3 sections with 131 unique questions in the second phase, "observation scan," focusing on the level of clinical competency.

CONCLUSIONS

A comprehensive 2-phase survey was created to evaluate facility readiness for pediatric critical care. Results will assist hospital administrators and policymakers to determine priority areas for quality improvement, enabling them to implement a Plan-Do-Study-Act cycle to improve care for the critically ill child.

Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments: A Multicenter Study in Latin America

OBJECTIVE

Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour.

METHODS

A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated.

RESULTS

We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001).

CONCLUSIONS

We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.

How Are Clinicians Treating Children With Sepsis in Emergency Departments in Latin America?: An International Multicenter Survey

OBJECTIVE

Guidelines adherence in emergency departments (EDs) relies partly on the availability of resources to improve sepsis care and outcomes. Our objective was to assess the management of pediatric septic shock (PSS) in Latin America's EDs and to determine the impact of treatment coordinated by a pediatric emergency specialist (PEMS) versus nonpediatric emergency specialists (NPEMS) on guidelines adherence.

METHODS

Prospective, descriptive, and multicenter study using an electronic survey administered to PEMS and NPEMS who treat PSS in EDs in 14 Latin American countries.

RESULTS

We distributed 2164 surveys with a response rate of 41.5%, of which 22.5% were PEMS. Overall American College of Critical Care Medicine reported guidelines adherence was as follows: vascular access obtained in 5 minutes, 76%; fluid infusion technique, 60%; administering 40 to 60 mL/kg within 30 minutes, 32%; inotropic infusion by peripheral route, 61%; dopamine or epinephrine in cold shock, 80%; norepinephrine in warm shock, 57%; and antibiotics within 60 minutes, 82%. Between PEMS and NPEMS, the following differences were found: vascular access in 5 minutes, 87.1% versus 72.7% (P < 0.01); fluid infusion technique, 72.3% versus 55.9% (P < 0.01); administering 40 to 60 mL/kg within 30 minutes, 42% versus 29% (P < 0.01); inotropic infusion by peripheral route, 75.7% versus 56.3% (P < 0.01); dopamine or epinephrine in cold shock, 87.1% versus 77.3% (P < 0.05); norepinephrine in warm shock, 67.8% versus 54% (P < 0.01); and antibiotic administration within first 60 minutes, 90.1% versus 79.3% (P < 0.01), respectively. Good adherence criteria were followed by 24%. The main referred barrier for sepsis care was a failure in its recognition, including the lack of triage tools.

CONCLUSIONS

In some Latin American countries, there is variability in self-reported adherence to the evidence-based recommendations for the treatment of PSS during the first hour. The coordination by PEMS support greater adherence to these recommendations.

The FAST-M complex intervention for the detection and management of maternal sepsis in low-resource settings: a multi-site evaluation

OBJECTIVE

To evaluate whether the implementation of the FAST-M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low-resource setting.

DESIGN

A before-and-after design.

SETTING

Fifteen government healthcare facilities in Malawi.

POPULATION

Women suspected of having maternal sepsis.

METHODS

The FAST-M complex intervention consisted of the following components: the FAST-M maternal sepsis treatment bundle and the FAST-M implementation programme. Performance of selected process outcomes was compared between a 2-month baseline phase and 6-month intervention phase with compliance used as a proxy measure of feasibility.

MAIN OUTCOME RESULT

Compliance with vital sign recording and use of the FAST-M maternal sepsis bundle.

RESULTS

Following implementation of the FAST-M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P < 0.001). Recognition of suspected maternal sepsis improved with more cases identified following the intervention (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001). Sepsis management improved, with women more likely to receive all components of the FAST-M treatment bundle within 1 hour of recognition (0/12 [0%] versus 21/107 [19.6%], P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.

CONCLUSION

Implementation of the FAST-M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low-resource setting such as Malawi.

TWEETABLE ABSTRACT

Implementation of a sepsis care bundle for low-resources improved recognition & management of maternal sepsis.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations

BACKGROUND

Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

METHODS

The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

RESULTS

The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

CONCLUSIONS

The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process

Objective

To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.

Design

Modified Delphi process.

Setting

Participants from 34 countries.

Population

Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.

Methods

We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.

Main outcome measure

Consensus on bundle items.

Results

Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.

Conclusion

A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.

Tweetable abstract

A maternal sepsis bundle for low resource settings has been developed by international consensus.

