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Provision of timely, safe, and affordable surgical care is an essential component of any high-quality health system. Increasingly, it is recognized that poor quality of care in the perioperative period (before, during, and after surgery) may contribute to significant excess mortality and morbidity. Therefore, improving access to surgical procedures alone will not address the disparities in surgical outcomes globally until the quality of perioperative care is addressed. We aimed to identify key barriers to quality perioperative care delivery for 3 "Bellwether" procedures (cesarean delivery, emergency laparotomy, and long-bone fracture fixation) in 5 low- and middle-income countries (LMICs).Ten hospitals representing secondary and tertiary facilities from 5 LMICs were purposefully selected: 2 upper-middle income (Colombia and South Africa); 2 lower-middle income (Sri Lanka and Tanzania); and 1 lower income (Uganda). We used a rapid appraisal design (pathway mapping, ethnography, and interviews) to map out and explore the complexities of the perioperative pathway and care delivery for the Bellwether procedures. The framework approach was used for data analysis, with triangulation across different data sources to identify barriers in the country and pattern matching to identify common barriers across the 5 LMICs.We developed 25 pathway maps, undertook30 periods of observation, and held40 interviews with patients and clinical staff. Although the extent and impact of the barriers varied across the LMIC settings, 4 key common barriers to safe and effective perioperative care were identified: (1) the fragmented nature of the care pathways, (2) the limited human and structural resources available for the provision of care, (3) the direct and indirect costs of care for patients (even in health systems for which care is ostensibly free of charge), and (4) patients' low expectations of care.We identified key barriers to effective perioperative care in LMICs. Addressing these barriers is important if LMIC health systems are to provide safe, timely, and affordable provision of the Bellwether procedures.

Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [VT] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median VT was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8–8.9], 8.0 [6.8–9.2], and 7.0 [5.8–8.4] mL/kg Predicted body weight; P = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5–7], five [5–8], and 10 [5–12] cmH2O; P < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66–71) and 7% (95% CI: 6–8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; P = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; P < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (receiver operating characteristic [ROC] area under the curve [AUC] of 0.62, 95% CI: 0.54–0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of VT is globally in line with current recommendations.

Purpose To study the efficacy of lopinavir-ritonavir and hydroxychloroquine in critically ill patients with coronavirus disease 2019 (COVID-19). Methods Critically ill adults with COVID-19 were randomized to receive lopinavir-ritonavir, hydroxychloroquine, combination therapy of lopinavir-ritonavir and hydroxychloroquine or no antiviral therapy (control). The primary endpoint was an ordinal scale of organ support-free days. Analyses used a Bayesian cumulative logistic model and expressed treatment effects as an adjusted odds ratio (OR) where an OR > 1 is favorable. Results We randomized 694 patients to receive lopinavir-ritonavir (n = 255), hydroxychloroquine (n = 50), combination therapy (n = 27) or control (n = 362). The median organ support-free days among patients in lopinavir-ritonavir, hydroxychloroquine, and combination therapy groups was 4 (– 1 to 15), 0 (– 1 to 9) and—1 (– 1 to 7), respectively, compared to 6 (– 1 to 16) in the control group with in-hospital mortality of 88/249 (35%), 17/49 (35%), 13/26 (50%), respectively, compared to 106/353 (30%) in the control group. The three interventions decreased organ support-free days compared to control (OR [95% credible interval]: 0.73 [0.55, 0.99], 0.57 [0.35, 0.83] 0.41 [0.24, 0.72]), yielding posterior probabilities that reached the threshold futility (≥ 99.0%), and high probabilities of harm (98.0%, 99.9% and > 99.9%, respectively). The three interventions reduced hospital survival compared with control (OR [95% CrI]: 0.65 [0.45, 0.95], 0.56 [0.30, 0.89], and 0.36 [0.17, 0.73]), yielding high probabilities of harm (98.5% and 99.4% and 99.8%, respectively). Conclusion Among critically ill patients with COVID-19, lopinavir-ritonavir, hydroxychloroquine, or combination therapy worsened outcomes compared to no antiviral therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06448-5.

