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Muttalib F, Memon ZA, Muhammad S, Soomro A, Khan S, Bano S, Jawwad M, Soofi S, Hansen B, Adhikari NKJ, Bhutta Z. The spectrum of acute illness and mortality of children and adolescents presenting to emergency services in Sanghar district hospital, Pakistan: a prospective cohort study. BMJ Open 2024; 14:e082255. [PMID: 39179281 PMCID: PMC11344522 DOI: 10.1136/bmjopen-2023-082255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 07/19/2024] [Indexed: 08/26/2024] Open
Abstract
OBJECTIVE To describe presenting diagnoses and rates and causes of death by age category and sex among children with acute illness brought to a district headquarter hospital in Pakistan. DESIGN Prospective cohort study. SETTING Sanghar district headquarter hospital, Sindh, Pakistan between December 2019 and April 2020 and August 2020 and December 2020. PARTICIPANTS 3850 children 0-14 years presenting with acute illness to the emergency and outpatient departments and 1286 children admitted to the inpatient department. OUTCOME MEASURES The primary outcome was Global Burden of Disease diagnosis category. Secondary outcomes were 28-day mortality rate, cause of death and healthcare delays, defined as delay in care-seeking, delay in reaching the healthcare facility and delay in appropriate treatment. RESULTS Communicable diseases were the most common presenting diagnoses among outpatients and among inpatients aged 1 month to 9 years. Non-communicable diseases and nutritional disorders were more common with increasing age. Few children presented with injuries. Newborn period (age <28 days) was associated with increased odds of death (OR 4.34 [95% CI 2.38 to 8.18], p<0.001, reference age 28 days-14 years) and there was no significant difference in odds of death between female vs male children (OR 1.12, 95% CI 0.6 to 2.04, p=0.72). 47 children died in the hospital (3.6%) and three (0.2%) died within 28 days of admission. Most children who died were <28 days old (n=32/50, 64%); leading diagnoses included neonatal sepsis/meningitis (n=13/50, 26%), neonatal encephalopathy (n=7/50, 14%) and lower respiratory tract infections (n=6/50, 12%). Delays in care-seeking (n=15) and in receiving appropriate treatment (n=12) were common. CONCLUSION This study adds to sparse literature surrounding the epidemiology of disease and hospital outcomes for children with acute illness seeking healthcare in rural Pakistan and, in particular, among children aged 5-14 years. Further studies should include public and private hospitals within a single region to comprehensively describe patterns of care-seeking and interfacility transfer in district health systems.
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Affiliation(s)
- Fiona Muttalib
- Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Zahid Ali Memon
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Shah Muhammad
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Asif Soomro
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Samia Khan
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Shazia Bano
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Muhammad Jawwad
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Sajid Soofi
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
- Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Neill KJ Adhikari
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Managament, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zulfiqar Bhutta
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
- Centre for Global Child Health, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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Abiodun MT, Ochaba EA, Kpongo-Ogieva A. Bedside critical care training: A quasi-experimental study in the paediatric emergency department of a referral hospital in Nigeria. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2024; 40:e1141. [PMID: 38989479 PMCID: PMC11232563 DOI: 10.7196/sajcc.2024.v40i1.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 07/12/2024] Open
Abstract
Background There is a need for critical care services outside intensive care units (ICUs), especially in emergency departments (EDs). However, there is a paucity of skilled manpower for ED critical care or emergency critical care (ECC) in resource-limited settings. Objectives To evaluate the impact of bedside training on emergency critical care practices of clinical staff. Methods This was a quasi-experimental study using a pretest - post-test design in a paediatric ED. The intervention was a six-week structured bedside training on bubble continuous positive airway pressure (CPAP) high-flow nasal cannula (HFNC) and mechanical ventilation. Participants' actual ECC practices pre and post training were evaluated, including their perceived proficiency on an uncalibrated 100 mm visual analogue scale (VAS). Descriptive and inferential analyses were done; p<0.05 was considered significant. Results A total of 35 clinical staff participated in the training, comprising 9 (24.3%) paediatric registrars, 12 (32.5%) senior registrars, 10 (27.0%) nurses, 4 (10.8%) house officers and 2 (5.4%) paediatric consultants. The male:female ratio of the participants was 1:1.6, and their mean (SD) age was 33.24 (6.30 years. Participants' understanding of testing the CPAP circuit, connecting the patient and weaning significantly improved following training (p=0.004). Their capacity to select appropriate HFNC parameters improved (p=0.013). They performed more endotracheal intubations in the post-training period (p=0.001). Their pretest-post-test proficiency in mechanical ventilation increased on VAS (mean scores 45.26+31.99 v. 63.26+22.26; p=0.038). Also, there was a significant increase in their perceived proficiency in paediatric analgesia/sedation (30.83+29.86 v. 49.83+23.90; p=0.029). Conclusion Short-term bedside critical care training enhanced the self-reported competency of paediatric ED staff. There is a need for on-the-job ECC training and retraining of clinical staff in our setting. Contribution of the study Paediatric emergency department clinical staff desire hands-on critical care training in developing settings. Bedside training improves the knowledge and skills of nursing staff in non-invasive ventilation. Bedside training also builds the capacity of medical staff in invasive ventilation in the emergency department. Overall, short-term bedside training enhances the clinical knowledge and self-reported critical care practice of clinical staff in Children's Emergency Room.
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Affiliation(s)
- M T Abiodun
- Paediatric Emergency Division, Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
- Department of Child Health, School of Medicine, College of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria
| | - E A Ochaba
- Paediatric Emergency Division, Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
| | - A Kpongo-Ogieva
- Paediatric Emergency Division, Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
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Shawon RA, Denno D, Tickell KD, Atuhairwe M, Bandsma R, Mupere E, Voskuijl W, Mbale E, Ahmed T, Chisti MJ, Saleem AF, Ngari M, Diallo AH, Berkley J, Walson J, Means AR. Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study. BMJ Open 2024; 14:e078404. [PMID: 38458789 DOI: 10.1136/bmjopen-2023-078404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVES This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings. DESIGN AND SETTING We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries. PARTICIPANTS A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study. PRIMARY OUTCOME MEASURES We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations. RESULTS Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted. CONCLUSIONS Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.
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Affiliation(s)
- Riffat Ara Shawon
- Epidemiology, University of Washington, Seattle, Washington, USA
- Global Health, University of Washington, Seattle, Washington, USA
| | - Donna Denno
- Global Health, University of Washington, Seattle, Washington, USA
- Pediatrics, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Kirkby D Tickell
- Epidemiology, University of Washington, Seattle, Washington, USA
- Global Health, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Michael Atuhairwe
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Uganda-Case Western Reserve University Research Collaboration, Makerere University, Kampala, Uganda
| | - Robert Bandsma
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Centre for Global Child Health, Toronto, Ontario, Canada
| | - Ezekiel Mupere
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Uganda-Case Western Reserve University Research Collaboration, Makerere University, Kampala, Uganda
- Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Wieger Voskuijl
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Kamuzu University for Health Sciences, Blantyre, Malawi
| | - Emmie Mbale
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Pediatrics, University of Malawi, Blantyre, Malawi
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - James Berkley
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Judd Walson
- Epidemiology, University of Washington, Seattle, Washington, USA
- Global Health, University of Washington, Seattle, Washington, USA
- Pediatrics, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Chandna A, Keang S, Vorlark M, Sambou B, Chhingsrean C, Sina H, Vichet P, Patel K, Habsreng E, Riedel A, Mwandigha L, Koshiaris C, Perera-Salazar R, Turner P, Chanpheaktra N, Turner C. A Prognostic Model for Critically Ill Children in Locations With Emerging Critical Care Capacity. Pediatr Crit Care Med 2024; 25:189-200. [PMID: 37947482 PMCID: PMC10904005 DOI: 10.1097/pcc.0000000000003394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVES To develop a clinical prediction model to risk stratify children admitted to PICUs in locations with limited resources, and compare performance of the model to nine existing pediatric severity scores. DESIGN Retrospective, single-center, cohort study. SETTING PICU of a pediatric hospital in Siem Reap, northern Cambodia. PATIENTS Children between 28 days and 16 years old admitted nonelectively to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and laboratory data recorded at the time of PICU admission were collected. The primary outcome was death during PICU admission. One thousand five hundred fifty consecutive nonelective PICU admissions were included, of which 97 died (6.3%). Most existing severity scores achieved comparable discrimination (area under the receiver operating characteristic curves [AUCs], 0.71-0.76) but only three scores demonstrated moderate diagnostic utility for triaging admissions into high- and low-risk groups (positive likelihood ratios [PLRs], 2.65-2.97 and negative likelihood ratios [NLRs], 0.40-0.46). The newly derived model outperformed all existing severity scores (AUC, 0.84; 95% CI, 0.80-0.88; p < 0.001). Using one particular threshold, the model classified 13.0% of admissions as high risk, among which probability of mortality was almost ten-fold greater than admissions triaged as low-risk (PLR, 5.75; 95% CI, 4.57-7.23 and NLR, 0.47; 95% CI, 0.37-0.59). Decision curve analyses indicated that the model would be superior to all existing severity scores and could provide utility across the range of clinically plausible decision thresholds. CONCLUSIONS Existing pediatric severity scores have limited potential as risk stratification tools in resource-constrained PICUs. If validated, our prediction model would be a readily implementable mechanism to support triage of critically ill children at admission to PICU and could provide value across a variety of contexts where resource prioritization is important.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | - Suy Keang
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Meas Vorlark
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Bran Sambou
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Chhay Chhingsrean
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Heav Sina
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Pav Vichet
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Kaajal Patel
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Department of Global Child Health, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Eang Habsreng
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Arthur Riedel
- Department of Global Child Health, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rafael Perera-Salazar
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Angkor Hospital for Children, Siem Reap, Cambodia
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Abbas Q, Shahbaz FF, Hussain MZH, Khan MA, Shahbaz H, Atiq H, Siddiqui NUR, Gowa MA, Jamil MT, Ali F, Khan AU, Ahmed AR, Haque AU, Hamid MH, Latif A, Bhutta A. Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan. Pediatr Crit Care Med 2023; 24:e611-e620. [PMID: 37191453 DOI: 10.1097/pcc.0000000000003285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES To evaluate nationwide pediatric critical care facilities and resources in Pakistan. DESIGN Cross-sectional observational study. SETTING Accredited pediatric training facilities in Pakistan. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring. CONCLUSIONS There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.
