1
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Sultan M, Zewdie A, Priyadarshani D, Hassen E, Tilahun M, Geremew T, Beane A, Haniffa R, Berenholtz SM, Checkley W, Hansoti B, Laytin AD. Implementing an ICU registry in Ethiopia-Implications for critical care quality improvement. J Crit Care 2024; 81:154525. [PMID: 38237203 PMCID: PMC10996997 DOI: 10.1016/j.jcrc.2024.154525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Intensive care units (ICUs) in low- and middle-income countries have high mortality rates, and clinical data are needed to guide quality improvement (QI) efforts. This study utilizes data from a validated ICU registry specially developed for resource-limited settings to identify evidence-based QI priorities for ICUs in Ethiopia. MATERIALS AND METHODS A retrospective cohort analysis of data from two tertiary referral hospital ICUs in Addis Ababa, Ethiopia from July 2021-June 2022 was conducted to describe casemix, complications and outcomes and identify features associated with ICU mortality. RESULTS Among 496 patients, ICU mortality was 35.3%. The most common reasons for ICU admission were respiratory failure (24.0%), major head injury (17.5%) and sepsis/septic shock (13.3%). Complications occurred in 41.0% of patients. ICU mortality was higher among patients with respiratory failure (46.2%), sepsis (66.7%) and vasopressor requirements (70.5%), those admitted from the hospital ward (64.7%), and those experiencing major complications in the ICU (62.3%). CONCLUSIONS In this study, ICU mortality was high, and complications were common and associated with increased mortality. ICU registries are invaluable tools to understand local casemix and clinical outcomes, especially in resource-limited settings. These findings provide a foundation for QI efforts and a baseline to evaluate their impact.
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Affiliation(s)
- Menbeu Sultan
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia
| | - Ayalew Zewdie
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia; Addis Ababa Burn, Emergency and Trauma Hospital, Addis Ababa, Ethiopia
| | | | - Ephrem Hassen
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia
| | - Melkamu Tilahun
- St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia
| | - Tigist Geremew
- Addis Ababa Burn, Emergency and Trauma Hospital, Addis Ababa, Ethiopia
| | - Abi Beane
- Centre for Inflammation Research, University of Edinburgh, Scotland, UK.
| | - Rashan Haniffa
- Centre for Inflammation Research, University of Edinburgh, Scotland, UK.
| | - Sean M Berenholtz
- Johns Hopkins University School of Medicine, Department of Anesthesia and Critical Care Medicine, Baltimore, MD, USA.
| | - William Checkley
- Johns Hopkins University School of Medicine, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, MD, USA.
| | - Bhakti Hansoti
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.
| | - Adam D Laytin
- Johns Hopkins University School of Medicine, Department of Anesthesia and Critical Care Medicine, Baltimore, MD, USA; Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.
