Development of a quality indicator set to measure and improve quality of ICU care in low- and middle-income countries

PURPOSE

To develop a set of actionable quality indicators for critical care suitable for use in low- or middle-income countries (LMICs).

METHODS

A list of 84 candidate indicators compiled from a previous literature review and stakeholder recommendations were categorised into three domains (foundation, process, and quality impact). An expert panel (EP) representing stakeholders from critical care and allied specialties in multiple low-, middle-, and high-income countries was convened. In rounds one and two of the Delphi exercise, the EP appraised (Likert scale 1-5) each indicator for validity, feasibility; in round three sensitivity to change, and reliability were additionally appraised. Potential barriers and facilitators to implementation of the quality indicators were also reported in this round. Median score and interquartile range (IQR) were used to determine consensus; indicators with consensus disagreement (median < 4, IQR ≤ 1) were removed, and indicators with consensus agreement (median ≥ 4, IQR ≤ 1) or no consensus were retained. In round four, indicators were prioritised based on their ability to impact cost of care to the provider and recipient, staff well-being, patient safety, and patient-centred outcomes.

RESULTS

Seventy-one experts from 30 countries (n = 45, 63%, representing critical care) selected 57 indicators to assess quality of care in intensive care unit (ICU) in LMICs: 16 foundation, 27 process, and 14 quality impact indicators after round three. Round 4 resulted in 14 prioritised indicators. Fifty-seven respondents reported barriers and facilitators, of which electronic registry-embedded data collection was the biggest perceived facilitator to implementation (n = 54/57, 95%) Concerns over burden of data collection (n = 53/57, 93%) and variations in definition (n = 45/57, 79%) were perceived as the greatest barrier to implementation.

CONCLUSION

This consensus exercise provides a common set of indicators to support benchmarking and quality improvement programs for critical care populations in LMICs.

Diagnosis and management of ureterovaginal fistula in a resource-constrained setting: experience at a district hospital in northern Nigeria

During 2007 we were invited at different times to review and manage four women with ureterovaginal fistula following caesarean section performed in different rural hospitals. We describe our experience of a simple technique of diagnosis and management of these indigent patients in a resource-constrained hospital. The condition was diagnosed by the three-swab test in all four patients, and abdominopelvic ultrasound was employed to help find the ureter involved. Transvesical ureteral implantation with a stent was carried out. Stent was removed after 2 weeks. All four patients were dry. Amidst the complexity of and sophistication of modern health care, it is important to remind ourselves of the common occurrence of this distressing condition following caesarean section and the use of a well known simple diagnostic technique and subsequent management in resource-poor communities.

External fixators in austere environments under surge capacity conditions: A systematic review

BACKGROUND

High-energy trauma causing open fractures can take place in low-resource settings ("austere" environment) and mainly affects the lower limbs. In these environments, external fixators often provide definitive surgical treatment. This systematic review identifies those external fixators for use on lower limbs as a definitive treatment that are most clinically effective in the austere environment.

METHODS

Multiple databases were searched to identify studies investigating outcomes of external fixators used in austere environments. Case reports were excluded. Hand searching and expert input identified additional references.

FINDINGS

33 publications met the inclusion criteria. These were used worldwide. Commercially available fixators were used in 18 publications, and non-commercial ones including Balkan-designed devices in 6. The remaining non-commercial devices had 1 or 2 publications each. Union rates, where reported, varied from 47 to 100 % with no discernible difference between devices or location of use. Clinical complications varied from infection (0-79 %) through to nonunion and delayed union (0-22 %), loosening (0-36 %), osteomyelitis (0-19 %), construct stability (27-100 %), and amputation (0-50 %).

INTERPRETATION

The variability in union and complication rates highlights the variability in severity of injuries, type of austere environment, and variability in fixator device efficacy. The non-commercial or "one-off" devices show promise, with comparable or better outcomes to the commercial devices, whereas others did not work well, with poor outcomes. The need for surge capacity availability in these austere environments would enable locally manufactured devices to be quickly made which are fit for purpose, yet regulation and quality control of these remains a challenge in their rollout.

Authentication Schemes for Healthcare Applications Using Wireless Medical Sensor Networks: A Survey

Many applications are developed with the quick emergence of the Internet of things (IoT) and wireless sensor networks (WSNs) in the health sector. Healthcare applications that use wireless medical sensor networks (WMSNs) provide competent communication solutions for enhancing people life. WMSNs rely on highly sensitive and resource-constrained devices, so-called sensors, that sense patients' vital signs then send them through open channels via gateways to specialists. However, these transmitted data from WMSNs can be manipulated by adversaries without data security, resulting in crucial consequences. In light of this, efficient security solutions and authentication schemes are needed. Lately, researchers have focussed highly on authentication for WMSNs, and many schemes have been proposed to preserve privacy and security requirements. These schemes face a lot of security and performance issues due to the constrained devices used. This paper presents a new classification of authentication schemes in WMSNs based on its architecture; as far as we know, it is the first of its kind. It also provides a comprehensive study of the existing authentication schemes in terms of security and performance. The performance evaluation is based on experimental results. Moreover, it identifies some future research directions and recommendations for designing authentication schemes in WMSNs.

Ultrasound as a triaging tool for the diagnosis of malaria and typhoid in a resource constrained setting: A proposed frame-work

INTRODUCTION

Ultrasound has proven to have great potentials in the diagnosis and work-up of patients affected by tropical diseases. Its role in the diagnosis of malaria and typhoid abounds, but its value as a triaging tool in a resource-constrained settings is indistinct. Our review aimed is aimed at assessing the utility of ultrasound in diagnosis and prognosis of malaria and typhoid.

MATERIALS AND METHOD

Extensive literature search was conducted using the PubMed electronic database, for original peer reviewed articles in English language within 1964-2023. Keywords like "malaria", "typhoid", "S. Typhi", "Salmonella Typhi", "enteric fever", "ultrasound", "sonography" and "ultrasonography" were searched, using Boolean operators such as (OR, AND) applying the following filters (English, Human). A systematic synthesis of the literature was done.

RESULT

Our initial search yielded 749 potentially relevant references out of which 55 were found to be eligible. Organs assessed include the liver, spleen, kidneys, intestines, mesenteric lymph nodes, among others. For malaria, pathognomonic conditions like splenic enlargement, hepatomegaly, renal abnormalities as well as mesenteric lymph nodes and intestinal wall thickening in patients with typhoid fever.

CONCLUSION

Ultrasound by experienced clinicians adds significantly to the diagnosis and work-up of patients with malaria and typhoid fever. However, it is important to note that ultrasound alone may not be sufficient for definitive diagnosis as laboratory tests may still be required for confirmatory diagnosis.

IMPLICATION FOR PRACTICE

This study provide information on ultrasound in diagnosis of Malaria and typhoid by evaluating the morphological changes in abdominal and other organs of the body. This can be a guide to clinicians and other healthcare providers for early diagnosis and work-up of patients in endemic areas where resources are scarce.