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Affiliation(s)
- Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Fatima Farrukh Shahbaz
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Mustafa Ali Khan
- Dean's Office, Medical College, Aga Khan University Hospital, Karachi, Pakistan
| | - Hamna Shahbaz
- Dean's Office, Medical College, Aga Khan University Hospital, Karachi, Pakistan
| | - Huba Atiq
- Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Murtaza Ali Gowa
- Pediatric Intensive Care Unit, National Institute of Child Health, Karachi, Pakistan
| | | | - Farman Ali
- Department of Pediatrics, Peshawar Institute of Cardiology, Peshawar, Pakistan
| | - Ata Ullah Khan
- Department of Pediatrics, Shifa International Hospital, Islamabad, Pakistan
| | | | - Anwar Ul Haque
- Department of Pediatrics, Sind Institute of Child Health, Karachi, Pakistan
| | | | - Asad Latif
- Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan
| | - Adnan Bhutta
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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Umphrey L, Wathen J, Chambliss A, Kalata K, Morgan L, Moua M, Collesides A, Berman S. Pediatrics in Disasters: Evolution of a Hybrid Global Health Training Program During the COVID-19 Pandemic. Adv Pediatr 2023; 70:1-15. [PMID: 37422288 DOI: 10.1016/j.yapd.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
This report describes the Pediatrics in Disasters (PEDS) course during a novel hybrid in-person and virtual format due to the coronavirus disease 2019 pandemic. International and local faculty collaborated on 2021 precourse revisions and course facilitation for multinational in-person and virtual students. Student and facilitator 2021 surveys and 2019 to 2021 student feedback reported overall satisfaction with the course while suggesting needed improvements to maximize international and virtual student participation. The hybrid PEDS course structure successfully achieved course goals and incorporated international faculty. Lessons learned will guide future course revisions and fellow global health educators.
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Affiliation(s)
- Lisa Umphrey
- Department of Pediatrics, University of Colorado, c/o Center for Global Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA; c/o Center for Global Health, Colorado School of Public Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA.
| | - Joseph Wathen
- Department of Pediatrics, University of Colorado, c/o Center for Global Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA; c/o Center for Global Health, Colorado School of Public Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA
| | - Amy Chambliss
- Department of Pediatrics, University of Colorado, c/o Center for Global Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA
| | - Kathryn Kalata
- Department of Pediatrics, University of Colorado, c/o Center for Global Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA
| | - Lucas Morgan
- Department of Pediatrics, University of Colorado, c/o Center for Global Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA
| | - Mary Moua
- c/o Center for Global Health, Colorado School of Public Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA
| | - Alexa Collesides
- c/o Center for Global Health, Colorado School of Public Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA
| | - Stephen Berman
- Department of Pediatrics, University of Colorado, c/o Center for Global Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA; Department of Epidemiology, Colorado School of Public Health, c/o Center for Global Health, 13199 East Montview Boulevard, Suite 310, Aurora, CO, USA
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7
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de Visser MA, Kululanga D, Chikumbanje SS, Thomson E, Kapalamula T, Borgstein ES, Langton J, Kadzamira P, Njirammadzi J, van Woensel JBM, Bentsen G, Weir PM, Calis JCJ. Outcome in Children Admitted to the First PICU in Malawi. Pediatr Crit Care Med 2023; 24:473-483. [PMID: 36856446 PMCID: PMC10226467 DOI: 10.1097/pcc.0000000000003210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVES Dedicated PICUs are slowly starting to emerge in sub-Saharan Africa. Establishing these units can be challenging as there is little data from this region to inform which populations and approaches should be prioritized. This study describes the characteristics and outcome of patients admitted to the first PICU in Malawi, with the aim to identify factors associated with increased mortality. DESIGN Review of a prospectively constructed PICU database. Univariate analysis was used to assess associations between demographic, clinical and laboratory factors, and mortality. Univariate associations ( p < 0.1) for mortality were entered in two multivariable models. SETTING A recently opened PICU in a public tertiary government hospital in Blantyre, Malawi. PATIENTS Children admitted to PICU between August 1, 2017, and July 31, 2019. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Of 531 included PICU admissions, 149 children died (28.1%). Mortality was higher in neonates (88/167; 52.7%) than older children (61/364; 16.8%; p ≤ 0.001). On univariate analysis, gastroschisis, trachea-esophageal fistula, and sepsis had higher PICU mortality, while Wilms tumor, other neoplasms, vocal cord papilloma, and foreign body aspiration had higher survival rates compared with other conditions. On multivariable analysis, neonatal age (adjusted odds ratio [AOR], 4.0; 95% CI, 2.0-8.3), decreased mental state (AOR, 5.8; 95 CI, 2.4-13.8), post-cardiac arrest (AOR, 2.0; 95% CI, 1.0-8.0), severe hypotension (AOR, 6.3; 95% CI, 2.0-19.1), lactate greater than 5 mmol/L (AOR, 4.2; 95% CI, 1.5-11.2), pH less than 7.2 (AOR, 3.1; 95% CI, 1.2-8.0), and platelets less than 150 × 10 9 /L (AOR, 2.4; 95% CI, 1.1-5.2) were associated with increased mortality. CONCLUSIONS In the first PICU in Malawi, mortality was relatively high, especially in neonates. Surgical neonates and septic patients were identified as highly vulnerable, which stresses the importance of improvement of PICU care bundles for these groups. Several clinical and laboratory variables were associated with mortality in older children. In neonates, severe hypotension was the only clinical variable associated with increased mortality besides blood gas parameters. This stresses the importance of basic laboratory tests, especially in neonates. These data contribute to evidence-based approaches establishing and improving future PICUs in sub-Saharan Africa.
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Affiliation(s)
- Mirjam A de Visser
- Department of Pediatric Intensive Care, Emma Children's Hospital of the Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Diana Kululanga
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Singatiya S Chikumbanje
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Anesthesiology and Intensive Care, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Emma Thomson
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tiyamike Kapalamula
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Eric S Borgstein
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Precious Kadzamira
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Anesthesiology and Intensive Care, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jenala Njirammadzi
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital of the Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Gunnar Bentsen
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Patricia M Weir
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Job C J Calis
- Department of Pediatric Intensive Care, Emma Children's Hospital of the Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
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8
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Pienaar MA, Sempa JB, Luwes N, George EC, Brown SC. Elicitation of domain knowledge for a machine learning model for paediatric critical illness in South Africa. Front Pediatr 2023; 11:1005579. [PMID: 36896402 PMCID: PMC9989015 DOI: 10.3389/fped.2023.1005579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/25/2023] [Indexed: 02/23/2023] Open
Abstract
Objectives Delays in identification, resuscitation and referral have been identified as a preventable cause of avoidable severity of illness and mortality in South African children. To address this problem, a machine learning model to predict a compound outcome of death prior to discharge from hospital and/or admission to the PICU was developed. A key aspect of developing machine learning models is the integration of human knowledge in their development. The objective of this study is to describe how this domain knowledge was elicited, including the use of a documented literature search and Delphi procedure. Design A prospective mixed methodology development study was conducted that included qualitative aspects in the elicitation of domain knowledge, together with descriptive and analytical quantitative and machine learning methodologies. Setting A single centre tertiary hospital providing acute paediatric services. Participants Three paediatric intensivists, six specialist paediatricians and three specialist anaesthesiologists. Interventions None. Measurements and main results The literature search identified 154 full-text articles reporting risk factors for mortality in hospitalised children. These factors were most commonly features of specific organ dysfunction. 89 of these publications studied children in lower- and middle-income countries. The Delphi procedure included 12 expert participants and was conducted over 3 rounds. Respondents identified a need to achieve a compromise between model performance, comprehensiveness and veracity and practicality of use. Participants achieved consensus on a range of clinical features associated with severe illness in children. No special investigations were considered for inclusion in the model except point-of-care capillary blood glucose testing. The results were integrated by the researcher and a final list of features was compiled. Conclusion The elicitation of domain knowledge is important in effective machine learning applications. The documentation of this process enhances rigour in such models and should be reported in publications. A documented literature search, Delphi procedure and the integration of the domain knowledge of the researchers contributed to problem specification and selection of features prior to feature engineering, pre-processing and model development.
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Affiliation(s)
- Michael A Pienaar
- Department of Paediatrics and Child Health, Paediatric Critical Care Unit, University of the Free State, Bloemfontein, South Africa
| | - Joseph B Sempa
- Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Nicolaas Luwes
- Department of Electrical, Electronic and Computer Engineering, Faculty of Engineering, Built Environment and Information Technology, Central University of Technology, Bloemfontein, South Africa
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Stephen C Brown
- Paediatric Cardiology Unit, Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
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Jain RA, Karnik HS, Kotwani DM. Utility and Predictive Value of CHIIDA Score in Pediatric Traumatic Brain Injury: A Prospective Observational Study. J Neurosurg Anesthesiol 2022; 34:227-232. [PMID: 33177365 DOI: 10.1097/ana.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Children's Intracranial Injury Decision Aid (CHIIDA) is a tool designed to stratify children with mild traumatic brain injury (mTBI). The aim of this study was to assess the utility and predictive value of CHIIDA in the assessment of the need for intensive care unit (ICU) admission in pediatric patients with mTBI. METHODS This prospective observational study included 425 children below 18 years of age admitted to the ICU of a tertiary care hospital with mTBI (Glasgow Coma Scale 13 to 15). The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Sensitivity, specificity, predictive values and likelihood ratios were calculated at CHIIDA scores 0 and 2. RESULTS Among 425 children with mTBI, 210 (49%) had a CHIIDA score 0, 16 (4%) scored 2 points, and 199 (47%) scored more than 2 points. Thirty-six (8.47%) patients experienced the primary outcome, and there were 3 deaths. A cutoff CHIIDA >0 to admit to ICU had a sensitivity of 97.22% (95% confidence interval [CI], 97.05%-97.39%) and a negative predictive value of 99.54% (95% CI, 99.50%-99.56%). A cutoff of score >2 had a sensitivity of 97.22% (95% CI, 97.05%-97.39%), and negative predictive value of 99.56% (95% CI, 99.54%-99.59%). The post-test probability at cutoff score of 0 and 2 was 16.65% and 16.27%, respectively. CONCLUSIONS CHIIDA score does not serve as reliable triage tool for identifying children with TBI who do not require ICU admission.
