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Mwale D, Manda-Taylor L, Langton J, Likumbo A, van Hensbroek MB, Calis J, Janssens W, Pell C. The role of healthcare providers and caregivers in monitoring critically ill children: a qualitative study in a tertiary hospital, southern Malawi. BMC Health Serv Res 2024; 24:595. [PMID: 38714998 PMCID: PMC11077805 DOI: 10.1186/s12913-024-11050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. METHODS A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. RESULTS The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. CONCLUSION Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.
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Affiliation(s)
- Daniel Mwale
- Kamuzu University of Health Sciences, Blantyre, Malawi.
- Training Research Unit of Excellence, Blantyre, Malawi.
| | - Lucinda Manda-Taylor
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Training Research Unit of Excellence, Blantyre, Malawi
| | | | - Alice Likumbo
- Training Research Unit of Excellence, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
| | - Job Calis
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciencies, Blantyre, Malawi
| | - Wendy Janssens
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Economics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Giriteka T, Bulakali DP, Wendler CB. Essential human and material resources for emergency care in the district hospitals of Burundi. Afr J Emerg Med 2023; 13:300-305. [PMID: 37859728 PMCID: PMC10582767 DOI: 10.1016/j.afjem.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 10/21/2023] Open
Abstract
Introduction Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery. Methods In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p<0.05 considered significant. Results Forty of 45 district hospitals completed the survey, of which 35 were rural (matching national demographics). The majority of district hospitals (21/40) had ready access to ≥4/5 critical drugs while few (5/40) were equipped with ≥4/5 key material. One quarter had 24/7 physician coverage and X-ray available. Only 3 had continuous access to ultrasound studies despite most district hospitals having ultrasound machines. Trained emergency room staff were almost totally absent from the field, with only 6 nurses, 4 generalists, and 1 specialist reported across 9 sites. Even a single EM-trained staff member was significantly correlated with being better equipped for emergencies (p<0.01). Conclusion Burundi needs a strategic investment in emergency preparedness and care. Policy initiatives and technology purchases have demonstrated reasonable penetration down to the district hospital level, however, trained personnel are essential to develop sustainable emergency capacity.
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Affiliation(s)
| | | | - Carlan Bruce Wendler
- Kibuye Hope Hospital, Kibuye, Bukirasazi, Gitega, Burundi
- Hope Africa University, Ngagara II, Bujumbura, Burundi
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Mboya EA, Ndumwa HP, Amani DE, Nkondora PN, Mlele V, Biyengo H, Mashoka R, Haniffa R, Beane A, Mfinanga J, Sunguya BF, Sawe HR, Baker T. Critical illness at the emergency department of a Tanzanian national hospital in a three-year period 2019-2021. BMC Emerg Med 2023; 23:86. [PMID: 37553630 PMCID: PMC10408204 DOI: 10.1186/s12873-023-00858-y] [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: 01/05/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Critically ill patients have life-threatening conditions requiring immediate vital organ function intervention. But, critical illness in the emergency department (ED) has not been comprehensively described in resource-limited settings. Understanding the characteristics and dynamics of critical illness can help hospitals prepare for and ensure the continuum of care for critically ill patients. This study aimed to describe the pattern and outcomes of critically ill patients at the ED of the National Hospital in Tanzania from 2019 to 2021. METHODOLOGY This hospital-records-based retrospective cohort study analyzed records of all patients who attended the ED of Muhimbili National Hospital between January 2019 and December 2021. Data extracted from the ED electronic database included clinical and demographic information, diagnoses, and outcome status at the ED. Critical illness in this study was defined as either a severe derangement of one or more vital signs measured at triage or the provision of critical care intervention. Data were analyzed using Stata 17 to examine critical illnesses' burden, characteristics, first-listed diagnosis, and outcomes at the ED. RESULTS Among the 158,445 patients who visited the ED in the study period, 16,893 (10.7%) were critically ill. The burden of critical illness was 6,346 (10.3%) in 2019, 5,148 (10.9%) in 2020, and 5,400 (11.0%) in 2021. Respiratory (18.8%), cardiovascular (12.6%), infectious diseases (10.2%), and trauma (10.2%) were the leading causes of critical illness. Most (81.6%) of the critically ill patients presenting at the ED were admitted or transferred, of which 11% were admitted to the ICUs and 89% to general wards. Of the critically ill, 4.8% died at the ED. CONCLUSION More than one in ten patients attending the Tanzanian National Hospital emergency department was critically ill. The number of critically ill patients did not increase during the pandemic. The majority were admitted to general hospital wards, and about one in twenty died at the ED. This study highlights the burden of critical illness faced by hospitals and the need to ensure the availability and quality of emergency and critical care throughout hospitals.