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2
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Li A, Ling L, Qin H, Arabi YM, Myatra SN, Egi M, Kim JH, Nor MBM, Son DN, Fang WF, Wahyuprajitno B, Hashmi M, Faruq MO, Patjanasoontorn B, Al Bahrani MJ, Shrestha BR, Shrestha U, Nafees KMK, Sann KK, Palo JEM, Mendsaikhan N, Konkayev A, Detleuxay K, Chan YH, Du B, Divatia JV, Koh Y, Phua J. Prognostic evaluation of quick sequential organ failure assessment score in ICU patients with sepsis across different income settings. Crit Care 2024; 28:30. [PMID: 38263076 PMCID: PMC10804657 DOI: 10.1186/s13054-024-04804-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND There is conflicting evidence on association between quick sequential organ failure assessment (qSOFA) and sepsis mortality in ICU patients. The primary aim of this study was to determine the association between qSOFA and 28-day mortality in ICU patients admitted for sepsis. Association of qSOFA with early (3-day), medium (28-day), late (90-day) mortality was assessed in low and lower middle income (LLMIC), upper middle income (UMIC) and high income (HIC) countries/regions. METHODS This was a secondary analysis of the MOSAICS II study, an international prospective observational study on sepsis epidemiology in Asian ICUs. Associations between qSOFA at ICU admission and mortality were separately assessed in LLMIC, UMIC and HIC countries/regions. Modified Poisson regression was used to determine the adjusted relative risk (RR) of qSOFA score on mortality at 28 days with adjustments for confounders identified in the MOSAICS II study. RESULTS Among the MOSAICS II study cohort of 4980 patients, 4826 patients from 343 ICUs and 22 countries were included in this secondary analysis. Higher qSOFA was associated with increasing 28-day mortality, but this was only observed in LLMIC (p < 0.001) and UMIC (p < 0.001) and not HIC (p = 0.220) countries/regions. Similarly, higher 90-day mortality was associated with increased qSOFA in LLMIC (p < 0.001) and UMIC (p < 0.001) only. In contrast, higher 3-day mortality with increasing qSOFA score was observed across all income countries/regions (p < 0.001). Multivariate analysis showed that qSOFA remained associated with 28-day mortality (adjusted RR 1.09 (1.00-1.18), p = 0.038) even after adjustments for covariates including APACHE II, SOFA, income country/region and administration of antibiotics within 3 h. CONCLUSIONS qSOFA was independently associated with 28-day mortality in ICU patients admitted for sepsis. In LLMIC and UMIC countries/regions, qSOFA was associated with early to late mortality but only early mortality in HIC countries/regions.
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Affiliation(s)
- Andrew Li
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Hanyu Qin
- State Key Laboratory of Complex, Severe and Rare Disease, Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Moritoki Egi
- Department of Anesthesiology and Intensive Care, Kyoto University Hospital, Kyoto, Japan
| | - Je Hyeong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Mohd Basri Mat Nor
- International Islamic University Malaysia Medical Center, Kuantan, Malaysia
| | - Do Ngoc Son
- Center of Critical Care Medicine, Bach Mai Hospital, Hanoi Medical University, VNU University of Medicine and Pharmacy, Hanoi, Vietnam
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Bambang Wahyuprajitno
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Airlangga, Intensive Care Unit, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Mohammad Omar Faruq
- General Intensive Care Unity and Emergency Department, United Hospital Ltd, Dhaka, Bangladesh
| | - Boonsong Patjanasoontorn
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Babu Raja Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | - Ujma Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | | | - Kyi Kyi Sann
- Department of Anaesthesiology and ICU, Yangon General Hospital, University of Medicine 1, Yangon, Myanmar
| | | | - Naranpurev Mendsaikhan
- Mongolia Japan Hospital, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Aidos Konkayev
- Anaesthesiology and Intensive Care Department, Astana Medical University, Astana, Kazakhstan
- Anaesthesiology and Intensive Care Department, National Scientific Center of Traumatology and Orthopedia Named After Academician N.D. Batpenov, Astana, Kazakhstan
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bin Du
- State Key Laboratory of Complex, Severe and Rare Disease, Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- FAST and Chronic Programmed, Alexandra Hospital, National University Health System, Singapore, Singapore
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Carter C, Notter J. Review of enteral nutrition practices in critically ill adults in resource-limited environments. BMJ Mil Health 2022; 168:499-502. [PMID: 35772796 DOI: 10.1136/bmjmilitary-2022-002102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/25/2022] [Indexed: 11/04/2022]
Abstract
Enteral nutrition in critical care is a complex area of practice. A resource-limited environment includes countries that are identified as low income and low/middle income. This review describes three themes for its successful implementation of enteral nutrition in a resource-limited environment. These include identification of patients at risk of malnutrition, using non-commercial feeds and the urgent need to develop practice. Malnutrition is a serious complication of critical illness and remains a crucial aspect of patient care in order to prevent complications. Further evidence to develop sustainable enteral nutrition strategies for critically ill patients is urgently required. This is a paper commissioned as part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.