Background The burden of critical illness in low-income countries is high and expected to rise. This has implications for wider public health measures including maternal mortality, deaths from communicable diseases, and the global burden of disease related to injury. There is a paucity of data pertaining to the provision of critical care in low-income countries. This study provides a review of critical care services in Ethiopia. Methods Multicenter structured onsite surveys incorporating face-to-face interviews, narrative discussions, and on-site assessment were conducted at intensive care units (ICUs) in September 2020 to ascertain structure, organization, workforce, resources, and service capacity. The 12 recommended variables and classification criteria of the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) taskforce criteria were utilized to provide an overview of service and service classification. Results A total of 51 of 53 (96%) ICUs were included, representing 324 beds, for a population of 114 million; this corresponds to approximately 0.3 public ICU beds per 100,000 population. Services were concentrated in the capital Addis Ababa with 25% of bed capacity and 51% of critical care physicians. No ICU had piped oxygen. Only 33% (106) beds had all of the 3 basic recommended noninvasive monitoring devices (sphygmomanometer, pulse oximetry, and electrocardiography). There was limited capacity for ventilation (n = 189; 58%), invasive monitoring (n = 9; 3%), and renal dialysis (n = 4; 8%). Infection prevention and control strategies were lacking. Conclusions This study highlights major deficiencies in quantity, distribution, organization, and provision of intensive care in Ethiopia. Improvement efforts led by the Ministry of Health with input from the acute care workforce are an urgent priority.

The ongoing novel coronavirus disease (COVID-19) pandemic is threatening the global human population, including in countries with resource-limited health facilities. Severe bilateral pneumonia is the main feature of severe COVID-19, and adequate ventilatory support is crucial for patient survival. Although our knowledge of the disease is still rapidly increasing, this review summarizes current guidance on the best provision of ventilatory support, with a focus on resource-limited settings. Key messages include that supplemental oxygen is a first essential step for the treatment of severe COVID-19 patients with hypoxemia and should be a primary focus in resource-limited settings where capacity for invasive ventilation is limited. Oxygen delivery can be increased by using a non-rebreathing mask and prone positioning. The presence of only hypoxemia should in general not trigger intubation because hypoxemia is often remarkably well tolerated. Patients with fatigue and at risk for exhaustion, because of respiratory distress, will require invasive ventilation. In these patients, lung protective ventilation is essential. Severe pneumonia in COVID-19 differs in some important aspects from other causes of severe pneumonia or acute respiratory distress syndrome, and limiting the positive end-expiratory pressure level on the ventilator may be important. This ventilation strategy might reduce the currently very high case fatality rate of more than 50% in invasively ventilated COVID-19 patients.

Purpose of review Critical care registries are synonymous with measurement of outcomes following critical illness. Their ability to provide longitudinal data to enable benchmarking of outcomes for comparison within units over time, and between units, both regionally and nationally is a key part of the evaluation of quality of care and ICU performance as well as a better understanding of case-mix. This review aims to summarize literature on outcome measures currently being reported in registries internationally, describe the current strengths and challenges with interpreting existing outcomes and highlight areas where registries may help improve implementation and interpretation of both existing and new outcome measures. Recent findings Outcomes being widely reported through ICU registries include measures of survival, events of interest, patient-reported outcomes and measures of resource utilization (including cost). Despite its increasing adoption, challenges with quality of reporting of outcomes measures remain. Measures of short-term survival are feasible but those requiring longer follow-ups are increasingly difficult to interpret given the evolving nature of critical care in the context of acute and chronic disease management. Furthermore, heterogeneity in patient populations and in healthcare organisations in different settings makes use of outcome measures for international benchmarking at best complex, requiring substantial advances in their definitions and implementation to support those seeking to improve patient care. Summary Digital registries could help overcome some of the current challenges with implementing and interpreting ICU outcome data through standardization of reporting and harmonization of data. In addition, ICU registries could be instrumental in enabling data for feedback as part of improvement in both patient-centred outcomes and in service outcomes; notably resource utilization and efficiency.

IntroductionAtrial fibrillation (AF) is the most common arrhythmia globally. It is associated with a fivefold risk in stroke, but early diagnosis and effective treatment can reduce this risk. AF is often underdiagnosed, particularly in low-income and middle-income countries (LMICs) where screening for AF is not always feasible or considered common practice in primary care settings. Epidemiological data on AF in LMICs is often incomplete particularly in vulnerable populations. This LMIC research collaborative aims to identify the prevalence of AF in the Northern Sri Lankan community.Methods and analysisA cross-sectional household survey piloted and codesigned through a series of community engagement events will be administered in all five districts in Northern Province, Sri Lanka. A multistage cluster sampling approach will be used starting at district level, then the Divisional Secretariats followed by Grama Niladhari divisions. Twenty households will be selected from each cluster. The study aims to recruit 10 000 participants aged 50 years or older, 1 participant per household. Demographic and socioeconomic characteristics, well-being and lifestyle and anthropometric measurements will be collected using a digital data platform (REDCap, Research Electronic Data Capture) by trained data collectors. Participants will be screened for AF using a fingertip single-lead ECG via a smartphone application (AliveCor) with rhythm strips reviewed by a consultant cardiologist. Prevalence of AF and risk factors will be established at province and district-levels. Adjusted ORs and population attributable fractions for AF risk factors will be determined.Ethics and disseminationThis study was approved by the Ethics Review Committee of Faculty of Medicine at University of Jaffna. Written informed consent will be obtained from all participants. Findings will be disseminated through publication in a peer-reviewed journal and presentations at conferences. The findings will enable early treatment for new AF diagnoses and inform interventions to improve community-based management of AF in LMICs.

