Cost effectiveness of intensive care in a low resource setting: A prospective cohort of medical critically ill patients

The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries

The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.

Factors associated with hospitalization in a pediatric population of rural Tanzania: findings from a retrospective cohort study

BACKGROUND

Despite pediatric acute illnesses being leading causes of death and disability among children, acute and critical care services are not universally available in low-middle income countries, such as Tanzania, even if in this country significant progress has been made in child survival, over the last 20 years. In these countries, the hospital emergency departments may represent the only or the main point of access to health-care services. Thus, the hospitalization rates may reflect both the health system organization and the patients' health status. The purpose of the study is to describe the characteristics of clinical presentations to a pediatric Outpatient Department (OPD) in Tanzania and to identify the predictive factors for hospitalization.

METHODS

Retrospective cohort study based on 4,324 accesses in the OPD at Tosamaganga Voluntary Agency Hospital (Tanzania). Data were collected for all 2,810 children (aged 0-13) who accessed the OPD services, within the period 1 January - 30 September 2022. The association between the hospitalization (main outcome) and potential confounding covariates (demographic, socio-contextual and clinical factors) was evaluated using univariate and multivariate logistic regression models.

RESULTS

Five hundred three (11.6%) of OPD accesses were hospitalized and 17 (0.4%) died during hospitalization. A higher (p < 0.001) risk of hospitalization was observed for children without health insurance (OR = 3.26), coming from more distant districts (OR = 2.83), not visited by a pediatric trained staff (OR = 3.58), and who accessed for the following conditions: burn/wound (OR = 70.63), cardiovascular (OR = 27.36), constitutional/malnutrition (OR = 62.71), fever (OR = 9.79), gastrointestinal (OR = 8.01), respiratory (OR = 12.86), ingestion/inhalation (OR = 17.00), injury (OR = 6.84).

CONCLUSIONS

The higher risk of hospitalization for children without health insurance, and living far from the district capital underline the necessity to promote the implementation of primary care, particularly in small villages, and the establishment of an efficient emergency call and transport system. The observation of lower hospitalization risk for children attended by a pediatric trained staff confirm the necessity of preventing admissions for conditions that could be managed in other health settings, if timely evaluated.

Breaking Barriers in Cranioplasty: 3D Printing in Low and Middle-Income Settings-Insights from Zenica, Bosnia and Herzegovina

Background and Objectives: Cranial defects pose significant challenges in low and middle-income countries (LIMCs), necessitating innovative and cost-effective craniofacial reconstruction strategies. The purpose of this study was to present the Bosnia and Herzegovina model, showcasing the potential of a multidisciplinary team and 3D-based technologies, particularly PMMA implants, to address cranial defects in a resource-limited setting. Materials and Methods: An observational, non-experimental prospective investigation involved three cases of cranioplasty at the Department of Neurosurgery, Cantonal Hospital Zenica, Bosnia and Herzegovina, between 2019 and 2023. The technical process included 3D imaging and modeling with MIMICS software (version 10.01), 3D printing of the prototype, mold construction and intraoperative modification for precise implant fitting. Results: The Bosnia and Herzegovina model demonstrated successful outcomes in cranioplasty, with PMMA implants proving cost-effective and efficient in addressing cranial defects. Intraoperative modification contributed to reduced costs and potential complications, while the multidisciplinary approach and 3D-based technologies facilitated accurate reconstruction. Conclusions: The Bosnia and Herzegovina model showcases a cost-effective and efficient approach for craniofacial reconstruction in LIMICs. Collaborative efforts, 3D-based technologies, and PMMA implants contribute to successful outcomes. Further research is needed to validate sustained benefits and enhance craniofacial reconstruction strategies in resource-constrained settings.

Digital Delivery of a Global Critical Care Education Program

Background

CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness and iNjury) education program was developed to accelerate the global dissemination of a standardized, systemic, structured approach to critical care delivery. The coronavirus disease (COVID-19) pandemic prompted the evolution of this program from a live in-person course to a blended synchronous and asynchronous learning experience, including virtual simulation.

Objectives

We describe our experience and insights gained through this digital program transformation and highlight areas in need of further research to advance the delivery of high-quality online education offerings to global interprofessional audiences.

Methods

The CERTAIN education program was delivered to a broad international audience first in person (2016-2019) and then virtually during the COVID-19 global pandemic (2020-present). During this transition, we adopted a flipped classroom model to deliver the core content asynchronously using an online learning management system, supplemented by a novel synchronous online experience to provide learners with the opportunity to apply these concepts using a series of simulated clinical cases.