A maternal sepsis bundle for low resource settings has been developed by international consensus.

Lipopolysaccharide exposure modulates the contractile and migratory phenotypes of vascular smooth muscle cells

INTRODUCTION

Sepsis survivors are at higher risk for cardiovascular events. Lipopolysaccharide (LPS) activates Toll-like receptor 4 (TLR4) in sepsis. Activation of TLR4 modulates vascular smooth muscle cells (VSMCs) phenotype and contributes to cardiovascular changes after sepsis.

AIM

Investigate changes in VSMCs phenotype caused by LPS-induced TLR4 activation.

METHODS

Rat VSMCs were incubated with LPS. Two incubation conditions were used in cell contraction and migration assays: acute stimulation - LPS stimulus was initiated at the beginning of the assay and maintained throughout; and preconditioning - LPS stimulation was applied prior to the assay then discontinued. Nitric oxide (NO) production, mRNA expression of cytokines and phenotype markers, and interleukin (IL)-6 production were evaluated.

KEY FINDINGS

LPS increased gene expression of IL-1β, IL-6, TNFα and MCP-1 (p < .001), of secretory phenotype markers collagen and vimentin (p < .0479) and of the contractile marker smooth muscle 22α (SM22α) (p = .0067). LPS exposure increased IL-6 secretion after 24 and 48 h (p < .0001), and NO at 8 and 24 h (p < .0249) via inducible nitric oxide synthase (iNOS), as demonstrated by a decrease in NO after incubation with aminoguanidine. Acute stimulation with LPS reduced migration and contraction in a NO-dependent manner, while preconditioning with LPS increased both in an IL-6-dependent manner.

SIGNIFICANCE

LPS affects VSMCs by modulating their secretory, contractile and migratory phenotypes. LPS acute stimulation of VSMCs promoted a NO-dependent reduction in migration and contraction, while preconditioning with LPS promoted IL-6-dependent increases in migration and contraction, evidencing that VSMCs can present phenotype modifications that persist after sepsis, thereby contributing to postsepsis cardiovascular events.

Increasing Evidence-Based Interventions in Patients with Acute Infections in a Resource-Limited Setting: A Before-and-After Feasibility Trial in Gitwe, Rwanda

OBJECTIVE

To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections.

DESIGN

Single-center, prospective, before-and-after feasibility trial.

SETTING

Emergency department of a sub-Saharan African district hospital.

PATIENTS

Patients > 28 days of life admitted to the study hospital for an acute infection.

INTERVENTIONS

The trial had three phases (each of four months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases.

MEASUREMENTS AND MAIN RESULTS

Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 hours after hospital admission; and at discharge. A total of 1,594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 hours (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed.

CONCLUSIONS

Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (www.clinicaltrials.gov: NCT02697513).

Availability of resources to treat sepsis in Brazil: a random sample of Brazilian institutions

OBJECTIVE

To characterize resource availability from a nationally representative random sample of intensive care units in Brazil.

METHODS

A structured online survey of participating units in the Sepsis PREvalence Assessment Database (SPREAD) study, a nationwide 1-day point prevalence survey to assess the burden of sepsis in Brazil, was sent to the medical director of each unit.

RESULTS

A representative sample of 277 of the 317 invited units responded to the resources survey. Most of the hospitals had fewer than 500 beds (94.6%) with a median of 14 beds in the intensive care unit. Providing care for public-insured patients was the main source of income in two-thirds of the surveyed units. Own microbiology laboratory was not available for 26.8% of the surveyed intensive care units, and 10.5% did not always have access to blood cultures. Broad spectrum antibiotics were not always available in 10.5% of surveyed units, and 21.3% could not always measure lactate within three hours. Those institutions with a high resource availability (158 units, 57%) were usually larger and preferentially served patients from the private health system compared to institutions without high resource availability. Otherwise, those without high resource availability did not always have broad-spectrum antibiotics (24.4%), vasopressors (4.2%) or crystalloids (7.6%).

CONCLUSION

Our study indicates that a relevant number of units cannot perform basic monitoring and therapeutic interventions in septic patients. Our results highlight major opportunities for improvement to adhere to simple but effective interventions in Brazil.

Increasing evidence-based interventions in patients with acute infections in a resource-limited setting: a before-and-after feasibility trial in Gitwe, Rwanda

OBJECTIVE

To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections.

DESIGN

Single-center, prospective, before-and-after feasibility trial.

SETTING

Emergency department of a sub-Saharan African district hospital.

