Research

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Objectives:
The aim of this article is to describe the delivery and acceptability of a short, structured training course for critical care physiotherapy and its effects on the knowledge and skills of the participants in Sri Lanka, a lower-middle income country.

Methods:
The two-day program combining short didactic sessions with small group workshops and skills stations was developed and delivered by local facilitators in partnership with an overseas specialist physiotherapist trainer. The impact was assessed using pre/post-course self-assessment, pre/post-course multiple-choice-question (MCQ) papers, and an end-of-course feedback questionnaire.

Results:
Fifty-six physiotherapists (26% of critical care physiotherapists in Sri Lanka) participated. Overall confidence in common critical care physiotherapy skills improved from 11.6% to 59.2% in pre/post-training self-assessments, respectively. Post-course MCQ scores (mean score = 63.2) and percentage of passes (87.5%) were higher than pre-course scores (mean score = 36.6; percentage of passes = 12.5%). Overall feedback was very positive as 75% of the participants were highly satisfied with the course’s contribution to improved critical care knowledge.

Conclusions:
This short, structured, critical care focused physiotherapy training has potential benefit to participating physiotherapists. Further, it provides an evidence that collaborative program can be planned and conducted successfully in a resource poor setting. This sustainable short course model may be adaptable to other resource-limited settings.

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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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Objective:
The objective of this study is to describe the characteristics of in-hospital cardiopulmonary resuscitation (CPR) attempts, the perspectives of junior doctors involved in those attempts and the use of do not attempt resuscitation (DNAR) orders.

Methods:
A cross-sectional telephone survey aimed at intern doctors working in all medical/surgical wards in government hospitals. Interns were interviewed based on the above objective.

Results:
A total of 42 CPR attempts from 82 hospitals (338 wards) were reported, 3 of which were excluded as the participating doctor was unavailable for interview. 16 (4.7%) wards had at least 1 patient with an informal DNAR order. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt, of which 6 occurred on wards with an informal DNAR order in place. 39 resuscitations were attempted. Survival at 24 h was 2 (5.1%). In 5 (13%) attempts, CPR was the only intervention reported. On 25 (64%) occasions, doctors were “not at all” or “only a little bit surprised” by the arrest.

Conclusions:
CPR attempts before death in hospitals across Sri Lanka is prevalent. DNAR use remains uncommon.

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Purpose:
To determine the applicability of APACHE II as a critical care prognostic score in a lower and-middle income setting and the implications of an incomplete dataset on model performance.

Materials and Methods:
The study was conducted in Sri Lanka with the participation of 18 state ICUs prior to initiation of a medical registry. Data needed for APACHE II probability calculation was extracted from case records of each patient by trained nursing officers onto paper case record forms (CRF). The study calculated the APACHE II physiological score and APACHE II mortality probability for this dataset using the 3 imputation methods; 1. imputed as normal as in the original APACHE II derivation; 2. imputed by the median value for that parameter in the dataset; 3. imputed by multiple imputation. APACHE II model performance was assessed by measuring discrimination using the area under the receiver operating characteristic curve, calibration using the Hosmer-Lemeshow Ĉ-statistic, and accuracy using the Brier score.

Results:
817 patients had APACHE II score calculated while 736 contained diagnoses enabling APACHE II probability calculation. Majority (70.3%) were medical admissions. Physiology measurements were complete in >70% with laboratory measurements varying from 60% to 20%. The standardized ICU mortality ratio varied from 0.59 (95% CI 0.56-0.62) when multiple imputation was applied to 0.84 (95% CI 0.79-0.91) when the scores are imputed as normal. Area under ROC curve for all three imputation techniques was approximately 0.7. The calibration of the APACHE II (Hosmer-Lemeshow C-statistic) was poor with p<0.005 for all three methods of imputation.

Conclusions:
APACHE II model is not applicable for the Sri Lankan ICU setting and the calculated score is highly dependent on the imputation method for missing values. A setting-adapted critical care prognostic model and exploration of imputation techniques are warranted.

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Introduction:
Quick Sequential Organ Failure Assessment (qSOFA) is potentially feasible tool to identify risk of deteriorating in the context of infection for to use in resource limited settings.

Purpose:
To compare the discriminative ability of qSOFA and a simplified systemic inflammatoryresponse syndrome (SIRS) score to detect deterioration in patients admitted with infection.

Methods:
Observational study conducted at District General Hospital Monaragala, Sri Lanka, utilising bedside available observations extracted from healthcare records. Discrimination was evaluated using area under the receiver operating curve (AUROC). 15,577 consecutive adult ( ≥ 18 years) admissions were considered. Patients classifi ed as having infection per ICD-10 diagnostic coding were included.