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Affiliation(s)
- Erick A. Mboya
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Harrieth P. Ndumwa
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Davis E. Amani
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Paulina N. Nkondora
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Victoria Mlele
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Happines Biyengo
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ramadhan Mashoka
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Rashan Haniffa
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- University College London Hospitals, London, UK
| | - Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Juma Mfinanga
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Bruno F. Sunguya
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hendry R. Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Tim Baker
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Ranjit S, Kissoon N, Argent A, Inwald D, Ventura AMC, Jaborinsky R, Sankar J, de Souza DC, Natraj R, De Oliveira CF, Samransamruajkit R, Jayashree M, Schlapbach LJ. Haemodynamic support for paediatric septic shock: a global perspective. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:588-598. [PMID: 37354910 DOI: 10.1016/s2352-4642(23)00103-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/26/2023]
Abstract
Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.
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Affiliation(s)
- Suchitra Ranjit
- Paediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, India.
| | | | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - David Inwald
- Addenbrooke's Hospital, University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andréa Maria Cordeiro Ventura
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil
| | - Roberto Jaborinsky
- Northeastern National University, Corrientes, Argentina; Latin American Society of Pediatric Intensive Care (LARed Network), Montevideo, Uruguay; SLACIP Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, Monterrey, Mexico
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, AIIMS, New Delhi, India
| | - Daniela Carla de Souza
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil; Latin American Sepsis Institute, São Paulo, Brazil
| | - Rajeswari Natraj
- Department of Paediatric Intensive Care, Apollo Children's Hospitals, Chennai, India
| | | | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Muralidharan Jayashree
- Pediatric Emergency and Intensive Care, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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Kayambankadzanja RK, Schell CO, Gerdin Wärnberg M, Tamras T, Mollazadegan H, Holmberg M, Alvesson HM, Baker T. Towards definitions of critical illness and critical care using concept analysis. BMJ Open 2022; 12:e060972. [PMID: 36606666 PMCID: PMC9445819 DOI: 10.1136/bmjopen-2022-060972] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE As 'critical illness' and 'critical care' lack consensus definitions, this study aimed to explore how the concepts' are used, describe their defining attributes, and propose potential definitions. DESIGN AND METHODS We used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O'Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts' defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents. RESULTS Nine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, 'a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility', and of critical care as, 'the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.' CONCLUSION The concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.
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Affiliation(s)
- Raphael Kazidule Kayambankadzanja
- Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Carl Otto Schell
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Internal Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Martin Gerdin Wärnberg
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Tamras
- Internal Medicine, Södertälje Hospital, Stockholm, Sweden
| | | | - Mats Holmberg
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Centre of Interprofessional Collaboration within Emergency care, Linnaeus University, Växjö, Sweden
- Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden
| | | | - Tim Baker
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Halverson CC, Bailey C, Ennis JA, Cox EE. Nursing surveillance of respiratory adverse events among hospitalized adults: A systematic review to guide evidence-based practice. Worldviews Evid Based Nurs 2022; 19:260-266. [PMID: 35638706 DOI: 10.1111/wvn.12581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/03/2021] [Accepted: 02/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nursing surveillance (NS) involves the purposeful, ongoing acquisition, interpretation, and synthesis of patient data for clinical decision-making. Surveillance is used to identify patients with early signs of distress and prevent adverse events. The processes that support and measure the outcomes of nursing surveillance are not clearly specified. AIM The aim of this systematic review was to describe the impact of NS on respiratory adverse events for adult hospitalized patients. METHODS The PRISMA model guided this systematic search of Academic Search Complete (EBSCOhost), CINAHL Complete (EBSCOhost), Nursing & Allied Health (ProQuest), and PubMed databases for articles published between 1990 and 2019. Search terms included nursing surveillance, data points typically attributed to nursing surveillance, adult hospitalized patients, and adverse respiratory events. The protocol for this review was registered as PROSPERO: CRD42020147557. RESULTS Of the 2907 references screened, 67 full-text articles were reviewed and 10 were eligible for inclusion. Research on nursing surveillance in the presence of respiratory deterioration is limited. Six studies used assessment tools that were generated from early warning scores, and four used research or institutionally designed trigger criteria. Surveillance, like other types of nursing care, was difficult to isolate and measure. Although components of surveillance were described in the selected studies, the nurse's role was not explicitly identified. Further research is required to highlight the role nursing surveillance plays in clinical decision-making to keep patients safe. LINKING EVIDENCE TO ACTION The attributes of NS provide a useful intervention guide for the hospitalized patient at risk of deterioration. Early warning score techniques provide empirical evidence for identifying patients at risk of deterioration. The findings of this study provide evidence of the significance for research focused on the attributes of NS relative to responding to patients at risk of deterioration.