PATIENTS

Patients > 28 days of life admitted to the study hospital for an acute infection.

INTERVENTIONS

The trial had three phases (each of 4 months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases.

MEASUREMENTS AND MAIN RESULTS

Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 h after hospital admission; and at discharge. A total of 1594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 h (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed.

CONCLUSIONS

Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population ( http://www.clinicaltrials.gov : NCT02697513).

Cost analysis of Omega-3 supplementation in critically ill patients with sepsis

INTRODUCTION

Nutritional supplement of omega-3 fatty acids have been proposed to improve clinical outcomes in critically ill patients. While previous work have demonstrated that omega-3 supplementation in patients with sepsis is associated with reduced ICU and hospital length of stay, the financial impact of this intervention is unknown.

OBJECTIVE

Perform a cost analysis to evaluate the impact of omega-3 supplementation on ICU and hospital costs.

METHODS

We extracted data related to ICU and hospital length of stay from the individual studies reported in a recent systematic review. The Cochrane Collaboration tool was used to assess the risk of bias in these studies. Average daily ICU and hospital costs per patient were obtained from a cost study by Kahn et al. We estimated the ICU and hospital costs by multiplying the mean length of stay by the average daily cost per patient in ICU or Hospital. Adjustments for inflation were made according to the USD annual consumer price index. We calculated the difference between the direct variable cost of patients with omega-3 supplementation and patients without omega-3 supplementation. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations.

RESULTS

A total of 12 RCT involving 925 patients were included in this cost analysis. Septic patients supplemented with omega-3 had both lower mean ICU costs ($15,274 vs. $18,172) resulting in $2897 in ICU savings per patient and overall hospital costs ($17,088 vs. $19,778), resulting in $2690 in hospital savings per patient. Sensitivity analyses were conducted to investigate the impact of different study methods on the LOS. The results were still consistent with the overall findings.

CONCLUSION

Patients with sepsis who received omega-3 supplementation had significantly shorter LOS in the ICU and hospital, and were associated with lower direct variable costs than control patients. The 12 RCTs used in this analysis had a high risk of bias. Large-scaled, high-quality, multi-centered RCTs on the effectiveness of this intervention is recommended to improve the quality of the existing evidence.

The practice of intensive care in Latin America: a survey of academic intensivists

Background

Intensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated.

Results

Our study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement.

Conclusions

Latin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1956-6) contains supplementary material, which is available to authorized users.

Management of potentially life-threatening emergencies at 74 primary level hospitals in Mongolia: results of a prospective, observational multicenter study

Background

While the capacities to care for and epidemiology of emergency and critically ill patients have been reported for secondary and tertiary level hospitals in Mongolia, no data exist for Mongolian primary level hospitals.

Methods

In this prospective, observational multicenter study, 74 primary level hospitals of Mongolia were included. We determined the capacities of these hospitals to manage medical emergencies. Furthermore, characteristics of patients presenting with potentially life-threatening emergencies to these hospitals were evaluated during a 6 month period.

Results

An emergency/resuscitation room was available in 62.2% of hospitals. One third of the study hospitals had an operation theatre (32.4%). No hospital ran an intensive care unit or had trained emergency/critical care physicians or nurses available. Diagnostic resources were inconsistently available (sonography, 59.5%; echocardiography, 0%). Basic emergency procedures (wound care, 97.3%; foreign body removal, 86.5%; oxygen application, 85.2%) were commonly but advanced procedures (advanced cardiac life support, 10.8%; airway management, 13.5%; mechanical ventilation, 0%; renal replacement therapy, 0%) rarely available. During 6 months, 14,545 patients were hospitalized in the 74 study hospitals, of which 8.7% [n = 1267; median age, 34 (IQR 18–53) years; male gender, 54.4%] were included in the study. Trauma (excl. brain trauma) (20.4%), acute abdomen (16.9%) and heart failure (9.6%) were the most common conditions. Five-hundred-thirty patients (41.8%) were transferred to a secondary level hospital. The hospital mortality of patients not transferred was 3.2%.

Conclusions

Capacities of Mongolian primary level hospitals to manage life-threatening emergencies are highly limited. Trauma, surgical and medical conditions make up the most common emergencies. In view of the fact that almost half of the patients with a potentially life-threatening emergency were transferred to secondary level hospitals and the mortality of those hospitalized in primary level hospitals was 3.2%, room for improvement is clearly evident. Based on our findings, improvements could be obtained by strengthening inter-hospital transfer systems, training staff in emergency/critical care skills and by making mechanical ventilation and advanced life support techniques available at the emergency rooms of primary level hospitals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-017-0127-4) contains supplementary material, which is available to authorized users.

Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future

BACKGROUND

Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.

AIM

To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.

FINDINGS

Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.

CONCLUSIONS

Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.

Presentation, management, and outcomes of sepsis in adults and children admitted to a rural Ugandan hospital: A prospective observational cohort study

Objectives

Limited data are available on sepsis in low-resource settings, particularly outside of urban referral centers. We conducted a prospective observational single-center cohort study in May 2013 to assess the presentation, management and outcomes of adult and pediatric patients admitted with sepsis to a community hospital in rural Uganda.

Methods

We consecutively screened all patients admitted to medical wards who met sepsis criteria. We evaluated eligible patients within 24 hours of presentation and 24–48 hours after admission, and followed them until hospital discharge. In addition to chart review, mental status evaluation, peripheral capillary oxygen saturation, and point-of-care venous whole blood lactate and glucose testing were performed.

Results

Of 56 eligible patients, we analyzed data on 51 (20 adults and 31 children). Median age was 8 years (IQR 2–23 years). Sepsis accounted for a quarter of all adult and pediatric medical ward admissions during the study period. HIV prevalence among adults was 30%. On enrollment, over half of patients had elevated point-of-care whole blood lactate, few were hypoglycemic or had altered mental status, and one third were hypoxic. Over 80% of patients received at least one antibiotic, all severely hypoxic patients received supplemental oxygen, and half of patients with elevated lactate received fluid resuscitation. The most common causes of sepsis were malaria and pneumonia. In-hospital mortality was 3.9%.

Conclusions

This study highlights the importance of sepsis among adult and pediatric patients admitted to a rural Ugandan hospital and underscores the need for continued research on sepsis in low resource settings.

Faecal Carriage of Gram-Negative Multidrug-Resistant Bacteria among Patients Hospitalized in Two Centres in Ulaanbaatar, Mongolia

Gram-negative multidrug-resistant organisms (GN-MDRO) producing β-lactamases (ESBL, plasmid-mediated AmpC β-lactamases and carbapenemases) are increasingly reported throughout Asia. The aim of this surveillance study was to determine the rate of bacterial colonization in patients from two hospitals in the Mongolian capital Ulaanbaatar. Rectal swabs were obtained from patients referred to the National Traumatology and Orthopaedics Research Centre (NTORC) or the Burn Treatment Centre (BTC) between July and September 2014, on admission and again after 14 days. Bacteria growing on selective chromogenic media (CHROMagar ESBL/KPC) were identified by MALDI-ToF MS. We performed susceptibility testing by disk diffusion and PCR (bla_IMP-1, bla_VIM, bla_GES, bla_NDM, bla_KPC, bla_OXA-48, bla_GIM-1, bla_OXA-23, bla_OXA-24/40, bla_OXA-51, bla_OXA-58, bla_OXA-143, bla_OXA-235, bla_CTX-M, bla_SHVbla_TEM and plasmid-mediated bla_AmpC). Carbapenemase-producing isolates were additionally genotyped by PFGE and MLST. During the study period 985 patients in the NTORC and 65 patients in the BTC were screened on admission. The prevalence of GN-MDRO-carriage was 42.4% and 69.2% respectively (p<0.001). Due to the different medical specialities the two study populations differed significantly in age (p<0.029) and gender (p<0.001) with younger and more female patients in the burn centre (BTC). We did not observe a significant difference in colonization rate in the respective age groups in the total study population. In both centres most carriers were colonized with CTX-M-producing E. coli, followed by CTX-M-producing K. pneumoniae and CTX-M-producing E. cloacae. 158 patients from the NTORC were re-screened after 14 days of whom 99 had acquired a new GN-MDRO (p<0.001). Carbapenemases were detected in both centres in four OXA-58-producing A. baumannii isolates (ST642) and six VIM-2-producing P. aeruginosa isolates (ST235). This study shows a high overall prevalence of GN-MDRO in the study population and highlights the importance of routine surveillance, appropriate infection control practice and antibiotic prescribing policies to prevent further spread especially of carbapenemases.