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Affiliation(s)
- Ruchi A Jain
- Department of Anesthesia, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharshtra, India
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10
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Baloch SH, Shaikh I, Gowa MA, Lohano PD, Ibrahim MN. Comparison of Pediatric Sequential Organ Failure Assessment and Pediatric Risk of Mortality III Score as Mortality Prediction in Pediatric Intensive Care Unit. Cureus 2022; 14:e21055. [PMID: 35155020 PMCID: PMC8825229 DOI: 10.7759/cureus.21055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 01/09/2023] Open
Abstract
Objective: To assess and compare the diagnostic accuracy of the Pediatric Risk of Mortality (PRISM) III score and Pediatric Sequential Organ Failure Assessment (p-SOFA) for the prediction of mortality in critically ill children. Methodology: This was a cross-validation study conducted at the Pediatric Intensive Care Unit (PICU) of the National Institute of Child Health Karachi from February 2021 to July 2021. Two hundred eighty-six critically ill children of age one month to 15 years of either gender staying in PICU for more than 24 hours were included. Within 24 hours of admission, the p-SOFA and PRISM III 24 scores were calculated for all eligible children. The outcome of the study was mortality within 30 days of PICU admitted children. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23. Results: The median age was 24 months (range: 1-144 months). The 30-day mortality was estimated as 57%. The p-SOFA and PRISM scores were significantly greater in children who did not survive than survivors. The maximum p-SOFA score (area under the curve (AUC)=0.81, 95% CI=0.76-0.86, p=0.001) and PRISM III 24 score (AUC=0.75, 95% CI=0.69-0.81, p=0.001) had good discrimination for 30-day mortality. For the prediction of 30-day mortality at the cut-off value of p-SOFA>2, the sensitivity was 93.87%, specificity was 38.21%, and accuracy was 69.93%. Whereas at the cut-off value of PRISM III 24 score>8, the sensitivity was 55.83%, specificity was 77.24%, and accuracy was 65.03%. Conclusion: The p-SOFA score is a good predictor for 30-day mortality in critically ill children and had better accuracy than the PRISM III 24 score.
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Ravikumar N, Sankar J, Das RR. Functional Outcomes in Survivors of Pediatric Sepsis: A Scoping Review and Discussion of Implications for Low- and Middle-Income Countries. Front Pediatr 2022; 10:762179. [PMID: 35345613 PMCID: PMC8957211 DOI: 10.3389/fped.2022.762179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 01/11/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pediatric sepsis is an important cause of mortality and morbidity in low- and middle-income countries (LMIC), where there is a huge burden of infectious diseases. Despite shortage of resources, adapting protocol-based care has reduced sepsis-related deaths but survivors of pediatric sepsis are at risk of poor functional outcomes. OBJECTIVES To perform a scoping review of the literature on functional outcomes of pediatric sepsis survivors after discharge from the intensive care unit (ICU) and discuss the implications for patients in LMICs. The outcomes include prevalence of survival with reduced functional outcomes or quality of life (QoL) and changes over time during follow-up or recovery, and these outcomes were compared with other groups of children. METHODS We searched major medical electronic databases for relevant literature from January 2005 until November 2021, including Medline (via PubMed), Embase, CINAHL, and Google Scholar databases. We included observational studies and follow-up data from clinical trials involving children/adolescents (≤18 years) who were admitted to pediatric intensive care unit (PICU) and got discharged finally. Major focus was on survivors of sepsis in LMIC. We followed PRISMA guidelines for scoping reviews (PRISM-ScR). RESULTS We included eight papers reporting data of functional outcomes in 2,915 children (males = 53%, and comorbidity present in 56.6%). All included studies were either a prospective or retrospective cohort study. Studies were classified as Level II evidence. Disabilities affecting physical, cognitive, psychological, and social function were reported in children following discharge. Overall disability reported ranged between 23 and 50% at hospital discharge or 28 days. Residual disability was reported at 1, 3, 6, and 12 months of follow-up with an overall improving trend. Failure to recover from a baseline HRQL on follow-up was seen in one-third of survivors. Organ dysfunction scores such as pSOFA, PeLOD, vasoactive inotrope score, neurological events, immunocompromised status, need for CPR, and ECMO were associated with poor functional outcome. CONCLUSIONS The research on functional outcomes in pediatric sepsis survivors is scarce in LMIC. Measuring baseline and follow-up functional status, low-cost interventions to improve management of sepsis, and multidisciplinary teams to identify and treat disabilities may improve functional outcomes.
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Affiliation(s)
- Namita Ravikumar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India
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Pienaar MA, Sempa JB, Luwes N, George EC, Brown SC. Development of artificial neural network models for paediatric critical illness in South Africa. Front Pediatr 2022; 10:1008840. [PMID: 36458145 PMCID: PMC9705750 DOI: 10.3389/fped.2022.1008840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Failures in identification, resuscitation and appropriate referral have been identified as significant contributors to avoidable severity of illness and mortality in South African children. In this study, artificial neural network models were developed to predict a composite outcome of death before discharge from hospital or admission to the PICU. These models were compared to logistic regression and XGBoost models developed on the same data in cross-validation. DESIGN Prospective, analytical cohort study. SETTING A single centre tertiary hospital in South Africa providing acute paediatric services. PATIENTS Children, under the age of 13 years presenting to the Paediatric Referral Area for acute consultations. OUTCOMES Predictive models for a composite outcome of death before discharge from hospital or admission to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS 765 patients were included in the data set with 116 instances (15.2%) of the study outcome. Models were developed on three sets of features. Two derived from sequential floating feature selection (one inclusive, one parsimonious) and one from the Akaike information criterion to yield 9 models. All developed models demonstrated good discrimination on cross-validation with mean ROC AUCs greater than 0.8 and mean PRC AUCs greater than 0.53. ANN1, developed on the inclusive feature-et demonstrated the best discrimination with a ROC AUC of 0.84 and a PRC AUC of 0.64 Model calibration was variable, with most models demonstrating weak calibration. Decision curve analysis demonstrated that all models were superior to baseline strategies, with ANN1 demonstrating the highest net benefit. CONCLUSIONS All models demonstrated satisfactory performance, with the best performing model in cross-validation being an ANN model. Given the good performance of less complex models, however, these models should also be considered, given their advantage in ease of implementation in practice. An internal validation study is now being conducted to further assess performance with a view to external validation.
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Affiliation(s)
- Michael A Pienaar
- Paediatric Critical Care Unit, Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
| | - Joseph B Sempa
- Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Nicolaas Luwes
- Department of Electrical, Electronic and Computer Engineering, Faculty of Engineering, Built Environment and Information Technology, Central University of Technology, Bloemfontein, South Africa
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Stephen C Brown
- Paediatric Cardiology Unit, Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
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Miller L, Richard M, Krmpotic K, Kennedy A, Seabrook J, Slumkoski C, Walls M, Foster J. Parental presence at the bedside of critically ill children in the pediatric intensive care unit: A scoping review. Eur J Pediatr 2022; 181:823-831. [PMID: 34626225 PMCID: PMC8501356 DOI: 10.1007/s00431-021-04279-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/14/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
Parental presence at the bedside (PPB) of critically ill children in the pediatric intensive care unit (PICU) is necessary for operationalizing family-centred care. Previous evidence syntheses emphasize parent-healthcare provider interactions at rounds and resuscitation; our focus is the parent-child dyad. Prior to embarking on further study, we performed a scoping review to determine the breadth and scope of the literature addressing PPB of critically ill children in the PICU. We searched five online databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and PSYCHINFO) and the grey literature to identify English and French reports from January 1960 to June 2020 addressing physical parental presence with children (birth to 18 years) in intensive care units, without limitation by methodology. Screening, reference selection, and data extraction were performed by two independent reviewers. Data were extracted into a researcher-designed tool. We identified 204 publications (81 quantitative, 68 qualitative, 22 mixed methods, and 9 descriptive case or practice change studies, and a further 24 non-study reports). PPB was directly assessed in 78 (38%) reports, and was the primary objective in 64 (31%). Amount or quality of presence was addressed by 114 reports, barriers and enablers by 152 sources, and impacts and outcomes by 134 sources. While only 6 reports were published in the first two decades of our search (1960-1980), 17 reports were published in 2019 alone. Conclusions: A relatively large body of literature exists addressing PPB of critically ill children. Separate systematic evidence syntheses to assess each element of PPB are warranted. Scoping review protocol registration: Open science framework, protocol nx6v3, registered 9-September-2019. What is Known: • Parental presence at the bedside of critically ill children must be enabled to facilitate family centeredness in care. • Systematic evidence syntheses have focused on parental presence at rounds or resuscitation, rather than with the child throughout the intensive care journey. What is New: • Many reports (n=204) address parental presence at the bedside in the pediatric intensive care unit, though most do as incidental findings • Identifies studies addressing key elements of parental presence in the PICU including barriers and enablers to, amount and quality of, and impact and outcomes of parental presence, and demonstrates trends over time and geography.
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Affiliation(s)
- Lauren Miller
- Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Monique Richard
- Department of Pediatric Critical Care, IWK Health, Halifax, NS Canada
| | - Kristina Krmpotic
- Department of Pediatric Critical Care, IWK Health, Halifax, NS Canada
- Department of Critical Care, Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Anne Kennedy
- School of Education, Acadia University, Wolfville, NS Canada
| | - Jamie Seabrook
- School of Food and Nutritional Sciences, Brescia University College at Western University, London, ON Canada
- Department of Pediatrics and Department of Epidemiology & Biostatistics, Western University, London, ON Canada
- Children’s Health Research Institute and Lawson Health Research Institute, London, ON Canada
| | - Corey Slumkoski
- Department of Pediatric Critical Care Parent Partner, IWK Health, Halifax, NS Canada
| | - Martha Walls
- Department of Pediatric Critical Care Parent Partner, IWK Health, Halifax, NS Canada
| | - Jennifer Foster
- Department of Pediatric Critical Care, IWK Health, Halifax, NS Canada
- Department of Critical Care, Faculty of Medicine, Dalhousie University, Halifax, NS Canada
- Children’s Health Research Institute and Lawson Health Research Institute, London, ON Canada
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14
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Mawji A, Li E, Dunsmuir D, Komugisha C, Novakowski SK, Wiens MO, Vesuvius TA, Kissoon N, Ansermino JM. Smart triage: Development of a rapid pediatric triage algorithm for use in low-and-middle income countries. Front Pediatr 2022; 10:976870. [PMID: 36483471 PMCID: PMC9723221 DOI: 10.3389/fped.2022.976870] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/01/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Early and accurate recognition of children at risk of progressing to critical illness could contribute to improved patient outcomes and resource allocation. In resource limited settings digital triage tools can support decision making and improve healthcare delivery. We developed a model for rapid identification of critically ill children at triage. METHODS This was a prospective cohort study of acutely ill children presenting at Jinja Regional Referral Hospital in Eastern Uganda. Variables collected in the emergency department informed the development of a logistic model based on hospital admission using bootstrap stepwise regression. Low and high-risk thresholds for 90% minimum sensitivity and specificity, respectively generated three risk level categories. Performance was assessed using receiver operating characteristic curve analysis on a held-out test set generated by an 80:20 split with 10-fold cross validation. A risk stratification table informed clinical interpretation. RESULTS The model derivation cohort included 1,612 participants, with an admission rate of approximately 23%. The majority of admitted patients were under five years old and presenting with sepsis, malaria, or pneumonia. A 9-predictor triage model was derived: logit (p) = -32.888 + (0.252, square root of age) + (0.016, heart rate) + (0.819, temperature) + (-0.022, mid-upper arm circumference) + (0.048 transformed oxygen saturation) + (1.793, parent concern) + (1.012, difficulty breathing) + (1.814, oedema) + (1.506, pallor). The model afforded good discrimination, calibration, and risk stratification at the selected thresholds of 8% and 40%. CONCLUSION In a low income, pediatric population, we developed a nine variable triage model with high sensitivity and specificity to predict who should be admitted. The triage model can be integrated into any digital platform and used with minimal training to guide rapid identification of critically ill children at first contact. External validation and clinical implementation are in progress.