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Affiliation(s)
| | - Joy Notter
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, West Midlands, B15 3TN, UK
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4
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Ranjit S, Kissoon N. Challenges and Solutions in translating sepsis guidelines into practice in resource-limited settings. Transl Pediatr 2021; 10:2646-2665. [PMID: 34765491 PMCID: PMC8578780 DOI: 10.21037/tp-20-310] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large global burden of sepsis including challenges in quantifying attributable morbidity and mortality, poverty, inadequate awareness, health inequity, under-resourced public health, and low-resilient acute health care delivery systems. Context-specific approaches to this significant problem are necessary on account of important differences in populations at-risk, the nature of infecting pathogens, and the healthcare capacity to manage sepsis in LMIC. We review these challenges and propose an outline of some solutions to tackle them which include strengthening the healthcare systems, accurate and early identification of sepsis the need for inclusive research and context-specific treatment guidelines, and advocacy. Specifically, strengthening pediatric intensive care units (PICU) services can effectively treat the life-threatening complications of common diseases, such as diarrhoea, respiratory infections, severe malaria, and dengue, thereby improving the quality of pediatric care overall without the need for expensive interventions. A thoughtful approach to developing paediatric intensive care services in LMICs begins with basic fundamentals: training healthcare providers in knowledge and skills, selecting effective equipment that is resource-appropriate, and having an enabling leadership to provide location-appropriate care. These basics, if built in sustainable manner, have the potential to permit an efficient pediatric critical care service to be established that can significantly improve sepsis and other critical care outcomes.
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Affiliation(s)
- Suchitra Ranjit
- Senior Consultant and Head, Pediatric ICU, Apollo Children's Hospital, Chennai, India
| | - Niranjan Kissoon
- Children's and Women's Global Health, UBC & BC Children's Hospital Professor in Critical Care - Global Child Health, Department of Pediatrics and Emergency Medicine, UBC, Child and Family Research Institute, Vice President Global Sepsis Alliance, Vancouver, Canada
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5
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Abstract
PURPOSE OF REVIEW Critical care registries are synonymous with measurement of outcomes following critical illness. Their ability to provide longitudinal data to enable benchmarking of outcomes for comparison within units over time, and between units, both regionally and nationally is a key part of the evaluation of quality of care and ICU performance as well as a better understanding of case-mix. This review aims to summarize literature on outcome measures currently being reported in registries internationally, describe the current strengths and challenges with interpreting existing outcomes and highlight areas where registries may help improve implementation and interpretation of both existing and new outcome measures. RECENT FINDINGS Outcomes being widely reported through ICU registries include measures of survival, events of interest, patient-reported outcomes and measures of resource utilization (including cost). Despite its increasing adoption, challenges with quality of reporting of outcomes measures remain. Measures of short-term survival are feasible but those requiring longer follow-ups are increasingly difficult to interpret given the evolving nature of critical care in the context of acute and chronic disease management. Furthermore, heterogeneity in patient populations and in healthcare organisations in different settings makes use of outcome measures for international benchmarking at best complex, requiring substantial advances in their definitions and implementation to support those seeking to improve patient care. SUMMARY Digital registries could help overcome some of the current challenges with implementing and interpreting ICU outcome data through standardization of reporting and harmonization of data. In addition, ICU registries could be instrumental in enabling data for feedback as part of improvement in both patient-centred outcomes and in service outcomes; notably resource utilization and efficiency.