Purpose To describe the extent and variation of critical care services in Pakistan. Materials and methods A cross-sectional survey was conducted in all intensive care units (ICUs) recognised for postgraduate training to determine administration, infrastructure, equipment, staffing, and training. Results There were 151 hospitals recognised for training, providing 2166 ICU beds and 1473 ventilators. Regional distribution of ICU beds per 100,000 population ranged from 1.0 in Sindh to none in Gilgit Baltistan (median 0.7). A senior clinician trained in critical care was available in 19 (12.1%) of units. One to one nurse to bed ratio during the day was available in 84 (53.5%) of units, dropping to 75 (47.8%) at night. Availability of 1:1 nursing also varied between provinces, ranging from 56.5% in Punjab compared to 0% in Azad Jamu Kashmir. Similarly there was disparity in availability of ventilators between provinces. All ICUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (electronic monitoring and infusion pumps). Conclusion Pakistan, a lower middle-income country, has an established network of critical care facilities with access to basic equipment, but inequalities in its distribution. Investment in critical care training for doctors and nurses is needed., Highlights • Critical care services are well established in Pakistan. • All intensive care units have access to basic equipment for essential critical care. • Inequity exists in access to critical care within and between regions. • Investment in specialist training for doctors and nurses is an urgent priority.

International audience; Benchmarking is a common and effective method for measuring and analyzing ICU performance. With the existence of national registries, objective information can now be obtained to allow benchmarking of ICU care within and between countries. The present manuscript briefly describes the current status of benchmarking in healthcare and critical care and presents the LOGIC project, an initiative to promote international benchmarking for intensive care units. Currently 13 registries have joined LOGIC. We showed large differences in the utilization of ICU as well as resources and in outcomes. Despite the need for careful interpretation of differences due to variation in definitions and limited risk adjustment, LOGIC is a growing worldwide initiative that allows access to insightful epidemiologic data from ICUs in multiple databases and registries.

A better understanding of the context-specific epidemiology, outcomes, and risk factors for death of critically ill parturients in resource-poor hospitals is needed to tackle the still alarming in-hospital maternal mortality in African countries. From October 2017 to October 2018, we performed a 1-year retrospective cohort study in a referral maternity hospital in Freetown, Sierra Leone. The primary endpoint was the association between risk factors and high-dependency unit (HDU) mortality. Five hundred twenty-three patients (median age 25 years, interquartile range [IQR]: 21-30 years) were admitted to the HDU for a median of 2 (IQR: 1-3) days. Among them, 65% were referred with a red obstetric early warning score (OEWS) code, representing 1.17 cases per HDU bed per week; 11% of patients died in HDU, mostly in the first 24 hours from admission. The factors independently associated with HDU mortality were ward rather than postoperative referrals (odds ratio [OR]: 3.21; 95% CI: 1.48-7.01; P = 0.003); admissions with red (high impairment of patients' vital signs) versus yellow (impairment of vital signs) or green (little or no impairment of patients' vital signs) OEWS (OR: 3.66; 95% CI: 1.15-16.96; P = 0.04); responsiveness to pain or unresponsiveness on the alert, voice, pain unresponsive scale (OR: 5.25; 95% CI: 2.64-10.94; P ≤ 0.0001); and use of vasopressors (OR: 3.24; 95% CI: 1.32-7.66; P = 0.008). Critically ill parturients were predominantly referred with a red OEWS code and usually required intermediate care for 48 hours. Despite the provided interventions, death in the HDU was frequent, affecting one of 10 critically ill parturients. Medical admission, a red OEWS code, and a poor neurological and hemodynamic status were independently associated with mortality, whereas adequate oxygenation was associated with survival.

Purpose The Good Intern Programme (GIP) in Sri Lanka has been implemented to bridge the ’theory to practice gap’ of doctors preparing for their internship. This paper evaluates the impact of a 2-day peer-delivered Acute Care Skills Training (ACST) course as part of the GIP. Study design The ACST course was developed by an interprofessional faculty, including newly graduated doctors awaiting internship (pre-intern), focusing on the recognition and management of common medical and surgical emergencies. Course delivery was entirely by pre-intern doctors to their peers. Knowledge was evaluated by a pre- and post-course multiple choice test. Participants’ confidence (post-course) and 12 acute care skills (pre- and post-course) were assessed using Likert scale-based questions. A subset of participants provided feedback on the peer learning experience. Results Seventeen courses were delivered by a faculty consisting of eight peer trainers over 4 months, training 320 participants. The mean (SD) multiple choice questionnaire score was 71.03 (13.19) pre-course compared with 77.98 (7.7) post-course (p Conclusions A peer-delivered ACST course was extremely well received and can improve newly qualified medical graduates’ knowledge, skills and confidence in managing medical and surgical emergencies. This peer-based model may have utility beyond pre-interns and beyond Sri Lanka.