Results:
Both scores were evaluated for their ability to discriminate patients at risk of death or a composite adverse outcome (death, cardiac arrest, intensive care unit [ICU], admission or critical care transfer). 1844 admissions (11.8%) were due to infections with 20 deaths (1.1%), 29 ICU admissions (1.6%), 30 cardiac arrests and 9 clinical transfers to a tertiary hospital (0.5%). Sixty-seven (3.6%) patients experienced at least one event. Complete datasets were available for qSOFA in 1238 (67.14%) and for simplified SIRS (mSIRS) in 1628 (88.29%) admissions. Mean (SD) qSOFA score and mSIRS score at admission were 0.58 (0.69) and 0.66 (0.79) respectively. Both demonstrated poor discrimination for predicting adverse outcome AUROC = 0.625; 95% CI, 0.56-0.69 and AUROC = 0.615; 95% CI, 0.55- 0.69 respectively) with no significant difference (p value = 0.74). Similarly, both systems had poor discrimination for predicting deaths (AUROC = 0.685; 95% CI, 0.55-0.82 and AUROC = 0.629; 95% CI, 0.50-0.76 respectively) with no statistically signifi cant difference (p value = 0.31).

Conclusions:
qSOFA at admission had poor discrimination and was not superior to the bedside observations featured in SIRS. Availability of observations, especially for mentation, is poor in these settings and requires strategies to improve reporting.

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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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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<0.05). Increased overall confidence in managing ward emergencies was reported by 97.2% (n=283) of respondents. Participants rated their post-course skills to be significantly higher (p<0.05) than pre-course in all 12 assessed skills. Extended feedback on the peer learning experience was overwhelmingly positive and 96.5% would recommend the course to a colleague.

Conclusion:
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.

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Purpose: In-hospital cardiac arrests result in mortality of over 60% even in high income settings where dedicated resuscitation teams are functional. In Low and middle Income countries (LMICs), cardiac arrest outcomes are less well known, with limited evidence pointing to poorer outcomes. This study describes the characteristics of cardiopulmonary resuscitation practices in a District General Hospital (DGH) in a LMIC where a cardiac arrest nurse responder had been deployed and the availability of physiological variables needed to calculate selected Early Warning Scores.

Methods: This retrospective study was carried out at DGH Monaragala, a state hospital located in the Uva province of Sri Lanka. All patients who had a cardiac arrest, whether in-hospital or on arrival, and who were reported to the cardiac arrest nurse team in 2013 and the first six months of 2014 were included in this study. Information regarding demographics, reasons for admission, diagnoses, co-morbidities, the time of arrest, details of resuscitation and immediate resuscitation outcomes and destinations were recorded. Data availability for the common EWS used worldwide were assessed at admission and at 24 and 48 hours prior to cardiac arrest.

Results: A total of 173 patients were reported to the cardiac arrest team during the study period, of whom 151 were 18 years or older and were thus included in the analysis. Most cardiac arrests to which the cardiac arrest nurse was summoned happened during the day shifts (7am- 7pm) and 45 (30.4%) were in the weekend (Friday 7 pm to Monday 7am). Overall, out of the 150 patients who had CPR during the study period, 52 (35.1 %) patients were discharged alive from the hospital. A total of 74 (47.2%) patients had return of spontaneous circulation (ROSC) after CPR. Out of them, only 31 were admitted to ICU and others remained in the original clinical area. Survival at hospital discharge was similarly not statistically significant between those treated outside an ICU after ROSC and those who were treated in an ICU, though a higher proportion of those treated in ICUs died.

Conclusion: The limited availability of simple physiological parameters makes validation and deployment of EWS for early detection of deteriorating patients difficult and reinforces the need for acute care skills training for healthcare teams in LMIC settings. EWS and rapid response system in this LMIC may need to be setting adapted.

The future: We are currently validating a 2 parameter early warning score using a mobile app from January 2016 to help front-line staff detect acutely unwell patients. So far the initiative has captured over 25000 patients and over 100000 observations.

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Purpose: 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 (ICU) in Sri Lanka, a Low-Middle Income Country (LMIC).

Methods: This was a national cross-sectional survey using an anonymous self-administered electronic questionnaire. Self-perceived competencies for 8 common ICU skills was assessed using a likert scale ranging from 0-10. The same scale was used to query which interventions would help develop their ICU and how “outsiders” to could contribute to such efforts.

Results: 539 doctors in 88 ICUs (5 ICUs declined) were contacted, generating 198 unique responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Junior doctors (150, 75.8%) had no previous exposure to anaesthesia and (134, 67.7%) had no previous ICU experience. One hundred and sixteen (60.7%) ICU doctors wished to specialize in critical care. However, only a few (10, 5%) doctors were currently engaged in any specialist training. Short-course training needs are shown in table 1. There was a statistically significant difference (p<0.05) between the self-assessed confidence of anaesthetic background junior doctors (median 8.9, IQR 1.75), and non-anaesthetists (median 8.1, IQR 2.38). The overall median competency for doctors overall improves with the length of ICU experience (<12 months- 6.88, IQR 2.75, 1-4 years – 8.69, IQR 1.62 and >4 years – 9, IQR 1.25) and is statistically significant (p<0.05). The median (IQR) competency for junior doctors who have been in a previous ICU post was 8.9 (1.6) when compared with 8 (2.25) for those who have not held a previous ICU post. This difference is also statistically significant (p<0.05). ICU postings were less happy and more stressful compared to last non-ICU posting (p < 0.05 for both). The vast majority 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 ICU where they work to a relative with the highest possible score of 10 (on a 0-10 likert scale). Helpful interventions, including “outsider” help, as perceived by doctors are shown in figure 1.