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Affiliation(s)
- Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Oxford University, UK
| | - Jorge I.F. Salluh
- D’Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Postgraduate program, Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rashan Haniffa
- Mahidol Oxford Tropical Medicine Research Unit, Oxford University, UK
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6
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Ranasinghe WG, Beane A, Vithanage TDP, Priyadarshani GDD, Colombage DDE, Ponnamperuma CJ, Karunarathne S, Schultsz C, Dondorp AM, Haniffa R. Quality evaluation and future priorities for delivering acute myocardial infarction care in Sri Lanka. Heart 2019; 106:603-608. [PMID: 31843877 PMCID: PMC7146937 DOI: 10.1136/heartjnl-2019-315396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/25/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023] Open
Abstract
Aim This study evaluates the quality of care for patients admitted with acute myocardial infarction (AMI) in a tertiary hospital in Colombo using the European Society of Cardiology Quality of Care Working Group’s guidelines (2017). Methods A recently implemented electronic AMI registry m-Health tool was used for prospective data collection. Each patient was assessed for eligibility for each of the six domains of quality. Global Registry of Acute Coronary Events Risk Model for predicted probability of mortality, and scores for risk of bleeding complications (CRUSADE) and severity of heart failure (Killip classification) were calculated as per published guidelines. A composite measure of quality was derived from compliance with the six domains. Patients were followed up via telephone at 30 days following discharge to evaluate outcome and satisfaction. Organisational information was assessed by administrative review and interview. Results Between March 2017 and April 2018, 934 patients with AMI presented to the cardiology department. The majority of patients (90.4%) presented with features of ST-elevation myocardial infarction (STEMI). Mean (SD) overall compliance with the composite quality indicator (CQI) was 44% (0.07). Compliance of ≥50% to the CQI was achieved in 9.8% of STEMI patients. The highest compliance was observed for antithrombotics during hospitalisation (79.1%) and continuous measure of patient satisfaction (76.1%). The lowest compliance was for organisational structure and care processes (22.4%). Conclusion This study reports a registry-based continuous evaluation of the quality of AMI care from a low and middle-income country. Priorities for improvement include improved referral, and networking of primary and secondary health facilities with the percutaneous coronary intervention centre.
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Affiliation(s)
| | - Abi Beane
- Department of Critical care and Malaria, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand .,Network for Improving Critical Care System and Training, Colombo, Sri Lanka.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Global Health - AIGHD Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Gamage Dona Dilanthi Priyadarshani
- Department of Critical care and Malaria, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Network for Improving Critical Care System and Training, Colombo, Sri Lanka
| | | | | | | | - Constance Schultsz
- Department of Global Health - AIGHD Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjen M Dondorp
- Department of Critical care and Malaria, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rashan Haniffa
- Department of Critical care and Malaria, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Network for Improving Critical Care System and Training, Colombo, Sri Lanka.,Internal Medicine, University College London, London, United Kingdom
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7
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Abstract
PURPOSE OF REVIEW The burden of critical illness in low-income and middle-income countries (LMICs) is substantial. A better understanding of critical care outcomes is essential for improving critical care delivery in resource-limited settings. In this review, we provide an overview of recent literature reporting on critical care outcomes in LMICs. We discuss several barriers and potential solutions for a better understanding of critical care outcomes in LMICs. RECENT FINDINGS Epidemiologic studies show higher in-hospital mortality rates for critically ill patients in LMICs as compared with patients in high-income countries (HICs). Recent findings suggest that critical care interventions that are effective in HICs may not be effective and may even be harmful in LMICs. Little data on long-term and morbidity outcomes exist. Better outcomes measurement is beginning to emerge in LMICs through decision support tools that report process outcome measures, studies employing mobile health technologies with community health workers and the development of context-specific severity of illness scores. SUMMARY Outcomes from HICs cannot be reliably extrapolated to LMICs, so it is important to study outcomes for critically ill patients in LMICs. Specific challenges to achieving meaningful outcomes studies in LMICs include defining the critically ill population when few ICU beds exist, the resource-intensiveness of long-term follow-up, and the need for reliable severity of illness scores to interpret outcomes. Although much work remains to be done, examples of studies overcoming these challenges are beginning to emerge.
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8
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Beane A, De Silva AP, Athapattu PL, Jayasinghe S, Abayadeera AU, Wijerathne M, Udayanga I, Rathnayake S, Dondorp AM, Haniffa R. Addressing the information deficit in global health: lessons from a digital acute care platform in Sri Lanka. BMJ Glob Health 2019; 4:e001134. [PMID: 30775004 PMCID: PMC6352842 DOI: 10.1136/bmjgh-2018-001134] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/08/2018] [Accepted: 12/13/2018] [Indexed: 12/19/2022] Open
Abstract
Lack of investment in low-income and middle-income countries (LMICs) in systems capturing continuous information regarding care of the acutely unwell patient is hindering global efforts to address inequalities, both at facility and national level. Furthermore, this of lack of data is disempowering frontline staff and those seeking to support them, from progressing setting-relevant research and quality improvement. In contrast to high-income country (HIC) settings, where electronic surveillance has boosted the capability of governments, clinicians and researchers to engage in service-wide healthcare evaluation, healthcare information in resource-limited settings remains almost exclusively paper based. In this practice paper, we describe the efforts of a collaboration of clinicians, administrators, researchers and healthcare informaticians working in South Asia, in addressing the inequality in access to patient information in acute care. Harnessing a clinician-led collaborative approach to design and evaluation, we have implemented a national acute care information platform in Sri Lanka that is tailored to priorities of frontline staff. Iterative adaptation has ensured the platform has the flexibility to integrate with legacy paper systems, support junior team members in advocating for acutely unwell patients and has made information captured accessible to diverse stakeholders to improve service delivery. The same platform is now empowering clinicians to participate in international research and drive forwards improvements in care. During this journey, we have also gained insights on how to overcome well-described barriers to implementation of digital information tools in LMIC. We anticipate that this north-south collaborative approach to addressing the challenges of health system implementation in acute care may provide learning and inspiration to other partnerships seeking to engage in similar work.
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Affiliation(s)
- Abi Beane
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
| | | | | | - Saroj Jayasinghe
- Department of Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Mandika Wijerathne
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Ishara Udayanga
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | | | | | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
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9
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Haniffa R, Silva APD, Beane A, Sigera PC, Athapattu PL, Rathnayake S, Jayasinghe KSA, Keizer NFD, Dondorp AM. To: The Epimed Monitor ICU Database®: a cloud-based national registry for adult intensive care unit patients in Brazil. Rev Bras Ter Intensiva 2018; 30:251-252. [PMID: 29995095 PMCID: PMC6031428 DOI: 10.5935/0103-507x.20180031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rashan Haniffa
- Network for Improving Critical Care Systems and Training - Colombo, Sri Lanka; Mahidol Oxford Tropical Medicine Research Unit - Bangkok, Thailand; University of Oxford - United Kingdom of Great Britain and Northern Ireland
| | | | - Abigail Beane
- Network for Improving Critical Care Systems and Training - Colombo, Sri Lanka
| | | | | | | | - Kosala Saroj Amarasiri Jayasinghe
- University of Colombo Faculty of Medicine - Anuja Unnathie Abayadeera - Faculty of Medicine, University of Colombo - Colombo, Western Sri Lanka
| | - Nicolette F de Keizer
- AMC - Medical Informatics - Amsterdam, Netherlands; National Intensive Care Evaluation Foundation - Amsterdam, Netherlands
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit - Bangkok, Thailand; University of Oxford - United Kingdom of Great Britain and Northern Ireland
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10
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Ramos JGR, da Hora Passos R, Teixeira MB, Gobatto ALN, Coutinho RVDS, Caldas JR, da Guarda SF, Ribeiro MP, Batista PBP. Prognostic ability of quick-SOFA across different age groups of patients with suspected infection outside the intensive care unit: A cohort study. J Crit Care 2018; 47:178-184. [DOI: 10.1016/j.jcrc.2018.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/09/2018] [Accepted: 07/05/2018] [Indexed: 01/07/2023]