Results

A total of 400 participants attended 11 CERTAIN courses. We transitioned our 10-hour live course to a 3-hour virtual workshop. The duration of simulation activities (admission, rounding, and shared decision-making) remained constant. Didactic lectures were eliminated from the synchronous online course and presented as recorded videos in precourse materials. We collected 306 postcourse surveys (response rate, 76.5%). The majority of the overall course ratings were excellent (147 [49.5%]) and very good (97 [32.7%]), and learner responses were similar to live and online courses. Simulation activities were consistently the most popular elements of our program. Access to digital learning platforms and language barriers during simulation activities proved to be the greatest challenges during our transition. Delivering mobile-friendly online content and close coordination between dedicated bilingual faculty and local champions helped overcome these challenges.

Conclusion

Critical care education and case-based simulation workshops can be delivered to international interprofessional audiences with similar, high degrees of learner satisfaction to in-person offerings.

The Burden of Critical Illness in Hospitalized Children in Low- and Middle-Income Countries: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

The majority of childhood deaths occur in low- and middle-income countries (LMICs). Many of these deaths are avoidable with basic critical care interventions. Quantifying the burden of pediatric critical illness in LMICs is essential for targeting interventions to reduce childhood mortality.

OBJECTIVE

To determine the burden of hospitalization and mortality associated with acute pediatric critical illness in LMICs through a systematic review and meta-analysis of the literature.

DATA SOURCES AND SEARCH STRATEGY

We will identify eligible studies by searching MEDLINE, EMBASE, CINAHL, and LILACS using MeSH terms and keywords. Results will be limited to infants or children (ages >28 days to 12 years) hospitalized in LMICs and publications in English, Spanish, or French. Publications with non-original data (e.g., comments, editorials, letters, notes, conference materials) will be excluded.

STUDY SELECTION

We will include observational studies published since January 1, 2005, that meet all eligibility criteria and for which a full text can be located.

DATA EXTRACTION

Data extraction will include information related to study characteristics, hospital characteristics, underlying population characteristics, patient population characteristics, and outcomes.

DATA SYNTHESIS

We will extract and report data on study, hospital, and patient characteristics; outcomes; and risk of bias. We will report the causes of admission and mortality by region, country income level, and age. We will report or calculate the case fatality rate (CFR) for each diagnosis when data allow.

CONCLUSIONS

By understanding the burden of pediatric critical illness in LMICs, we can advocate for resources and inform resource allocation and investment decisions to improve the management and outcomes of children with acute pediatric critical illness in LMICs.

White Paper on Early Critical Care Services in Low Resource Settings

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.

Development of paediatric critical care in northwestern Nigeria: Initial implementation with a needs assessment model

INTRODUCTION

There is high paediatric morbidity and mortality in northwestern Nigeria, attributable in part to vaccine-preventable illnesses and lack of comprehensive training of medical and nursing staff in the healthcare delivery of paediatric critical care. Pediatric Universal Life-Saving Effort Inc. (PULSE), a New York-based nonprofit organisation with a mission to develop paediatric critical care in resource-limited settings, collaborated with Aminu Kano University Teaching Hospital to decrease the gaps in knowledge and skills of medical and nursing personnel. The joint effort also aims to address and remove barriers to the delivery of paediatric critical care in northwestern Nigeria. The primary objective was to perform a needs assessment for paediatric intensive care resources in northwestern Nigeria, identify barriers to delivering these services, and designate a hub for the development of paediatric critical care educational programs for healthcare professionals.

METHODS

An anonymous survey was designed and distributed using SurveyMonkey® online software to medical and nursing staff from nine healthcare institutions in northwestern Nigeria.

RESULTS

Analysis from 67 responses revealed that care delivered to critically ill paediatric patients was by anaesthesiologists (77%), pediatricians (26%), and adult intensive care specialists (10%). The acquisition of clinical skills was perceived to be an essential need (65%), followed by adequate staffing of critical care units (19%), continuing medical and nursing education (13%), and availability of medical equipment (3%).

DISCUSSION

There is an identified need for paediatric critical care training and resources in northwestern Nigeria.

CONCLUSION

The needs assessment conducted has provided important results that will form the basis for building staff capacity and training programs for paediatric critical care in northwestern Nigeria.

Health-Related Quality-of-Life and Cost Utility Analyses in Critical Care: A Systematic Review

OBJECTIVES

Cost utility analyses compare the costs and health outcome of interventions, with a denominator of quality-adjusted life year, a generic health utility measure combining both quality and quantity of life. Cost utility analyses are difficult to compare when methods are not standardized. It is unclear how cost utility analyses are measured/reported in critical care and what methodologic challenges cost utility analyses pose in this setting. This may lead to differences precluding cost utility analyses comparisons. Therefore, we performed a systematic review of cost utility analyses conducted in critical care. Our objectives were to understand: 1) methodologic characteristics, 2) how health-related quality-of-life was measured/reported, and 3) what costs were reported/measured.

DESIGN

Systematic review.

DATA SOURCES

We systematically searched for cost utility analyses in critical care in MEDLINE, Embase, American College of Physicians Journal Club, CENTRAL, Evidence-Based Medicine Reviews' selected subset of archived versions of UK National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and American Economic Association electronic databases from inception to April 30, 2020.

SETTING

Adult ICUs.

PATIENTS

Adult critically ill patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 8,926 citations, 80 cost utility analyse studies were eligible. The time horizon most commonly reported was lifetime (59%). For health utility reporting, health-related quality-of-life was infrequently measured (29% reported), with only 5% of studies reporting baseline health-related quality-of-life. Indirect utility measures (generic, preference-based health utility measurement tools) were reported in 85% of studies (majority Euro-quality-of-life-5 Domains, 52%). Methods of estimating health-related quality-of-life were seldom used when the patient was incapacitated: imputation (19%), assigning fixed utilities for incapacitation (19%), and surrogates reporting on behalf of incapacitated patients (5%). For cost utility reporting transparency, separate incremental costs and quality-adjusted life years were both reported in only 76% of studies. Disaggregated quality-adjusted life years (reporting separate health utility and life years) were described in only 34% of studies.

CONCLUSIONS

We identified deficiencies which warrant recommendations (standardized measurement/reporting of resource use/unit costs/health-related quality-of-life/methodological preferences) for improved design, conduct, and reporting of future cost utility analyses in critical care.

Cost of Treating Maternal Complications and Associated Factors in Mekelle General Hospital, Northern Ethiopia

Background

The government of Ethiopia introduced an exemption policy that guarantees free maternal healthcare services from public providers. This policy aims to ensure financial protection and enhance utilization of services especially for low-income people. However, patients in most cases incur health expenditure when seeking health care. This paper aims to assess direct and indirect medical costs of treating maternal complications and associated factors at a public hospital in Northern Ethiopia.

Methods

An institution-based cross-sectional study design was carried on 267 mothers with complications. A multivariate linear regression model at 5% level of significance was used to analyze factors driving the outcome.

Results

The median cost was more than seven times the monthly minimum wage, and this may cause severe financial consequences for the poor. Direct medical costs accounted for the major share (68%) of total cost, and this was mainly driven by lack of diagnostic services at public facilities and paying for private providers. Expenditure for treatment of maternal complications is positively associated with income, absence from work, travel time to the facility and being diagnosed at a private facility.

Conclusion

The overall evidence in this study poses a concern about the context in which fee exemption reforms are being implemented.

Global PARITY: Study Design for a Multi-Centered, International Point Prevalence Study to Estimate the Burden of Pediatric Acute Critical Illness in Resource-Limited Settings

BACKGROUND

The burden of pediatric critical illness and resource utilization by children with critical illness in resource limited settings (RLS) are largely unknown. Without specific data that captures key aspects of critical illness, disease presentation, and resource utilization for pediatric populations in RLS, development of a contextual framework for appropriate, evidence-based interventions to guide allocation of limited but available resources is challenging. We present this methods paper which describes our efforts to determine the prevalence, etiology, hospital outcomes, and resource utilization associated with pediatric acute, critical illness in RLS globally.