Conclusion: Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed. The authors acknowledge Dr Dineshan Ranasinghe and Dr Kaushila Thilakasiri for their contribution for the study.

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Purpose: Though undergraduate medical training lays the foundation for the knowledge and analytical skills that are required by junior doctors there is a gap in the transference of this knowledge into the skills needed to act quickly and confidently in emergency situations. Good Intern Programme (GIP) in Sri Lanka has been initiated to bridge the “theory to practice gap’ of graduate doctors prior to their internship. This study describes the delivery and impact of an Acute Care Skills Training (ACST) programme for pre-internship doctors through a peer based training model, as part of the GIP.

Methods: A needs assessment was performed by an anonymous online survey of newly graduated doctors. The focus of the ACST programme was the recognition and management of common medical and surgical ward based emergencies. Course content was developed by a multidisciplinary and inter-professional group including newly graduated doctors. The faculties of trainers were selected from the group of graduate doctors via a series of Train the Trainer programmes.

Results: 81% (n=902) of pre interns who completed the needs assessment survey stated that they would like to participate in a 2-day practically focused ACST programme. 48% of them reported lack of confidence in interpreting key investigations for management of emergency situations, including ECG and ABG results. The 2-day training programme was conducted for small groups of up to 20 doctors over 4 months in late 2015. It was evaluated by 20 pre and post-course multiple choice test of 20 questions, a five station OSCE, a self-perceived skills assessment questionnaire and an anonymous candidate feedback form. We delivered 17 courses over 4 months, training 320 participants by a faculty consisting of 8 peer trainers. Post-MCQ scores were significantly higher when compared with pre-MCQ (p<0.05). The post course self-assessments for all skills were significantly higher (p<0.05) than the pre course self-assessments. The overall feedbacks from participants indicate a great majority strongly agreed that the course has improved their knowledge skills and confidence.

Conclusion: This experience demonstrates that it is possible to design and effectively deliver acute care skills training for pre-internship doctors in a Low Middle Income Countries using a peer based training model with support from more experienced local and overseas faculty. Peer learning could assist established medical schools in delivering interactive skills training necessary with minimal additional resources during their undergraduate training. Furthermore, similar peer programmes may have applicability beyond interns and beyond Sri Lanka, for honing essential practical skills.

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Purpose: Early recognition of patients with sepsis is crucial in a LMIC, especially as critical care availability is limited. Availability of observations is an added challenge in this setting. qSOFA has been proposed as a superior to the previously SIRS based sepsis definitions. This study is an external validation of qSOFA (AVPU was used instead of GCS) and SIRS (white cell count was not collected) in Monaragala District General Hospital (MDGH) in Sri Lanka .

Methods: 15577 consecutive adult (>=18 years) admissions from May to December 2015 were considered.

Results: 1844 admissions (11.8%) were due to infective causes as per ICD 10 coding and were included in this validation study. Observations from nursing charts and medical notes were extracted daily. Outcomes of interest were defined as deaths (20, 1.1%), ICU admissions (29, 1.6%), cardiac arrests needing CPR (30, 1.6%) and clinical transfers to a tertiary hospital (9, 0.5%). Sixty seven (3.6%) patients experienced at least one of these events. Observation availability is shown in figure 1. Mean (SD) qSOFA score and SIRS score at admission were 0.58 (0.69) and 0.66 (0.79) respectively. (figure 1). Validity was assessed using area under the receiver operating curve (AUROC), Hosmer Lemeshow (HL) test and odds ratio over baseline risk (age) for the recommended qSOFA and SIRS cut offs. qSOFA and SIRS both demonstrated poor discrimination for predicting events (AUROC=0.63 ; 95% CI, 0.56 – 0.69 and AUROC=0.62 ; 95% CI, 0.55– 0.69 respectively) but were both well calibrated (HL statistic p=0.51 and p=0.27 respectively). AUROC for qSOFA and SIRS were not significantly different (p=0.74). Discrimination for predicting deaths for qSOFA and SIRS were AUROC=0.68 (95% CI, 0.55 – 0.82) and AUROC=0.63 (95% CI, 0.50 – 0.76) respectively with HL statistic of p=0.16 and p=0.046 respectively. AUROC values for deaths were also not significantly different (p=0.31). Odds ratios over baseline risk (age) for qSOFA and SIRS are illustrated in figure 2.

Conclusion: This first validation study of qSOFA in a low acuity DGH in a LMIC demonstrates poor discrimination and good calibration in predicting adverse outcomes at admission for hospitalized patients with infections but is overall no better than the previous SIRS criteria. Observation availability (especially AVPU) needs to be improved.