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11
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Fortis S, O'Shea AMJ, Beck BF, Nair R, Goto M, Kaboli PJ, Perencevich EN, Reisinger HS, Sarrazin MV. An automated computerized critical illness severity scoring system derived from APACHE III: modified APACHE. J Crit Care 2018; 48:237-242. [PMID: 30243204 DOI: 10.1016/j.jcrc.2018.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the performance of an automated computerized ICU severity scoring derived from the APACHE III. MATERIALS AND METHODS Within a retrospective cohort of patients admitted to Veterans Health Administration ICUs between 2009 and 2015, we created an automated illness severity score(modified APACHE or mAPACHE), that we extracted from the electronic health records, using the same scoring as the APACHE III excluding the Glasgow Coma Scale, urine output, arterial blood gas components of APACHE III. We assessed the mAPACHE discrimination by using the area under the curve(AUC), and calibration by using the Hosmer-Lemeshow test and calculating the difference between observed and expected mortality across equal-sized risk deciles for death. RESULTS The ICU and 30-day mortality was 5.07% of 7.82%, respectively (n = 490,955 patients). The AUC of mAPACHE for ICU and 30-day mortality was 0.771 and 0.786, respectively. The Hosmer-Lemeshow test was significant for both ICU and 30-day mortality (p < .001). The absolute difference between observed and expected mortality did not exceed ±1.53% across equal-sized deciles of risk for death. The AUC for ICU mortality was >0.7 in all admission diagnosis categories except in endocrine, respiratory, and sepsis. The AUC for 30-day mortality was >0.7 in every category. CONCLUSION mAPACHE has adequate performance to predict mortality.
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Affiliation(s)
- Spyridon Fortis
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupation Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.
| | - Amy M J O'Shea
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice F Beck
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Rajeshwari Nair
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Mary V Sarrazin
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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12
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Haniffa R, Beane A, Baker T, Riviello ED, Schell CO, Dondorp AM. Development and internal validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). Acta Anaesthesiol Scand 2018; 62:407-408. [PMID: 29368381 DOI: 10.1111/aas.13080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- R. Haniffa
- Network for Improving Critical Care Systems and Training, NICST; Colombo Sri Lanka
| | - A. Beane
- Network for Improving Critical Care Systems and Training, NICST; Colombo Sri Lanka
| | - T. Baker
- Public Health Sciences; Karolinska Institutet; Stockholm Sweden
| | | | - C. O. Schell
- Public Health Sciences; Karolinska Institutet; Stockholm Sweden
| | - A. M. Dondorp
- Tropical Medicine Research Unit; Faculty of Tropical Medicine; Mahidol-Oxford; Mahidol University Phayathai Campus; Bangkok Thailand
- Nuffield Department of Medicine; Centre for Tropical Medicine and Global Health; University of Oxford; Oxford UK
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13
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Haniffa R, Isaam I, De Silva AP, Dondorp AM, De Keizer NF. Performance of critical care prognostic scoring systems in low and middle-income countries: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:18. [PMID: 29373996 PMCID: PMC5787236 DOI: 10.1186/s13054-017-1930-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/21/2017] [Indexed: 12/15/2022]
Abstract
Background Prognostic models—used in critical care medicine for mortality predictions, for benchmarking and for illness stratification in clinical trials—have been validated predominantly in high-income countries. These results may not be reproducible in low or middle-income countries (LMICs), not only because of different case-mix characteristics but also because of missing predictor variables. The study objective was to systematically review literature on the use of critical care prognostic models in LMICs and assess their ability to discriminate between survivors and non-survivors at hospital discharge of those admitted to intensive care units (ICUs), their calibration, their accuracy, and the manner in which missing values were handled. Methods The PubMed database was searched in March 2017 to identify research articles reporting the use and performance of prognostic models in the evaluation of