A review and analysis of intensive care medicine in the least developed countries

The burden of pediatric critical illness among pediatric oncology patients in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Pediatric oncology patients have increased risk for critical illness; outcomes are well described in high-income countries (HICs); however, data is limited for low- and middle-income countries (LMICs).

METHODS

We systematically searched PubMed, EMBASE, Web of Science, CINAHL and Global Health databases for articles in 6 languages describing mortality in children with cancer admitted to intensive care units (ICUs) in LMICs. Two investigators independently assessed eligibility, data quality, and extracted data. We pooled ICU mortality estimates using random effect models.

RESULTS

Of 3641 studies identified, 22 studies were included, covering 4803 ICU admissions. Overall pooled mortality was 30.3 % [95 % Confidence-interval (CI) 21.7-40.6 %]. Mechanical ventilation [odds ratio (OR) 12.2, 95 %CI:6.2-24.0, p-value<0.001] and vasoactive infusions [OR 6.3 95 %CI:3.3-11.9, p-value<0.001] were associated with ICU mortality.

CONCLUSIONS

ICU mortality among pediatric oncology patients in LMICs is similar to that in HICs, however, this review likely underestimates true mortality due to underrepresentation of studies from low-income countries.

Prevalence of mortality among mechanically ventilated patients in the intensive care units of Ethiopian hospitals and the associated factors: A systematic review and meta-analysis

BACKGROUND

In the intensive care unit (ICU), mechanical ventilation (MV) is a typical way of respiratory support. The severity of the illness raises the likelihood of death in patients who require MV. Several studies have been done in Ethiopia; however, the mortality rate differs among them. The objective of this systematic review and meta-analysis is to provide a pooled prevalence of mortality and associated factors among ICU-admitted patients receiving MV in Ethiopian hospitals.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria to conduct a comprehensive systematic review and meta-analysis in this study. We searched PubMed/Medline, SCOPUS, Embase, Hinari, and Web of Science and found 22 articles that met our inclusion criteria. We used a random-effects model. To identify heterogeneity within the included studies, meta-regression and subgroup analysis were used. We employed Egger's regression test and funnel plots for assessing publication bias. STATA version 17.0 software was used for all statistical analyses.

RESULTS

In this systematic review and meta-analysis, the pooled prevalence of mortality among 7507 ICU-admitted patients from 22 articles, who received MV was estimated to be 54.74% [95% CI = 47.93, 61.55]. In the subgroup analysis by region, the Southern Nations, Nationalities, and Peoples (SNNP) subgroup (64.28%, 95% CI = 51.19, 77.37) had the highest prevalence. Patients with COVID-19 have the highest mortality rate (75.80%, 95% CI = 51.10, 100.00). Sepsis (OR = 6.85, 95%CI = 3.24, 14.46), Glasgow Coma Scale (GCS) score<8 (OR = 6.58, 95%CI = 1.96, 22.11), admission with medical cases (OR = 4.12, 95%CI = 2.00, 8.48), Multi Organ Dysfunction Syndrome (MODS) (OR = 2.70, 95%CI = 4.11, 12.62), and vasopressor treatment (OR = 19.06, 95%CI = 9.34, 38.88) were all statistically associated with mortality.

CONCLUSION

Our review found that the pooled prevalence of mortality among mechanically ventilated ICU-admitted patients in Ethiopia was considerably high compared to similar studies in the United States (US), China, and other countries. Sepsis, GCS<8, medical cases, MODS, and use of vasopressors were statistically associated with mortality. Clinicians should exercise caution while mechanically ventilating ICU-admitted patients with these factors. However, it should be noted that the exact cause and effect relationship could not be established with this meta-analysis, as the available evidence is not sufficient. Thus, more studies using prospective methods will be required.

Interventions for improving critical care in low- and middle-income countries: a systematic review

PURPOSE

To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs).

METHODS

MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions' effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesised using the Consolidated Framework for Implementation Research.

RESULTS

78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with clinical workflows.

CONCLUSIONS

The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.

Impact and Feasibility of Mechanical Ventilation at a Surgical Center in Sierra Leone: Experience From EMERGENCY's Hospital in Goderich

OBJECTIVES

Despite the large burden of critically ill patients in developing countries, mechanical ventilation (MV) is scarce in these low-resource settings. In the absence of data, issues like costs and lack of training are often felt to outweigh the benefits of potential MV implementation in such places. We aimed to investigate the impact and feasibility of MV in a surgical ICU in West Africa.

DESIGN

This is a 7-month retrospective observational study (from October 25, 2022, to May 25, 2023), covering all patients consecutively admitted to ICU.

SETTING

The NGO EMERGENCY's hospital in Goderich, Freetown, Sierra Leone. The hospital is a referral center for acute care surgery.

PATIENTS

Critical patients admitted to the hospital's ICU.

INTERVENTIONS

Following brief, practical training of the nursing staff, one basic mechanical ventilator was installed at the hospital's ICU, under the supervision of two intensivists. Only patients with a body weight of over 15 kg and who met the "extreme criteria" for MV received this life-saving therapy.

MEASUREMENTS AND MAIN RESULTS

Of the 195 files of patients admitted to ICU during the study period, 162 were analyzed. The median age was 16 (interquartile range 7-27) and 48.1% of the population were under 14 years. The most common cause of admission was trauma (58.6%), followed by acute abdomen (33.3%), caustic soda ingestion (6.2%), and burns (1.9%). Of the overall population, 26 patients (16%) underwent MV (88.5% trauma cases vs. 11.5% acute abdomen). Median time on MV was 24 hours (12-64). The mortality rate in the MV group was 30.8% (8/26), while in the overall study population, it was 11.7% (19/162). One potentially life-threatening event of tube obstruction was handled appropriately.

CONCLUSIONS

This study strongly supports the implementation of MV in low-resource settings. In our experience, the consistent benefit of reduced mortality among critical patients largely outweighs the associated challenges.

Hospital readiness for the provision of care to critically ill patients in Tanzania- an in-depth cross-sectional study

BACKGROUND

Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and potential for reversibility. The burden of critical illness is high, especially in low- and middle-income countries. Critical care can be provided as Essential Emergency and Critical Care (EECC)- the effective, low-cost, basic care that all critically ill patients should receive in all parts of all hospitals in the world- and advanced critical care- complex, resource-intensive care usually provided in an intensive care unit. The required resources may be available in the hospital and yet not be ready in the wards for immediate use for critically ill patients. The ward readiness of these resources, although harder to evaluate, is likely more important than their availability in the hospital. This study aimed to assess the ward readiness for EECC and the hospital availability of resources for EECC and for advanced critical care in hospitals in Tanzania.

METHODS

An in-depth, cross-sectional study was conducted in five purposively selected hospitals by visiting all wards to collect data on all the required 66 EECC and 161 advanced critical care resources. We defined hospital-availability as a resource present in the hospital and ward-readiness as a resource available, functioning, and present in the right place, time and amounts for critically ill patient care in the wards. Data were analyzed to calculate availability and readiness scores as proportions of the resources that were available at hospital level, and ready at ward level respectively.

RESULTS

Availability of EECC resources in hospitals was 84% and readiness in the wards was 56%. District hospitals had lower readiness scores (less than 50%) than regional and tertiary hospitals. Equipment readiness was highest (65%) while that of guidelines lowest (3%). Availability of advanced critical care resources was 31%.

CONCLUSION

Hospitals in Tanzania lack readiness for the provision of EECC- the low-cost, life-saving care for critically ill patients. The resources for EECC were available in hospitals, but were not ready for the immediate needs of critically ill patients in the wards. To provide effective EECC to all patients, improvements are needed around the essential, low-cost resources in hospital wards that are essential for decreasing preventable deaths.