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Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Edmond Li
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dustin Dunsmuir
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Stefanie K Novakowski
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Matthew O Wiens
- Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Abstract
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.
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Abiodun MT, Eki-Udoko FE. Evaluation of Paediatric Critical Care Needs and Practice in Nigeria: Paediatric Residents' Perspective. Crit Care Res Pract 2021; 2021:2000140. [PMID: 34513090 PMCID: PMC8426102 DOI: 10.1155/2021/2000140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is a dire need for paediatric critical care (PCC) services, but their availability in tertiary hospitals in Nigeria is not well defined. OBJECTIVE We evaluated self-reported PCC practice, resources, and perceived challenges in various zones of the country, using paediatric residents' perspective. METHODS This is a descriptive cross-sectional survey, carried out at an Intensive Course in Paediatrics at the University of Benin Teaching Hospital, Nigeria. Participants' PCC practice and perceived adequacy of PCC resources and services were assessed using a 100 mm uncalibrated visual analogue scale (VAS). A comparison between northern and southern zones was done. A 2-sided p value < 0.05 was considered significant. RESULTS A total of 143 residents participated in the study, 37.1% of them were male, and 62.9% were female. Their mean age was 34.6 ± 3.2 years. They were mainly (86.7%) from federal institutions across the country. Less than a half (46.7%) of the trainees attended to critically ill children daily, but only 4 out of every 10 respondents stated that such severely ill children survived till hospital discharge; 12.1% of the trainees had PICUs in their institutions. Financial constraints hindered PICU admissions. PCC staff were relatively fewer in northern zones than southern zones (p < 0.05). Their perceived adequacy of PCC equipment and services were low (VAS scores 32.7 ± 2.6 and 30.9 ± 2.8, respectively) with a strong positive correlation between the two measurements (r = 0.839; p < 0.001). CONCLUSION There is an unmet need for PCC practice in Nigerian tertiary hospitals with a resultant low survival rate of critically ill children. PCC training curricula and improved critical care resources are desirable in the setting.
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Affiliation(s)
- Moses Temidayo Abiodun
- Paediatric Emergency & Critical Care Division, Department of Child Health, University of Benin Teaching Hospital, & School of Medicine, University of Benin, Benin City, Nigeria
| | - Fidelis E. Eki-Udoko
- Paediatric Emergency & Critical Care Division, Department of Child Health, University of Benin Teaching Hospital, & School of Medicine, University of Benin, Benin City, Nigeria
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17
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Managing the Critically Ill Child-What Resources Do You Really Need (and What Do You Have)? Crit Care Med 2021; 49:712-714. [PMID: 33731612 DOI: 10.1097/ccm.0000000000004841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Padhya D, Tripathi S, Kashyap R, Alsawas M, Murthy S, Arteaga GM, Dong Y. Training of Pediatric Critical Care Providers in Developing Countries in Evidence Based Medicine Utilizing Remote Simulation Sessions. Glob Pediatr Health 2021; 8:2333794X211007473. [PMID: 33997121 PMCID: PMC8072099 DOI: 10.1177/2333794x211007473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background. Remote simulation training provides a unique
opportunity to captivate providers despite language, distance, and cultural
barriers. Previously we developed a novel electronic decision support and
rounding tool, the Checklist for Early Recognition and Treatment of Acute
Illness in Pediatrics (CERTAINp). This study was conducted to determine the
feasibility and impact of remote simulation training of international PICU
providers using CERTAINp. Methods. We conducted
train-the-trainer sessions in 7 hospitals based in 5 countries (China, Congo,
Croatia, India, and Turkey) between 11/2015 and 11/2016. Providers first took
part in a base line simulation session to assess their clinical performance.
They had structured hands-on training using CERTAINp, which was done remotely
using video conference with recording capabilities. Performance in PICU
“admission” and “rounding” scenarios was assessed by their adherence to standard
of care guidelines using CERTAINp. After this training, the providers were
re-evaluated for performance using a validated instrument by 2 independent
trained reviewers. Results. A total of 7 hospitals completed
both baseline and post simulation sessions. We observed improved critical task
(total 14) completion in the admission scenarios where pre training task
completion was 8.2 ± 2.6, while after remote training was 11.2 ± 1.8,
P = .01. In rounding scenarios, compliance to standard of
care guidelines improved overall from 45% to 95% (P < .01).
Conclusion. We observed an improvement in compliance for
measures determined as best practice guidelines in simulation rounding and
overall improvement in critical tasks for simulated admission cases after remote
training.
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Affiliation(s)
- Dipti Padhya
- Cedars-Sinai Medical Center, West Hollywood, CA, USA
| | | | | | - Mouaz Alsawas
- University of Iowa Hospitals and Clinics Pathology, Iowa City, IA, USA
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Muttalib F, González-Dambrauskas S, Lee JH, Steere M, Agulnik A, Murthy S, Adhikari NKJ. Pediatric Emergency and Critical Care Resources and Infrastructure in Resource-Limited Settings: A Multicountry Survey. Crit Care Med 2021; 49:671-681. [PMID: 33337665 DOI: 10.1097/ccm.0000000000004769] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the infrastructure and resources for pediatric emergency and critical care delivery in resource-limited settings worldwide. DESIGN Cross-sectional survey with survey items developed through literature review and revised following piloting. SETTING The electronic survey was disseminated internationally in November 2019 via e-mail directories of pediatric intensive care societies and networks and using social media. PATIENTS Healthcare providers who self-identified as working in resource-limited settings. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Results were summarized using descriptive statistics and resource availability was compared across World Bank country income groups. We received 328 responses (238 hospitals, 60 countries), predominantly in Latin America and Sub-Saharan Africa (n = 161, 67.4%). Hospitals were in low-income (28, 11.7%), middle-income (166, 69.5%), and high-income (44, 18.4%) countries. Across 174 PICU and adult ICU admitting children, there were statistically significant differences in the proportion of hospitals reporting consistent resource availability ("often" or "always") between country income groups (p < 0·05). Resources with limited availability in lower income countries included advanced ventilatory support, invasive and noninvasive monitoring, central venous access, renal replacement therapy, advanced imaging, microbiology, biochemistry, blood products, antibiotics, parenteral nutrition, and analgesic/sedative drugs. Seventy-seven ICUs (52.7%) were staffed 24/7 by a pediatric intensivist or anesthetist. The nurse-to-patient ratio was less than 1:2 in 71 ICUs (49.7%). CONCLUSIONS Contemporary data demonstrate significant disparity in the availability of essential and advanced human and material resources for the care of critically ill children in resource-limited settings. Minimum standards for essential pediatric emergency and critical care in resource-limited settings are needed.
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Affiliation(s)
- Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Sebastián González-Dambrauskas
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Jan Hau Lee
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore
- Department of Pediatrics, Duke-NUS Medical School, Singapore
- Pediatric Acute and Critical Care Medicine Asian Network
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kenya
- Pediatric Emergency and Critical Care Africa
- Royal Flying Doctor Service of Australia, Central Operations, Mile End, SA, Australia
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mardi Steere
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore
- Department of Pediatrics, Duke-NUS Medical School, Singapore
- Pediatric Acute and Critical Care Medicine Asian Network
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kenya
- Pediatric Emergency and Critical Care Africa
- Royal Flying Doctor Service of Australia, Central Operations, Mile End, SA, Australia
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Srinivas Murthy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Neill K J Adhikari
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore
- Department of Pediatrics, Duke-NUS Medical School, Singapore
- Pediatric Acute and Critical Care Medicine Asian Network
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kenya
- Pediatric Emergency and Critical Care Africa
- Royal Flying Doctor Service of Australia, Central Operations, Mile End, SA, Australia
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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20
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Muttalib F, Ballard E, Langton J, Malone S, Fonseca Y, Hansmann A, Remy K, Hovmand P, Doctor A. Application of systems dynamics and group model building to identify barriers and facilitators to acute care delivery in a resource limited setting. BMC Health Serv Res 2021; 21:26. [PMID: 33407458 PMCID: PMC7787401 DOI: 10.1186/s12913-020-06014-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. Methods Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed. Results Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias. Conclusions GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.