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Purpose: Inclusion of Advanced Life Support (ALS) algorithms during cardiopulmonary resuscitation (CPR) is considered a bench-mark of a country’s health system. In Europe, proactive decisions are increasingly made as to whether resuscitation should be attempted in the event of a cardiac arrest. A national cardiac arrest audit undertaken in Sri Lanka in 2015 reported a high ratio of resuscitation attempts to deaths and poor outcomes following those attempts . The objective of this study to explore the characteristics of in hospital CPR practices, the use of Do Not Attempt Resuscitation (DNAR) orders and the perspectives of junior doctors involved in those attempts.

Methods: A cross-sectional telephone survey aimed at all consultant led medical and surgical wards in secondary and tertiary hospitals in Sri Lanka. Junior doctor interviews explored the practices and outcomes following CPR attempts, their perceptions regarding occurrence of cardiac arrest and probability of successful return of spontaneous circulation (ROSC) along with the use of DNAR orders.

Results: 82 (338 wards) of the 90 hospitals included were successfully contacted. The remaining 8 hospitals were not reachable despite multiple attempts. 42 CPR attempts were reported. 16 (4.7 %) wards had at least one patient with an informal DNAR order. 3 CPR attempts were excluded as the doctor interviewed did not participate in the attempt. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt. Of these 6 deaths occurred on wards with an informal DNAR order in place. Of the 39 attempted resuscitations 34 were immediately unsuccessful, 5 resulted in ROSC (3 sent to ICU for post-resuscitation care, whilst 2 remained on the ward). At 24 hours 2 (both in ICU) were still alive. Defibrillation was attempted in 5 cases. Intubation was attempted on 5 occasions. In 5 (13 %) of the resuscitation attempts CPR was the only intervention reported while 27 (69 %) received more than 1 vial of adrenaline, or defibrillation, and or intubation. Interviewees reported that in 25 (64 %) of these patients they were ‘not at all’ or only a ‘little bit surprised’ by the patient having a cardiac arrest. They further described the chances of a successful outcome as ‘unlikely or very unlikely 61 % of the time and likely or very likely only 10.3 % of the time.

Conclusions: Perspectives of junior doctors interviewed suggest many cardiac arrests were not a surprise and that the probability of ROSC following attempted resuscitation was unlikely. There is high incidence of patients receiving CPR attempts before death in hospitals across Sri Lanka with DNAR practices remaining uncommon. Outcomes remain poor, with ROSC after cardiac arrest being 12.8 % and survival at 24 hrs. 5.1 %. Of the 34 unsuccessful resuscitation attempts, defibrillation and or repeated adrenaline was reported in 67.6 % of cases.

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Background: To perform a comparative analysis of in-hospital results obtained from patients with acute ST elevation myocardial infarction (STEMI), who underwent rescue or primary percutaneous coronary intervention (PCI). The aim is to determine rescue PCI as a practical option for patients with no immediate access to primary PCI.

Methods: From Cardiology PCI Clinic of the National Hospital of Sri Lanka (NHSL), we selected all consecutive patients who underwent early percutaneous coronary intervention for acute STEMI presenting with ≤ 24 h door-to-balloon delay for primary PCI and ≤ 72 h door-to-balloon delay, (90 minutes after failed thrombolysis) for rescue PCI from March 2013 to April 2015 and their inhospital results were analyzed, comparing rescue and primary PCI patients.

Results: We evaluated 159 patients, of which 78 underwent rescue PCI and 81 underwent primary PCI. The culprit left anterior descending (LAD) vessel (76.9% vs. 58.8%; P=0.015) was more prevalent in rescue than in primary patients. Thrombus aspiration was less frequent in rescue group (19.2% vs. 40.7%; P=0.003). The degree of moderate-to-severe left ventricular dysfunction reflected by the ejection fraction <40% (24.3% vs. 23.7%; P=0.927) and prevalence of multivessel disease (41.0% vs. 43.8%; P=0.729) revealed no significant difference. Coronary stents were implanted at similar rates in both strategies (96.2% vs. 92.6%; P=0.331). Procedural success (97.4% vs. 97.5%; P=0.980) and mortality rates (5.1% vs. 3.8%; P=0.674), were similar in the rescue and primary groups.

Conclusion: In-hospital major adverse cardiac events (MACE) are similar in both rescue and primary coronary intervention groups, supporting the former as a practical option for patients with no immediate access to PCI facilities

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Purpose: This study describes the outcomes and complications after laparotomy and abdominal laparoscopic surgery in National Hospital, Sri Lanka.

Methods: All in-ward patients who had undergone intraperitoneal surgeries of 3 surgical units of National Hospital, Sri Lanka were interviewed on admission, post-op day 1, day 3, day 7, on discharge, day 30 and day 90 from March to August 2016. Demographic data, clinical and investigation findings and functional outcomes (using EQ5D and QoR-15) were prospectively collected. Ethical approval was provided by the Ethics review committee of Faculty of Medicine, University of Colombo.