Assessing the Awareness and Understanding of Hospital Triage Among the General Population of Al-Ahsa, Saudi Arabia

Background Hospital triage is a critical process in emergency departments (EDs) worldwide. The efficiency of the triage process significantly impacts the overall functioning of the ED and patient outcomes. However, the effectiveness of triage is not solely dependent on the healthcare professionals conducting it. The awareness and understanding of the triage process among the general population also play a crucial role. Methods This study aimed to assess the awareness and understanding of hospital triage among the general population of Al-Ahsa. A cross-sectional design was conducted in Al-Ahsa, Saudi Arabia, from July to September 2023. Data were collected using an online questionnaire. Results This study examined the awareness, understanding, attitude, and socio-demographic factors of hospital triage among 389 participants in Al-Ahsa, Saudi Arabia. Results showed that 59.4% (n=231) of participants were aware of emergency triage, with 91.8% (n=457) agreeing with patient classification based on deterioration. Expectations for waiting time varied, with 38.8% (n=151) expecting 5-10 minutes. Participants expressed positive attitudes, with 91% (n=354) believing triage improves patient care. Socio-demographic analysis revealed higher awareness among younger age groups, males, and highly educated individuals. Educational level was associated with participants' attitudes. These findings emphasize the importance of targeted awareness campaigns and improved waiting room amenities for effective hospital triage. Conclusion The study found that public awareness of emergency triage is average, with high satisfaction with the concept of patient classification based on deterioration. Periodic health education sessions regarding the importance of ER triage are recommended for healthcare visitors and staff.

Management of Guillain-Barré syndrome in Bangladesh: Clinical practice, limitations and recommendations for low- and middle-income countries

BACKGROUND AND AIMS

Considerable variation in clinical practice for management of Guillain-Barré syndrome (GBS) has been observed worldwide. Diagnosis and treatment are challenging in low- and middle-income countries (LMIC) due to lack of facilities and treatment availability. We aimed to evaluate current clinical practice and limitations and to provide recommendation for GBS management in low-resource settings.

METHODS

We conducted an explanatory-sequential mixed-methods survey among neurologists and internists working in tertiary and secondary government hospitals in Bangladesh. There were two phases: (1) quantitative (cross-sectional survey to evaluate clinical practice and limitations); (2) qualitative (key informant interview to explain certain clinical practice and provide recommendations for GBS management in LMIC). Data were analyzed by frequencies, χ2 test and thematic analysis.

RESULTS

Among 159 physicians (65 neurologists and 94 internists), 11% and 8% physicians used Brighton and NINDS criteria respectively to diagnose GBS. Specific treatment protocols of GBS were used by 12% physicians. Overcrowding of patients, inadequate diagnostic facilities, high costs of standard therapy, and inadequate logistics and trained personnel for intensive care unit and rehabilitation services were considered major challenges for GBS management. In qualitative part, respondents recommended regular training for the physicians, development of cost-effective treatment strategies and appropriate patients' referral and management guideline considering existing limitations in health service delivery and socio-economic status of the country.

INTERPRETATION

Current study design and recommendations might be applied for other LMIC. Such data can assist policymakers to identify areas requiring urgent attention and take required action to improve GBS management in LMIC.

A health systems approach to critical care delivery in low-resource settings: a narrative review

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Attitude of nurses caring critically ill patients admitted in the ICUs of AIIMS Hospital, Jodhpur

BACKGROUND

Nurses are internationally recognized to be largest group of registered and regulated practitioner in the health workforce of any country. There is an increase in number of critically ill patients seeking optimal care, and this rapidly increases the demand for the critical care nurses at the end of life. Caring for a critically ill patient creates anxiety and emotional exhaustion and may sometimes lead to burnout. So, it is imperative for the nurses to have an optimistic approach while caring patients in the ICU. The aim of the study was to assess the attitude of the nurses caring critically ill patients and to determine the association of the level of attitude with the selected personal variable. The study was conducted at ICUs of tertiary care hospital by using descriptive research design.

METHODS AND MATERIAL

A cross-sectional descriptive study was conducted in ICUs of tertiary care hospital from October to December 2018. The sample was selected by total enumeration technique. Data was collected from 60 critical care nurses with the help of self-structured five-point Likert scale to assess the attitude of nurses. Descriptive statistics and inferential statistics were used for data analysis such as mean, frequency, percentage, standard deviation, and Chi-square test.

RESULTS

Majority (81.7%) of the nurses were having favorable attitude toward caring the critically ill patients, and there was no significant association of the attitude score with the selected personal variable at P < 0.05.

CONCLUSIONS

Majority of critical care nurses have favorable attitude. If they have supportive environment at workplace, their willingness to work toward quality care will improve further.

Doctors' experiences of referring and admitting patients to the intensive care unit: a qualitative study of doctors' practices at two tertiary hospitals in Malawi

OBJECTIVE

To explore doctors' experiences of referring and admitting patients to the intensive care unit (ICU) at two tertiary hospitals in Malawi.

DESIGN

This was a qualitative study that used face-to-face interviews. The interviews were audiotaped and transcribed verbatim into English. The data were analysed manually through conventional content analysis.

SETTING

Two public tertiary hospitals in the central and southern regions of Malawi. Interviews were conducted from January to June 2021.

PARTICIPANTS

Sixteen doctors who were involved in the referral and admission of patients to the ICU.

RESULTS

Four themes were identified namely, lack of clear admission criteria, ICU admission requires a complex chain of consultations, shortage of ICU resources, and lack of an ethical and legal framework for discontinuing treatment of critically ill patients who were too sick to benefit from ICU.

CONCLUSION

Despite the acute disease burden and increased demand for ICU care, the two hospitals lack clear processes for referring and admitting patients to the ICU. Given the limited bed space in ICUs, hospitals in low-income countries, including Malawi, need to improve or develop admission criteria, severity scoring systems, ongoing professional development activities, and legislation for discontinuing intensive care treatments and end-of-life care.

Implementation of a Surgical Critical Care Service Reduces Failure to Rescue in Emergency Gastrointestinal Surgery in Rural Kenya

OBJECTIVE

We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya.

SUMMARY BACKGROUND DATA

FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care.

METHODS

All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score.

RESULTS

A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%-47.8%) to 21.8% (95% CI: 13.2%-32.6%) ( P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1-14.9) to 15.2 (95% CI, 14.7-15.7) ( P =0.03).

CONCLUSIONS

The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.

ICU-Managed Patients' Epidemiology, Characteristics, and Outcomes: A Retrospective Single-Center Study

Background

Resources are limited, and it is exceedingly difficult to provide intensive care in developing nations. In Somalia, intensive care unit (ICU) care was introduced only a few years ago.

Purpose

In this study, we aimed to determine the epidemiology, characteristics, and outcome of ICU-managed patients in a tertiary hospital in Mogadishu.

Methods

We retrospectively evaluated the files of 1082 patients admitted to our ICU during the year 2021.

Results

The majority (39.7%) of the patients were adults (aged between 20 and 39 years), and 67.8% were male patients. The median ICU length of stay was three days (IQR = 5 days), and nonsurvivors had shorter stays, one day. The mortality rate was 45.1%. The demand for critical care services in low-income countries is high.

Conclusion

The country has a very low ICU bed capacity. Critical care remains a neglected area of health service delivery in this setting, with large numbers of patients with potentially treatable conditions not having access to such services.

Factors Associated with the Outcome of a Pediatric Patients Admitted to Intensive Care Unit in Resource-Limited Setup: Cross-Sectional Study

Background

Critical care is a multidisciplinary and interprofessional specialty devoted to treating patients who already have or are at danger of developing acute, life-threatening organ dysfunction. Due to the higher disease load and mortality from preventable illness, patient outcomes in intensive care units are challenging in settings with inadequate resources. This study aimed to determine factors associated with outcomes of pediatric patients admitted to intensive care units.

Methods

A cross-sectional study was conducted at Wolaita Sodo and Hawassa University teaching hospitals in southern Ethiopia. Data were entered and analyzed using SPSS version 25. Normality tests using the Shapiro-Wilk and Kolmogorov-Smirnov data were normally distributed. The frequency, percentage, and cross-tabulation of the different variables were then determined. Finally, the magnitude and associated factors were first analyzed using binary logistic regression and then multivariate logistic regression. Statistical significance was set at P < 0.05.