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.

AimThis study evaluates the quality of care for patients admitted with acute myocardial infarction (AMI) in a tertiary hospital in Colombo using the European Society of Cardiology Quality of Care Working Group’s guidelines (2017).MethodsA recently implemented electronic AMI registry m-Health tool was used for prospective data collection. Each patient was assessed for eligibility for each of the six domains of quality. Global Registry of Acute Coronary Events Risk Model for predicted probability of mortality, and scores for risk of bleeding complications (CRUSADE) and severity of heart failure (Killip classification) were calculated as per published guidelines. A composite measure of quality was derived from compliance with the six domains. Patients were followed up via telephone at 30 days following discharge to evaluate outcome and satisfaction. Organisational information was assessed by administrative review and interview.ResultsBetween March 2017 and April 2018, 934 patients with AMI presented to the cardiology department. The majority of patients (90.4%) presented with features of ST-elevation myocardial infarction (STEMI). Mean (SD) overall compliance with the composite quality indicator (CQI) was 44% (0.07). Compliance of ≥50% to the CQI was achieved in 9.8% of STEMI patients. The highest compliance was observed for antithrombotics during hospitalisation (79.1%) and continuous measure of patient satisfaction (76.1%). The lowest compliance was for organisational structure and care processes (22.4%).ConclusionThis study reports a registry-based continuous evaluation of the quality of AMI care from a low and middle-income country. Priorities for improvement include improved referral, and networking of primary and secondary health facilities with the percutaneous coronary intervention centre.

Background The use of severity of illness scoring systems such as the Acute Physiology and Chronic Health Evaluation in lower-middle income settings comes with important limitations, primarily due to data burden, missingness of key variables and lack of resources. To overcome these challenges, in Asia, a simplified model, designated as e-TropICS was previously developed. We sought to externally validate this model using data from a multi-centre critical care registry in India. Methods Seven ICUs from the Indian Registry of IntenSive care(IRIS) contributed data to this study. Patients > 18 years of age with an ICU length of stay > 6 hours were included. Data including age, gender, co-morbidity, diagnostic category, type of admission, vital signs, laboratory measurements and outcomes were collected for all admissions. e-TropICS was calculated as per original methods. The area under the receiver operator characteristic curve was used to express the model’s power to discriminate between survivors and non-survivors. For all tests of significance, a 2-sided P less than or equal to 0.05 was considered to be significant. AUROC values were considered poor when ≤ to 0.70, adequate between 0.71 to 0.80, good between 0.81 to 0.90, and excellent at 0.91 or higher. Calibration was assessed using Hosmer-Lemeshow C -statistic. Results We included data from 2062 consecutive patient episodes. The median age of the cohort was 60 and predominantly male (n = 1350, 65.47%). Mechanical Ventilation and vasopressors were administered at admission in 504 (24.44%) and 423 (20.51%) patients respectively. Overall, mortality at ICU discharge was 10.28% (n = 212). Discrimination (AUC) for the e-TropICS model was 0.83 (95% CI 0.812–0.839) with an HL C statistic p value of < 0.05. The best sensitivity and specificity (84% and 72% respectively) were achieved with the model at an optimal cut-off for probability of 0.29. Conclusion e-TropICS has utility in the care of critically unwell patients in the South Asia region with good discriminative capacity. Further refinement of calibration in larger datasets from India and across the South-East Asia region will help in improving model performance.

We read with interest the study by Andrews et al. and the related correspondence from Shrestha et al.. We share the concern that clinical examination (and observations) appear(s) to be perceived as relatively unimportant in both the detection of the unwell patient and in the titration of interventions such as fluids, oxygen, antibiotics and vasopressors in LMICs. Studies have highlighted the limited availability of clinical observations in acutely unwell LMIC settings, which in addition to hindering detection of the deteriorating patient also complicates evaluation of an individual’s treatment and standards of care evaluation; for example, the assessment and implementation of early warning scores and prognostic models. In settings where potential for rescue by resourceintense interventions (e.g. ventilation) is remote, we too are surprised by the absence of a more central role for clinical examination and observations. It is of further concern that such limitations remain in the relatively highresource, high-visibility environment of a clinical trial.