Development of an intensive care unit resource assessment survey for the care of critically ill patients in resource-limited settings

PURPOSE

Capacity to provide critical care in resource-limited settings is poorly understood because of lack of data about resources available to manage critically ill patients. Our objective was to develop a survey to address this issue.

METHODS

We developed and piloted a cross-sectional self-administered survey in 9 resource-limited countries. The survey consisted of 8 domains; specific items within domains were modified from previously developed survey tools. We distributed the survey by e-mail to a convenience sample of health care providers responsible for providing care to critically ill patients. We assessed clinical sensibility and test-retest reliability.

RESULTS

Nine of 15 health care providers responded to the survey on 2 separate occasions, separated by 2 to 4 weeks. Clinical sensibility was high (3.9-4.9/5 on assessment tool). Test-retest reliability for questions related to resource availability was acceptable (intraclass correlation coefficient, 0.94; 95% confidence interval, 0.75-0.99; mean (SD) of weighted κ values = 0.67 [0.19]). The mean (SD) time for survey completion survey was 21 (16) minutes.

CONCLUSIONS

A reliable cross-sectional survey of available resources to manage critically ill patients can be feasibly administered to health care providers in resource-limited settings. The survey will inform future research focusing on access to critical care where it is poorly described but urgently needed.

Potentially Preventable Deaths by Intensive Care Medicine in Mongolian Hospitals

Purpose. To evaluate the portion of hospitalized patients dying without prior intensive care unit (ICU) admission and assess whether death could have been prevented by intensive care. Methods. In this prospective, observational, multicenter study, data of adults dying in and outside the ICU in 5 tertiary and 14 secondary hospitals were collected during six months. A group of experts categorized patients dying without prior ICU admission as whether their death was potentially preventable or not. Results. 617 patients died (72.9% in and 27.1% outside the ICU) during the observation period. In 54/113 patients (32.3%) dying in the hospital without prior ICU admission, death was considered potentially preventable. The highest number of these deaths was seen in patients aged 16–30 years and those who suffered from an infection (83.3%), underwent surgery (58.3%), or sustained trauma (52%). Potentially preventable deaths resulted in a total number of 1,078 years of life lost and 709 productive years of life lost. Conclusions. Twenty-seven percent of adults dying in Mongolian secondary and tertiary level hospitals do so without prior ICU admission. One-third, mostly young patients suffering from acute reversible conditions, may have potentially been saved by intensive care medicine.

A Nationwide Census of ICU Capacity and Admissions in Mongolia

In Mongolia, a Central Asian lower-middle income country, intensive care medicine is an under-resourced and–developed medical specialty. The burden of critical illness and capacity of intensive care unit (ICU) services in the country is unknown. In this nationwide census, we collected data on adult and pediatric/neonatal ICU capacities and the number of ICU admissions in 2014. All hospitals registered to run an ICU service in Mongolia were surveyed. Data on the availability of an adult and/or pediatric/neonatal ICU service, the number of available ICU beds, the number of available functional mechanical ventilators, the number of patients admitted to the ICU, and the number of patients admitted to the study hospital were collected. In total, 70 ICUs with 349 ICU beds were counted in Mongolia (11.7 ICU beds/100,000 inhabitants; 1.7 ICU beds/100 hospital beds). Of these, 241 (69%) were adult and 108 (31%) pediatric/neonatal ICU beds. Functional mechanical ventilators were available for approximately half of the ICU beds (5.1 mechanical ventilators/100,000 inhabitants). While all provincial hospitals ran a pediatric/neonatal ICU, only dedicated pediatric hospitals in Ulaanbaatar did so. The number of adult and pediatric/neonatal ICU admissions varied between provinces. The number of adult ICU beds and adult ICU admissions per 100,000 inhabitants correlated (r = 0.5; p = 0.02), while the number of pediatric/neonatal ICU beds and pediatric/neonatal ICU admissions per 100,000 inhabitants did not (r = 0.25; p = 0.26). In conclusion, with 11.7 ICU beds per 100,000 inhabitants the ICU capacity in Mongolia is higher than in other low- and lower-middle-income countries. Substantial heterogeneities in the standardized ICU capacity and ICU admissions exist between Mongolian provinces. Functional mechanical ventilators are available for only half of the ICU beds. Pediatric/neonatal ICU beds make up one third of the national ICU capacity and appear to meet or even exceed the demand of pediatric/neonatal critical care.

The epidemiology and outcome of critical illness in Mongolia: A multicenter, prospective, observational cohort study

Context:

The epidemiology and outcome of critical illness in Mongolia remain undefined.