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Affiliation(s)
- Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, 555 University avenue, Toronto, ON, M5G 1X8, Canada.
| | - Ellis Ballard
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | | | - Sara Malone
- Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Yudy Fonseca
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Andreas Hansmann
- Neonatal and Paediatric ICU, National Pediatric Hospital, Phnom Penh, Cambodia
| | - Kenneth Remy
- Departments of Pediatrics and Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Peter Hovmand
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Allan Doctor
- Pediatric Critical Care Medicine and Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, USA
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21
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Puttiteerachot P, Anantasit N, Chaiyakulsil C, Vaewpanich J, Lertburian R, Chantra M. Management of Pediatric Septic Shock and Acute Respiratory Distress Syndrome in Thailand: A Survey of Pediatricians. Front Pediatr 2021; 9:792524. [PMID: 35096708 PMCID: PMC8790317 DOI: 10.3389/fped.2021.792524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Pediatric septic shock and acute respiratory distress syndrome (pARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). While standardized guidelines for sepsis and pARDS are published regularly, their implementation and adherence to guidelines are different in resource-rich and resource-limited countries. The purpose of this study was to conduct a survey to ascertain variation in current clinician-reported practice in pediatric septic shock and acute respiratory distress syndrome, and the clinician skills in a variety of hospital settings throughout Thailand. Methods: We conducted an electronic survey in pediatricians throughout the country between August 2020 and February 2021 using multiple choice questions and clinical case scenarios based on the 2017 American College of Critical Care Medicine's Consensus guideline for pediatric and neonatal septic shock and the 2015 Pediatric Acute Lung Injury Consensus Conference. Results: The survey elicited responses from 255 pediatricians (125 general pediatricians, 38 pulmonologists, 27 cardiologists, 32 intensivists, and 33 other subspecialists), with 54.5% of the respondents having <5 years of PICU experience. Among the six sepsis scenarios, 72.5 and 78.4% of the respondents had good adherence to the guidelines for managing fluid refractory shock and sedation for intubation, respectively. The ICU physicians reported greater adherence during more complex shock. In ARDS scenarios, 80.8% of the respondents reported having difficulty diagnosing ARDS mimic conditions and used lesser PEEP than the recommendation. Acceptance of permissive hypercapnia and mild hypoxemia was accepted by 62.4 and 49.4% of respondents, respectively. The ICU physicians preferred decremental PEEP titration, whereas general pediatricians preferred incremental PEEP titration. Conclusion: This survey variation could be the result of resource constraints, knowledge gaps, or ambiguous guidelines. Understanding the perspective and rationale for variation in pediatricians' practices is critical for successful guideline implementation.
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Affiliation(s)
- Pasita Puttiteerachot
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattachai Anantasit
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chanapai Chaiyakulsil
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Bangkok, Thailand
| | - Jarin Vaewpanich
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rojjanee Lertburian
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Marut Chantra
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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22
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Gardner Yelton SE, McCaw JM, Reuland CJ, Steppan DA, Evangelista PPG, Shilkofski NA. Evolution of a Bidirectional Pediatric Critical Care Educational Partnership in a Resource-Limited Setting. Front Pediatr 2021; 9:738975. [PMID: 34722421 PMCID: PMC8555020 DOI: 10.3389/fped.2021.738975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah E Gardner Yelton
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Julia M McCaw
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carolyn J Reuland
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Diana A Steppan
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Paula Pilar G Evangelista
- Department of Pediatric Critical Care Medicine, Philippine Children's Medical Center, Quezon City, Philippines
| | - Nicole A Shilkofski
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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23
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Teshager NW, Amare AT, Tamirat KS. Incidence and predictors of mortality among children admitted to the pediatric intensive care unit at the University of Gondar comprehensive specialised hospital, northwest Ethiopia: a prospective observational cohort study. BMJ Open 2020; 10:e036746. [PMID: 33067274 PMCID: PMC7569923 DOI: 10.1136/bmjopen-2019-036746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine the incidence and predictors of mortality among children admitted to the paediatric intensive care unit (PICU) at the University of Gondar comprehensive specialised hospital, northwest Ethiopia. DESIGN A single-centre prospective observational cohort study. PARTICIPANTS A total of 313 children admitted to the ICU of the University of Gondar comprehensive specialised hospital during a one-and-a-half-year period. MEASUREMENTS Data were collected using standard case record form, physical examination and patient document review. Clinical characteristics such as systolic blood pressure, pupillary light reflex, oxygen saturation and need for mechanical ventilation (MV) were assessed and documented within the first hour of admission and entered into an electronic application to calculate the modified Pediatric Index of Mortality 2 (PIM 2) Score. We fitted the Cox proportional hazards model to identify predictors of mortality. RESULT The median age at admission was 48 months with IQR: 12-122, 28.1% were infants and adolescents accounted for 21.4%. Of the total patients studied, 59.7% were males. The median observation time was 3 days with (IQR: 1-6). One hundred and two (32.6%) children died during the follow-up time, and the incidence of mortality was 6.9 deaths per 100 person-day observation. Weekend admission (adjusted HR (AHR)=1.63, 95% CI: 1.02 to 2.62), critical illness diagnoses (AHR=1.79, 95% CI: 1.13 to 2.85), need for MV (AHR=2.36, 95% CI: 1.39 to 4.01) and modified PIM 2 Score (AHR=1.53, 95% CI: 1.36 to 1.72) were the predictors of mortality. CONCLUSION The rate of mortality in the PICU was high, admission over weekends, need for MV, critical illness diagnoses and higher PIM 2 scores were significant and independent predictors of mortality.
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Affiliation(s)
- Nahom Worku Teshager
- Department of Pediatrics and Child Health, School of Medicine, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Ashenafi Tazebew Amare
- Department of Pediatrics and Child Health, School of Medicine, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Koku Sisay Tamirat
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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24
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Giri S, Halvas-Svendsen T, Rogne T, Shrestha SK, Døllner H, Solligård E, Risnes K. Pediatric Patients in a Local Nepali Emergency Department: Presenting Complaints, Triage and Post-Discharge Mortality. Glob Pediatr Health 2020; 7:2333794X20947926. [PMID: 32995370 PMCID: PMC7502999 DOI: 10.1177/2333794x20947926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 12/29/2022] Open
Abstract
Background. In low-income countries, pediatric emergency care is largely underdeveloped although child mortality in emergency care is more than twice that of adults, and mortality after discharge is high. Aim. We aimed at describing characteristics, triage categories, and post-discharge mortality in a pediatric emergency population in Nepal. Methods. We prospectively assessed characteristics and triage categories of pediatric patients who entered the emergency department (ED) in a local hospital. Patient households were followed-up by telephone interviews at 90 days. Results. The majority of pediatric emergency patients presented with injuries and infections (~40% each). Girls attended ED less frequent than boys. High triage priority categories (orange and red) were strong indicators for intensive care need and for mortality after discharge. Conclusion. The study supports the use and development of a pediatric triage systems in a low-resource general ED setting. We identify a need for interventions that can reduce mortality after pediatric emergency care. Interventions to reduce pediatric emergency disease burden in this setting should emphasize prevention and effective treatment of infections and injuries.
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Affiliation(s)
- Samita Giri
- Norwegian University of Science and Technology, Trondheim, Norway.,Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - Tormod Rogne
- Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Henrik Døllner
- Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Solligård
- Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kari Risnes
- Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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25
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Arias AV, Garza M, Murthy S, Cardenas A, Diaz F, Montalvo E, Nielsen KR, Kortz T, Sharara-Chami R, Friedrich P, McArthur J, Agulnik A. Quality and capacity indicators for hospitalized pediatric oncology patients with critical illness: A modified delphi consensus. Cancer Med 2020; 9:6984-6995. [PMID: 32777172 PMCID: PMC7541142 DOI: 10.1002/cam4.3351] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 01/09/2023] Open
Abstract
Background Hospitalized pediatric hematology‐oncology (PHO) patients are at high risk for critical illness, especially in resource‐limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients. Methods A comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three‐round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high‐resource and resource‐limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys. Results PROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high‐median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care. Conclusions PROACTIVE is a consensus‐derived tool to assess the capacity and quality of pediatric onco‐critical care in resource‐limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement.
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Affiliation(s)
- Anita V Arias
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Adolfo Cardenas
- Hospital Infantil Teletón de Oncología (HITO), Querétaro, México
| | - Franco Diaz
- Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Erika Montalvo
- Pediatric Critical Care Unit, SOLCA Quito, Quito, Ecuador
| | - Katie R Nielsen
- Division of Pediatric Critical Care, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Teresa Kortz
- Division of Pediatric Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Rana Sharara-Chami
- Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer McArthur
- Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.,Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
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Trailblazing the Path Toward Pediatric Critical Care in Kenya. Pediatr Crit Care Med 2019; 20:1204-1205. [PMID: 31804445 DOI: 10.1097/pcc.0000000000002152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dekker-Boersema J, Hector J, Jefferys LF, Binamo C, Camilo D, Muganga G, Aly MM, Langa EBR, Vounatsou P, Hobbins MA. Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique. Afr J Emerg Med 2019; 9:172-176. [PMID: 31890479 PMCID: PMC6933270 DOI: 10.1016/j.afjem.2019.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/16/2019] [Accepted: 05/20/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The majority of emergency paediatric death in African countries occur within the first 24 h of admission. A coloured triage system is widely implemented in high-income countries and the emergency triage and assessment treatment (ETAT) is recommended by the World Health Organization, but not put into practice in Mozambique. We implemented a three-colour triage system in a rural district hospital with lay-staff workers conducting the first triage. METHODS A retrospective, before and after, mortality analysis was performed using routine patient files from the district hospital between 2014 and 2017. The triage system was implemented in August 2016. Inclusion criteria were children under 15 years of age that entered the emergency centre. Primary outcome was child mortality rate. Secondary outcomes included the percentage agreement between the clinical and non-clinical staff and the duration from triage to first treatment. We used a negative binomial model in STATA 15 to compare mortality rates, and Kappa statistics to estimate the agreement between clinical and non-clinical staff. RESULTS 4176 admissions were included. The mortality rate ratio (MMR) was 45% lower after the start of the intervention (2016; MRR = 0.55; 0.38, 0.81; p = 0.002), compared to before. To estimate the agreement between non-clinical and clinical staff, 548 (of the 671) patient files were included. The agreement was estimated at 88.7% (Kappa = 0.644; p < 0.001). The median waiting time decreased with urgency of the triage: 2 h33 for 'green'/least serious (IQR 1 h58-3 h30), 21 min for yellow/serious (IQR 0 h10-0 h58) and nine minutes for 'red'/urgent (IQR 2-40 min). CONCLUSION In a rural setting with nurse-led clinical care and non-clinician staff working at the triage reception, implementation of a three-coloured triage system was feasible. Triage and ETAT training was associated with a decrease of 45% of paediatric deaths. The impact on mortality, low cost, and ease of the implementation supports scaling this intervention in similar settings.