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Affiliation(s)
- Colleen C Halverson
- The Houston J and Florence A Doswell, Dallas, Texas, USA.,College of Nursing, Texas Woman's University, Dallas, Texas, USA
| | - Catherine Bailey
- The Houston J and Florence A Doswell, Dallas, Texas, USA.,College of Nursing, Texas Woman's University, Dallas, Texas, USA
| | - Joyce Arlene Ennis
- The Houston J and Florence A Doswell, Dallas, Texas, USA.,College of Nursing, Texas Woman's University, Dallas, Texas, USA
| | - E Elaine Cox
- Mary Evelyn Blagg-Huey Library, Texas Woman's University, Denton, Texas, USA
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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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Camargo MM, Furieri LB, Lima EDFA, Lucena ADF, Fioresi M, Romero WG. Cross mapping between clinical indicators for assistance in intensive care and nursing interventions. Rev Bras Enferm 2020; 73:e20190728. [PMID: 32901752 DOI: 10.1590/0034-7167-2019-0728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/13/2020] [Indexed: 08/30/2023] Open
Abstract
OBJECTIVE Identify the main clinical indicators for assistance in the Intensive Care Unit (ICU) and map them in the nursing interventions described by the Nursing Interventions Classification (NIC). METHODS Integrative literature review study, followed by cross-mapping between clinical indicators for assistance in the ICU care and NIC nursing interventions and activities. RESULTS 36 articles were identified, which resulted in 285 clinical indicators for ICU care, with mechanical ventilatory assistance, pain, sedation, psychomotor agitation, delirium, anxiety, altered heart rate, diet by naso tube / oroenteral and diarrhea the clinical indicators for assistance in the ICU the most prevalent. These were mapped in 12 Nursing Interventions Classification interventions and 130 nursing activities. FINAL CONSIDERATIONS It is concluded that the clinical indicators for ICU care associated with Nursing Interventions Classification are concrete data that assist intensive care nurses in their clinical practice.
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Affiliation(s)
| | | | | | | | - Mirian Fioresi
- Universidade Federal do Espírito Santo. Vitória, Espírito Santo, Brazil
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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. Emerg Med Int 2020; 2020:4819805. [PMID: 32377435 PMCID: PMC7199585 DOI: 10.1155/2020/4819805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/30/2019] [Indexed: 12/23/2022] Open
Abstract
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.
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Almeida MC, Portela MC, Paiva EP, Guimarães RR, Pereira Neto WC, Cardoso PR, Mattos DAD, Mendes IMADCC, Tavares MV, Jácome GPO, Fernandes GC. Implementation of a rapid response team in a large nonprofit Brazilian hospital: improving the quality of emergency care through Plan-Do-Study-Act. Rev Bras Ter Intensiva 2019; 31:217-226. [PMID: 31215601 PMCID: PMC6649208 DOI: 10.5935/0103-507x.20190036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 09/20/2018] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To describe the implementation of a rapid response team in a large nonprofit hospital, indicating relevant issues for other initiatives in similar contexts, particularly in Latin America. METHODS In general terms, the intervention consisted of three major components: (1) a tool to detect aggravation of clinical conditions in general wards; (2) the structuring of a rapid response team to attend to all patients at risk; and (3) the monitoring of indicators regarding the intervention. This work employed four half-year Plan-Do-Study-Act cycles to test and adjust the intervention from January 2013 to December 2014. RESULTS Between 2013 and 2014, the rapid response team attended to 2,296 patients. This study showed a nonsignificant reduction in mortality from 8.3% in cycle 1 to 5.0% in cycle 4; however, death rates remained stable in cycles 3 and 4, with frequencies of 5.2% and 5.0%, respectively. Regarding patient flow and continuum of critical care, which is a premise of the rapid response system, there was a reduction in waiting time for intensive care unit beds with a decrease from 45.9% to 19.0% in the frequency of inpatients who could not be admitted immediately after indication (p < 0.001), representing improved patient flow in the hospital. In addition, an increase in the recognition of palliative care patients from 2.8% to 10.3% was noted (p = 0.005). CONCLUSION Implementing a rapid response team in contexts where there are structural restrictions, such as lack of intensive care unit beds, may be very beneficial, but a strategy of adjustment is needed.