Introduction Current evidence on epidemiology and outcomes of invasively mechanically ventilated intensive care unit (ICU) patients is predominantly gathered in resource-rich settings. Patient casemix and patterns of critical illnesses, and probably also ventilation practices are likely to be different in resource-limited settings. We aim to investigate the epidemiological characteristics, ventilation practices and clinical outcomes of patients receiving mechanical ventilation in ICUs in Asia. Methods and analysis PRoVENT-iMIC (study of PRactice of VENTilation in Middle-Income Countries) is an international multicentre observational study to be undertaken in approximately 60 ICUs in 11 Asian countries. Consecutive patients aged 18 years or older who are receiving invasive ventilation in participating ICUs during a predefined 28-day period are to be enrolled, with a daily follow-up of 7 days. The primary outcome is ventilatory management (including tidal volume expressed as mL/kg predicted body weight and positive end-expiratory pressure expressed as cm H 2 O) during the first 3 days of mechanical ventilation—compared between patients at no risk for acute respiratory distress syndrome (ARDS), patients at risk for ARDS and in patients with ARDS (in case the diagnosis of ARDS can be made on admission). Secondary outcomes include occurrence of pulmonary complications and all-cause ICU mortality. Ethics and dissemination PRoVENT-iMIC will be the first international study that prospectively assesses ventilation practices, outcomes and epidemiology of invasively ventilated patients in ICUs in Asia. The results of this large study, to be disseminated through conference presentations and publications in international peer-reviewed journals, are of ultimate importance when designing trials of invasive ventilation in resource-limited ICUs. Access to source data will be made available through national or international anonymised datasets on request and after agreement of the PRoVENT-iMIC steering committee. Trial registration number NCT03188770; Pre-results.

To describe the Epimed Monitor Database®, a Brazilian intensive care unit quality improvement database.We described the Epimed Monitor® Database, including its structure and core data. We presented aggregated informative data from intensive care unit admissions from 2010 to 2016 using descriptive statistics. We also described the expansion and growth of the database along with the geographical distribution of participating units in Brazil.The core data from the database includes demographic, administrative and physiological parameters, as well as specific report forms used to gather detailed data regarding the use of intensive care unit resources, infectious episodes, adverse events and checklists for adherence to best clinical practices. As of the end of 2016, 598 adult intensive care units in 318 hospitals totaling 8,160 intensive care unit beds were participating in the database. Most units were located at private hospitals in the southeastern region of the country. The number of yearly admissions rose during this period and included a predominance of medical admissions. The proportion of admissions due to cardiovascular disease declined, while admissions due to sepsis or infections became more common. Illness severity (Simplified Acute Physiology Score - SAPS 3 - 62 points), patient age (mean = 62 years) and hospital mortality (approximately 17%) remained reasonably stable during this time period.A large private database of critically ill patients is feasible and may provide relevant nationwide epidemiological data for quality improvement and benchmarking purposes among the participating intensive care units. This database is useful not only for administrative reasons but also for the improvement of daily care by facilitating the adoption of best practices and use for clinical research.Descrever a Epimed Monitor ICU Database®, uma base de dados brasileira cujo objetivo é a melhora da qualidade nas unidades de terapia intensiva do país.Descrevemos a Epimed Monitor ICU Database®, inclusive sua estrutura e seus dados principais. Com utilização de estatística descritiva, apresentamos dados informativos agregados das admissões às unidades de terapia intensiva entre os anos de 2010 e 2016. Descrevemos também a expansão e o crescimento da base de dados juntamente da distribuição geográfica das unidades participantes no Brasil.Os dados principais da base de dados incluíram informações demográficas, parâmetros administrativos e fisiológicos, assim como formulários específicos de relato para obter dados detalhados, com relação ao uso dos recursos da unidade de terapia intensiva, episódios infecciosos, eventos adversos e uma lista de verificação para adesão às melhores práticas clínicas. Até o final de 2016 tomou parte desta base de dados um total de 598 unidades de terapia intensiva para pacientes adultos, localizadas em 318 hospitais, perfazendo 8.160 leitos de terapia intensiva. Em sua maioria, as unidades participantes se localizavam em hospitais privados da Região Sudeste. O número anual de admissões apresentou um crescimento neste período, com predominância de admissões clínicas. A proporção de admissões em razão de doença cardiovascular diminuiu, enquanto as admissões por sepse ou infecções se tornaram mais comuns. Severidade da doença (Simplified Acute Physiology Score - SAPS 3 - 62 pontos), idade (média = 62 anos) e mortalidade hospitalar (cerca de 17%) permaneceram razoavelmente estáveis durante o período.Uma grande base de dados de pacientes críticos privados é viável e pode oferecer dados epidemiológicos abrangentes e relevantes para fins de melhoria da qualidade e comparação de resultados entre as unidades de terapia intensiva participantes. A base de dados é útil não apenas por razões administrativas, mas também por melhorar os cuidados diários, ao facilitar a adoção das melhores práticas e pode também ser utilizada em pesquisas clínicas.