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Affiliation(s)
| | | | | | | | - Deavis Camilo
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Gerard Muganga
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Mussa Manuel Aly
- Operational Research Unit Pemba, Pemba, Cabo Delgado, Mozambique
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González-Dambrauskas S, Jaramillo-Bustamante JC, Díaz F. No one is better than all together: the role of networks in pediatric intensive care. Rev Bras Ter Intensiva 2019; 31:277-281. [PMID: 31618344 PMCID: PMC7005951 DOI: 10.5935/0103-507x.20190043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/31/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network) - Montevidéu, Uruguai.,Cuidados Intensivos Pediátricos Especializados, Casa de Galicia - Montevidéu, Uruguai
| | - Juan Camilo Jaramillo-Bustamante
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network) - Montevidéu, Uruguai.,Unidad de Cuidados Intensivos Pediátricos, Hospital General de Medellín - Medelín, Colômbia.,Cátedra de Facultad de Medicina, Universidad de Antioquia - Antioquia, Colômbia
| | - Franco Díaz
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network) - Montevidéu, Uruguai.,Facultad de Medicina Clínica Alemana, Universidad del Desarrollo - Santiago, Chile.,Unidad de Cuidados Intensivos Pediátricos, Clínica Alemana de Santiago - Santiago, Chile
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Alali H, Kazzaz Y, Alshehri A, Antar M, Alhamouieh O, Hasan Z, Al-Surimi K. Reducing unnecessary delays during the transfer of patients from the paediatric intensive care unit to the general ward: a quality improvement project. BMJ Open Qual 2019; 8:e000695. [PMID: 31544165 PMCID: PMC6730600 DOI: 10.1136/bmjoq-2019-000695] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/31/2019] [Accepted: 08/13/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Delaying the discharge of paediatric intensive care unit (PICU) patients is directly proportional to increased occupancy rate and cost. We aimed to study the process of transferring patients from the PICU to the general ward in order to improve the timeliness of this process while guaranteeing patient safety. Methods A multidisciplinary quality improvement (QI) team was formed to analyse the transfer process. Several Plan Do Study Act cycles were tested, targeting all steps of the transfer process, and applying turnaround time (TAT)-the duration from the time of clinical transfer decision until the physical transfer of the patient-as an outcome measure, aiming for a TAT of 4 hours. Results Baseline results showed that medical transfer decisions by PICU attending physicians were taken late for most patients: only 19% of decisions were made by 08:00 by the on-call team. Average TAT of the transfer process was over 7 hours, with duration ranging from 7 to 17 hours. After implementing all suggested improvement interventions, early decision compliance improved to 59%. TAT improved gradually, starting in January 2017, until it approached our target (284-261 min≈4 hours) in February-May 2017. Conclusion PICU patient transfer process delays can be reduced by early evaluation, timely team communication and proper preparation. It is recommended that all personnel with early involvement avoid unnecessary delays by paying more attention to all process steps, starting with the clinical decision, until the physical transfer. Standardising transfer processes might lead to a decrease in the length of PICU stay, which is a desirable outcome, but this observation needs further exploration.
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Affiliation(s)
- Hamza Alali
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yasser Kazzaz
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali Alshehri
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohannad Antar
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia
| | - Ousaima Alhamouieh
- Quality and Patient Safety Department, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia
| | - Zahra Hasan
- Nursing Services, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia
| | - Khaled Al-Surimi
- Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Primary Care and Public Health, Imperial college London, London, United Kingdom
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Nadar M, Jouvet P, Tucci M, Toledano B, Cyr M, Sicotte C. The implementation of a synchronous telemedicine platform linking off-site pediatric intensivists and on-site fellows in a pediatric intensive care unit: A feasibility study. Int J Med Inform 2019; 129:219-225. [PMID: 31445259 DOI: 10.1016/j.ijmedinf.2019.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/02/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess the feasibility of implementing a synchronous telemedicine platform in a pediatric intensive care unit (STEP-PICU). METHOD A prospective mixed study was conducted. Two sources of data were mobilised: a survey with structured questionnaires and direct non-intrusive observation. The study site was the PICU of a university hospital. Users' perceptions of six aspects of the STEP-PICU were studied: telemedicine system quality, data quality, quality of technical support, use of the new system, overall satisfaction and system benefits. RESULTS During the 6-month experimentation period, use of the telemedicine platform was rather limited and fell short of the promoter's expectations.The mean scores for the six user perception dimensions were low, with no differences between the two groups of users. A Mann-Whitney test showed that being an off-site pediatric intensivist or on-site fellow did not make a statistically significant difference in responses on system quality (p = .518), data quality (p = 1.00), quality of technical support (p = 1.00), system use (p = .556), overall satisfaction (p = .482), or benefits (p = .365). The low use of the STEP-PICU was attributed to three root causes: human factors, the platform's functionalities, and technical problems. DISCUSSION The synchronous telemedicine service for PICU was feasible but would need good pre-implementation preparation to be truly helpful. Its usefulness during the night shift and holiday on-call periods was scored as low by the off-site pediatric intensivists and the on-site fellows. It would appear that such a service could be more beneficial for communications with other remote healthcare facilities, where there is a greater need for the expertise of a pediatric critical care intensivist.
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Affiliation(s)
- Mahmoud Nadar
- Department of Nursing and Health Sciences, Université du Québec en Outaouais, C.P. 1250, Succursale Hull, Gatineau, Quebec, J8X 3X7, Canada; Department of Management, Evaluation and Health Policy, School of Public Health, University of Montreal, 7101 Park Ave, Montreal, Québec, H3N1X9, Canada; Public Health Research Institute of the University of Montreal, 7101 Park Ave, Montreal, Québec, H3N1X9, Canada.
| | - Philippe Jouvet
- Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine University Hospital, 3175 Chemin de la côte-Sainte-Catherine, Montreal, Québec, H3T1C5, Canada.
| | - Marisa Tucci
- Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine University Hospital, 3175 Chemin de la côte-Sainte-Catherine, Montreal, Québec, H3T1C5, Canada.
| | - Baruch Toledano
- Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine University Hospital, 3175 Chemin de la côte-Sainte-Catherine, Montreal, Québec, H3T1C5, Canada.
| | - Martin Cyr
- Department of Biomedical Engineering, Sainte-Justine University Hospital, 3175 Chemin de la côte-Sainte-Catherine, Montreal, Québec, H3T1C5, Canada.
| | - Claude Sicotte
- Department of Management, Evaluation and Health Policy, School of Public Health, University of Montreal, 7101 Park Ave, Montreal, Québec, H3N1X9, Canada; Public Health Research Institute of the University of Montreal, 7101 Park Ave, Montreal, Québec, H3N1X9, Canada.
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Nariadhara MR, Sawe HR, Runyon MS, Mwafongo V, Murray BL. Modified systemic inflammatory response syndrome and provider gestalt predicting adverse outcomes in children under 5 years presenting to an urban emergency department of a tertiary hospital in Tanzania. Trop Med Health 2019; 47:13. [PMID: 30766443 PMCID: PMC6359824 DOI: 10.1186/s41182-019-0136-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/14/2019] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Modified systemic inflammatory response syndrome (mSIRS) criteria for the pediatric population together with the provider gestalt have the potential to predict clinical outcomes. However, this has not been studied in low-income countries. We investigated the ability of mSIRS and provider gestalt to predict mortality and morbidity among children presenting to the ED of a tertiary level hospital in Tanzania. METHODS This prospective observational study enrolled a convenience sample of children under 5 years old, presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2015 to April 2016. Trained researchers used a structured case report form to record patient demographics, clinical presentation, initial provider gestalt of severity of illness, and the mSIRS criteria. Primary outcomes were 24-h mortality and overall in-hospital mortality. Data was analyzed using simple descriptive statistics, Kruskal-Wallis, Mann-Whitney U, and chi-squared tests. RESULTS We enrolled 1350 patients, median age 17 months (interquartile range 8-32 months), and 58% were male. Provider gestalt estimates of illness severity were recorded for all patients and 1030 (76.3%) had complete data for mSIRS categorization. Provider gestalt classified 97 (7.2%) patients as healthy, 546 (40.4%) as mildly ill, 457 (33.9%) as moderately ill, and 250 (18.5%) as severely ill. Of the patients, classifiable by mSIRS, 411/1030 (39.9%) had ≥ 2 mSIRS criteria. In predicting 24-h mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 82% and 81%, respectively, and specificity of 61% and 84%, respectively. In predicting overall in-hospital mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 66% and 70% with a specificity of 62% and 86% respectively. CONCLUSION Both the mSIRS and provider gestalt were highly specific for predicting 24-h and overall in-hospital mortality in our patient population. The clinical utility of these assessment methods is limited by the low positive predictive value.
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Affiliation(s)
- Meera R. Nariadhara
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Hendry R. Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Michael S. Runyon
- Deparment of Emergency Medicine, Carolinas Medical Centre, Charlotte, NC USA
| | - Victor Mwafongo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Brittany L. Murray
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar Es Salaam, Tanzania
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA USA
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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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Nwankwor OC, McKelvie B, Frizzola M, Hunter K, Kabara HS, Oduwole A, Oguonu T, Kissoon N. A National Survey of Resources to Address Sepsis in Children in Tertiary Care Centers in Nigeria. Front Pediatr 2019; 7:234. [PMID: 31245338 PMCID: PMC6579914 DOI: 10.3389/fped.2019.00234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/22/2019] [Indexed: 01/11/2023] Open
Abstract
Background: Infections leading to sepsis are major contributors to mortality and morbidity in children world-wide. Determining the capacity of pediatric hospitals in Nigeria to manage sepsis establishes an important baseline for quality-improvement interventions and resource allocations. Objectives: To assess the availability and functionality of resources and manpower for early detection and prompt management of sepsis in children at tertiary pediatric centers in Nigeria. Methods: This was an online survey of tertiary pediatric hospitals in Nigeria using a modified survey tool designed by the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The survey addressed all aspects of pediatric sepsis identification, management, barriers and readiness. Results: While majority of the hospitals 97% (28/29) reported having adequate triage systems, only 60% (16/27) follow some form of guideline for sepsis management. There was no consensus national guideline for management of pediatric sepsis. Over 50% of the respondents identified deficit in parental education, poor access to healthcare services, failure to diagnose sepsis at referring institutions, lack of medical equipment and lack of a definitive protocol for managing pediatric sepsis, as significant barriers. Conclusions: Certain sepsis-related interventions were reportedly widespread, however, there is no standardized sepsis protocol, and majority of the hospitals do not have pediatric intensive care units (PICU). These findings could guide quality improvement measures at institutional level, and healthcare policy/spending at the national level.