Results

A total of 396 Pediatric ICU patients were included in this study, and 165 (41.7%) deaths were recorded. The odds of patients from urban areas (AOR = 45%, CI 95%: 8%, 67% p-value = 0.025) were less likely to die than those in rural areas. Patients with co morbidities (AOR = 9.4, CI 95%: 4.5, 19.7, p = 0.000) were more likely to die than pediatric patients with no co-morbidities. Patients admitted with Acute respiratory distress syndrome (AOR = 12.86, CI 95%: 4.3, 39.2, p = 0.000) were more likely to die than those with not. Pediatric patients on mechanical ventilation (AOR = 3, CI 95%: 1.7, 5.9, p = 0.000) more likely to die than not mechanically ventilated.

Conclusion

Mortality of paediatric ICU patients was high (40.7%) in this study. Co-morbid disease, residency, the use of inotropes, and the length of ICU stay were all statistically significant predictors of death.

Effect of triage training on the knowledge application and practice improvement among the practicing nurses of the emergency departments of the National Referral Hospitals, 2018; a pre-post study in Asmara, Eritrea

BACKGROUND

Triage starts at the front door of the Emergency Department (ED), and repeatedly performed by the responsible duty nurses with the aim of facilitating a timely and appropriate treatment of patients. A triage system called the Orotta Triage System was implemented in the emergency settings of the selected hospitals in 2006, with the emergency nurses trained to triage using the system. Since the introduction, a majority of nurses have been replaced by new untrained nurses. This study was conducted to assess the impact of an educational intervention on the triage nurses knowledge and performance.

METHODS

A single group pre-posttest study design was performed in the adult EDs of the National Referral Eritrean Referral Hospitals, from January to July of 2018. All staff members in the ED were involved. Data collection tools utilized were, a self-administered knowledge assessing questionnaire and a practice observation checklist. Analysis was done in SPSS (version 22) using repeated measures ANOVA. Statistical significance level was set at P < 0.05.

RESULTS

The mean knowledge scores at Time 1(prior to the intervention), Time 2 (following the intervention) and Time 3 (three month follow up) were 6.23 (SD = 2.29), 10.55 (SD = 1.79), and 9.39(SD = 2.67) respectively. During the pre-intervention phase, only one (3%) nurse was determined to have adequate knowledge. Two days post training (immediate post-intervention), the percentage possessing adequate knowledge increased to 39% but dropped back to 19% three months later. Mean knowledge difference scores (95% CI) of immediate post and pre-intervention (Diff. = 4.32, 1 95%CI: 3.08-5.56), three months later and pre-intervention (Diff. = 3.16, 95%CI: 1.71-4.62) and immediate post and three months later (Diff. = 1.16, 95%CI: 0.12-2.20) were found to be statistically significant. The median score of appropriate triage practice at pre-intervention (Md = 6, IQR = 3) was not significantly different (p = 0.053) from that at post-intervention (Md = 8, IQR = 5).

CONCLUSION

The level of triage knowledge and appropriate application was low among the emergency nurses prior to training. The training provided an initial improvement in knowledge, but no significant improvement in triage nursing performance. To optimize ED triage performance, appropriate, timely in-service training is required to ensure new staff are educated and experienced staff have their knowledge and skills refreshed.

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.

Effect of Coronavirus Disease 2019 (Covid-19), a Nationwide Mass Casualty Disaster on Intensive Care Units: Clinical Outcomes and Associated Cost-of-Care

OBJECTIVE

The COVID-19 pandemic resulted in millions of deaths worldwide and is considered a significant mass-casualty disaster (MCD). The surge of patients and scarcity of resources negatively impacted hospitals, patients and medical practice. We hypothesized ICUs during this MCD had a higher acuity of illness, and subsequently had increased lengths of stay (LOS), complication rates, death rates and costs of care. The purpose of this study was to investigate those outcomes.

METHODS

This was a multicenter, retrospective study that compared intensive care admissions in 2020 to those in 2019 to evaluate patient outcomes and cost of care. Data were obtained from the Vizient Clinical Data Base/Resource Manager (Vizient Inc., Irvine, Texas, USA).

RESULTS

Data included the number of ICU admissions, patient outcomes, case mix index and summary of cost reports. Quality outcomes were also collected, and a total of 1304981 patients from 333 hospitals were included. For all medical centers, there was a significant increase in LOS index, ICU LOS, complication rate, case mix index, total cost, and direct cost index.

CONCLUSION

The MCD caused by COVID-19 was associated with increased adverse outcomes and cost-of-care for ICU patients.

Evaluation of a contactless neonatal physiological monitor in Nairobi, Kenya

BACKGROUND

Globally, 2.5 million neonates died in 2018, accounting for 46% of under-5 deaths. Multiparameter continuous physiological monitoring (MCPM) of neonates allows for early detection and treatment of life-threatening health problems. However, neonatal monitoring technology is largely unavailable in low-resource settings.

METHODS

In four evaluation rounds, we prospectively compared the accuracy of the EarlySense under-mattress device to the Masimo Rad-97 pulse CO-oximeter with capnography reference device for heart rate (HR) and respiratory rate (RR) measurements in neonates in Kenya. EarlySense algorithm optimisations were made between evaluation rounds. In each evaluation round, we compared 200 randomly selected epochs of data using Bland-Altman plots and generated Clarke error grids with zones of 20% to aid in clinical interpretation.

RESULTS

Between 9 July 2019 and 8 January 2020, we collected 280 hours of MCPM data from 76 enrolled neonates. At the final evaluation round, the EarlySense MCPM device demonstrated a bias of -0.8 beats/minute for HR and 1.6 breaths/minute for RR, and normalised spread between the 95% upper and lower limits of agreement of 6.2% for HR and 27.3% for RR. Agreement between the two MCPM devices met the a priori-defined threshold of 30%. The Clarke error grids showed that all observations for HR and 197/200 for RR were within a 20% difference.

CONCLUSION

Our research indicates that there is acceptable agreement between the EarlySense and Masimo MCPM devices in the context of large within-subject variability; however, further studies establishing cost-effectiveness and clinical effectiveness are needed before large-scale implementation of the EarlySense MCPM device in neonates.

TRIAL REGISTRATION NUMBER

NCT03920761.

Intensive Care in Sub-Saharan Africa: A National Review of the Service Status in Ethiopia

BACKGROUND

The burden of critical illness in low-income countries is high and expected to rise. This has implications for wider public health measures including maternal mortality, deaths from communicable diseases, and the global burden of disease related to injury. There is a paucity of data pertaining to the provision of critical care in low-income countries. This study provides a review of critical care services in Ethiopia.

METHODS

Multicenter structured onsite surveys incorporating face-to-face interviews, narrative discussions, and on-site assessment were conducted at intensive care units (ICUs) in September 2020 to ascertain structure, organization, workforce, resources, and service capacity. The 12 recommended variables and classification criteria of the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) taskforce criteria were utilized to provide an overview of service and service classification.

RESULTS

A total of 51 of 53 (96%) ICUs were included, representing 324 beds, for a population of 114 million; this corresponds to approximately 0.3 public ICU beds per 100,000 population. Services were concentrated in the capital Addis Ababa with 25% of bed capacity and 51% of critical care physicians. No ICU had piped oxygen. Only 33% (106) beds had all of the 3 basic recommended noninvasive monitoring devices (sphygmomanometer, pulse oximetry, and electrocardiography). There was limited capacity for ventilation (n = 189; 58%), invasive monitoring (n = 9; 3%), and renal dialysis (n = 4; 8%). Infection prevention and control strategies were lacking.

CONCLUSIONS

This study highlights major deficiencies in quantity, distribution, organization, and provision of intensive care in Ethiopia. Improvement efforts led by the Ministry of Health with input from the acute care workforce are an urgent priority.