In Sri Lanka, rabies prevention initiatives are hindered by fragmented and delayed information-sharing that limits clinicians' ability to follow patients and impedes public health surveillance.In a project led by the health ministry, we adapted existing technologies to create an electronic platform for rabies surveillance. Information is entered by trained clinical staff, and both aggregate and individual patient data are visualized in real time. An automated short message system (SMS) alerts patients for vaccination follow-up appointments and informs public health inspectors about incidents of animal bites.The platform was rolled out in June 2016 in four districts of Sri Lanka, linking six rabies clinics, three laboratories and the public health inspectorate.Over a 9-month period, 12 121 animal bites were reported to clinics and entered in the registry. Via secure portals, clinicians and public health teams accessed live information on treatment and outcomes of patients started on post-exposure prophylaxis (9507) or receiving deferred treatment (2614). Laboratories rapidly communicated the results of rabies virus tests on dead mammals (328/907 positive). In two pilot districts SMS reminders were sent to 1376 (71.2%) of 1933 patients whose contact details were available. Daily SMS reports alerted 17 public health inspectors to bite incidents in their area for investigation.Existing technologies in low-resource countries can be harnessed to improve public health surveillance. Investment is needed in platform development and training and support for front-line staff. Greater public engagement is needed to improve completeness of surveillance and treatment.Au Sri Lanka, les initiatives de prévention de la rage sont entravées par une diffusion des informations fragmentaire et lente, ce qui limite la capacité des cliniciens à suivre les patients et empêche la mise en œuvre d'une surveillance sanitaire.Dans le cadre d'un projet supervisé par le ministère de la Santé, nous avons adapté les technologies existantes afin de créer une plateforme électronique pour la surveillance de la rage. Les informations y sont saisies par du personnel clinique formé, et les données de chaque patient ainsi que les données globales y sont accessibles en temps réel. Un service automatisé de minimessages (SMS) avertit les patients à l'approche de leurs rendez-vous de suivi et de vaccination de rappel et informe les inspecteurs de santé publique des nouveaux cas de morsures d'animaux.La plateforme a été mise en œuvre en juin 2016 dans quatre districts du Sri Lanka. Elle relie six centres antirabiques, trois laboratoires et l'inspection de la santé publique.En 9 mois, 12 121 cas de morsures d'animaux ont été pris en charge par les centres antirabiques et saisis dans le registre. Les cliniciens et les équipes de santé publique ont pu accéder, via des portails sécurisés, à des informations actualisées en direct sur les traitements et l'évolution des patients, suivis dans le cadre d'un traitement prophylactique post-exposition (9 507) ou d'un traitement retardé (2 614). Les laboratoires ont pu communiquer rapidement les résultats des tests de dépistage de la rage réalisés sur des mammifères morts (328 cas positifs sur 907). Dans deux districts pilotes correspondant à un total de 1 933 patients pris en charge, des rappels par SMS ont été envoyés aux 1 376 patients (71,2%) dont les coordonnées de contact étaient connues. Des rapports SMS quotidiens ont permis d'avertir 17 inspecteurs de santé publique de nouveaux cas de morsures survenus dans leur secteur, pour enquête.Il est possible d'exploiter les technologies existantes, dans les régions à faibles ressources, pour améliorer la surveillance de la santé publique. Il est encore nécessaire d'investir dans le développement de cette plateforme et dans la formation et l'assistance du personnel de première ligne. Une plus grande sensibilisation du public est également nécessaire pour améliorer l'exhaustivité de la surveillance et des traitements.En Sri Lanka, las iniciativas de prevención de la rabia se ven obstaculizadas por un intercambio de información fragmentado y retrasado que limita la capacidad de los médicos de hacer seguimientos a sus pacientes e impide el control de la atención sanitaria.En un proyecto dirigido por el ministerio de sanidad, se adaptaron las tecnologías existentes para crear una plataforma electrónica para el control de la rabia. Personal clínico formado introduce la información, y los datos sobre pacientes se pueden consultar en tiempo real tanto de forma individual como global. Un sistema automatizado de mensajes cortos (SMS) alerta a los pacientes de citas para vacunas de seguimiento e informa a los inspectores de salud pública sobre incidentes de mordeduras de animales.La plataforma se implementó en junio de 2016 en cuatro distritos de Sri Lanka y vinculó seis clínicas de atención contra la rabia, tres laboratorios y el cuerpo de inspectores de salud pública.En un periodo de 9 meses, se informó a las clínicas de 12 121 mordeduras de animales, las cuales fueron inscritas en el registro. A través de portales seguros, los médicos y los equipos de salud pública accedieron a información en directo sobre el tratamiento y los resultados de los pacientes que comenzaron con profilaxis posterior a la exposición (9 507) o con tratamiento aplazado (2 614). Los laboratorios comunicaron con rapidez los resultados de las pruebas del virus de la rabia en animales muertos (328/907 positivos). En dos distritos piloto, se enviaron recordatorios SMS a 1 376 (71,2%) de los 1 933 pacientes de los que se disponían detalles de contacto. Informes con SMS diarios alertaron a 17 inspectores de salud pública sobre incidentes de mordeduras en su zona para que los investigaran.Las tecnologías existentes se pueden aprovechar en países con pocos recursos para mejorar el control de la salud pública. Se necesita invertir en el desarrollo de plataformas y en la formación y el apoyo del personal de primera línea. Es necesario un mayor compromiso público para mejorar la finalización del control y el tratamiento.تواجه مبادرات الوقاية من داء الكَلْب صعوبات في سرى لانكا بسبب التشتت والتأخير في مشاركة المعلومات، الأمر الذي يحد من قدرة الأطباء على متابعة المرضى كما يعوق رصد الصحة العامة. اتم طرح المنصة للعمل في شهر حزيران/يونيو عام 2016 في أربعة أحياء في سرى لانكا، مما ساعد في ربط ست عيادات لمعالجة داء الكَلْب وثلاثة مختبرات فضلاً عن هيئة التفتيش على الصحة العامة.على مدى فترة 9 أشهر، وردت بلاغات عن 12,121 حالة من عضات الحيوانات إلى العيادات وتم إدخالها في السجل. ومن خلال البوابات الإلكترونية الآمنة، فقد تمكن الأطباء وفرق الصحة العامة من الوصول إلى معلومات مباشرة عن العلاج ونتائج المرضى الذين بدأوا الوقاية المرض بعد التعرض للإصابة (9507) أو الذين بدأوا العلاج المؤجل (2614). وسرعان ما أبلغت المختبرات عن نتائج اختبارات فيروس داء الكَلْب على الثدييات الميتة (‏328/907 إيجابية). وفي منطقتين تجريبيتين، تم إرسال رسائل تذكيرية إلى 1376 (71.2‏٪) من أصل 1933 مريضًا توفرت تفاصيل الاتصال بهم. كما نبهت التقارير اليومية عبر الرسائل القصيرة 17 مفتشًا للصحة العامة عن حوادث لدغ في مناطق اختصاصهم لإجراء التحقيق فيها.يمكن تسخير التقنيات القائمة في البلدان منخفضة الموارد لتحسين مراقبة الصحة العامة. كما يلزم الاستثمار في المنصة لتطوير وتدريب ودعم العاملين في الخطوط الأمامية. وهناك حاجة إلى مزيد من المشاركة العامة لتحسين إتمام عمليات الرصد والعلاج.在斯里兰卡，狂犬病预防措施因分散和延迟的信息共享而受到阻碍，这也限制了临床医生追踪患者的能力，并且妨碍了公共卫生监督。.在一个卫生部领导的项目中，我们对现有技术进行了调整，建立了一个狂犬病监测电子平台。 由经过培训的临床人员输入信息，并且会实时显示总体和个体患者数据。 自动化短信系统 (SMS) 可通知患者进行后续的疫苗接种，并向公共卫生检查员通报动物咬伤事件。.该平台于 2016 年 6 月在斯里兰卡的四个地区推出，连接六个狂犬病诊所、三个实验室和相应公共卫生检查员。.在 9 个月的期间，共向诊所报告并登记在册 12 121 例动物咬伤事件。 通过安全门户网站，临床医生和公共卫生团队访问了从接触后预防开始治疗 (9507) 或接受延迟治疗 (2614) 的患者的治疗和结果实时信息。 实验室迅速传达了死亡哺乳动物狂犬病病毒检测的结果（328/907 阳性）。 在两个试点地区，向 1933 名提供了详细联系信息的患者中的 1376 (71.2%) 发送了短信提醒。 每日短信报告向 17 名公共卫生检查员通报其区域内发生的咬伤事件以进行调查。.可利用低资源国家的现有技术改善公共卫生监督。 需要在平台开发以及一线员工的培训和支持方面进行投资。 需要更多的公众参与以完善监督和治疗的完整性。.В Шри-Ланке инициативам по профилактике бешенства препятствует фрагментированный и медленный обмен информацией, который ограничивает возможности врачей по наблюдению за пациентами и препятствует надзору за общественным здравоохранением.В рамках проекта, возглавляемого Министерством здравоохранения, мы адаптировали существующие технологии для создания электронной платформы наблюдения за бешенством. Информация вводится обученным клиническим персоналом, при этом как совокупные, так и индивидуальные данные о пациенте визуализируются в реальном времени. Автоматизированная система коротких сообщений (SMS) предупреждает пациентов о назначении последующих прививок и информирует инспекторов общественного здравоохранения о случаях нападения животных на людей.Платформа была внедрена в июне 2016 года в четырех районах Шри-Ланки, объединив шесть клиник бешенства, три лаборатории и инспекцию общественного здравоохранения.За 9-месячный период в клиниках был зарегистрирован и внесен в реестр 12 121 случай укусов со стороны животных. Через защищенные порталы медицинские работники и группы общественного здравоохранения получили доступ к актуальной информации о лечении и исходах пациентов, начавших постконтактную профилактику (9507) или пациентов с отсроченным лечением (2614). Лаборатории быстро сообщали результаты тестов на вирус бешенства у мертвых млекопитающих (328 положительных из 907). В двух экспериментальных районах SMS-напоминания были отправлены 1376 (71,2%) из 1933 пациентов, чьи контактные данные были доступны. Ежедневные SMS-отчеты предупреждали 17 инспекторов здравоохранения о случаях нападения животных на людей в их районе для проведения контроля.Существующие технологии в странах с низким уровнем ресурсов могут быть использованы для улучшения эпиднадзора за общественным здравоохранением. Необходимы инвестиции в разработку платформы, обучение и поддержку обслуживающего персонала. Для улучшения полноты эпиднадзора и лечения требуется более активное участие общественности.