mortality in ICUs in LMICs. Studies carried out in ICUs in high-income countries or paediatric ICUs and studies that evaluated disease-specific scoring systems, were limited to a specific disease or single prognostic factor, were published only as abstracts, editorials, letters and systematic and narrative reviews or were not in English were excluded. Results Of the 2233 studies retrieved, 473 were searched and 50 articles reporting 119 models were included. Five articles described the development and evaluation of new models, whereas 114 articles externally validated Acute Physiology and Chronic Health Evaluation, the Simplified Acute Physiology Score and Mortality Probability Models or versions thereof. Missing values were only described in 34% of studies; exclusion and or imputation by normal values were used. Discrimination, calibration and accuracy were reported in 94.0%, 72.4% and 25% respectively. Good discrimination and calibration were reported in 88.9% and 58.3% respectively. However, only 10 evaluations that reported excellent discrimination also reported good calibration. Generalisability of the findings was limited by variability of inclusion and exclusion criteria, unavailability of post-ICU outcomes and missing value handling. Conclusions Robust interpretations regarding the applicability of prognostic models are currently hampered by poor adherence to reporting guidelines, especially when reporting missing value handling. Performance of mortality risk prediction models in LMIC ICUs is at best moderate, especially with limitations in calibration. This necessitates continued efforts to develop and validate LMIC models with readily available prognostic variables, perhaps aided by medical registries. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1930-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rashan Haniffa
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka. .,AA (Ltd), London, UK. .,National Intensive Care Surveillance, Ministry of Health, Amsterdam, Netherlands.
| | - Ilhaam Isaam
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,AA (Ltd), London, UK
| | - A Pubudu De Silva
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,National Intensive Care Surveillance, Ministry of Health, Amsterdam, Netherlands
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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14
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Samanamalee S, Sigera PC, De Silva AP, Thilakasiri K, Rashan A, Wadanambi S, Jayasinghe KSA, Dondorp AM, Haniffa R. Traumatic brain injury (TBI) outcomes in an LMIC tertiary care centre and performance of trauma scores. BMC Anesthesiol 2018; 18:4. [PMID: 29310574 PMCID: PMC5759275 DOI: 10.1186/s12871-017-0463-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/18/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND This study evaluates post-ICU outcomes of patients admitted with moderate and severe Traumatic Brain Injury (TBI) in a tertiary neurocritical care unit in an low middle income country and the performance of trauma scores: A Severity Characterization of Trauma, Trauma and Injury Severity Score, Injury Severity Score and Revised Trauma Score in this setting. METHODS Adult patients directly admitted to the neurosurgical intensive care units of the National Hospital of Sri Lanka between 21st July 2014 and 1st October 2014 with moderate or severe TBI were recruited. A telephone administered questionnaire based on the Glasgow Outcome Scale Extended (GOSE) was used to assess functional outcome of patients at 3 and 6 months after injury. The economic impact of the injury was assessed before injury, and at 3 and 6 months after injury. RESULTS One hundred and one patients were included in the study. Survival at ICU discharge, 3 and 6 months after injury was 68.3%, 49.5% and 45.5% respectively. Of the survivors at 3 months after injury, 43 (86%) were living at home. Only 19 (38%) patients had a good recovery (as defined by GOSE 7 and 8). Three months and six months after injury, respectively 25 (50%) and 14 (30.4%) patients had become "economically dependent". Selected trauma scores had poor discriminatory ability in predicting mortality. CONCLUSIONS This observational study of patients sustaining moderate or severe TBI in Sri Lanka (a LMIC) reveals only 46% of patients were alive at 6 months after ICU discharge and only 20% overall attained a good (GOSE 7 or 8) recovery. The social and economic consequences of TBI were long lasting in this setting. Injury Severity Score, Revised Trauma Score, A Severity Characterization of Trauma and Trauma and Injury Severity Score, all performed poorly in predicting mortality in this setting and illustrate the need for setting adapted tools.