VS, Mabovula N, MacAllister M, Macie AA, Maduri R, Mahfoud M, Mahmood A, Mahmoud F, Mahoney D, Makhlouf W, Malcolm G, Malomo A, Malomo T, Mani MK, Marçal TG, Marchello J, Marchesini N, Marhold F, Marklund N, Martín-Láez R, Mathaneswaran V, Mato-Mañas DJ, Maye H, McLean AL, McMahon C, Mediratta S, Mehboob M, Meneses A, Mentri N, Mersha H, Mesa AM, Meyer C, Millward C, Mimbir SA, Mingoli A, Mishra P, Mishra T, Misra B, Mittal S, Mohammed I, Moldovan I, Molefe M, Moles A, Moodley P, Morales MAN, Morgan L, Morillo GDC, Moustafa W, Moustakis N, Mrichi S, Munjal SS, Muntaka AJM, Naicker D, Nakashima PEH, Nandigama PK, Nash S, Negoi I, Negoita V, Neupane S, Nguyen MH, Niantiarno FH, Noble A, Nor MAM, Nowak B, Oancea A, O'Brien F, Okere O, Olaya S, Oliveira L, Oliveira LM, Omar F, Ononeme O, Opšenák R, Orlandini S, Osama A, Osei-Poku D, Osman H, Otero A, Ottenhausen M, Otzri S, Outani O, Owusu EA, Owusu-Agyemang K, Ozair A, Ozoner B, Paal E, Paiva MS, Paiva W, Pandey S, Pansini G, Pansini L, Pantel T, Pantelas N, Papadopoulos K, Papic V, Park K, Park N, Paschoal EHA, Paschoalino MCDO, Pathi R, Peethambaran A, Pereira TA, Perez IP, Pérez CJP, Periyasamy T, Peron S, Phillips M, Picazo SS, Pinar E, Pinggera D, Piper R, Pirakash P, Popadic B, Posti JP, Prabhakar RB, Pradeepan S, Prasad M, Prieto PC, Prince R, Prontera A, Provaznikova E, Quadros D, Quintero NJR, Qureshi M, Rabiel H, Rada G, Ragavan S, Rahman J, Ramadhan O, Ramaswamy P, Rashid S, Rathugamage J, Rätsep T, Rauhala M, Raza A, Reddycherla NR, Reen L, Refaat M, Regli L, Ren H, Ria A, Ribeiro TF, Ricci A, Richterová R, Ringel F, Robertson F, Rocha CMSC, Rogério JDS, Romano AA, Rothemeyer S, Rousseau GRG, Roza R, Rueda KDF, Ruiz R, Rundgren M, Rzeplinski R, S.Chandran R, Sadayandi RA, Sage W, Sagerer ANJ, Sakar M, Salami M, Sale D, Saleh Y, Sánchez-Viguera C, Sandila S, Sanli AM, Santi L, Santoro A, Santos AKDD, Santos SCD, Sanz B, Sapkota S, Sasidharan G, Sasillo I, Satoskar R, Sayar AC, Sayee V, Scheichel F, Schiavo FL, Schupper A, Schwarz A, Scott T, Seeberger E, Segundo CNC, Seidu AS, Selfa A, Selmi NH, Selvarajah C, Şengel N, Seule M, Severo L, Shah P, Shahzad M, Shangase T, Sharma M, Shiban E, Shimber E, Shokunbi T, Siddiqui K, Sieg E, Siegemund M, Sikder SR, Silva ACV, Silva A, Silva PA, Singh D, Skadden C, Skola J, Skouteli E, Słoniewski P, Smith B, Solanki G, Solla DF, Solla D, Sonmez O, Sönmez M, Soon WC, Stefini R, Stienen MN, Stoica B, Stovell M, Suarez MN, Sulaiman A, Suliman M, Sulistyanto A, Sulubulut Ş, Sungailaite S, Surbeck M, Szmuda T, Taddei G, Tadele A, Taher ASA, Takala R, Talari KM, Tan BH, Tariciotti L, Tarmohamed M, Taroua O, Tatti E, Tenovuo O, Tetri S, Thakkar P, Thango N, Thatikonda SK, Thesleff T, Thomé C, Thornton O, Timmons S, Timoteo EE, Tingate C, Tliba S, Tolias C, Toman E, Torres I, Torres L, Touissi Y, Touray M, Tropeano MP, Tsermoulas G, Tsitsipanis C, Turkoglu ME, Uçkun ÖM, Ullman J, Ungureanu G, Urasa S, Ur-Rehman O, Uysal M, Vakis A, Valeinis E, Valluru V, Vannoy D, Vargas P, Varotsis P, Varshney R, Vats A, Veljanoski D, Venturini S, Verma A, Villa C, Villa G, Villar S, Villard E, Viruez A, Voglis S, Vulekovic P, Wadanamby S, Wagner K, Walshe R, Walter J, Waseem M, Whitworth T, Wijeyekoon R, Williams A, Wilson M, Win S, Winarso AWW, Ximenes AWP, Yadav A, Yadav D, Yakoub KM, Yalcinkaya A, Yan G, Yaqoob E, Yepes C, Yılmaz AN, Yishak B, Yousuf FB, Zahari MZ, Zakaria H, Zambonin D, Zavatto L, Zebian B, Zeitlberger AM, Zhang F, Zheng F, Ziga M. Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

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.

A low-cost field ventilator: An urgent global need

Modern ventilators are increasingly compact and able to deliver a wide range of ventilator modes and sophisticated monitoring capabilities. However, the global availability of ventilators is woefully short of demand. Data on intensive care units (ICUs), a proxy measure for hospital ventilator capacity in low and middle-income countries (LMIC's), suggest that capacity is extremely limited where it exists at all. In LMIC's, the four most common indications for mechanical ventilation (MV) in ICUs are post-surgical care, sepsis, trauma, and maternal peripartum or neonatal complications. A significant majority of these cases can be managed with intervention involving a short course of MV. Widespread and timely access to MV can thus effectively be used to help patients in these settings and improve outcomes. This paper implores this need and highlights the requirements for a low-cost ventilator or a respiratory support device.

IT-Enabled Sustainable Innovation and the Global Digital Divides

This article investigates the impact of information and communication technologies (ICTs), human capital, institutional settings, socio-economic, and environmental parameters on sustainable innovation (SI) using archival data for 127 economies from 2008 to 2017. We developed an econometrics research framework for investigating factors influencing SI on a global scale. We found that ICT variables, such as ICT access and ICT broadband network, positively influence sustainable innovation in conjunction with the socio-economic and political parameters. Despite differences among economies in terms of ICTs, socio-economic development, and educational attainment, ICTs are the significant drivers of sustainable innovation and economic growth. We observed a growing digital divide among nations within the context of the knowledge-based economy and the expansion of digital commerce, particularly in the least developed countries and Africa, a phenomenon impeding sustainable innovation growth. To the best of our knowledge, this is the first study that empirically investigates the global digital divide from sustainable innovation perspectives. The results of this study suggest that to tackle the digital divide issues, policymakers and educational institutes need to perform constructive educational reform in higher education curricula, particularly concerning STEM programs, which should reflect the necessary skills and competencies for deploying emergent technologies. In addition, ICT should be considered part of a country’s critical infrastructure, particularly investment in the broadband networks regarded as the backbone of today’s innovation.

Current situation of pediatric intensive care specialty and pediatric intensive care units in Turkey: Results of a national survey

Objective

In this study, we have planned to present the results of a national survey performed to evaluate the last situation of pediatric intensive care specialty and pediatric intensive care units in Turkey.

Material and Methods

We have sent an electronic survey which includes 47 questions about the characteristics of pediatric intensive care units, staff, and equipment to members of the Turkish Society of Pediatric Emergency and Intensive Care via email.

Results

A total of 58 participant units responded to our survey. 93.2% of the centers have tertiary level pediatric intensive care units. There were 841 tertiary level pediatric intensive care beds. There were 35 pediatric intensive care faculty members, 44 pediatric intensive care specialists, and 53 pediatric intensive care fellows. In the participant units, the total number of invasive mechanical ventilators in the units was 806, the number of specific non-invasive mechanical ventilators was 126. It was learned that 79.3% of the centers could apply continuous renal replacement therapy, 84.4% of therapeutic plasma exchange, 46.5% of extracorporeal membrane oxygenation.