Results: Total of 154 abdominal surgeries were performed during the above time period [elective 82.5%(n=127), emergency 17.5%(n=27)]. Mean age was 46.0±18.8 years. Majority of the patients (55.2%, n=85) were male. 77 (50.0%) were overweight (BMI>25kg /m2 ). Preoperatively 49 (31.8%) females and 43 (27.9%) males were detected to be anaemic (Hb<13g/dl for male, Hb<12g/dl for female). Co-morbidities were detected in 70 (45.4%) of the participants. [Hypertension = 39(25.3%) and Diabetes Mellitus= 37(24.0%)]. 61.0%(n=94) had laparotomies, 30.5%(n=47) had laparoscopic procedures and 8.5%(n=13) had laparoscopy converted to laparotomy. Postoperatively 64(41.5%) and 26(16.8%) stayed for 3days and 7 days in the ward respectively. Three deaths were reported before discharge. 86 (55.8%) patients were followed-up after 30 days with two deaths been reported. (Follow-up ongoing). 17 (11.0%) patients were followed up after 90 days with one death been reported. (Follow-up ongoing). Post-operative complications are mentioned in table 2. Functional outcomes are demonstrated in figure 1 and 2. There were no statistically significant associations between preoperative haemoglobin level, BMI, operative approach and co-morbidities with post-operative complications and functional outcome at day 30 and day 90 (p>0.05).

Conclusion: This is preliminary data of an ongoing study with follow up for 90 days. Following-up a larger number of patients up is indicated to produce a significant conclusion.

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High income countries increasingly focus on training staff in the recognition and management of reversible conditions associated with preventable cardiac arrest. Such courses aim to equip healthcare professionals to manage and rescue the acutely deteriorating patient. In low and middle income countries (LMICs) there remains limited availability of critical care therapies. Thus training to support early interventions to prevent significant physiological deterioration and cardiac arrest may be even more beneficial.

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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.

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The availability and role of physical therapists in critical care is variable in resource-poor settings, including lower middle-income countries.

The aim of this study was to determine: (1) the availability of critical care physical therapist services, (2) the equipment and techniques used and needed, and (3) the training and continuous professional development of physical therapists.

All physical therapists working in critical care units (CCUs) of state hospitals in Sri Lanka were contacted. The study tool used was an interviewer-administered telephone questionnaire.

The response rate was 100% (N=213). Sixty-one percent of the physical therapists were men. Ninety-four percent of the respondents were at least diploma holders in physical therapy, and 6% had non–physical therapy degrees. Most (n=145, 68%) had engaged in some continuous professional development in the past year. The majority (n=119, 56%) attended to patients after referral from medical staff. Seventy-seven percent, 98%, and 96% worked at nights, on weekends, and on public holidays, respectively. Physical therapists commonly perform manual hyperinflation, breathing exercises, manual airway clearance techniques, limb exercises, mobilization, positioning, and postural drainage in the CCUs. Lack of specialist training, lack of adequate physical therapy staff numbers, a heavy workload, and perceived lack of infection control in CCUs were the main difficulties they identified.

Details on the proportions of time spent by the physical therapists in the CCUs, wards, or medical departments were not collected.

Conclusions

The availability of physical therapist services in CCUs in Sri Lanka, a lower middle-income country, was comparable to that in high-income countries, as per available literature, in terms of service availability and staffing, although the density of physical therapists remained very low, critical care training was limited, and resource limitations to physical therapy practices were evident.

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Methods: Cross sectional descriptive study on a stratified random sample of 1300 individuals was conducted by an interviewer administered questionnaire, clinical examinations and blood investigations. A single fasting venous blood sugar of ≥126 mg/dl was considered diagnostic of new diabetics and poor control of diabetes mellitus as HbA₁C > 6.5 %.

Results: There were 202 (14.7 %) with diabetes mellitus. Poor control was seen in 130 (90.7 %) while 71 (49.6 %) were not on regular treatment. Highest proportions of poor control and not on regular medication were observed in estate sector, poorest social status category and poorest geographical area. The annual HbA_1C, microalbuminuria, retinal and neuropathy examination were performed in less than 6.0 %. Social gradient not observed in the management lapses. Most (76.6 %) had accessed private sector while those in estate (58.1 %) accessed the state system.

The microvascular complications of retinopathy, neuropathy and microalbuminuria observed in 11.1 %, 79.3 % and 54.5 % respectively. Among the macrovascular diseases, angina, ischaemic heart disease and peripheral arterial disease seen in 15.5 %, 15.7 % and 5.5 % respectively. These complications do not show a social gradient.

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Purpose

To assess the impact of a nurse-led, short, structured training program for intensive care unit (ICU) nurses in a resource-limited setting.