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Affiliation(s)
- Odiraa C Nwankwor
- Division of Critical Care Medicine, Department of Pediatrics, Alfred I. DuPont Hospital for Children, Wilmington, DE, United States.,Division of Critical Care Medicine, Department of Pediatrics, Cooper University Hospital, Camden, NJ, United States
| | - Brianna McKelvie
- Department of Pediatrics, Children's Hospital, Western University, London, ON, Canada
| | - Meg Frizzola
- Division of Critical Care Medicine, Department of Pediatrics, Alfred I. DuPont Hospital for Children, Wilmington, DE, United States
| | - Krystal Hunter
- Cooper University Hospital, Cooper Research Institute, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Halima S Kabara
- Department of Anaesthesia/Intensive Care Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Abiola Oduwole
- Department of Paediatrics, Lagos University Teaching Hospital/College of Medicine, University of Lagos, Lagos, Nigeria
| | - Tagbo Oguonu
- Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada
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Pierre L, Adeyinka A, Kioko M, Hernandez Rivera JF, Pinto R. Performance comparison in Pediatric Fundamental Critical Care Support among staff from the USA versus those from resource-limited countries. J Int Med Res 2018; 46:4640-4649. [PMID: 30066610 PMCID: PMC6259384 DOI: 10.1177/0300060518787312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/15/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the performance of participants in the USA compared with international participants taking the Pediatric Fundamental Critical Care Support (PFCCS) course, and the significance of training for resource-limited environments. METHODS PFCCS courses were conducted in the USA, El Salvador, Haiti, Kenya, and Nepal between January 2011 and July 2013. All of the participants took pre- and post-tests. We compared the performance of these tests between international and USA participants. All participants answered a post-course survey to evaluate the didactic lectures and skill stations. RESULTS A total of 244 participants took the PFCCS course, comprising 71 from the USA, 68 from Kenya, 37 from Haiti, 48 from Nepal, and 20 from El Salvador. The mean pre-test score of USA participants (50.6%) was significantly higher than that of international participants (44.7%). There was no significant difference in the post-test score between USA and international participants (78.6% versus 81.4%). There was a significant difference between pre- and post-test scores. There was better appreciation of the course content by the USA participants. CONCLUSION International course takers without prior pediatric intensive care training have similar test scores to USA participants suggesting comparable efficacy.
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Affiliation(s)
- Louisdon Pierre
- The Brooklyn Hospital Center, 121 DeKalb Avenue,
Brooklyn, NY, USA
| | - Adebayo Adeyinka
- The Brooklyn Hospital Center, 121 DeKalb Avenue,
Brooklyn, NY, USA
| | - Marilyn Kioko
- The Brooklyn Hospital Center, 121 DeKalb Avenue,
Brooklyn, NY, USA
| | | | - Rohit Pinto
- The Brooklyn Hospital Center, 121 DeKalb Avenue,
Brooklyn, NY, USA
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Umphrey L, Brown A, Hiffler L, Lafferty N, Garcia DM, Morton N, Ogundipe O. Delivering paediatric critical care in humanitarian settings. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:846-848. [PMID: 30297309 DOI: 10.1016/s2352-4642(18)30284-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/23/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Lisa Umphrey
- Médecins Sans Frontières, Operational Centre Paris, Glebe, NSW 2037, Australia.
| | - Alexandra Brown
- Médecins Sans Frontières, Operational Centre Paris, Glebe, NSW 2037, Australia
| | - Laurent Hiffler
- Médecins Sans Frontières, Operational Centre Barcelona, Barcelona, Spain
| | - Nadia Lafferty
- Médecins Sans Frontières, Operational Centre Barcelona, Barcelona, Spain
| | | | - Nikola Morton
- Médecins Sans Frontières, Operational Centre Paris, Glebe, NSW 2037, Australia
| | - Oluwakemi Ogundipe
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
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Education of Healthcare Workers: Avoiding a Square Peg in a Round Hole. Pediatr Crit Care Med 2018; 19:794-795. [PMID: 30095723 DOI: 10.1097/pcc.0000000000001616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kiragu AW, Dunlop SJ, Mwarumba N, Gidado S, Adesina A, Mwachiro M, Gbadero DA, Slusher TM. Pediatric Trauma Care in Low Resource Settings: Challenges, Opportunities, and Solutions. Front Pediatr 2018; 6:155. [PMID: 29915778 PMCID: PMC5994692 DOI: 10.3389/fped.2018.00155] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/09/2018] [Indexed: 12/15/2022] Open
Abstract
Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3-6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers for trauma care within each LMIC are key to improved outcomes and the lowering of trauma-related morbidity and mortality globally. Resource limitations in LMICs make it necessary to develop injury prevention strategies and optimize the use of locally available resources when injury prevention measures fail. This will lead to the achievement of the best possible outcomes for critically ill and injured children. A commitment by the governments in LMICs working alone or in collaboration with international non-governmental organizations (NGOs) to provide adequate healthcare to their citizens is also crucial to improved survival after major trauma. The increase in global conflicts also has significantly deleterious effects on children, and governments and international organizations like the United Nations have a significant role to play in reducing these. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.
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Affiliation(s)
- Andrew W. Kiragu
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
| | - Stephen J. Dunlop
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- Division of Global Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Njoki Mwarumba
- Department of Political Science, Oklahoma State University, Stillwater, OK, United States
| | - Sanusi Gidado
- Department of Surgery, Bingham University Teaching Hospital, Jos, Nigeria
| | - Adesope Adesina
- Department of Surgery, Bowen University Teaching Hospital, Ogbomosho, Nigeria
| | | | - Daniel A. Gbadero
- Department of Pediatrics, Bowen University Teaching Hospital, Ogbomosho, Nigeria
| | - Tina M. Slusher
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
- Division of Global Pediatrics, University of Minnesota, Minneapolis, MN, United States
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Crow SS, Ballinger BA, Rivera M, Tsibadze D, Gakhokidze N, Zavrashvili N, Ritter MJ, Arteaga GM. A "Fundamentals" Train-the-Trainer Approach to Building Pediatric Critical Care Expertise in the Developing World. Front Pediatr 2018; 6:95. [PMID: 29780789 PMCID: PMC5945996 DOI: 10.3389/fped.2018.00095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/26/2018] [Indexed: 01/09/2023] Open
Abstract
Pediatric Fundamental Critical Care Support (PFCCS) is an educational tool for training non-intensivists, nurses, and critical care practitioners in diverse health-care settings to deal with the acute deterioration of pediatric patients. Our objective was to evaluate the PFCCS course as a tool for developing a uniform, reproducible, and sustainable model for educating local health-care workers in the optimal management of critically ill children in the Republic of Georgia. Over a period of 18 months and four visits to the country, we worked with Georgian pediatric critical care leadership to complete the following tasks: (1) survey health-care needs within the Republic of Georgia, (2) present representative PFCCS lectures and simulation scenarios to evaluate interest and obtain "buy-in" from key stakeholders throughout the Georgian educational infrastructure, and (3) identify PFCCS instructor candidates. Georgian PFCCS instructor training included the following steps: (1) US PFCCS consultant and content experts presented PFCCS course to Georgian instructor candidates. (2) Simulation learning principles were taught and basic equipment was acquired. (3) Instructor candidates presented PFCCS to Georgian learners, mentored by PFCCS course consultants. Objective evaluation and debriefing with instructor candidates concluded each visit. Between training visits Georgian instructors translated PFCCS slides to the Georgian language. Six candidates were identified and completed PFCCS instructor training. These Georgian instructors independently presented the PFCCS course to 15 Georgian medical students. Student test scores improved significantly from pretest results (n = 14) (pretest: 38.7 ± 7 vs. posttest 62.7 ± 6, p < 0.05). A Likert-type scale of 1 to 5 (1 = not useful or effective, 5 = extremely useful or effective) was used to evaluate each student's perception regarding (1) relevance of course content to clinical work students rated as median (IQR): (a) relevance of PFCCS content to clinical work, 5 (4-5); (b) effectiveness of lecture delivery, 4 (3-4); and (c) value of skill stations for clinical practice, 5 (4-5). Additionally, the mean (±SD) responses were 4.6 (±0.5), 3.7 (±0.6), and 4.5 (±0.6), respectively. Training local PFCCS instructors within an international environment is an effective method for establishing a uniform, reproducible, and sustainable approach to educating health-care providers in the fundamentals of pediatric critical care. Future collaborations will evaluate the clinical impact of PFCCS throughout the Georgian health-care system.
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Affiliation(s)
- Sheri S Crow
- Pediatric Critical Care, Mayo Clinic, Rochester, NY, United States
| | - Beth A Ballinger
- Department of Surgery, Division of Trauma, Acute Care General Surgery and Surgical Critical Care, Mayo Clinic, Rochester, NY, United States
| | - Mariela Rivera
- Department of Surgery, Division of Trauma, Acute Care General Surgery and Surgical Critical Care, Mayo Clinic, Rochester, NY, United States
| | - David Tsibadze
- Head of Maternal and Child Health Department, EVEX Medical Corporation, Tbilisi, Georgia
| | | | | | - Matthew J Ritter
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, NY, United States
| | - Grace M Arteaga
- Pediatric Critical Care, Mayo Clinic, Rochester, NY, United States
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Abstract
Pediatric critical care services in India have grown with leaps and bounds. There has been a growing need of physicians specially trained in pediatric critical care medicine (PCCM) in India. Physicians returning to India after their formal training in PCCM abroad have partly supported this growing need. Development of formal PCCM training programs in India has been a huge step toward supporting the growing clinical needs. This article focuses on advances in pediatric critical care training in India and its future directions.
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Affiliation(s)
- Utpal Bhalala
- Baylor College of Medicine at the Children's Hospital of San Antonio, San Antonio, TX, United States
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Slusher TM, Kiragu AW, Day LT, Bjorklund AR, Shirk A, Johannsen C, Hagen SA. Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned. Front Pediatr 2018; 6:49. [PMID: 29616202 PMCID: PMC5864848 DOI: 10.3389/fped.2018.00049] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/20/2018] [Indexed: 01/09/2023] Open
Abstract
Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.
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Affiliation(s)
- Tina M Slusher
- Department of Pediatrics, University of Minnesota and Hennepin County Medical Center, Minneapolis, MN, United States
| | - Andrew W Kiragu
- Department of Pediatrics, University of Minnesota and Hennepin County Medical Center, Minneapolis, MN, United States
| | - Louise T Day
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ashley R Bjorklund
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Arianna Shirk
- Department of Pediatrics AIC Kijabe Hospital, Kijabe, Kenya
| | - Colleen Johannsen
- Cardiac Intensive Care Unit of Regions Medical Center, St. Paul, MN, United States
| | - Scott A Hagen
- Department of Pediatrics, University of Wisconsin, Madison, WI, United States
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Argent AC. Considerations for Assessing the Appropriateness of High-Cost Pediatric Care in Low-Income Regions. Front Pediatr 2018; 6:68. [PMID: 29637061 PMCID: PMC5880905 DOI: 10.3389/fped.2018.00068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/08/2018] [Indexed: 12/24/2022] Open
Abstract
It may be difficult to predict the consequences of provision of high-cost pediatric care (HCC) in low- and middle-income countries (LMICs), and these consequences may be different to those experienced in high-income countries. An evaluation of the implications of HCC in LMICs must incorporate considerations of the specific context in that country (population age profile, profile of disease, resources available), likely costs of the HCC, likely benefits that can be gained versus the costs that will be incurred. Ideally, the process that is followed in decision making around HCC should be transparent and should involve the communities that will be most affected by those decisions. It is essential that the impacts of provision of HCC are carefully monitored so that informed decisions can be made about future provision medical interventions.