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Affiliation(s)
| | - Ponsuge Chathurani Sigera
- Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo, 08 Sri Lanka
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, 08 Sri Lanka
| | - Ambepitiyawaduge Pubudu De Silva
- Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo, 08 Sri Lanka
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, 08 Sri Lanka
- Intensive Care National Audit & Research Centre, No. 24, High Holborn, London, WC1V 6AZ UK
| | - Kaushila Thilakasiri
- Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo, 08 Sri Lanka
| | - Aasiyah Rashan
- Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo, 08 Sri Lanka
| | | | | | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400 Thailand
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo, 08 Sri Lanka
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, 08 Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400 Thailand
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15
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Shrestha GS. Developing a feasible and valid scoring system for critically ill patients in resource-limited settings. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:2. [PMID: 29304846 PMCID: PMC5756425 DOI: 10.1186/s13054-017-1902-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 11/29/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Gentle Sunder Shrestha
- Department of Anaesthesiology, Critical Care Unit, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
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16
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Haniffa R, Mukaka M, Munasinghe SB, De Silva AP, Jayasinghe KSA, Beane A, de Keizer N, Dondorp AM. Simplified prognostic model for critically ill patients in resource limited settings in South Asia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:250. [PMID: 29041985 PMCID: PMC5645891 DOI: 10.1186/s13054-017-1843-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 09/15/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Current critical care prognostic models are predominantly developed in high-income countries (HICs) and may not be feasible in intensive care units (ICUs) in lower- and middle-income countries (LMICs). Existing prognostic models cannot be applied without validation in LMICs as the different disease profiles, resource availability, and heterogeneity of the population may limit the transferability of such scores. A major shortcoming in using such models in LMICs is the unavailability of required measurements. This study proposes a simplified critical care prognostic model for use at the time of ICU admission. METHODS This was a prospective study of 3855 patients admitted to 21 ICUs from Bangladesh, India, Nepal, and Sri Lanka who were aged 16 years and over and followed to ICU discharge. Variables captured included patient age, admission characteristics, clinical assessments, laboratory investigations, and treatment measures. Multivariate logistic regression was used to develop three models for ICU mortality prediction: model 1 with clinical, laboratory, and treatment variables; model 2 with clinical and laboratory variables; and model 3, a purely clinical model. Internal validation based on bootstrapping (1000 samples) was used to calculate discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer-Lemeshow C-Statistic; higher values indicate poorer calibration). Comparison was made with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II models. RESULTS Model 1 recorded the respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), blood urea, haemoglobin, mechanical ventilation, and vasopressor use on ICU admission. Model 2, named TropICS (Tropical Intensive Care Score), included emergency surgery, respiratory rate, systolic blood pressure, GCS, blood urea, and haemoglobin. Model 3 included respiratory rate, emergency surgery, and GCS. AUC was 0.818 (95% confidence interval (CI) 0.800-0.835) for model 1, 0.767 (0.741-0.792) for TropICS, and 0.725 (0.688-0.762) for model 3. The Hosmer-Lemeshow C-Statistic p values were less than 0.05 for models 1 and 3 and 0.18 for TropICS. In comparison, when APACHE II and SAPS II were applied to the same dataset, AUC was 0.707 (0.688-0.726) and 0.714 (0.695-0.732) and the C-Statistic was 124.84 (p < 0.001) and 1692.14 (p < 0.001), respectively. CONCLUSION This paper proposes TropICS as the first multinational critical care prognostic model developed in a non-HIC setting.
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Affiliation(s)
- Rashan Haniffa
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo 08, Sri Lanka. .,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand. .,Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo 08, Sri Lanka.
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Sithum Bandara Munasinghe
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo 08, Sri Lanka
| | - Ambepitiyawaduge Pubudu De Silva
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo 08, Sri Lanka.,Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo 08, Sri Lanka.,Intensive Care National Audit & Research Centre, No. 24, High Holborn, London, WC1V 6AZ, UK
| | | | - Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo 08, Sri Lanka
| | - Nicolette de Keizer
- Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, Netherlands
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
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