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Affiliation(s)
- Meire Cavalieri Almeida
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil
| | - Margareth Crisóstomo Portela
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil
| | - Elenir Pereira Paiva
- Faculdade de Enfermagem, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brasil
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Abstract
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.
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Cecconi M, Hernandez G, Dunser M, Antonelli M, Baker T, Bakker J, Duranteau J, Einav S, Groeneveld ABJ, Harris T, Jog S, Machado FR, Mer M, Monge García MI, Myatra SN, Perner A, Teboul JL, Vincent JL, De Backer D. Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force. Intensive Care Med 2018; 45:21-32. [DOI: 10.1007/s00134-018-5415-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 10/11/2018] [Indexed: 12/21/2022]
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Schell CO, Gerdin Wärnberg M, Hvarfner A, Höög A, Baker U, Castegren M, Baker T. The global need for essential emergency and critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:284. [PMID: 30373648 PMCID: PMC6206626 DOI: 10.1186/s13054-018-2219-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/04/2018] [Indexed: 01/09/2023]
Abstract
Critical illness results in millions of deaths each year. Care for those with critical illness is often neglected due to a lack of prioritisation, co-ordination, and coverage of timely identification and basic life-saving treatments. To improve care, we propose a new focus on essential emergency and critical care (EECC)—care that all critically ill patients should receive in all hospitals in the world. Essential emergency and critical care should be part of universal health coverage, is appropriate for all countries in the world, and is intended for patients irrespective of age, gender, underlying diagnosis, medical specialty, or location in the hospital. Essential emergency and critical care is pragmatic and low-cost and has the potential to improve care and substantially reduce preventable mortality.
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Affiliation(s)
- Carl Otto Schell
- Global Health-Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Martin Gerdin Wärnberg
- Global Health-Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Anna Hvarfner
- Faculty of Medicine, Uppsala University, Uppsala, Sweden
| | - Andreas Höög
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Ulrika Baker
- Global Health-Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,College of Medicine, Blantyre, Malawi
| | - Markus Castegren
- Perioperative medicine and intensive care (PMI), Karolinska University Hospital, Stockholm, Sweden
| | - Tim Baker
- Global Health-Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. .,College of Medicine, Blantyre, Malawi. .,Perioperative medicine and intensive care (PMI), Karolinska University Hospital, Stockholm, Sweden.
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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. J Crit Care 2017; 42:351-354. [PMID: 29174463 DOI: 10.1016/j.jcrc.2017.11.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 12/29/2022]
Abstract
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.
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Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, Baker T. Erratum to: Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes 2017; 10:365. [PMID: 28768537 PMCID: PMC5540540 DOI: 10.1186/s13104-017-2554-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 11/23/2022] Open
Affiliation(s)
- Carl Otto Schell
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden. .,Department of Internal Medicine, Medicinkliniken, Nyköping Hospital, Sörmland County Council, 61185, Nyköping, Sweden.
| | - Markus Castegren
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Edwin Lugazia
- Department of Anaesthesia and Intensive Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jonas Blixt
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Moses Mulungu
- Department of Anaesthesia and Intensive Care, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - David Konrad
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Tim Baker
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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DU C. A Comparative Study of the Efficacy and Psychological States between Patients with Senile Ischemic Heart Failure Undergone ICU and Conventional Therapies. IRANIAN JOURNAL OF PUBLIC HEALTH 2016; 45:748-53. [PMID: 27648417 PMCID: PMC5026829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Our aim was to forward an effective therapeutic approach by comparing efficacy and psychological states between patients with senile ischemic heart failure undergone ICU and conventional therapies. METHODS We selected 64 patients from Hospital of Traditional Chinese Medicine of Rizhao (Shandong, China) between June 2013 and June 2014. The patients had ischemic heart disease, and were monitored for one-year time span. They were randomly divided into the experiment and control group, each of which of 32 cases. The experimental group received an ICU therapy, whereas the control group was treated with conventional therapy. The result of patients' cardiac function, SDSSAS index and clinical efficacies were monitored and compared. RESULTS Both groups, especially the experiment group showed significant improvement in the left ventricular end-diastolic diameter, left ventricular ejection fraction and cardiac NYHA rating (P<0.05). The experiment group needed less hospital stay and hence significantly more cost effective in comparison to control group (P<0.05). The therapy in terms of stent implantation, coronary artery bypass surgery and pure medication was not of statistical significant (P>0.05). In comparison to control group, the experiment group showed significantly lower mortality rate in short and long term (P<0.05). The SDSSAS rating of the 2 groups, especially the control group was significantly increased (P< 0.05). CONCLUSION We observed improvement in clinical efficacy and depressed anxiety among patients with serious senile ischemic heart failure, after specialized ICU therapy.