Conclusion

We see that the way we have traveled in the 20 years since the establishment of the first units is very important and proud. The number of educated new generation pediatric intensive care specialists and the well-equipped pediatric intensive care units established by these specialists in every region of our country together with the fellowship education applied in many centers make a great contribution to the treatment of the critically ill pediatric patient population in our country.

Preterm birth and severe morbidity in hospitalized neonates who are HIV exposed and uninfected compared with HIV unexposed

OBJECTIVES

Infants who are HIV exposed but uninfected (HEU) compared with HIV unexposed uninfected (HUU) have an increased risk of adverse birth outcomes, morbidity and hospitalization. In the era of universal maternal antiretroviral treatment, there are few insights into patterns of neonatal morbidity specifically.

DESIGN

A prospective cohort study.

METHODS

We compared neonatal hospitalizations among infants who were HEU (n = 463) vs. HUU (n = 466) born between 2017 and 2019 to a cohort of pregnant women from a large antenatal clinic in South Africa. We examined maternal and infant factors associated with hospitalization using logistic regression.

RESULTS

Hospitalization rates were similar between neonates who were HEU and HUU (13 vs. 16%; P = 0.25). Overall, most hospitalizations occurred directly after birth (87%); infection-related causes were identified in 34%. The most common reason for hospitalization unrelated to infection was respiratory distress (25%). Very preterm birth (<32 weeks) (29 vs. 11%; P = 0.01) as well as very low birthweight (<1500 g) (34 vs. 16%; P = 0.02) occurred more frequently among hospitalized neonates who were HEU. Of those hospitalized, risk of intensive care unit (ICU) admission was higher in neonates who were HEU (53%) than HUU (27%) [risk ratio = 2.1; 95% confidence interval (95% CI) 1.3-3.3]. Adjusted for very preterm birth, the risk of ICU admission remained higher among neonates who were HEU (aRR = 1.8; 95% CI 1.1-2.9).

CONCLUSION

Neonates who were HEU (vs. HUU) did not have increased all-cause or infection-related hospitalization. However, very preterm birth, very low birthweight and ICU admission were more likely in hospitalized neonates who were HEU, indicating increased severity of neonatal morbidity.

Prevalence and outcome of sepsis and septic shock in intensive care units in Addis Ababa, Ethiopia: A prospective observational study

Background

Sepsis and septic shock are the major causes of morbidity and mortality in Intensive care Units (ICUs) in low and middle-income countries. However, little is known about their prevalence and outcome in these settings. The study aimed to assess the prevalence and outcome of sepsis and septic shock in ICUs in Addis Ababa, Ethiopia.

Methods

A prospective observational study was conducted from March 2017 to February 2018 in four selected ICUs in Addis Ababa from a total of twelve hospitals having ICU services. There were 1145 total ICU admissions during the study period. All admissions into those ICUs with sepsis, severe sepsis, and septic shock using the Systemic Inflammatory Response Syndrome (SIRS) criteria (SEPSIS-2) during the study period were screened for sepsis or septic shock based on the new sepsis definition (SEPSIS-3). All patients with sepsis and septic shock during ICU admission were included and followed for 28 days of ICU admission. Data analysis was done using the Statistical Package for Social Sciences (SPSS) software version 20.0.

Results

A total of 275 patients were diagnosed with sepsis and septic shock. The overall prevalence of sepsis and septic shock was 26.5 per 100 ICU admissions. The most frequent source of sepsis was respiratory infection (53.1%). The median length of stay in the ICUs was 5 (IQR, 2–8) days. The most common bacterium isolate was Pseudomonas aeroginosa (34.5%). The ICU and 28-day mortality rate was 41.8% and 50.9% respectively. Male sex, modified Sequential Organ Failure Assessment score ≥10 on day 1 of ICU admission, and comorbidity of HIV or malignancy were the independent predictors of 28-day mortality.

Conclusion

Sepsis and septic shock are common among our ICU admissions, and are associated with a high mortality rate.

Worldwide Organization of Neurocritical Care: Results from the PRINCE Study Part 1

INTRODUCTION

Neurocritical care focuses on the care of critically ill patients with an acute neurologic disorder and has grown significantly in the past few years. However, there is a lack of data that describe the scope of practice of neurointensivists and epidemiological data on the types of patients and treatments used in neurocritical care units worldwide. To address these issues, we designed a multicenter, international, point-prevalence, cross-sectional, prospective, observational, non-interventional study in the setting of neurocritical care (PRINCE Study).

METHODS

In this manuscript, we analyzed data from the initial phase of the study that included registration, hospital, and intensive care unit (ICU) organizations. We present here descriptive statistics to summarize data from the registration case report form. We performed the Kruskal-Wallis test followed by the Dunn procedure to test for differences in practices among world regions.

RESULTS

We analyzed information submitted by 257 participating sites from 47 countries. The majority of those sites, 119 (46.3%), were in North America, 44 (17.2%) in Europe, 34 (13.3%) in Asia, 9 (3.5%) in the Middle East, 34 (13.3%) in Latin America, and 14 (5.5%) in Oceania. Most ICUs are from academic institutions (73.4%) located in large urban centers (44% > 1 million inhabitants). We found significant differences in hospital and ICU organization, resource allocation, and use of patient management protocols. The highest nursing/patient ratio was in Oceania (100% 1:1). Dedicated Advanced Practiced Providers are mostly present in North America (73.7%) and are uncommon in Oceania (7.7%) and the Middle East (0%). The presence of dedicated respiratory therapist is common in North America (85%), Middle East (85%), and Latin America (84%) but less common in Europe (26%) and Oceania (7.7%). The presence of dedicated pharmacist is highest in North America (89%) and Oceania (85%) and least common in Latin America (38%). The majority of respondents reported having a dedicated neuro-ICU (67% overall; highest in North America: 82%; and lowest in Oceania: 14%).

CONCLUSION

The PRINCE Study results suggest that there is significant variability in the delivery of neurocritical care. The study also shows it is feasible to undertake international collaborations to gather global data about the practice of neurocritical care.

Evolution of a Bidirectional Pediatric Critical Care Educational Partnership in a Resource-Limited Setting

Introduction: Children in resource-limited settings are disproportionately affected by common childhood illnesses, resulting in high rates of mortality. A major barrier to improving child health in such regions is limited pediatric-specific training, particularly in the care of children with critical illness. While global health rotations for trainees from North America and Europe have become commonplace, residency and fellowship programs struggle to ensure that these rotations are mutually beneficial and do not place an undue burden on host countries. We created a bidirectional, multimodal educational program between trainees in Manila, Philippines, and Baltimore, Maryland, United States, to improve the longitudinal educational experience for all participants. Program Components: Based on stakeholder input and a needs assessment, we established a global health training program in which pediatricians from the Philippines traveled to the United States for observerships, and pediatric residents from a tertiary care center in Baltimore traveled to Manila. Additionally, we created and implemented a contextualized simulation-based shock curriculum for pediatric trainees in Manila that can be disseminated locally. This bidirectional program was adapted to include telemedicine and regularly scheduled "virtual rounds" and educational case conferences during the COVID-19 pandemic. Providers from the two institutions have collaborated on educational and clinical research projects, offering opportunities for resource sharing, bidirectional professional development, and institutional improvements. Conclusion: Although creating a mutually beneficial global health partnership requires careful planning and investment over time, establishment of a successful bidirectional educational and professional development program in a limited-resource setting is feasible and benefits learners in both countries.

Eye clinic attendance at the olympic and paralympic games Rio 2016 and its correlation to the WHO indicators on eye health

OBJECTIVES

To evaluate athletes' frequency of attendance at the eye clinic during the Olympic and Paralympic Games Rio 2016 and to correlate it to WHO core indicators on progress in ophthalmology care in a country.

METHODS

Frequencies of athletes' attendance at the eye clinic were calculated for each country. Countries were classified according to the World Bank income levels in high, upper-middle, low-middle or low-income country. Data on ophthalmology care for each country were derived from the International Agency for the Prevention of Blindness atlas. Data were analysed in view of WHO indicators for each country: visual impairment prevalence considering presenting visual acuity <6/18 to ≥3/60 in the better vision eye; number of ophthalmologists per million people and the cataract surgical rate per year, per million population.