METHODS

We will conduct a prospective, observational, multicenter, multinational point prevalence study in sixty-one participating RLS hospitals from North, Central and South America, Africa, Middle East and South Asia with four sampling time points over a 12-month period. Children aged 29 days to 14 years evaluated for acute illness or injury in an emergency department) or directly admitted to an inpatient unit will be enrolled and followed for hospital outcomes and resource utilization for the first seven days of hospitalization. The primary outcome will be prevalence of acute critical illness, which Global PARITY has defined as death within 48 hours of presentation to the hospital, including ED mortality; or admission/transfer to an HDU or ICU; or transfer to another institution for a higher level-of-care; or receiving critical care-level interventions (vasopressor infusion, invasive mechanical ventilation, non-invasive mechanical ventilation) regardless of location in the hospital, among children presenting to the hospital. Secondary outcomes include etiology of critical illness, in-hospital mortality, cause of death, resource utilization, length of hospital stay, and change in neurocognitive status. Data will be managed via REDCap, aggregated, and analyzed across sites.

DISCUSSION

This study is expected to address the current gap in understanding of the burden, etiology, resource utilization and outcomes associated with pediatric acute and critical illness in RLS. These data are crucial to inform future research and clinical management decisions and to improve global pediatric hospital outcomes.

Effectiveness of a Daily Rounding Checklist on Processes of Care and Outcomes in Diverse Pediatric Intensive Care Units Across the World

BACKGROUND

Implementation of checklists has been shown to be effective in improving patient safety. This study aims to evaluate the effectiveness of implementation of a checklist for daily care processes into clinical practice of pediatric intensive care units (PICUs) with limited resources.

METHODS

Prospective before-after study in eight PICUs from China, Congo, Croatia, Fiji, and India after implementation of a daily checklist into the ICU rounds.

RESULTS

Seven hundred and thirty-five patients from eight centers were enrolled between 2015 and 2017. Baseline stage had 292 patients and post-implementation 443. The ICU length of stay post-implementation decreased significantly [9.4 (4-15.5) vs. 7.3 (3.4-13.4) days, p = 0.01], with a nominal improvement in the hospital length of stay [15.4 (8.4-25) vs. 12.6 (7.5-24.4) days, p = 0.055]. The hospital mortality and ICU mortality between baseline group and post-implementation group did not show a significant difference, 14.4% vs. 11.3%; p = 0.22 for each. There was a variable impact of checklist implementation on adherence to various processes of care recommendations. A decreased exposure in days was noticed for; mechanical ventilation from 42.6% to 33.8%, p < 0.01; central line from 31.3% to 25.3%, p < 0.01; and urinary catheter from 30.6% to 24.4%, p < 0.01. Although there was an increased utilization of antimicrobials (89.9-93.2%, p < 0.01).

CONCLUSIONS

Checklists for the treatment of acute illness and injury in the PICU setting marginally impacted the outcome and processes of care. The intervention led to increasing adherence with guidelines in multiple ICU processes and led to decreased length of stay.

Cost-Utility of Intermediate Obstetric Critical Care in a Resource-Limited Setting: A Value-Based Analysis

Background:

Sierra Leone faces among the highest maternal mortality rates worldwide. Despite this burden, the role of life–saving critical care interventions in low–resource settings remains scarcely explored. A value-based approach may be used to question whether it is sustainable and useful to start and run an obstetric intermediate critical care facility in a resource–poor referral hospital. We also aimed to investigate whether patient outcomes in terms of quality of life justified the allocated resources.

Objective:

To explore the value-based dimension performing a cost-utility analysis with regard to the implementation and one-year operation of the HDU. The primary endopoint was the quality-adjusted life-years (QALYs) of patients admitted to the HDU, against direct and indirect costs. Secondary endpoints included key procedures or treatments performed during the HDU stay.

Methods:

The study was conducted from October 2, 2017 to October 1, 2018 in the obstetric high dependency unit (HDU) of Princess Christian Maternity Hospital (PCMH) in Freetown, Sierra Leone.

Findings:

523 patients (median age 25 years, IQR 21–30) were admitted to HDU. The total 1 year investment and operation costs for the HDU amounted to €120,082 – resulting in €230 of extra cost per admitted patient. The overall cost per QALY gained was of €10; this value is much lower than the WHO threshold defining high cost effectiveness of an intervention, i.e. three times the current Sierra Leone annual per capita GDP of €1416.

Conclusion:

With an additional cost per QALY of only €10.0, the implementation and one-year running of the case studied obstetric HDU can be considered a highly cost-effective frugal innovation in limited resource contexts. The evidences provided by this study allow a precise and novel insight to policy makers and clinicians useful to prioritize interventions in critical care and thus address maternal mortality in a high burden scenario.

Cost-Effectiveness Studies in the ICU: A Systematic Review

OBJECTIVES

Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs.

DESIGN

We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist.

