Intensive care--a cost effective option for developing countries?

Outcomes in critical care delivery at Jimma University Specialised Hospital, Ethiopia

The aim of this study was to assess outcomes following intensive care unit (ICU) admissions at Jimma University Specialised Hospital, Ethiopia. This was a retrospective observational study. Data were collected regarding all ICU admissions and discharges during a 12-month period beginning August 2011. Demographic data and information regarding diagnosis, length-of-stay and outcome were gathered and data analysed. There were 370 admissions to the ICU during the study period. Median age (interquartile range) was 32.0 (22.0-47.0) years and 56.2% were males. The median length-of-stay (interquartile range) was 3.0 (1.0-7.0) days. The overall ICU mortality rate was 50.4% and major causes included trauma, cardiac disease, acute abdominal presentations, septic shock, tetanus and hysterectomy secondary to uterine rupture. Medical diagnoses accounted for 50.1% of admissions followed by surgery (43.2%) and obstetrics (5.8%). Corresponding mortality rates were 53.6, 48.0 and 42.9%, respectively. The main cause for surgical admission was trauma, with head injury carrying a mortality of 52.1%. The principal cause for medical admission was cardiac disease. In children, trauma, upper airway obstruction and communicable diseases were most common. Critical care mortality rates at this Ethiopian university hospital reflect the challenges facing critical care delivery in the developing world. Delayed presentation to hospital secondary to poor access to healthcare plays a predominant role. This is confounded by inadequate staffing, training, diagnostic and interventional limitations. Despite resource restraints, simple cost-effective measures may improve morbidity and mortality.

Challenges in setting up pediatric and neonatal intensive care units in a resource-limited country

In collaboration with a host country and international medical volunteers, a PICU and an NICU were conceptualized and realized in the developing country of Nepal. We present here the challenges that were encountered during and after the establishment of these units. The decision to develop an ICU with reasonable goals in a developing country has to be made with careful assessments of need of that patient population and ethical principles guiding appropriate use of limited resources. Considerations during unit design include space allocation, limited supply of electricity, oxygen source, and clean-water availability. Budgetary challenges might place overall sustainability at stake, which can also lead to attrition of trained manpower and affect the quality of care. Those working in the PICU in resource-poor nations perpetually face the challenges of lack of expert support (subspecialists), diagnostic facilities (laboratory and radiology), and appropriate medications and equipment. Increasing transfer of severely ill patients from other health facilities can lead to space constraints, and lack of appropriate transportation for these critically ill patients increases the severity of illness, which leads to increased mortality rates. The staff in these units must make difficult decisions on effective triage of admissions to the units on the basis of individual cases, futility of care, availability of resources, and financial ability of the family.

Clinical review: impact of emergency department care on intensive care unit costs

Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. Although limited, current data suggest that ED care has a significant impact on ICU costs both positive and negative. ICU practices can also affect the ED, with a lack of ICU beds being the primary reason for ED overcrowding and ambulance diversion in the USA. Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.