RESULTS

The athletes' overall frequency of attendance in the eye clinic was 6.47%. Frequencies of attendance for high, upper-middle, low-middle or low-income country were 1.97%, 9.66%, 16.54% and 22.43%, respectively. A positive correlation was observed between the athletes' attendance frequency of a country and its visual impairment prevalence (r=0.2290, p=0.0017). A negative correlation was observed between the athletes' attendance frequency of a country and its eye health workforce (r=-0.2152, p=0.0026).

CONCLUSION

Countries with highest athletes' frequencies of attendance were those that face barriers to eye care provision. These results reinforce the importance of the eye clinic service during the Olympic and Paralympic Games proving access to specialised care to athletes and members of delegation.

Emergency and critical care services in Malawi: Findings from a nationwide survey of health facilities

Background

Globally, critical illness causes up to 45 million deaths every year. The burden is highest in low-income countries such as Malawi. Critically ill patients require good quality, essential care in emergency departments and in hospital wards to avoid negative outcomes such as death. Little is known about the quality of care or the availability of necessary resources for emergency and critical care in Malawi. The aim of this study was to assess the availability of resources for emergency and critical care in Malawi using data from the Service Provision Assessment (SPA).

Methods

We conducted a secondary data analysis of the SPA — a nationwide survey of all health facilities. We assessed the availability of resources for emergency and critical care using previously developed standards for hospitals in low-income countries. Each health facility received an availability score, calculated as the proportion of resources that were present. Resource availability was sub-divided into the seven a-priori defined categories of drugs, equipment, support services, emergency guidelines, infrastructure, training and routines.

Results

Of the 254 indicators in the standards necessary for assessing the quality of emergency and critical care, SPA collected data for 102 (40.6%). Hospitals had a median resource availability score of 51.6% IQR (42.2–67.2) and smaller health facilities had a median of 37.5% (IQR 28.1–45.3). For the category of drugs, the hospitals' median score was 62.0% IQR (52.4–81.0), for equipment 51.9% IQR (40.7–66.7), support services 33.3% IQR (22.2–77.8) and emergency guidelines 33.3% IQR (0–66.7). SPA did not collect any data for resources in the categories of infrastructure, training or routines.

Conclusion

Hospitals in Malawi lack resources for providing emergency and critical care. Increasing data about the availability of resources for emergency and critical care and improving the hospital systems for the care of critically ill patients in Malawi should be prioritized.

Post-traumatic stress disorder in critical illness survivors and its relation to memories of ICU

BACKGROUND

Stressors in intensive care units (ICUs) are sometimes so severe that they result in Post-traumatic Stress Disorder (PTSD) in ICU survivors. The memories that survivors have from the ICU may play a role in developing PTSD.

AIM

This study aimed to determine the prevalence of PTSD-related symptoms in ICU survivors in Southeast Iran and its relationship with their memories of the ICU.

METHODS

In this descriptive correlational study, 100 people discharged from ICUs in southeastern Iran completed the Impact of Event Scale-Revised (IES-R) and ICU memory tool (ICU-MT).

RESULTS

Findings indicated that, from 100 participants who, on average, were assessed 3.19 ± 5.37 months after discharge, 13% were suffering from PTSD. The total mean IES-R score and the scores of "Intrusion," "Avoidance," and "Hyperarousal" subscales in patients with delusional memories were higher compared with the patients who did not have such memories. In the patients who were mechanically ventilated at the time of their stay in the ICU, the total mean IES-R score was 6.86 times higher (P = .03).

CONCLUSION

This research provided further evidence of the relationship between delusional memories and PTSD in patients who had been discharged from the ICU.

RELEVANCE TO CLINICAL PRACTICE

In the care of patients admitted to the ICU, preventive strategies should be used to minimize delusional memories and PTSD. It is necessary to detect post-ICU psychiatric morbidities and provide early psychological intervention in post-discharge follow-up programmes to improve psychological outcomes after critical illness.

COVID-19: Implications, Reactions and Future Directions

Humanity has faced several foes over the centuries, a formidable one amongst them is the current pandemic of COVID-19. The symptoms of COVID-19 are more or less related to the nose and throat. Therefore, patients more often present to Ear Nose Throat (ENT) clinics with symptoms including cough, sore throat, fever and shortness of breath. In the management of head and neck pathologies, as the airway is a direct source of infection, the impact of COVID-19 holds special significance. This review has attempted to explain the various aspects of the disease itself, its diagnosis, the use of personal protective equipment (PPE) to provide an overview of the evolving recommendations in head and neck patients, the future outlook and the limitations faced in developing countries specifically for ENT patients.

Eye care and ocular findings at the Olympic and Paralympic Games Rio 2016

OBJECTIVES

To describe the attendance and ocular profile of competitors and members of delegations who attended the Polyclinic Ophthalmology Division during the Olympic and Paralympic Games Rio 2016.

METHODS

The eye clinic was allocated in the purpose-built polyclinic opened for competitors and members of delegations from 24 July to 18 September 2016. All individuals who attended the service received a comprehensive ocular examination including biomicroscopy, subjective refraction and fundus evaluation. A main clinical finding was assigned for each eye by the ophthalmologist.

RESULTS

5.6% of Olympic Games competitors and 8.9% of Paralympic Games competitors attended the Polyclinic Ophthalmology Division during the Rio Olympic and Paralympic Games. These rates compare with 2.6% and 6.5% at the London Olympic and Paralympic Games (2012). The main clinical finding was refractive error with 79.0% of the individuals receiving a glass prescription during the Olympic Games and 81.3% during the Paralympic Games.

CONCLUSION

Our outcomes highlight the importance of the eye service at the polyclinic as it may represent the only opportunity for many individuals involved with the Olympic and Paralympic Games to receive ocular evaluation. Our description of clinic structure, delivery of service and clinical results will be useful in the organisation not only for the Olympic and Paralympic Games Tokyo 2020 but also for any other large sporting events that involves medical attention in a polyclinic format.

Scales Used to Measure Job Stressors in Intensive Care Units: Are They Relevant and Reliable? A Systematic Review

Background: Many studies have been conducted in intensive care units (ICUs) to identify the stress factors involved in the health of professionals and the quality and safety of care. The objectives are to identify the psychometric scales used in these studies to measure stressors and to assess their relevance and validity/reliability. Methods: All peer-reviewed full-text articles published in English between 1997 and 2016 and focusing on an empirical quantitative study of job stressors were identified through searches on seven databases and editorial portals. Results: From the 102 studies analyzed, we identified 59 different scales: 17 "all settings scales" (16 validated scales), 20 "healthcare settings scales" (13 validated scales), and 22 "ICU settings scales" (two validated scales). All these scales used measured stressors from at least one of the following eight broad categories: High job demands, Problematic relationships with other professionals, Lack of control over work situations and career, Lack of organizational resources, Problematic situations with users and relatives, Dealing with ethical- and moral-related situations, Risk management issues, and Disadvantages in comparison to other occupational situations. The "all settings scales" and "healthcare settings scales," the most often validated, did not measure, or only slightly measured, the stressors most specific to ICUs. Where these were taken into account, the authors were forced to develop their own tools or modify existing scales without testing the validity of the tool used. Conclusions: This review highlights the lack of a tool that meets both the criteria of validity and relevance with regard to the specificity of work in ICUs. Future research must focus on developing reliable/valid tools covering all types of relevant stressors to ensure the quality of the studies carried out in this field.