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Ulisubisya M, Jörnvall H, Irestedt L, Baker T. Establishing an Anaesthesia and Intensive Care partnership and aiming for national impact in Tanzania. Global Health 2016; 12:7. [PMID: 26993790 PMCID: PMC4799533 DOI: 10.1186/s12992-016-0144-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 03/09/2016] [Indexed: 01/09/2023] Open
Abstract
Anaesthesia and Intensive Care is a neglected specialty in low-income countries. There is an acute shortage of health workers – several low-income countries have less than 1 anaesthesia provider per 100,000 population. Only 1.5 % of hospitals in Africa have the intensive care resources needed for managing patients with sepsis. Health partnerships between institutions in high and low-income countries have been proposed as an effective way to strengthen health systems. The aim of this article is to describe the origin and conduct of a health partnership in Anaesthesia and Intensive Care between institutions in Tanzania and Sweden and how the partnership has expanded to have an impact at regional and national levels. The Muhimbili-Karolinska Anaesthesia and Intensive Care Collaboration was initiated in 2008 on the request of the Executive Director of Muhimbili National Hospital in Dar es Salaam. The partnership has conducted training courses, exchanges, research projects and introduced new equipment, routines and guidelines. The partnership has expanded to include all hospitals in Dar es Salaam. Through the newly formed Life Support Foundation, the partnership has had a national impact assisting the reanimation of the Society of Anaesthesiologists of Tanzania and has seen a marked increase of the number of young doctors choosing a residency in Anaesthesia and Intensive Care.
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Affiliation(s)
- Mpoki Ulisubisya
- Society of Anaesthesiologists of Tanzania, PO Box 65588, Dar es Salaam, Tanzania. .,Mbeya Zonal Referral Hospital, Mbeya, Tanzania.
| | - Henrik Jörnvall
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden
| | - Lars Irestedt
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden
| | - Tim Baker
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden.,Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
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Baker T, Schell CO, Lugazia E, Blixt J, Mulungu M, Castegren M, Eriksen J, Konrad D. Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country. PLoS One 2015; 10:e0144801. [PMID: 26693728 PMCID: PMC4687915 DOI: 10.1371/journal.pone.0144801] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 11/24/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Global Critical Care is attracting increasing attention. At several million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LICs) have a disproportionally greater share of critical illness, and yet critical care facilities are scarce in such settings. Routines utilizing abnormal vital signs to identify critical illness and trigger medical interventions have become common in high-income countries but have not been investigated in LICs. The aim of the study was to assess whether the introduction of a vital signs directed therapy protocol improved acute care and reduced mortality in an Intensive Care Unit (ICU) in Tanzania. METHODS AND FINDINGS Prospective, before-and-after interventional study in the ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger levels of severely abnormal vital signs and stipulated acute treatment responses was implemented in a four week period using sensitisation, training, job aids, supervision and feedback. Acute treatment of danger signs at admission and during care in the ICU and in-hospital mortality were compared pre and post-implementation using regression models. Danger signs from 447 patients were included: 269 pre-implementation and 178 post-implementation. Acute treatment of danger signs was higher post-implementation (at admission: 72.9% vs 23.1%, p<0.001; in ICU: 16.6% vs 2.9%, p<0.001). A danger sign was five times more likely to be treated post-implementation (Prevalence Ratio (PR) 4.9 (2.9-8.3)). Intravenous fluids were given in response to 35.0% of hypotensive episodes post-implementation, as compared to 4.1% pre-implementation (PR 6.4 (2.5-16.2)). In patients admitted with hypotension, mortality was lower post-implementation (69.2% vs 92.3% p = 0.02) giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality rates were unchanged (49.4% vs 49.8%, p = 0.94). CONCLUSION The introduction of a vital signs directed therapy protocol improved the acute treatment of abnormal vital signs in an ICU in a low-income country. Mortality rates were reduced for patients with hypotension at admission but not for all patients.
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Affiliation(s)
- Tim Baker
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden
- Global Health, Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Carl Otto Schell
- Global Health, Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
- Department of Internal Medicine, Nyköping Hospital, Sörmland County Council, Nyköping, Sweden
| | - Edwin Lugazia
- Department of Anaesthesia and Intensive Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jonas Blixt
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Moses Mulungu
- Department of Anaesthesia and Intensive Care, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Markus Castegren
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Jaran Eriksen
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - David Konrad
- Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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