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Affiliation(s)
- Andrew C Argent
- Paediatric Critical Care, Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Murni IK, Musa NL. The Need for Specialized Pediatric Cardiac Critical Care Training Program in Limited Resource Settings. Front Pediatr 2018; 6:59. [PMID: 29594089 PMCID: PMC5861149 DOI: 10.3389/fped.2018.00059] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/27/2018] [Indexed: 12/30/2022] Open
Abstract
Congenital heart disease (CHD) is one of the major global health problems with the highest birth prevalence in low- and middle-income countries. In these populous countries, basic health services for the children with CHD, including surgery, are lacking. Even though surgery is performed, outcome after cardiac surgery is influenced by the quality of the postoperative management with a reported high morbidity and mortality. Henceforth, there is an urgent need for comprehensive interventions to provide high quality cardiac intensive care programs to improve the quality of pediatric cardiac surgery services in order to address high morbidity and mortality after cardiac surgery. The development and training of the health workers in the field of pediatric cardiac intensive care program is required. It is imperative to conduct this training prior to actual implementation of the program in limited resources settings.
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Affiliation(s)
- Indah K Murni
- Department of Pediatrics, Dr Sardjito Hospital, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ndidiamaka L Musa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, United States
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43
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Haniffa R, Pubudu De Silva A, de Azevedo L, Baranage D, Rashan A, Baelani I, Schultz MJ, Dondorp AM, Dünser MW. Improving ICU services in resource-limited settings: Perceptions of ICU workers from low-middle-, and high-income countries. J Crit Care 2017; 44:352-356. [PMID: 29275269 DOI: 10.1016/j.jcrc.2017.12.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 11/24/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate perceptions of intensive care unit (ICU) workers from low-and-middle income countries (LMICs) and high income countries (HICs). MATERIALS AND METHODS A cross sectional design. Data collected from doctors using an anonymous online, questionnaire. RESULTS Hundred seventy-five from LMICs and 43 from HICs participated. Barriers in LMICs were lack of formal training (Likert score median 3 [inter quartile range 3]), lack of nurses (3[3]) and low wages (3[4]). Strategies for LMICs improvement were formal training of ICU staff (4[3]), an increase in number of ICU nurses (4[2]), collection of outcome data (3[4]), as well as maintenance of available equipment [3(3)]. The most useful role of HIC ICU staff was training of LMIC staff (4[2]). Donation of equipment [2(4)], drugs [2(4)], and supplies (2[4]) perceived to be of limited usefulness. The most striking difference between HIC and LMIC staff was the perception on the lack of physician leadership as an obstacle to ICU functioning (4[3] vs. 0[2], p<0.005). CONCLUSION LMICs ICU workers perceived lack of training, lack of nurses, and low wages as major barriers to functioning. Training, increase of nurse workforce, and collection of outcome data were proposed as useful strategies to improve LMIC ICU services.
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Affiliation(s)
- Rashan Haniffa
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo 08, Sri Lanka; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo 08, Sri Lanka.
| | - A Pubudu De Silva
- National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo 08, Sri Lanka; Intensive Care National Audit & Research Centre, No. 24, High Holborn, London WC1V 6AZ, United Kingdom
| | - Luciano de Azevedo
- Intensive Care Unit, Hospital Sirio-Libanes, Sao Paulo, Brazil; Emergency Medicine Discipline, University of Sao Paulo, Sao Paulo, Brazil
| | - Dilini Baranage
- Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo 08, Sri Lanka
| | - Aasiyah Rashan
- Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo 08, Sri Lanka
| | | | - Marcus J Schultz
- Intensive Care Medicine at the Academic Medical Center of the University of Amsterdam, Netherlands
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Martin W Dünser
- Department of Critical Care Medicine, University College of London Hospital, London, United Kingdom
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Argent AC, Chisti MJ, Ranjit S. What's new in PICU in resource limited settings? Intensive Care Med 2017; 44:467-469. [PMID: 28913544 DOI: 10.1007/s00134-017-4905-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/09/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Andrew C Argent
- School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa. .,Paediatric Intensive Care, Red Cross War Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, South Africa.
| | - Mohammod J Chisti
- Clinical Research, Hospitals, Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.,ICU, Dhaka Hospital, NCSD, icddr,b, Dhaka, Bangladesh
| | - Suchitra Ranjit
- Pediatric Intensive Care, Apollo Children's Hospital, Chennai, India
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Nyirasafari R, Corden MH, Karambizi AC, Kabayiza JC, Makuza JD, Wong R, Canarie MF. Predictors of mortality in a paediatric intensive care unit in Kigali, Rwanda. Paediatr Int Child Health 2017; 37:109-115. [PMID: 27922344 DOI: 10.1080/20469047.2016.1250031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The enormous burden of critical illness in resource-limited settings has led to a growing interest in paediatric critical care in these regions. However, published data on the practice of critical care and patient outcomes in these settings are scant. OBJECTIVE This study sought to identify risk factors associated with mortality in the newly established Paediatric Intensive Care Unit (PICU) at Kigali University Teaching Hospital (KUTH) in Rwanda and test the predictive ability of a newly devised mortality risk score, the modified PRISM (MP) score. METHODS All admissions to the PICU at KUTH from October 2012 to October 2014 were included. Demographic and physiological data on each patient were gathered and each was assigned a MP score. This prospective cross-sectional study examined the association between the characteristics and physiological status of these patients and mortality. Using logistic regression, factors associated with mortality in the PICU were analysed. RESULTS A total of 213 children were admitted to the PICU during the study period. Three patients were excluded because of missing data. Of this total, 59% were male, 25% were neonates and nearly 60% were moderately to severely malnourished. The overall mortality rate was 50%. On bivariate analysis, factors associated with increased mortality were male sex, use of vasoactive medications, a MP score ≥ 5, a discharge diagnosis of septic shock, and malnutrition on admission. On multivariate analysis, only the use of vasoactive drugs [odds ratio (OR) 12.24, 95% confidence interval (CI) 4.4-35.4, p < 0.001] and MP score ≥ 5 (OR 16.1, CI 6.3-40.8, p < 0.001) were associated with mortality. CONCLUSION The observed mortality rate was in the range reported in other resource-limited settings. The initial attempt to create and implement a risk of mortality tool for this setting determined a score that could identify those patients at higher risk of mortality. In PICUs in resource-limited settings, the gathering of data and use of severity of illness tools could improve care in a number of ways.
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Affiliation(s)
- Rosine Nyirasafari
- a Department of Pediatrics and Child Health , Ministry of Health, Rwamagana Provincial Hospital , Rwamagana , Rwanda
| | - Mark H Corden
- b Division of Hospital Medicine , Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | | | - Jean Claude Kabayiza
- d School of Medicine and Pharmacy, College of Medicine and Health Sciences , University of Rwanda , Butare , Rwanda
| | - Jean Damascene Makuza
- e STIs Care and Treatment Senior Office, HIV and STIs Division, Rwanda Biomedical Centre , Kigali , Rwanda
| | - Rex Wong
- f Yale University Global Health Leadership Institute , New Haven , CT , USA
| | - Michael F Canarie
- g Department of Pediatrics, Division of Critical Care , Yale University School of Medicine , New Haven , CT , USA
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George EC. Good-quality research: a vital step in improving outcomes in paediatric intensive care units in low- and middle-income countries. Paediatr Int Child Health 2017; 37:79-81. [PMID: 28263089 DOI: 10.1080/20469047.2017.1295198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Elizabeth C George
- a Medical Research Council Clinical Trials Unit (MRC CTU) at UCL , Institute of Clinical Trials and Methodology, UCL , London , UK
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De Silva AP, Baranage DDS, Padeniya A, Sigera PC, De Alwis S, Abayadeera AU, Mahipala PG, Jayasinghe KS, Dondorp AM, Haniffa R. Critical Care Junior Doctors' Profile in a Lower Middle-income Country: A National Cross-sectional Survey. Indian J Crit Care Med 2017; 21:733-739. [PMID: 29279633 PMCID: PMC5699000 DOI: 10.4103/ijccm.ijccm_268_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background and Aims: Retention of junior doctors in specialties such as critical care is difficult, especially in resource-limited settings. This study describes the profile of junior doctors in adult state intensive care units in Sri Lanka, a lower middle-income country. Materials and Methods: This was a national cross-sectional survey using an anonymous self-administered electronic questionnaire. Results: Five hundred and thirty-nine doctors in 93 Intensive Care Units (ICUs) were contacted, generating 207 responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Most junior doctors (150, 75.8%) had no previous exposure to anesthesia and 134 (67.7%) had no previous ICU experience while 116 (60.7%) ICU doctors wished to specialize in critical care. However, only a few (12, 6.3%) doctors had completed a critical care diploma course. There was a statistically significant difference (P < 0.05) between the self-assessed confidence of anesthetic background junior doctors and non-anesthetists. The overall median competency for doctors improves with the length of ICU experience and is statistically significant (P < 0.05). ICU postings were less happy and more stressful compared to the last non-ICU posting (P < 0.05 for both). The vast majority, i.e., 173 (88.2%) of doctors felt the care provided for patients in their ICUs was good, very good, or excellent while 71 doctors (36.2%) would be happy to recommend the ICU where they work to a relative with the highest possible score of 10. Conclusion: Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed.
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Affiliation(s)
- Ambepitiyawaduge Pubudu De Silva
- National Intensive Care Surveillance, Ministry of Health, Sri Lanka.,Intenisve Care National Audit and Research Centre, London, United Kingdom
| | - D D S Baranage
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Anuruddha Padeniya
- Paediatric Neurology Unit, Lady Ridgeway Hospital, Colombo, Sri Lanka.,Faculty of Medicine, University of Rajarata, Anuradhapura, Colombo, Sri Lanka.,Sri Lanka Government Medical Officers Association, Colombo, Sri Lanka
| | - Ponsuge Chathurani Sigera
- National Intensive Care Surveillance, Ministry of Health, Sri Lanka.,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Sunil De Alwis
- Education, Training and Research Unit, Ministry of Health, Colombo, Sri Lanka
| | | | | | | | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Rashan Haniffa
- National Intensive Care Surveillance, Ministry of Health, Sri Lanka.,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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