Vital Signs Directed Therapy for the Critically Ill: Improved Adherence to the Treatment Protocol Two Years after Implementation in an Intensive Care Unit in Tanzania

Treating deranged vital signs is a mainstay of critical care throughout the world. In an ICU in a university hospital in Tanzania, the implementation of the Vital Signs Directed Therapy Protocol in 2014 led to an increase in acute treatments for deranged vital signs. The mortality rate for hypotensive patients decreased from 92% to 69%. In this study, the aim was to investigate the sustainability of the implementation two years later. An observational, patient-record-based study was conducted in the ICU in August 2016. Data on deranged vital signs and acute treatments were extracted from the patients' charts. Adherence to the protocol, defined as an acute treatment in the same or subsequent hour following a deranged vital sign, was calculated and compared with before and immediately after implementation. Two-hundred and eighty-nine deranged vital signs were included. Adherence was 29.8% two years after implementation, compared with 16.6% (p < 0.001) immediately after implementation and 2.9% (p < 0.001) before implementation. Consequently, the implementation of the Vital Signs Directed Therapy Protocol appears to have led to a sustainable increase in the treatment of deranged vital signs. The protocol may have potential to improve patient safety in other settings where critically ill patients are managed.

Intensive Care Outcomes and Mortality Prediction at a National Referral Hospital in Western Kenya

RATIONALE

The burden of critical care is greatest in resource-limited settings. Intensive care unit (ICU) outcomes at public hospitals in Kenya are unknown. The present study is timely, given the Kenyan Ministry of Health initiative to expand ICU capacity.

OBJECTIVES

To identify factors associated with mortality at Moi Teaching and Referral Hospital and validate the Mortality Probability Admission Model II (MPM₀-II).

METHODS

A retrospective cohort of 450 patients from January 1, 2013, to April 5, 2015, was evaluated using demographics, presenting diagnoses, interventions, mortality, and cost data.

RESULTS

ICU mortality was 53.6%, and 30-day mortality was 57.3%. Most patients were male (61%) and at least 18 years old (70%); the median age was 29 years. Factors associated with high adjusted odds of mortality were as follows: age younger than 10 years (adjusted odds ratio [aOR], 3.59; P ≤ 0.001), ages 35-49 years (aOR, 3.13; P = 0.002), and age above 50 years (aOR, 2.86; P = 0.004), with reference age range 10-24 years; sepsis (aOR, 3.39; P = 0.01); acute stroke (aOR, 8.14; P = 0.011); acute respiratory failure or mechanical ventilation (aOR, 6.37; P < 0.001); and vasopressor support (aOR, 7.98; P < 0.001). Drug/alcohol poisoning (aOR, 0.33; P = 0.005) was associated with lower adjusted odds of mortality. MPM₀-II discrimination showed an area under the receiver operating characteristic curve of 0.78 (95% confidence interval, 0.72-0.82). The result of the Hosmer-Lemeshow test for calibration was significant (P < 0.001).

CONCLUSIONS

In a Kenyan public ICU, high mortality was noted despite the use of advanced therapies. MPM₀-II has acceptable discrimination but poor calibration. Modification of MPM₀-II or development of a new model using a prospective multicenter global collaboration is needed. Standardized triage and treatment protocols for high-risk diagnoses are needed to improve ICU outcomes.

Referral and admission to intensive care: A qualitative study of doctors' practices in a Tanzanian university hospital

BACKGROUND

Intensive care is care for critically ill patients with potentially reversible conditions. Patient selection for intensive care should be based on potential benefit but since demand exceeds availability, rationing is needed. In Tanzania, the availability of Intensive Care Units (ICUs) is very limited and the practices for selecting patients for intensive care are not known. The aim of this study was to explore doctors' experiences and perceptions of ICU referral and admission processes in a university hospital in Tanzania.

METHODS

We performed a qualitative study using semi-structured interviews with fifteen doctors involved in the recent care of critically ill patients in university hospital in Tanzania. Inductive conventional content analysis was applied for the analysis of interview notes to derive categories and sub-categories.

RESULTS

Two main categories were identified, (i) difficulties with the identification of critically ill patients in the wards and (ii) a lack of structured triaging to the ICU. A lack of critical care knowledge and communication barriers were described as preventing identification of critically ill patients. Triaging to the ICU was affected by a lack of guidelines for admission, diverging ideas about ICU indications and contraindications, the lack of bed capacity in the ICU and non-medical factors such as a fear of repercussions.

CONCLUSION

Critically ill patients may not be identified in general wards in a Tanzanian university hospital and the triaging process for the admission of patients to intensive care is convoluted and not explicit. The findings indicate a potential for improved patient selection that could optimize the use of scarce ICU resources, leading to better patient outcomes.

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.

Energy poverty in healthcare facilities: a "silent barrier" to improved healthcare in sub-Saharan Africa

This paper addresses an important topic, energy poverty in healthcare facilities. We try to provide an interesting perspective on bringing together two SDGs. The SDG 7, which seeks to ensure access to affordable, sustainable, and modern energy for all, is interlinked with Goal 3 on Health. The literature studies as well as data on the subject are sparse. Nevertheless, a systematic documentation of the levels and variation in access to energy at the health-facility level is important for designing effective policies to improve the quality of healthcare and the ultimate health of the population. Using the 2012-2013 Senegal Service Provision Assessment (SCSPA), we assessed energy access in health facilities and health systems' performance. Data were also geocoded using ArcGIS 10.3 to give a snapshot of the situation.

Characteristics of Critically-Ill Patients at Two Tertiary Care Hospitals in Sudan

Objectives

Knowledge of intensive care unit (ICU) admission patterns and characteristics is necessary for the development of critical care services, particularly in low-resource settings. This study aimed to describe the characteristics of critically-ill patients admitted to ICUs in Sudan.

Methods

This prospective observational study was conducted between February and May 2017 in the ICUs of two government tertiary care hospitals in Khartoum, Sudan. A total of 100 consecutive adult patients admitted to the ICUs were included in the study. The patients' demographic and clinical characteristics and Acute Physiologic Assessment and Chronic Health Evaluation (APACHE II) scores upon admission were recorded, as well as the reason for admission, presence of any underlying comorbidities, interventional requirements like mechanical ventilation or haemodialysis, length of stay in the ICU and patient outcome.

Results

Of the sample, 58% were female and 42% were male. The mean age was 47.4 ± 18.3 years old. Upon admission, the mean APACHE II score was 14.2 ± 9.6. In total, 54% of the patients had no known underlying comorbidities. The most common reasons for ICU admission were neurological diseases (27%), sepsis or infectious diseases (19%) and postoperative management (12%). Mechanical ventilation and haemodialysis were required by 35% and 11% of the patients, respectively. The average length of stay was 10.0 ± 7.2 days and the mortality rate was 24%.

Conclusion

Most of the patients admitted to the ICUs were middle-aged females with no known underlying comorbidities. Larger studies are necessary to provide a comprehensive understanding of the critical care needs of Sudanese hospitals.

Development of a National Core Dataset for the Iranian ICU Patients Outcome Prediction; a Comprehensive Approach

OBJECTIVE

To define a core dataset for ICU Patients Outcome Prediction in Iran. This core data set will lead us to design ICU outcome prediction models with the most effective parameters.

METHODS

A combination of literature review, national survey and expert consensus meetings were used. First, a literature review was performed by a general search in PubMed to find the most appropriate models for intensive care mortality prediction and their parameters. Secondly, in a national survey, experts from a couple of medical centers in all parts of Iran were asked to comment on a list of items retrieved from the earlier literature review study. In the next step, a multi-disciplinary committee of experts was installed.  In 4 meetings each data item was examined separately and included/excluded by committee consensus.

RESULTS

The combination of the literature review findings and experts' consensus resulted in a draft dataset including 26 data items. 92% percent of data items in the draft dataset were retrieved from the literature study and the others were suggested by the experts. The final dataset of 24 data items covers patient history and physical examination, chemistry, vital signs, oxygenations and some more specific parameters. Conclusions: This dataset was designed to develop a nationwide prognostic model for predicting ICU mortality and length of stay. This dataset opens the door for creating standardized approaches in data collection in the Iranian intensive care unit estimation of resource utility.

PRactice of VENTilation in Middle-Income Countries (PRoVENT-iMIC): rationale and protocol for a prospective international multicentre observational study in intensive care units in Asia

INTRODUCTION

Current evidence on epidemiology and outcomes of invasively mechanically ventilated intensive care unit (ICU) patients is predominantly gathered in resource-rich settings. Patient casemix and patterns of critical illnesses, and probably also ventilation practices are likely to be different in resource-limited settings. We aim to investigate the epidemiological characteristics, ventilation practices and clinical outcomes of patients receiving mechanical ventilation in ICUs in Asia.