Aim:

The aim of this study was to evaluate the epidemiology and outcome of critical illness in Mongolia.

Settings and Design:

This is a multicenter, prospective, observational cohort study including 19 Mongolian centers.

Materials and Methods:

Demographic, clinical, and outcome data of patients >15 years admitted to the Intensive Care Units (ICUs) were collected during a 6-month period.

Statistical Analysis:

Descriptive methods, Mann–Whitney-U test, Fisher's exact or Chi-square test, and logistic regression analyses were used for statistical analysis.

Results:

Two thousand and thirty-two patients (53.6% male) with a median age of 49 years (36–62 years) were included. The most frequent ICU admission diagnoses were stroke (17.4%), liver failure (9.2%), heart failure (9%), infection (8.3%), severe trauma (7.5%), traumatic brain injury (7.1%), acute abdomen (7%), pre-eclampsia/eclampsia (5.8%), renal failure (3.9%), and postoperative care following elective and emergency surgeries (3.2%). ICU mortality was 23.5% in the study population and 26.6% when maternal cases were excluded. The five ICU admission diagnoses with the highest ICU mortality were lung tuberculosis (51.9%), traumatic brain injury (42.1%), liver failure (33.7%), stroke (31.9%), and infection (30.8%). The five ICU admission diagnoses causing most death cases were stroke (n = 113), liver failure (n = 63), traumatic brain injury (n = 61), infection (n = 52), and acute abdomen (n = 38).

Conclusion:

Critical illness in Mongolia affects younger patients compared to high-income countries. ICU admission diagnoses are similar with a particularly high incidence of stroke and liver failure. ICU mortality is approximately 25% with most deaths caused by stroke, liver failure, and traumatic brain injury.

A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions

Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.

A "three delays" model for severe sepsis in resource-limited countries

PURPOSE

The developing world carries the greatest burden of sepsis-related mortality, but success in managing severe sepsis in resource-limited countries (RLCs) remains challenging. A "three delays" model has been developed to describe factors influencing perinatal mortality in developing nations. This model has been validated across different World Health Organization regions and has provided the framework for policymakers to plan targeted interventions. Here, we propose a three delays model for severe sepsis in RLCs.

MATERIALS AND METHODS

A literature review was performed using the PubMed, Google Scholar, and Ovid databases. Additional sources were found after review of the reference lists from retrieved articles.

RESULTS

We propose a three delays model for severe sepsis in adults in RLCs. The model highlights limitations in the 3 basic pillars of sepsis management: (1) sepsis recognition and diagnosis at the time of triage, (2) initial focused resuscitation, and (3) postresuscitation clinical monitoring and reassessment.

CONCLUSIONS

Characterizing the major barriers to effective treatment of severe sepsis in RLCs frames the problem in a language common to global health circles, which may stimulate further research, streamline treatment, and reduce sepsis-related mortality in the developing world.

Pattern of antibiotic prescription and resistance profile of common bacterial isolates in the internal medicine wards of a tertiary referral centre in Nigeria

Indiscriminate and excessive use of antibiotics is the major driver to the development of bacterial resistance, which is now a global challenge. Information regarding antibiotic use in Nigerian hospitals is lacking. This study examined the pattern of antibiotic prescription in a tertiary hospital in Nigeria. In a retrospective survey, case records of patients who were admitted into the medical wards over a 6-month period were reviewed. A pre-formed questionnaire was administered that sought information such as sociodemographic data, drug data, basis of prescription and other relevant information on all patients who received antibiotics. Data were analysed using SPSS for Windows v.16. Of 412 patients admitted into the internal medicine ward during the study period, 202 (49.0%) received antibiotics, of whom 125 (61.9%) received more than one antibiotic. Overall there were 334 antibiotic prescriptions. Community-acquired pneumonia (67/202; 33.2%) was the leading cause of antibiotic prescription, and ceftriaxone (132/334; 39.5%) was the most commonly prescribed antibiotic. The parenteral route was the commonest route of administration (270/334; 80.8%) and most of the prescriptions were empirical (323/334; 96.7%). Antimicrobial resistance among common bacterial isolates was noted. Inappropriate antibiotic prescription is common. There was frequent use of third-generation cephalosporins as empirical therapy, with de-escalation in only a handful of cases. This highlights the need for introduction of antibiotic guidelines.