Background Current critical care prognostic models are predominantly developed in high-income countries (HICs) and may not be feasible in intensive care units (ICUs) in lower- and middle-income countries (LMICs). Existing prognostic models cannot be applied without validation in LMICs as the different disease profiles, resource availability, and heterogeneity of the population may limit the transferability of such scores. A major shortcoming in using such models in LMICs is the unavailability of required measurements. This study proposes a simplified critical care prognostic model for use at the time of ICU admission. Methods This was a prospective study of 3855 patients admitted to 21 ICUs from Bangladesh, India, Nepal, and Sri Lanka who were aged 16 years and over and followed to ICU discharge. Variables captured included patient age, admission characteristics, clinical assessments, laboratory investigations, and treatment measures. Multivariate logistic regression was used to develop three models for ICU mortality prediction: model 1 with clinical, laboratory, and treatment variables; model 2 with clinical and laboratory variables; and model 3, a purely clinical model. Internal validation based on bootstrapping (1000 samples) was used to calculate discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer-Lemeshow C-Statistic; higher values indicate poorer calibration). Comparison was made with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II models. Results Model 1 recorded the respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), blood urea, haemoglobin, mechanical ventilation, and vasopressor use on ICU admission. Model 2, named TropICS (Tropical Intensive Care Score), included emergency surgery, respiratory rate, systolic blood pressure, GCS, blood urea, and haemoglobin. Model 3 included respiratory rate, emergency surgery, and GCS. AUC was 0.818 (95% confidence interval (CI) 0.800–0.835) for model 1, 0.767 (0.741–0.792) for TropICS, and 0.725 (0.688–0.762) for model 3. The Hosmer-Lemeshow C-Statistic p values were less than 0.05 for models 1 and 3 and 0.18 for TropICS. In comparison, when APACHE II and SAPS II were applied to the same dataset, AUC was 0.707 (0.688–0.726) and 0.714 (0.695–0.732) and the C-Statistic was 124.84 (p < 0.001) and 1692.14 (p < 0.001), respectively. Conclusion This paper proposes TropICS as the first multinational critical care prognostic model developed in a non-HIC setting.