METHODS AND ANALYSIS

PRoVENT-iMIC (study of PRactice of VENTilation in Middle-Income Countries) is an international multicentre observational study to be undertaken in approximately 60 ICUs in 11 Asian countries. Consecutive patients aged 18 years or older who are receiving invasive ventilation in participating ICUs during a predefined 28-day period are to be enrolled, with a daily follow-up of 7 days. The primary outcome is ventilatory management (including tidal volume expressed as mL/kg predicted body weight and positive end-expiratory pressure expressed as cm H₂O) during the first 3 days of mechanical ventilation-compared between patients at no risk for acute respiratory distress syndrome (ARDS), patients at risk for ARDS and in patients with ARDS (in case the diagnosis of ARDS can be made on admission). Secondary outcomes include occurrence of pulmonary complications and all-cause ICU mortality.

ETHICS AND DISSEMINATION

PRoVENT-iMIC will be the first international study that prospectively assesses ventilation practices, outcomes and epidemiology of invasively ventilated patients in ICUs in Asia. The results of this large study, to be disseminated through conference presentations and publications in international peer-reviewed journals, are of ultimate importance when designing trials of invasive ventilation in resource-limited ICUs. Access to source data will be made available through national or international anonymised datasets on request and after agreement of the PRoVENT-iMIC steering committee.

TRIAL REGISTRATION NUMBER

NCT03188770; Pre-results.

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.

Non-invasive ventilation in children and adults in low- and low-middle income countries: A systematic review and meta-analysis

PURPOSE

We systematically reviewed the effects of NIV for acute respiratory failure (ARF) in low- and low-middle income countries.

MATERIALS AND METHODS

We searched MEDLINE, CENTRAL, and EMBASE (to January 2016) for observational studies and trials of NIV for ARF or in the peri-extubation period in adults and post-neonatal children. We abstracted outcomes data and assessed quality. Meta-analyses used random-effect models.

RESULTS

Fifty-four studies (ten pediatric/n=1099; 44 adult/n=2904), mostly South Asian, were included. Common diagnoses were pneumonia and chronic obstructive pulmonary disease (COPD). Considering observational studies and the NIV arm of trials, NIV was associated with moderate risks of mortality (pooled risk 9.5%, 95% confidence interval (CI) 4.6-14.5% in children; 16.2% [11.2-21.2%] in adults); NIV failure (10.5% [4.6-16.5%] in children; 28.5% [22.4-34.6%] in adults); and intubation (5.3% [0.8-9.7%] in children; 28.8% [21.9-35.8%] in adults). The risk of mortality was greater (p=0.035) in adults with hypoxemic (25.7% [15.2-36.1%]) vs. hypercapneic (12.8% [7.0-18.6%]) ARF. NIV reduced mortality in COPD (relative risk [RR] 0.47 [0.27-0.79]) and in patients weaning from ventilation (RR 0.48 [0.28-0.80]). The pooled pneumothorax risk was 2.4% (0.8-3.9%) in children and 5.2% (1.0-9.4%) in adults. Meta-analyses had high heterogeneity.

CONCLUSIONS

NIV for ARF in these settings appears to be effective.

Critical care of tropical disease in low income countries: Report from the Task Force on Tropical Diseases by the World Federation of Societies of Intensive and Critical Care Medicine

Tropical disease results in a great burden of critical illness. The same life-saving and supportive therapies to maintain vital organ functions that comprise critical care are required by these patients as for all other diseases. In low income countries, the little available data points towards high mortality rates and big challenges in the provision of critical care. Improving critical care in low income countries requires a focus on hospital design, training, triage, monitoring & treatment modifications, the basic principles of critical care, hygiene and the involvement of multi-disciplinary teams. As a large proportion of critical illness from tropical disease is in low income countries, the impact and reductions in mortality rates of improved critical care in such settings could be substantial.

Retrospective Descriptive Study of an Intensive Care Unit at a Ugandan Regional Referral Hospital

BACKGROUND

We describe delivery and outcomes of critical care at Mbarara Regional Referral Hospital, a Ugandan secondary referral hospital serving a large, widely dispersed rural population.

METHODS

Retrospective observational study of ICU admissions was performed from January 2008 to December 2011.

RESULTS

Of 431 admissions, 239 (55.4 %) were female, and 142 (33.2 %) were children (<18 years). The median length of stay was 2 (IQR 1-4) days, with 365 patients (85 %) staying less than 8 days. Indications for admission were surgical 49.3 % (n = 213), medical/pediatric 27.4 % (n = 118), or obstetrical/gynecological 22.3 % (n = 96). The overall mortality rate was 37.6 % (162/431) [adults 39.3 % (n = 113/287), children 33.5 % (n = 48/143), unspecified age 100 % (n = 1/1)]. Of the 162 deaths, 76 (46.9 %) occurred on the first, 20 (12.3 %) on the second, 23 (14.2 %) on the third, and 43 (26.5 %) on a subsequent day of admission. Mortality rates for common diagnoses were surgical abdomen 31.9 % (n = 29/91), trauma 45.5 % (n = 30/66), head trauma 59.6 % (n = 28/47), and poisoning 28.6 % (n = 10/35). The rate of mechanical ventilation was 49.7 % (n = 214/431). The mortality rate of ventilated patients was 73.5 % (n = 119/224). The multivariate odd ratio estimates of mortality were significant for ventilation [aOR 6.15 (95 % CI 3.83-9.87), p < 0.0001] and for length of stay beyond seven days [aOR 0.37 (95 % CI 0.19-0.70), p = 0.0021], but not significant for decade of age [aOR 1.06 (95 % CI 0.94-1.20), p = 0.33], gender [aOR 0.61(95 % CI 0.38-0.99), p = 0.07], or diagnosis type [medical vs. surgical aOR 1.08 (95 % CI 0. 63-1.84), medical vs. obstetric/gynecology aOR 0.73 (95 % CI 0.37-1.43), p = 0.49].

CONCLUSIONS

The ICU predominantly functions as an acute care unit for critically ill young patients, with most deaths occurring within the first 48 h of admission. Expansion of critical care capacity in low-income countries should be accompanied by measurement of the nature and impact of this intervention.

Clinical and Economic Outcomes of Telemedicine Programs in the Intensive Care Unit: A Systematic Review and Meta-Analysis

Objective:

To evaluate the impact of telemedicine programs in intensive care unit (Tele-ICU) on ICU or hospital mortality or ICU or hospital length of stay and to summarize available data on implementation cost of Tele-ICU.

Methods:

Controlled trails or observational studies assessing outcomes of interest were identified by searching 7 electronic databases from inception to July 2016 and related journals and conference literatures between 2000 and 2016. Two reviewers independently screened searched records, extracted data, and assessed the quality of included studies. Random-effect models were applied to meta-analyses and sensitivity analysis.

Results:

Nineteen of 1035 records fulfilled the inclusion criteria. The pooled effects demonstrated that Tele-ICU programs were associated with reductions in ICU mortality (15 studies; risk ratio [RR], 0.83; 95% confidence interval [CI], 0.72 to 0.96; P = .01), hospital mortality (13 studies; RR, 0.74; 95% CIs, 0.58 to 0.96; P = .02), and ICU length of stay (9 studies; mean difference [MD], −0.63; 95% CI, −0.28 to 0.17; P = .007). However, there is no significant association between the reduction in hospital length of stay and Tele-ICU programs. Summary data concerning costs suggested approximately US$50 000 to US$100 000 per Tele-ICU bed was required to implement Tele-ICU programs for the first year. Hospital costs of US$2600 reduction to US$5600 increase per patient were estimated using Tele-ICU programs.

Conclusions:

This systematic review and meta-analysis provided limited evidence that Tele-ICU approaches may reduce the ICU and hospital mortality, shorten the ICU length of stay, but have no significant effect in hospital length of stay. Implementation of Tele-ICU programs substantially costs and its long-term cost-effectiveness is still unclear.