Methods

A training program using a structured approach to patient assessment and management for ICU nurses was designed and delivered by local nurse tutors in partnership with overseas nurse trainers. The impact of the course was assessed using the following: pre-course and post-course self-assessment, a pre-course and post-course Multiple Choice Questionnaire (MCQ), a post-course Objective Structured Clinical Assessment station, 2 post-course Short Oral Exam (SOE) stations, and post-course feedback questionnaires.

Results

In total, 117 ICU nurses were trained. Post-MCQ scores were significantly higher when compared with pre-MCQ (P < .0001). More than 95% passed the post-course Objective Structured Clinical Assessment (patient assessment) and SOE 1 (arterial blood gas analysis), whereas 76.9% passed SOE 2 (3-lead electrocardiogram analysis). The course was highly rated by participants, with 98% believing that this was a useful experience.

Conclusions

Nursing Intensive Care Skills Training was highly rated by participants and was effective in improving the knowledge of the participants. This sustainable short course model may be adaptable to other resource-limited settings.

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Introduction: Early recognition and prevention of deterioration of ward patients can improve patient outcome and reduce critical care admission. In low and middle income countries (LMICs), with often minimal access to critical care therapies, the benefit may be even greater. However, training to assist ward nurses develop acute care skills remains limited such settings. As part of the NICST portfolio of acute care training, the Sri Lankan nursing faculty sought assistance to deliver a 2-day course for ward nurses.

Objectives: To design clinically relevant short course for ward nurses in a LMIC to be delivered by local nursing tutors and facilitators. To assess whether such a clinically focused programme would increase ward nurse’s knowledge and skills in identifying and managing deteriorating patients.

Methods: A multi modal 2-day acute care course for ward nurses was co-designed and delivered by specialist overseas trainers in partnership with national tutors. The courses were sponsored by the Ministry of Health, Sri Lanka. Based upon the NICST model of collaborative course design, local faculty were up skilled in delivery and content through a pre course Train the Trainer programme. Candidates were invited to undertake on-line pre course e-learning. Core clinical guidelines were delivered using mini lectures. Facilitator-led skills stations and structured scenarios were used to develop clinical skills. Short term knowledge acquisition was tested by a pre and post course Multi-Choice Questionnaire (MCQ). Newly acquired skills and their application was assessed through a post course Objective Clinical Skills Assessment (OSCA) station.

Results: 122 ward nurses were trained over 6 courses in 2 locations. Post MCQ scores were significantly higher for each course compared to pre MCQ (Wilcoxon sign rank test P < 0.0001). Over 71% passed the OSCA (pass mark of 60). Feedback reveals high candidate satisfaction.

Conclusion: Our short course results demonstrate an increase in relevant knowledge and clinical skills of the participants. Our NICST model demonstrates the feasibility of a local nursing faculty in a LMIC co-designing and effectively delivering a setting adapted acute care training programme integrated into the local nurse training system.

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There have been impressive gains in public health in low- and middle-income countries in recent decades, which are contributing to significant reductions in infant mortality, malaria attributable mortality and a general improvement in life expectancy in these countries. With basic public health needs better addressed, improvements in curative care, in particular for the critically ill, are becoming more important for saving lives. The recent and continuing outbreaks of severe acute respiratory infections due to emerging infections give further political and media attention to critical care. Increased awareness of the importance of critical care is reflected in an increase in availability of dedicated intensive care units (ICUs) in low-middle-income and middle-income countries. However, with the scarce data available, it appears that severity adjusted case fatality in ICUs in these settings remains much higher than in higher income countries.3,4 Improving these outcomes will require evaluation of setting specific factors adversely affecting performance and identification of investments and interventions to address them.

In general, ICUs in low- and middle-income countries have to function with important limitations in material and human resources, although improving in some countries.1,2,5 Laboratory support is limited, supplies of consumables and medication can be unpredictable, and proper maintenance of crucial equipment for monitoring and treatment is often a challenge. Nevertheless, many of the basic principles of good critical care are as applicable (or are even more so) to resource poor settings, but are often not practiced. These include management and organizational aspects, such as regular ward rounds, empowerment of nurses, proper and frequent documentation of vital signs, structured handover to the next shift of doctors and nurses, admission and discharge policies, the use of both short-term and long-term treatment plans, and adherence to strict hygiene rules.

The ‘Surviving Sepsis Campaign’ guidelines for severe sepsis and septic shock management6 have been implemented widely in ICUs in high-income countries and have, together with timely administration of essential therapies, contributed to improved survival. Part of these recommendations can be applied to more resource-limited settings at low or no extra costs. These include the use of low tidal volumes for mechanical ventilation, prompt start of appropriate empirical antibiotic treatment, restricted use of fluid therapy after the initial phase in septic shock and restricted use of sedation. From the limited data available, these practices are often not implemented.7

An important drawback of the ‘Surviving Sepsis Campaign’ guidelines is that the evidence for the recommendations has been mainly gathered from studies in high-income countries. Often this evidence cannot be directly translated to the resource-poor setting.8 The causes of severe sepsis are different in tropical countries and often require different approaches for their management. Examples are severe falciparum malaria and severe dengue, which require more restricted fluid therapy than recommended for bacterial sepsis.8,9 Also, some of the widely accepted recommendations for well-equipped ICUs can be dangerous in a resource-poor setting. An example is the early start of enteral feeding, including in sedated and comatose patients. In resource-poor settings, intubation for airway protection in patients with reduced consciousness is commonly not possible because of limited availability of mechanical ventilation. Early start of enteral feeding through a nasogastric tube in this group of patients results in aspiration pneumonia in an unacceptably large proportion of patients10 and should be reconsidered. Thus, many guidelines will require careful setting-adjusted re-evaluation.

A basic requirement for improving critical care in resource-poor settings are tools for evaluation of baseline ICU facilities, practices and performance, which also facilitates assessment of improvement over time when changes are implemented. In rich countries, ICU registries have proven to be critical tools for monitoring ICU performance. These registries can be adjusted to the more resource-limited setting and can be implemented at relatively low costs.2 A limited number of low- and middle-income countries are using such registries, and a wider roll-out is clearly warranted. Such registries (local, national or regional across borders) will also enable inventorying existing ICUs and availability of equipment and other resources. Minimum standards for equipment, monitoring and treatment required for critical care adjusted to low- and middle-income countries have not been described and a registry can help make these recommendations. Monitoring of nosocomial infections and antimicrobial resistance patterns in the ICU could be an important part of the registry, but facilities for microbiology are unfortunately underdeveloped in these countries. Training of both doctors and nurses working in the ICU is another important area for sustained improvement of care. Collaboration between countries where ICU medicine has been established, and countries where critical care as a separate specialty is still at its early stages, can facilitate this. International networks and linked registries can help identify priority areas for improvement and training, develop communication channels and contribute to create a critical mass of critical care trainers.

It is clear from the multitude of these issues, that research and quality improvement initiatives at different levels targeted towards critical care in resource-limited settings are warranted. The potential gains for the individual, families, ICU, hospital and healthcare systems are likely to be large and potentially of greater magnitude than is currently possible in high-income countries. Currently there is only a limited body of literature available on the topic and the usual funding schemes rarely focus on this important area. At the same time there is widespread interest on the topic of critical care as a global need, as witnessed by an increasing number of professional organizations with active working groups on the topic. We should capitalize on this development and make a concerted effort to make quality care for the critically ill patient a reachable goal for the entire globe.

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Purpose: Although positive effects of structured training programs were demonstrated previously there is a paucity of research regarding the effectiveness of critical care training for physiotherapists and its effectiveness, specifically in resource-limited settings. The aim of this study is to describe the delivery and acceptability of a short, structured training course in critical care physiotherapy and its effects on the knowledge and skills of the participants in Sri Lanka, a lower-middle income country.

Methods: Cross sectional design with pre and post assessments. The 2-day program combining short didactic sessions with small group workshops and skills stations was developed and delivered by local facilitators in partnership with an overseas specialist physiotherapist trainer. The study setting was School of Physiotherapy and Occupational Therapy, Ministry of Health, Sri Lanka. The participants were physiotherapists who participated in the 2-day program. The impact of the course was assessed using pre and post-course self-assessment, pre and postcourse MCQ papers and an end-of-course feedback questionnaire.

Results: Fifty-six physiotherapists (26% of CCU physiotherapists in Sri Lanka) participated. Overall confidence in common critical care physiotherapy skills improved from 11.6% to 59.2% in pre and post-training self-assessments respectively. Post- course MCQ scores (mean score = 63.2) and percentage of passes (87.5%) were higher than pre-course scores (mean score = 36.6, percentage of passes = 12.5%). Overall feedback was very positive with 75% of the participants were highly satisfied with the course’s contribution to improved critical care knowledge.

Conclusion: This short, structured, critical care focused physiotherapy training has potential to benefit the participating physiotherapists. It also provides evidence such a collaborative program can be planned and conducted successfully in a resource poor setting. This sustainable short course model may be adaptable to other resource-limited settings.

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Introduction: The global burden of critical care is increasing in lower and lower middle income countries (LICs/LMICs). The critically ill in these settings, mainly the younger age group, commonly suffer high mortality due to reversible illnesses and there is fierce competition for limited available ICU resources. Improving access to critical care and improving quality of care can thus potentially save many lives. An emergency bed availability system and a critical care clinical registry are significant ways in which this can be done by improving transparency and accountability.

The absence of a bed availability system for ICUs in Sri Lanka costs lives. Its absence causes healthcare workers to waste time looking for a bed for a patient when their own ICU has no beds. Some patients even die during this inefficient, incomplete and often futile hunt for beds across more than 100 ICUs. Suboptimal care is often provided for patient during the wait to find ICU bed as staff are engaged in the search for beds. With critically ill patients remaining in the ward/theatre/OPD awaiting transfer, the care for remaining patients is compromised. Patients are transferred to remote hospitals when nearby beds may have been available, inconveniencing them and their relatives. The actual demand for ICU beds is concealed from health care professionals and health care planners. This prevents targeted action to improve circumstances and increases health care costs.

An ICU clinical registry tracks performance of ICUs scientifically, enabling benchmarking of units. Clinical critical care scoring systems are used for categorization and prognostication of ICU patients helping resource planning in ICUs, comparing quality of patient care across ICUs, and standardizing research in the field of critical care medicine. There is evidence that the establishment of such a system, including feedback mechanisms and monitoring, improves critical care services. ICU performance tools and indicators developed in high-middle income countries are of uncertain use in developing countries. Methodologies from high-income countries cannot be directly transplanted to LICs/LMICs. Sri Lanka lacked a critical care surveillance system. The country therefore needed an ICU surveillance system that is comprehensive, structured and sustainable. Such a registry would also promote sustainable local capacity building, aid quality improvement strategies, promote research and clinical audit, and encourage training of staff.

Solution: Our solution, NICS, is a national critical care clinical registry and bed availability system gathering, cleaning, analysing and disseminating information from ICUs regarding patients, staffing, beds and other available resources. Our system, in addition, captures information to enable benchmarking of ICUs relative to how ill ICU patients are (severity scoring) using standard available severity scoring algorithms such as Acute Physiological And Chronic Health Evaluation (APACHE) II, IV and Nine Equivalents of nursing Manpower Score (NEMS). The system also makes it possible to assess 30 day post ICU mortality. The system can function off line while transmitting data centrally when connected to the Internet. It is useable by ICU staff (doctors and nurses) with minimal or no computer literacy and has in-built validation tools to improve data accuracy.

The other core features incorporated in our NICS system for Sri Lanka include relevance, low cost for setup and maintenance, use of simple technology, sustainability, capacity building benefits, having cross platform utility, having a quick feedback loop, having a validation component and being user friendly.

Solution Details: Each ICU in the NICS system is provided with a computer, a landline telephone, internet access and software to capture the information. The medical staff is trained to enter the information which is stored in the secure government data cloud. . A multi-disciplinary needs analysis was conducted at the start of the software cycle. A software system requirements and system design document were prepared. A minimal iterative dataset for Sri Lankan ICUs was designed. The mock ups of the registry system were created and feedback was obtained. A prototype was developed which iteratively led to our definitive software with assistance from Information Communication Technology Agency (ICTA), Respere (Pvt.) Ltd and overseas collaborators. The essential features of the software are: the entire application is web based, does not require installation, can function online and offline, provides validation tools, provides data for quick feedback to users, is user friendly and supports the emergency bed system. The system also allows ICUs to report equipment defects and operational problems to the centres.

Feedback is provided, after validation and analysis, through weekly and quarterly reports. Training and research needs have been identified using the information provided from the ICUs and led to remedial measures.

Business Benefits or Social Benefits: NICS functions 24/7 and has networked more than 95% of general, medical and surgical ICUs. It has registered more than 14,230 admissions to ICUs in Sri Lanka. The bed availability system helps to save patient lives directly by reducing the time spent on searching a bed and has been functional from October 2013. This system provides bed usage and bed pressure information to the Ministry of Health (MoH), which is used to improve access to critical care. NICS allows ICU performance outcomes to be expressed relative to other units. Once benchmarked, ICUs are now able to learn from others which practices allowed them to excel in comparison. NICS has improved transparency, accountability and the ability to direct scarce resources towards identified needs in a targeted manner. The NICS system was utilized for capacity building of critical care personnel with more than 30% of ICU nurses nationally being trained clinically during the past year. The system has led to local and international research in critical care with over 10 research proposals actioned.

Summary: NICS is the only national electronic bed availability system and electronic critical care clinical registry in a lower middle income country worldwide. It has begun to transform practice of critical care in Sri Lanka and is a potential model for the rest of the developing world.

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Purpose:

To assess the impact of a nurse-led, short, structured training program for intensive care unit (ICU) nurses in a resource-limited setting.

Methods:

A training program using a structured approach to patient assessment and management for ICU nurses was designed and delivered by local nurse tutors in partnership with overseas nurse trainers. The impact of the course was assessed using the following: pre-course and post-course self-assessment, a pre-course and post-course Multiple Choice Questionnaire (MCQ), a post-course Objective Structured Clinical Assessment station, 2 post-course Short Oral Exam (SOE) stations, and post-course feedback questionnaires.

Results:

In total, 117 ICU nurses were trained. Post-MCQ scores were significantly higher when compared with pre-MCQ (P < .0001). More than 95% passed the post-course Objective Structured Clinical Assessment (patient assessment) and SOE 1 (arterial blood gas analysis), whereas 76.9% passed SOE 2 (3-lead electrocardiogram analysis). The course was highly rated by participants, with 98% believing that this was a useful experience.

Conclusion:

Nursing Intensive Care Skills Training was highly rated by participants and was effective in improving the knowledge of the participants. This sustainable short course model may be adaptable to other resource-limited settings.

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