SETTING

Critical care units.

PATIENTS OR SUBJECTS

Critical care patients.

INTERVENTIONS

Identified studies with cost-effectiveness analyses.

MEASUREMENTS AND MAIN RESULTS

We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]).

CONCLUSIONS

Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.

Global Critical Care: Moving Forward in Resource-Limited Settings

Caring for critically ill patients is challenging in resource-limited settings, where the burden of disease and mortality from potentially treatable illnesses is higher than in resource-rich areas. Barriers to delivering quality critical care in these settings include lack of epidemiologic data and context-specific evidence for medical decision-making, deficiencies in health systems organization and resources, and institutional obstacles to implementation of life-saving interventions. Potential solutions include the development of common definitions for intensive care unit (ICU), intensivist, and intensive care to create a universal ICU organization framework; development of educational programs for capacity building of health care professionals working in resource-limited settings; global prioritization of epidemiologic and clinical research in resource-limited settings to conduct timely and ethical studies in response to emerging threats; adaptation of international guidelines to promote implementation of evidence-based care; and strengthening of health systems that integrates these interventions. This manuscript reviews the field of global critical care, barriers to safe high-quality care, and potential solutions to existing challenges. We also suggest a roadmap for improving the treatment of critically ill patients in resource-limited settings.

Development of a Malawi Intensive care Mortality risk Evaluation (MIME) model, a prospective cohort study

INTRODUCTION

Intensive care medicine can contribute to population health in low-income countries by reducing premature mortality related to surgery, trauma, obstetrical and other medical emergencies. Quality improvement is guided by risk stratification models, which are developed primarily within high-income settings. Models validated for use in low-income countries are needed.

METHODS

This prospective cohort study consisted of 261 patients admitted to the intensive care unit (ICU) of Kamuzu Central Hospital in Malawi, from September 2016 to March 2018. The primary outcome was in-hospital mortality. We performed univariable analyses on putative predictors and included those with a significance of 0.15 in the Malawi Intensive care Mortality risk Evaluation model (MIME). Model discrimination was evaluated using the area under the curve.

RESULTS

Males made up 37.9% of the study sample and the mean age was 34.4 years. A majority (73.9%) were admitted to the ICU after a recent surgical procedure, and 59% came directly from the operating theater. In-hospital mortality was 60.5%. The MIME based on age, sex, admitting service, systolic pressure, altered mental status, and fever during the ICU course had a fairly good discrimination, with an AUC of 0.70 (95% CI 0.63-0.76).

CONCLUSIONS

The MIME has modest ability to predict in-hospital mortality in a Malawian ICU. Multicenter research is needed to validate the MIME and assess its clinical utility.

Feasibility of an International Remote Simulation Training Program in Critical Care Delivery: A Pilot Study

Objective

To determine the feasibility and effectiveness of a video-enabled remote simulation training program to teach a systematic, standardized approach to the evaluation and management of the critically ill patients as part of an international quality improvement intervention.

Patients and Methods

In this pilot "train-the-trainer" prospective cohort study, we provided a remote simulation-based educational program for practicing clinicians from intensive care units involved in an international quality improvement project (www.icertain.org). Between February 21, 2014, and August 6, 2015, participants completed a self-guided online curriculum and participated in structured simulation training using web conference software with recording capabilities. The performance was assessed using a matched pair analysis at baseline and using standardized scenarios and a validated assessment tool postintervention. Participants rated their satisfaction with the training experience and confidence in implementing these skills in clinical practice.

Results

Eighteen local champions from 8 hospitals in 7 countries in Asia, Europe, and South and Central America completed the educational program. Learners exhibited significant improvements in cumulative critical task performance during simulated critical care scenarios with training (60.3%-81.8%; P=.002). Most clinicians (94%) reported that they felt well prepared to manage the common critical care scenarios after training. These local champions have subsequently delivered this educational program to more than 800 international clinicians over a 4-year period.

Conclusion

Insufficient training is a major barrier to the delivery of cost-effective critical care in many areas of the world. Video-enabled remote simulation training is a low-cost, feasible, and effective method to disseminate clinical skills to critical care practitioners in diverse international settings.

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.

Challenges and Priorities for Pediatric Critical Care Clinician-Researchers in Low- and Middle-Income Countries

INTRODUCTION

There is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high.

MATERIALS AND METHODS

To inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis.

RESULTS

The majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation.

CONCLUSION

LMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success.