Quality Care for Critically Ill Should be Goal for All

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A viewpoint article in JAMA suggests that while more beds and a focus on quality will improve critical care in developing countries disease-specific and setting-specific factors need to be factored in.

Problems in the care for critically ill patients in developing countries go beyond the ICU. Because of a lack of appropriate ambulance and out-of-hospital care, there is often a delay in treatment for patients with trauma, stroke and myocardial infarction, thus increasing mortality.

Arjen M. Dondorp, MD, PhD, Mahidol University, Bangkok, Thailand, Shivakumar S. Iyer, MD, Bharati Vidyapeeth, University Medical College, Pune, India. and Marcus J. Schultz, MD, address the limitations of critical care in these settings, and advise on the disease-specific and setting-specific factors to consider when working to improve quality.

Diseases
Mortality due to infectious diseases is higher in developing countries. Sepsis is also a major reason for ICU admission. Antibiotic-resistant infections are growing. There are regional variations in in bacterial epidemiology that require tailored empirical antibiotic treatment.

Settings
Challenges to ICUs in developing countries include lack of basic equipment and equipment maintenance. Basic supplies may be intermittent. Some of these limitations can be overcome, for example hand gel in areas where running water is not always available or reuse of consumables such as ventilator tubing. The authors suggest that monitoring arterial blood gas analysis can be replaced by pulse oximetry. Point-of-care ultrasound should be evaluated in these settings for haemodynamic and pulmonary assessment. While care is low cost compared to developed countries, the burden often falls on the patient, for whom it is a large proportion of their income. They advise increasing ICU beds in public hospitals or improved subsidise health insurance.

Training and Quality Improvement
Basic principles of good critical care are the subject of various training initiatives in place from organisations including the World Health Organization. Such training should include management and organisational skills as well as clinical skills. The authors suggest that ICUs in resource-rich hospitals could partner with an ICU in resource-limited countries to support them and exchange knowledge.

Setting-specific recommendations are beginning to be produced, including an initiative from the European Society of Intensive Care Medicine (ESICM), for example Serpa Neto et al. (2016).

Research into translating and applying ICU guidelines from resource-rich countries to resource-limited settings is limited as is access to funding for such research. However, it is to be welcomed that, increasingly, professional organisations have started initiatives to improve critical care in low- and middle-income countries.

Source: JAMA
Image credit: freeimages.com

References:

Dondorp AM, Iyer SS, Schultz MJ (2016) Critical care in resource-restricted settings. JAMA, 315(8):753-4. doi: 10.1001/jama.2016.0976.

Serpa Neto A, Schultz MJ, Festic E (2016) Ventilatory support of patients with sepsis or septic shock in resource-limited settings. Intensive Care Med. 2016;
42(1):100-103.

Published on : Mon, 21 Mar 2016


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Critically ill, ICU, developing countries A viewpoint article in JAMA suggests that while more beds and a focus on quality will improve critical care in developing countries disease-specific and setting-specific factors need to be factored in. disease-specific and setting-specific factors may hin

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