Antimicrobial resistance and molecular epidemiology of Staphylococcus aureus from Ulaanbaatar, Mongolia

This study aimed to characterize Staphylococcus aureus (S. aureus) strains isolated from human infections in Mongolia. Infection samples were collected at two time periods (2007–08 and 2011) by the National Center for Communicable Diseases (NCCD) in Ulaanbaatar, Mongolia. S. aureus isolates were characterized using polymerase chain reaction (PCR) for mecA, PVL, and sasX genes and tested for agr functionality. All isolates were also spa typed. A subset of isolates selected by frequency of spa types was subjected to antimicrobial susceptibility testing and multilocus sequence typing. Among 251 S. aureus isolates, genotyping demonstrated methicillin resistance in 8.8% of isolates (22/251). Approximately 28% of the tested S. aureus isolates were observed to be multidrug resistant (MDR). Sequence type (ST) 154 (spa t667) was observed to be a strain with high virulence potential, as all isolates for this spa type were positive for PVL, had a functional agr system and 78% were MDR. S. aureus isolates of ST239 (spa t037) were observed to cause infections and roughly 60% had functional agr system with a greater proportion being MDR. Additionally, new multilocus sequence types and new spa types were identified, warranting continued surveillance for S. aureus in this region.

Integrating sepsis management recommendations into clinical care guidelines for district hospitals in resource-limited settings: the necessity to augment new guidelines with future research

Several factors contribute to the high mortality attributed to severe infections in resource-limited settings. While improvements in survival and processes of care have been made in high-income settings among patients with severe conditions, such as sepsis, guidelines necessary for achieving these improvements may lack applicability or have not been tested in resource-limited settings. The World Health Organization's recent publication of the Integrated Management of Adolescent and Adult Illness District Clinician Manual provides details on how to optimize management of severely ill, hospitalized patients in such settings, including specific guidance on the management of patients with septic shock and respiratory failure without shock. This manuscript provides the context, process and underpinnings of these sepsis guidelines. In light of the current deficits in care and the limitations associated with these guidelines, the authors propose implementing these standardized best practice guidelines while using them as a foundation for sepsis research undertaken in, and directly relevant to, resource-limited settings.

Emergency and critical care services in Tanzania: a survey of ten hospitals

BACKGROUND

While there is a need for good quality care for patients with serious reversible disease in all countries in the world, Emergency and Critical Care tends to be one of the weakest parts of health systems in low-income countries. We assessed the structure and availability of resources for Emergency and Critical Care in Tanzania in order to identify the priorities for improving care in this neglected specialty.

METHODS

Ten hospitals in four regions of Tanzania were assessed using a structured data collection tool. Quality was evaluated with standards developed from the literature and expert opinion.

RESULTS

Important deficits were identified in infrastructure, routines and training. Only 30% of the hospitals had an emergency room for adult and paediatric patients. None of the seven district and regional hospitals had a triage area or intensive care unit for adults. Only 40% of the hospitals had formal systems for adult triage and in less than one third were critically ill patients seen by clinicians more than once daily. In 80% of the hospitals there were no staff trained in adult triage or critical care. In contrast, a majority of equipment and drugs necessary for emergency and critical care were available in the hospitals (median 90% and 100% respectively. The referral/private hospitals tended to have a greater overall availability of resources (median 89.7%) than district/regional hospitals (median 70.6).

CONCLUSIONS

Many of the structures necessary for Emergency and Critical Care are lacking in hospitals in Tanzania. Particular weaknesses are infrastructure, routines and training, whereas the availability of drugs and equipment is generally good. Policies to improve hospital systems for the care of emergency and critically ill patients should be prioritised.

Global paediatric advanced life support: improving child survival in limited-resource settings

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.

Recommendations for sepsis management in resource-limited settings

PURPOSE

To provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis.

METHODS

The medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings.

RESULTS

Recommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included.

CONCLUSION

Only scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries.

The economics of sepsis

Sepsis, severe sepsis, and septic shock impose a growing economic burden on health care systems globally. This article first describes the epidemiology of sepsis within the United States and internationally. It then reviews costs associated with sepsis and its management in the United States and internationally, including general cost sources in intensive care, direct costs of sepsis, and indirect costs of the burden of illness imposed by sepsis. Finally, it examines the cost-effectiveness of sepsis interventions, focusing on formal cost-effectiveness analyses of nosocomial sepsis prevention strategies, drotrecogin alfa (activated),and integrated sepsis protocols.