Objectives To deliver and evaluate a short critical care nurse training course whilst simultaneously building local training capacity. Research Methodology A multi-modal short course for critical care nursing skills was delivered in seven training blocks, from 06/2013-11/2014. Each training block included a Train the Trainer programme. The project was evaluated using Kirkpatrick’s Hierarchy of Learning. There was a graded hand over of responsibility for course delivery from overseas to local faculty between 2013 and 2014. Setting Sri Lanka Main Outcome Measures Participant learning assessed through pre/post course Multi-Choice Questionnaires. Results A total of 584 nurses and 29 faculty were trained. Participant feedback was consistently positive and each course demonstrated a significant increase (p ≤ 0.0001) in MCQ scores. There was no significant difference MCQ scores (p = 0.186) between overseas faculty led and local faculty led courses. Conclusions In a relatively short period, training with good educational outcomes was delivered to nearly 25% of the critical care nursing population in Sri Lanka whilst simultaneously building a local faculty of trainers. Through use of a structured Train the Trainer programme, course outcomes were maintained following the handover of training responsibility to Sri Lankan faculty. The focus on local capacity building increases the possibility of long term course sustainability

Objective This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. Design Longitudinal observational cohort study. Setting District General Hospital Monaragala Participants All adult (age >17 years) admitted patients. Main outcome measures Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. Statistical Analysis Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve. Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). Results Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). Conclusion There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients.