Research
Since 2013 we have built a portfolio of research projects, encompassing acute and critical care. Projects are informed by the evaluations of existing care made possible by our investment in establishing clinician co-designed, continuous surveillance networks in low and middle-income countries. Our projects have resulted in international publications informing regional policy, national training programmes, and the implementation of national health surveillance systems.



Our research is driven by frontline clinicians and patient priorities. Our research output focuses on improving the quality of and access to acute and critical care services. To achieve this our research combines clinical medicine with health informatics, epidemiological and social science, along with health systems and improvement science methods to find innovative solutions to improving care.
Our current research extends into the following areas:
- Risk stratification and prognostic modelling in acute and critical illness
- Outcomes following critical care
- Impact of education and clinical training in acute critical care
- Importance of information for health service evaluation in acute and critical care
- Recognition of deteriorating ward patients
- Perioperative outcomes and recovery
- Symptom burden in acute and chronic care
- Economic impact for patients receiving renal dialysis
- Role of technology in improving health systems
- Patient reported outcome and experience priorities following critical illness
Our publications and their citations can be accessed through our Google Scholar profile.
Publications
2019
Global Critical Care: Add Essentials to the Roadmap
Schell, C.E., Beane, A., Kayambankadzanja, R.K., Khalid, K., Haniffa, R., Baker, T.
July 2019
Annals of Global Health
SAT-231 Quality of Life and Burden of Symptoms in Chronic Kidney Disease Patients Undergoing Dialysis in Sri Lanka, A Population-Based Survey Using a Electronic Renal Registry
Nazar, L., Herath, C., Lokugama, H., Priyadarshani, G. D. D., De Silva, P., Ranasinghe, A.V., Beane, A., Haniffa, R.
July 2019
Kidney International Reports
Addressing the information deficit in Global Health: Lessons from a digital acute care platform in Sri Lanka
Beane, A., De Silva, P., Lakmini Athapattu, P., Jayasinghe, S., Unnathie Abayadeera, A., Wijerathne, M., Gamage, I., Rathnayake, S., Dondorp, A.M., Haniffa, R.
January 2019
British Medical Journal Global Health
Show Abstract
Abstract:
Lack of investment in low-income and middle-income countries (LMICs) in systems capturing continuous information regarding care of the acutely unwell patient is hindering global efforts to address inequalities, both at facility and national level. Furthermore, this of lack of data is disempowering frontline staff and those seeking to support them, from progressing setting-relevant research and quality improvement. In contrast to high-income country (HIC) settings, where electronic surveillance has boosted the capability of governments, clinicians and researchers to engage in service-wide healthcare evaluation, healthcare information in resource-limited settings remains almost exclusively paper based. In this practice paper, we describe the efforts of a collaboration of clinicians, administrators, researchers and healthcare informaticians working in South Asia, in addressing the inequality in access to patient information in acute care. Harnessing a clinician-led collaborative approach to design and evaluation, we have implemented a national acute care information platform in Sri Lanka that is tailored to priorities of frontline staff. Iterative adaptation has ensured the platform has the flexibility to integrate with legacy paper systems, support junior team members in advocating for acutely unwell patients and has made information captured accessible to diverse stakeholders to improve service delivery. The same platform is now empowering clinicians to participate in international research and drive forwards improvements in care. During this journey, we have also gained insights on how to overcome well-described barriers to implementation of digital information tools in LMIC. We anticipate that this north–south collaborative approach to addressing the challenges of health system implementation in acute care may provide learning and inspiration to other partnerships seeking to engage in similar work.
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Commentary: Challenges and Priorities for Paediatric Critical Care Clinician-Researchers in Low- and Middle-Income Countries
Beane, A., Lakmini Athapattu, P., Dondorp, A.M., Haniffa, R.
February 2019
frontiers in Pediatrics
A learning health systems approach to improving the quality of care for patients in South Asia
Beane, A., Wagstaff, D., Abayadeera, A., Wijeyaratne, M., Ranasinge, G., Mirando, S., Dondorp, A.M., Walker, D., Haniffa, R.
April 2019
Global Health Action
Show Abstract
Abstract:
Poor quality of care is a leading cause of excess morbidity and mortality in low- and middle- income countries (LMICs). Improving the quality of healthcare is complex, and requires an interdisciplinary team equipped with the skills to design, implement and analyse setting-relevant improvement interventions. Such capacity is limited in many LMICs. However, training for healthcare workers in quality improvement (QI) methodology without buy-in from multidisciplinary stakeholders and without identifying setting-specific priorities is unlikely to be successful. The Care Quality Improvement Network (CQIN) was established between Network for Improving Critical care Systems and Training (NICST) and University College London Centre for Perioperative Medicine, with the aim of building capacity for research and QI. A two-day international workshop, in collaboration with the College of Surgeons of Sri Lanka, was conducted to address the above deficits. Innovatively, the CQIN adopts a learning health systems (LHS) approach to improving care by leveraging information captured through the NICST electronic multi-centre acute and critical care surveillance platform. Fifty-two delegates from across the CQIN representing clinical, civic and academic healthcare stakeholders from six countries attended the workshop. Mapping of care processes enabled identification of barriers and drivers to the delivery of care and facilitated the selection of feasible QI methods and matrices. Six projects, reflecting key priorities for improving the delivery of acute care in Asia, were collaboratively developed: improving assessment of postoperative pain; optimising sedation in critical care; refining referral of deteriorating patients; reducing surgical site infection after caesarean section; reducing surgical site infection after elective general surgery; and improving provision of timely electrocardiogram recording for patients presenting with signs of acute myocardial infarction. Future project implementation and evaluation will be supported with resources and expertise from the CQIN partners. This LHS approach to building capacity for QI may be of interest to others seeing to improve care in LMICs.
Hide Abstract
2018
Show Abstract
Importance:
The quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs).
Objective:
To assess the association of qSOFA with excess hospital death among patients with suspected infection in LMICs and to compare qSOFA with the systemic inflammatory response syndrome (SIRS) criteria.
Design, Settings, and Participants:
Retrospective secondary analysis of 8 cohort studies and 1 randomized clinical trial from 2003 to 2017. This study included 6569 hospitalized adults with suspected infection in emergency departments, inpatient wards, and intensive care units of 17 hospitals in 10 LMICs across sub-Saharan Africa, Asia, and the Americas.
Exposures:
Low (0), moderate (1), or high (≥2) qSOFA score (range, 0 [best] to 3 [worst]) or SIRS criteria (range, 0 [best] to 4 [worst]) within 24 hours of presentation to study hospital.
Main Outcomes and Measures:
Predictive validity (measured as incremental hospital mortality beyond that predicted by baseline risk factors, as a marker of sepsis or analogous severe infectious course) of the qSOFA score (primary) and SIRS criteria (secondary).
Results:
The cohorts were diverse in enrollment criteria, demographics (median ages, 29-54 years; males range, 36%-76%), HIV prevalence (range, 2%-43%), cause of infection, and hospital mortality (range, 1%-39%). Among 6218 patients with nonmissing outcome status in the combined cohort, 643 (10%) died. Compared with a low or moderate score, a high qSOFA score was associated with increased risk of death overall (19% vs 6%; difference, 13% [95% CI, 11%-14%]; odds ratio, 3.6 [95% CI, 3.0-4.2]) and across cohorts (P < .05 for 8 of 9 cohorts). Compared with a low qSOFA score, a moderate qSOFA score was also associated with increased risk of death overall (8% vs 3%; difference, 5% [95% CI, 4%-6%]; odds ratio, 2.8 [95% CI, 2.0-3.9]), but not in every cohort (P < .05 in 2 of 7 cohorts). High, vs low or moderate, SIRS criteria were associated with a smaller increase in risk of death overall (13% vs 8%; difference, 5% [95% CI, 3%-6%]; odds ratio, 1.7 [95% CI, 1.4-2.0]) and across cohorts (P < .05 for 4 of 9 cohorts). qSOFA discrimination (area under the receiver operating characteristic curve [AUROC], 0.70 [95% CI, 0.68-0.72]) was superior to that of both the baseline model (AUROC, 0.56 [95% CI, 0.53-0.58; P < .001) and SIRS (AUROC, 0.59 [95% CI, 0.57-0.62]; P < .001).
Conclusions and Relevance:
When assessed among hospitalized adults with suspected infection in 9 LMIC cohorts, the qSOFA score identified infected patients at risk of death beyond that explained by baseline factors. However, the predictive validity varied among cohorts and settings, and further research is needed to better understand potential generalizability.
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PRactice of VENTilation in Middle-Income Countries (PRoVENT-iMIC): rationale and protocol for a prospective international multicentre observational study in intensive care units in Asia
Pisani, L., Algera, A.G., Neto, A.S., Ahsan, A., Beane, A., Chittawatanarat, K., Faiz, A., Haniffa, R., Hashemian, R., Hashmi, M. and Imad, H.A.
April 2018
BMJ open
Show Abstract
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 H2O) 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.
Hide Abstract
Is the Tail Wagging the Dog in Sepsis?
Haniffa, R., Beane, A. and Dondorp, A.M
August 2018
Critical Care Medicine
Inequalities in the prevalence of diabetes mellitus and its risk factors in Sri Lanka: a lower middle income country
De Silva, A.P., De Silva, S.H.P., Haniffa, R., Liyanage, I.K., Jayasinghe, S., Katulanda, P., Wijeratne, C.N., Wijeratne, S. and Rajapaksa, L.C.
April 2018
International Journal for Equity in Health
Show Abstract
Background:
Explorations into quantifying the inequalities for diabetes mellitus (DM) and its risk factors are scarce in low and lower middle income countries (LICs/LMICs). The aims of this study were to assess the inequalities of DM and its risk factors in a suburban district of Sri Lanka.
Methods:
A sample of 1300 participants, (aged 35–64 years) randomly selected using a stratified multi-stage cluster sampling method, were studied employing a cross sectional descriptive design. The socioeconomic indicators (SEIs) of the individual were education level and occupational category, and at the household level, the household income, social status level and area deprivation level. DM was diagnosed if the fasting plasma glucose was ≥126 and a body mass index (BMI) of > 27.5 kg/m2 was considered high. Asian cut-off values were used for high waist circumference (WC). Validated tools were used to assess the diet and level of physical activity. The slope index of inequality (SII), relative index of inequality (RII) and concentration index (CI) were used to assess inequalities.
Results:
The prevalence of DM and its risk factors (at individual or household level) showed no consistent relationship with the three measures of inequality (SII, RII and CI) of the different indices of socio economic status (education, occupation, household income, social status index or area unsatisfactory basic needs index).
The prevalence of diabetes showed a more consistent pro-rich distribution in females compared to males. Of the risk factors in males and females, the most consistent and significant pro-rich relationship was for high BMI and WC. In males, the significant positive relationship with high BMI for SII ranged from 0.18 to 0.35, and RII from 1.56 to 2.25. For high WC, the values were: SII from 0.13 to 0.27 and RII from 1.9 to 3.97. In females the significant positive relationship with high BMI in SII ranged from 0.13 to 0.29, and RII from 2.3 to 4.98. For high WC the values were: SII from 028 to 0.4 and RII 1.99 to 2.39.
Of the other risk factors, inadequate fruit intake showed a consistent significant pro-poor distribution only in males using SII (− 0.25 to − 0.36) and in both sexes using CI. Smoking also showed a pro-poor distribution in males especially using individual measures of socio-economic status (i.e. education and occupation).
Conclusions:
The results show a variable relationship between socioeconomic status and prevalence of diabetes and its risk factors. The inequalities in the prevalence of diabetes and risk factors vary depending on gender and the measures used. The study suggests that measures to prevent diabetes should focus on targeting specific factors based on sex and socioeconomic status. The priority target areas for interventions should include prevention of obesity (BMI and central obesity) specifically in more affluent females. Males who have a low level of education and in non-skilled occupations should be especially targeted to reduce smoking and increase fruit intake.
Hide Abstract
Experiences of ICU survivors in a low middle income country- a multicenter study
Pieris L, Sigera PC, De Silva AP, Munasinghe S, Rashan A, Athapattu PL, Jayasinghe KS, Samarasinghe K, Beane A, Dondorp AM, Haniffa R.
March 2018
BMC Anesthesiology
Show Abstract
Background:
Stressful patient experiences during the intensive care unit (ICU) stay is associated with reduced satisfaction in High Income Countries (HICs) but has not been explored in Lower and Middle Income Countries (LMICs). This study describes the recalled experiences, stress and satisfaction as perceived by survivors of ICUs in a LMIC.
Methods:
This follow-up study was carried out in 32 state ICUs in Sri Lanka between July and December 2015.ICU survivors’ experiences, stress factors encountered and level of satisfaction were collected 30 days after ICU discharge by a telephone questionnaire adapted from Granja and Wright.
Results:
Of 1665 eligible ICU survivors, 23.3% died after ICU discharge, 49.1% were uncontactable and 438 (26.3%) patients were included in the study. Whilst 78.1% (n = 349) of patients remembered their admission to the hospital, only 42.3% (n = 189) could recall their admission to the ICU. The most frequently reported stressful experiences were: being bedridden (34.2%), pain (34.0%), general discomfort (31.7%), daily needle punctures (32.9%), family worries (33.6%), fear of dying and uncertainty in the future (25.8%).
The majority of patients (376, 84.12%) found the atmosphere of the ICU to be friendly and calm. Overall, the patients found the level of health care received in the ICU to be “very satisfactory” (93.8%, n = 411) with none of the survivors stating they were either “dissatisfied” or “very dissatisfied”.
Conclusion:
In common with HIC, survivors were very satisfied with their ICU care. In contrast to HIC settings, specific ICU experiences were frequently not recalled, but those remembered were reported as relatively stress-free. Stressful experiences, in common with HIC, were most frequently related to uncertainty about the future, dependency, family, and economic concerns.
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Decision-making in the detection and management of patients with sepsis in resource-limited settings: the importance of clinical examination
Haniffa, R., Beane, A., & Dondorp, A. M.
March 2018
Critical Care
A short, structured skills training course for critical care physiotherapists in a lower-middle income country
Tunpattu, S., Newey, V., Sigera, C., De Silva, P., Goonarathna, A., Aluthge, I., Thambavita, P., Perera, R., Meegahawatte, A., Isaam, I. and Dondorp, A.M.
January 2018
Physiotherapy Theory and Practice
Show Abstract
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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Commentary: Challenges and Priorities for Pediatric Critical Care Clinician–Researchers in Low- and Middle-Income Countries
Beane, A., Athapattu, P. L., Dondorp, A. M., & Haniffa, R.
February 2018
Frontiers in pediatrics
Developing a feasible and valid scoring system for critically ill patients in resource-limited settings
Rashan Haniffa, Mavuto Mukaka, Sithum Bandara Munasinghe, Ambepitiyawaduge Pubudu De Silva, Kosala Saroj Amarasiri Jayasinghe, Abi Beane, Nicolette de Keizer and Arjen M Dondorp
January 2018
Critical Care
2017
Improving ICU services in resource-limited settings: Perceptions of ICU workers from low-middle-, and high-income countries.
Rashan Haniffa, A. Pubudu De Silva, Luciano de Azevedo, Dilini Baranage, Aasiyah Rashan, Inipavudu Baelani, Marcus J. Schultz, Arjen M. Dondorp, and Martin W. Dünser
December 2017
Elsevier
Show Abstract
Purpose:
To evaluate perceptions of intensive care unit (ICU) workers from low-and-middle income countries (LMICs) and high income countries (HICs).
Materials and Methods:
A cross sectional design. Data collected from doctors using an anonymous online, questionnaire.
Results:
Hundred seventy-five from LMICs and 43 from HICs participated. Barriers in LMICs were lack of formal training (Likert score median 3 [inter quartile range 3]), lack of nurses (3[3]) and low wages (3[4]). Strategies for LMICs improvement were formal training of ICU staff (4[3]), an increase in number of ICU nurses (4[2]), collection of outcome data (3[4]), as well as maintenance of available equipment [3(3)]. The most useful role of HIC ICU staff was training of LMIC staff (4[2]). Donation of equipment [2(4)], drugs [2(4)], and supplies (2[4]) perceived to be of limited usefulness. The most striking difference between HIC and LMIC staff was the perception on the lack of physician leadership as an obstacle to ICU functioning (4[3] vs. 0[2], p < 0.005).
Conclusion:
LMICs ICU workers perceived lack of training, lack of nurses, and low wages as major barriers to functioning. Training, increase of nurse workforce, and collection of outcome data were proposed as useful strategies to improve LMIC ICU services.
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Practices and perspectives in cardiopulmonary resuscitation attempts and the use of do not attempt resuscitation orders: A cross-sectional survey in Sri Lanka
Beane A, Ambepitiyawaduge PS, Thilakasiri K, Stephens T, Padeniya A, Athapattu P, Mahipala PG, Sigera PC, Dondorp AM, Haniffa R
December 2017
Indian Journal of Critical Care Medicine
Show Abstract
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.
Hide Abstract
Applicability of the APACHE II model to a lower middle income country.
Dr Rashan Haniffa, Dr A Pubudu de Silva, Prasad Weerathunga, Dr Mavuto Mukaka, Dr Priyantha Athapattu, Situm Munasinghe, Dr Buddhika Mahesh, Dr Palitha Mahipala, Dr Terrrence de Silva, Prof Anuja Abayadeera, Prof Saroj Jayasinghe, Prof Nicolette de Keizer, Prof Arjen M Dondorp
December 2017
Journal of Critical Care
Show Abstract
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.
Hide Abstract
Comparison of Quick Sequential Organ Failure Assessment and Modified Systematic Inflammatory Response Syndrome Criteria in a Lower Middle Income Setting
Abi Beane, Ambepitiyawaduge Pubudu De Silva, Sithum Munasinghe, Nirodha De Silva, Sujeewa Jayasinghe Arachchige, Priyantha Athapattu, Ponsuge Chathurani Sigera, Muhammed Faisal Miskin, Pramod Madushanka Liyanagama, Rathnayake Mudiyanselage Dhanapala Rathnayake, Kosala Saroj Amarasiri Jayasinghe, Arjen M Dondorp, Rashan Haniffa
December 2017
Journal of Acute Medicine
DOI: 10.6705/j.jacme.2017.0704.002
Show Abstract
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.
Hide Abstract
Critical care junior doctors’ profile in a lower middle-income country: A national cross-sectional survey
De Silva AP, Baranage DDS, Padeniya A, Sigera PC, De Alwis S, Abayadeera AU, Mahipala PG, Jayasinghe KS, Dondorp AM, Haniffa R.
November 2017
Indian Journal of Critical Care Medicine
Show Abstract
Background and aims:
Retention of junior doctors in specialties such as critical care is difficult, especially in resource-limited settings. This study describes the profile of junior doctors in adult state intensive care units in Sri Lanka, a lower middle-income country.
Materials and Methods:
This was a national cross-sectional survey using an anonymous self-administered electronic questionnaire.
Results:
Five hundred and thirty-nine doctors in 93 Intensive Care Units (ICUs) were contacted, generating 207 responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Most junior doctors (150, 75.8%) had no previous exposure to anesthesia and 134 (67.7%) had no previous ICU experience while 116 (60.7%) ICU doctors wished to specialize in critical care. However, only a few (12, 6.3%) doctors had completed a critical care diploma course. There was a statistically significant difference (P < 0.05) between the self-assessed confidence of anesthetic background junior doctors and non-anesthetists. The overall median competency for doctors improves with the length of ICU experience and is statistically significant (P < 0.05). ICU postings were less happy and more stressful compared to the last non-ICU posting (P < 0.05 for both). The vast majority, i.e., 173 (88.2%) of doctors felt the care provided for patients in their ICUs was good, very good, or excellent while 71 doctors (36.2%) would be happy to recommend the ICU where they work to a relative with the highest possible score of 10.
Conclusion:
Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed.
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Closing the theory to practice gap for newly qualified doctors: evaluation of a peer-delivered practical skills training course for newly qualified doctors in preparation for clinical practice.
Beane A, Padeniya A, De Silva AP, Stephens T, De Alwis S, Mahipala PG, Sigera PC, Munasinghe S, Weeratunga P, Ranasinghe D, Deshani EM, Weerasinghe T, Thilakasiri K, Jayasinghe K, Dondorp AM, Haniffa R.
October 2017
Postgraduate Medical Journal
Show Abstract
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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Performance of critical care prognostic scoring systems in low and middle income countries: A systematic review
Haniffa et al
September 2017
Critical Care
DOI: 10.1186/s13054-017-1930-8
Show Abstract
Background:
Prognostic models – used in critical care medicine for mortality predictions, benchmarking and for illness stratification in clinical trials- have been validated predominantly in high-income countries. These results may not be reproducible in low or middle income countries (LMICs) not only because of different case-mix characteristics but also because of missing predictor variables.
Objective:
To systematically review literature on the use of critical care scoring systems in Low and Middle Income Countries (LMICs) and assess their ability to discriminate between survivors and nonsurvivors of Intensive Care Unit (ICU) admissions, their calibration and accuracy, and the manner in which missing values were handled.
Method:
The PubMed database was searched in March 2107 to identify research articles reporting the use and performance of prognostic models in the evaluation of mortality in ICUs in LMICs. Studies that were carried out in ICUs in high-income countries or paediatric ICUs, studies that evaluated disease specific scoring systems, were limited to a specific disease or single prognostic factor or published only as abstracts, editorials, letters and systematic and narrative reviews or not in English were excluded.
Result:
Of the 2237 studies retrieved, 477 were searched and 54 articles reporting 160 models were included. Four described the development and evaluation of new models and 156 externally validated APACHE, GCS, MPM, OSF, SAPS, SOFA and TISS or versions thereof. Missing values were described in 26.9%. Discrimination, calibration and accuracy were reported in 91.0%, 65.4% and 28.5% respectively. Only thirteen evaluations that reported excellent discrimination also reported good calibration. Generalisability of the findings was limited by missing value handling, non availability of post ICU outcomes, and variability of inclusion and exclusion criteria.
Conclusions:
Robust interpretations on the applicability of prognostic models are currently hampered by poor adherence to reporting guidelines, especially when reporting missing value handling. Performance of mortality risk prediction models for ICU patients- predominantly developed in and for HIC settings- in LMICs is at most moderate, especially with limitations in calibration. This necessitates continued efforts to develop and validate LMIC models with readily available prognostic variables, perhaps aided by medical registries.
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A short structured skills training course for critical care physiotherapists in a lower-middle income country.
De Silva et al, 2016
September 2017
Show Abstract
Objectives:
The aim 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 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 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 with 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 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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Evaluation of the feasibility and performance of existing Early Warning Systems to identify patients at risk for adverse outcomes in Low Middle Income settings.
A. Beane, A.P. De Silva, N. De Silva, J.A. Sujeewa, R.M.D. Rathnayake, P.C. Sigera, P.L. Athapattu, D.G. Mahipala, A. Padeniya, A. Rashan, S. Munasinghe, K.A.S. Jayasinghe, A. Dondorp, R. Haniffa
September 2017
Show Abstract
Introduction:
Early Warning Systems (EWS) common in high-income countries to identify hospital patients at risk for deterioration have not been widely evaluated in resource-poor settings. This study aimed to assess the feasibility and performance of selected aggregate weighted track and trigger systems (AWTTS) and single parameter track and trigger systems (SPTTS) to discriminate patients at risk of adverse outcomes in a low-middle income setting; Sri Lanka.
Methods:
Available physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients (age >17 years) admitted to District General Hospital, Monaragala over an 8-month period, where no EWS exists. Discrimination for selected AWTTS was assessed by the AUROC. The ability of SPTTS, to predict adverse outcomes was also evaluated.
Results:
Of the 16,386 patients included, 502 (3.06%) had 1 or more adverse outcomes; 102 (0.62%) c ardiac arrests; 83 (0.51%) unplanned admission to ICU; 253 (1.54%) transfers to tertiary facilities; and 149 (0.91%) died. Availability of physiological parameters on admission was heart rate 90.97% (CI 90.52, 91.40), systolic blood pressure 86.80% (CI 86.27, 87.31), respiratory rate 65.24 % (CI 64.51, 65.97), assessment of mentation 32.89% (32.17, 33.61) and oxygen saturation 23.94% (23.29, 24.60). Selected AWTTS had AUROC ranging from 0.667 to 0.781 to predict death when applied at admission. Discrimination of all AWTTS was poor (AUROC<0.60) in predicting other adverse outcomes. Sensitivity of the best performing AWTTS and SPTTS to predict death when applied at admission were 63.2% and 59.1% (p>0.05) respectively.
Conclusion:
There is limited availability of observation reporting in this setting. Existing AWTTS and SPTTS, possibly impeded by missingness, are not sufficiently able to discriminate patients at risk of death or adverse event so as to be deployed in this clinical setting. Efforts to improve availability of observations in this setting are necessary in order to enable robust evaluation of EWS.
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Traumatic Brain Injury (TBI) outcomes in an LMIC tertiary care centre and performance of trauma scores
Samanmalee, P.C. Sigera, A.P. De Silva, K. Thilakasiri, A. Rashan, S. Wadanambi, P.L. Athapattu, K.A.S. Jayasinghe, A.M. Dondorp, R. Haniffa
September 2017
BMC Anesthesiology
DOI: 10.1186/s12871-017-0463-7
Show Abstract
Introduction:
This study evaluates post-ICU outcomes of patients admitted with moderate and severe Traumatic Brain Injury (TBI) in a tertiary neurocritical care unit in a low middle income country and the performance of trauma scores: A Severity Characterization of Trauma, Trauma and Injury Severity Score, Injury Severity Score and Revised Trauma Score in this setting.
Methods:
Adult patients directly admitted to the neurosurgical intensive care units of the National Hospital of Sri Lanka between 21st July 2014 and 1 st October 2014 with moderate or severe TBI were recruited.
A telephone administered questionnaire based on the Glasgow Outcome Scale Extended was used to assess functional outcome of patients at 3 and 6 months after injury. The economic impact of the injury was assessed before injury, and at 3 and 6 months after injury.
Results:
One hundred and one patients were included in the study. Survival at ICU discharge, 3 and 6 months after injury was 68.3%, 49.5% and 45.5% respectively. Of the survivors at 3 months after injury, 43 (86%) were living at home. Only 19 (38%) patients had a good recovery (as defined by GOSE 7 and 8). Three months and six months after injury, respectively 25 (50%) and 14 (30.4%) patients had become “economically dependent”. Selected trauma scores had poor discriminatory ability in predicting mortality.
Discussion:
The social and economic consequences of TBI were long lasting in this setting. The study illustrates the need for setting adapted trauma severity tools in low and middle income countries.
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A data platform to improve rabies prevention, Sri Lanka
De Silva et al, Bulletin of the World Health Organization
September 2017
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Problem:
Surveillance of rabies epidemiology, clinical treatment and prevention initiatives in affected lower- middle income countries (LMIC), are hindered by delayed and disparate information, and paper based records, limiting ability to evaluate Public Health Veterinary Services (PHVS) programmes and follow- up victims of animal bites.
Approach:
Adapting existing technologies, Network for Improving Critical care skills and Training (NICST) in collaboration with Ministry of Health, Sri Lanka (MoH) and clinicians have implemented an electronic surveillance platform. Information is entered by front-line clinical staff with both aggregate and individual information visualised in real-time. Automated SMS alerts PH inspectors to bite incidence and victims of bites to treatment follow-up.
Setting:
Anti-rabies treatment units, laboratories and public health (PH) services in 4 districts in Sri Lanka.
Relevant changes:
The platform enables real-time surveillance of incidence, characteristics, laboratory reporting, and management including vaccination completeness following mammalian bite. Information is centralised, and accessible to clinicians and PH teams through secure portals. SMS and mobile technology is being used to improve communication of information between services and for patients undergoing follow-up. The platform captures time- series information on incidence, laboratory reported disease prevalence, post exposure treatment decisions and outcomes for 12,121 reported mammalian bites.
Lessons learnt:
Harnessing existing technologies can improve surveillance of disease epidemiology in developing countries. A clinician-led distributed data platform can improve surveillance of and response to, rabies disease management, where existing paper based systems often result in fragmented and delayed information sharing and evaluation. Public and patient engagement is essential to improve surveillance and treatment completeness.
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Preparing medical graduates in Sri Lanka for a productive internship and beyond: The ‘Good Intern Programme
Padeniya AB, de Alwis S, Mahesh B, Senanayake S, Ranasinghe D, De Silva AP, Ferdinando R, Mahipala PG, Dharmagunawardene D, Epitakaduwa C, Subramaniam N, Askin S, Weerasinghe S, Herath N, Jinadasa L and Haniffa R.
June 2017
Allied Journal of Medical Research
Show Abstract
Problem:
The transition from undergraduate student to independent practitioner for medical graduates is a challenging one. This paper describes a multi-faceted training model-the “Good Intern Programme (GIP)”-that aims to provide such training for newly qualified doctors (pre-interns, PI) in Sri Lanka.
Methods:
The development and implementation of the GIP included the following: focus group discussions to understand the requirements; a needs assessment including identification of the main stressors; a 10-day practical Tamil language-training programme; a 4-day acute care skills training (ACST) program; and a 4-day Good Medical Practice (GMP) workshop based on the system building blocks of the WHO.
Results:
980 PIs participated in the needs assessment; 383 (39.1%) stated that the first half of their internship was more stressful than the second (p<0.003). Amongst the 866 PI who registered for the GIP, 783 (90.4%) considered knowledge of medical administrative matters to be of importance to doctors. Hospital based clinical training, conducted in 28 hospitals island-wide, was attended by 278 PI; a statistically significant increase for all surveyed skills was demonstrated. The feedback for the GMP workshop, attended by 796 PI, was broadly positive with the session on “essential skills for interns” receiving the highest positive rating for relevance.
Conclusion:
The GIP provides a comprehensive opportunity to facilitate the transition of medical graduates in Sri Lanka using a multimodal, integrated and sustainable platform. This national program may have applicability beyond Sri Lanka.
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A retrospective study of physiological observation-reporting practices and the recognition, response, and outcomes following cardiopulmonary arrest in a low-to-middle-income country.
De Silva et al
June 2017
Indian Journal of Critical Care Medicine
Show Abstract
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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Simplified prognostic model for critically ill patients in resource limited settings in South Asia
Rashan Haniffa, Mavuto Mukaka, Sithum Bandara Munasinghe, Ambepitiyawaduge Pubudu De Silva, Kosala Saroj Amarasiri Jayasinghe, Abi Beane, Nicolette de Keizer and Arjen M. Dondorp
May 2017
Show Abstract
Introduction:
Current critical care prognostic models have been almost entirely developed in high income countries (HICs) and are usually based on hospital outcomes, which may not be feasible in LMIC ICUs due to the lack of electronic records or follow-up systems (1). Existing prognostic models cannot be imposed without validation in lower-and middle income countries (LMICs) as the diseases encountered in these settings (e.g. malaria, snakebite and poisoning), treatment modalities and available resources may be different (2).
Objective:
This study proposes a simplified critical care prognostic model for use at the time of Intensive Care Unit (ICU) admission.
Methods:
A cohort of ICU admissions was followed up until discharge in 21 ICUs in 4 countries: Bangladesh, India, Nepal and Sri Lanka. There were 3855 patients aged 18 and over admitted to these 21 ICUs.
Initial selection of candidate covariates for model development was based on their use in existing case-mix prediction models, perceived clinical importance and the feasibility of measurement in the settings of the participating ICUs. Multivariate logistic regression was used to develop three models – model 1 with clinical, laboratory and treatment variables, model 2 with clinical and laboratory variables and a purely clinical model 3 – for ICU mortality prediction.
Internal validation based on bootstrapping (1000 samples) was used to calculate discrimination (Area Under the Receiver Operating Characteristic, AUROC) and calibration (Hosmer-Lemeshow C-Statistic, HL C-S) (3). Comparison was made with the APACHE II model.
Results:
Model 1 retained respiratory rate, systolic blood pressure, 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% CI 0.800-0.835) for model 1, 0.767 (95% CI 0.741-0.792) for TropICS and 0.725 (95% CI 0.688-0.762) for model 3, and. The H-L C- S p-values were less than 0.05 for models 1 and 3 and 0.18 for TropICS. In comparison, for
APACHE II, AUC was 0.707 (95% CI- 0.688- 0.726) and H-L C-S was 124.84 (p< 0.001). Table 1: Multivariable logistic regression model of mortality
Model 3 95% CI |
Model 3 Beta-coeffici ent |
Model 2 95% CI |
Model 2 Beta-coeffici ent |
Model 1 95% CI |
Model 1 Beta-coeffici ent |
Covariate |
0.439, 1.020 |
0.730 |
0.025, 1.069 |
0.547 |
-0.136, 1.010 |
0.437 |
Emergency surgery |
0.041, 0.087 |
0.064 |
0.002, 0.007 |
0.005 |
0.018, 0.102 |
0.060 |
Respiratory rate |
-0.002, 0.008 |
0.003 |
0.001, 0.004 |
0.002 |
-0.031, -0.008 |
-0.019 |
Systolic blood pressure |
-0.151, -0.105 |
-0.128 |
-0.185, -0.115 |
-0.150 |
-0.139, -0.059 |
-0.099 |
Glasgow Coma Score |
– |
NA |
0.004, 0.009 |
0.006 |
0.003, 0.008 |
0.006 |
Blood Urea |
– |
NA |
-0.161, -0.034 |
-0.098 |
-0.160, -0.027 |
-0.093 |
Haemoglobin |
– |
NA |
– |
NA |
0.5613, 1.5527 |
1.057 |
Vasoactive use |
– |
NA |
– |
NA |
0.9919 , 1.8661 |
1.429 |
Mechanical ventilation |
-0.061, 0.518 |
0.229 |
-0.358, 1.534 |
0.588 |
4.374, 7.953 |
6.164 |
Constant |
Table 2: Performance of the 3 models and APACHE II
APACHE II |
Model 3 |
Model 2 |
Model 1 |
Performance item |
17.35 (6.16) |
– |
– |
– |
Score, mean (SD) |
0.26 (0.81) |
0.28 (0.14) |
0.20 (0.16) |
0.20 (0.20) |
Probability, mean (SD) |
0.20 |
0.26 |
0.18 |
0.18 |
Optimal cut-off probability |
0.67 |
0.63 |
0.70 |
0.72 |
Sensitivity (at optimum cut-off) |
0.71 |
0.67 |
0.69 |
0.77 |
Specificity (at optimum cut-off) |
0.707 (0.688-0.727) |
0.689 (0.664-0.714) |
0.767 (0.734-0.800) |
0.812 (0.781-0.842) |
AUC (95% CI) |
124.84 (P<0.01) |
15.94 (p=0.01) |
11.31 (p=0.19) |
16.91 (p=0.03) |
H/L C-statistic (p) |
0.18 (0.17-0.18) |
0.18 (0.18-0.19) |
0.14 (0.12-0.15) |
0.13 (0.11-0.14) |
Brier score (95% CI) |
Conclusion:
This paper proposes TropICS as the first multinational critical care prognostic model developed in a non-HIC setting.
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A comparison of rescue and primary percutaneous coronary interventions for acute ST elevation myocardial infarction.
M.B. Faslur Rahuman, Jayanthimala B. Jayawardena, George R. Francis, Niraj Mahboob, Wasantha Kumara A.H.T., Aruna Wijesinghe, Rashan Haniffa, Ranithrie Ariyapperuma, Abbyramy Paramanayakam, Pubudu A. De Silva
April 2017
Show Abstract
Objective:
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 the Cardiology PCI Clinic of the National Hospital of Sri Lanka (NHSL), we selected all consecutive patients presenting with acute STEMI </ = 24 h door-to-balloon delay for primary PCI and </ = 72 h door-to-balloon delay, (90 min after failed thrombolysis) for rescue PCI, from March 2013 to April 2015 and their in-hospital results were analyzed, comparing rescue and primary PCI patients.
Results:
We evaluated 159 patients; 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 = 0.004). The degree of moderate-to-severe left ventricular dysfunction reflected by the ejection fraction <40% (24.3% vs. 23.7%; 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 intervention groups, supporting the former as a practical option for patients with no immediate access to PCI facilities.
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Capacity building for critical care training delivery: Development and evaluation of the Network for Improving Critical care Skills Training (NICST) programme in Sri Lanka.
Stephens T, De Silva AP, Beane A, Welch J, Sigera C, De Alwis S, Athapattu P, Dharmagunawardene D, Peiris L, Siriwardana S, Abeynayaka A, Jayasinghe KS, Mahipala PG, Dondorp A, Haniffa R; NICST Collaborating Group.
April 2017
Show Abstract
Objective:
To deliver and evaluate a short critical care nurse training course whilst simultaneously building local training capacity.
Method:
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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Current challenges in the management of sepsis in ICUs in resource- poor settings and suggestions for the future.
March 2017
Show Abstract
Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.
Aim:
To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.
Findings:
Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.
Conclusions:
Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.
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Impact of a structured ICU program in resource limited settings in Asia
Rashan Haniffa, Yoel Lubell, Ben S Cooper, Sanjib Mohanty, Shamsul Alam, Arjun Karki, Rajya Pattnaik, Ahmed Maswood, R. Haque, Raju Pangeni, Marcus J. Schultz, Arjen M. Dondorp, for the ICU Training in South Asia Group
Published: 2017
Show Abstract
Objective:
To assess the impact on ICU performance of a modular training program in three resource-limited general adult ICUs in India, Bangladesh, and Nepal.
Method:
A modular ICU training programme was evaluated using performance indicators from June 2009 to June 2012 using an interrupted time series design with an 8 to 15 month pre-intervention and 18 to 24 month post-intervention period. ICU physicians and nurses trained in Europe and the USA provided training for ICU doctors and nurses. The training program consisted of six modules on basic intensive care practices of 2–3 weeks each over 20 months. The performance indicators consisting of ICU mortality, time to ICU discharge, rate at which patients were discharged alive from the ICU, discontinuation of mechanical ventilation or vasoactive drugs and duration of antibiotic use were extracted. Stepwise changes and changes in trends associated with the intervention were analysed.
Results:
Pre-Training ICU mortality in Rourkela (India), and Patan (Nepal) Chittagong (Bangladesh), was 28%, 41% and 62%, respectively, compared to 30%, 18% and 51% post-intervention. The intervention was associated with a stepwise reduction in cumulative incidence of in-ICU mortality in Chittagong (adjusted subdistribution hazard ratio [aSHR] (95% CI): 0.62 (0.40, 0.97), p = 0.03) and Patan (aSHR 0.16 (0.06, 0.41), p<0.001), but not in Rourkela (aSHR: 1.17 (0.75, 1.82), p = 0.49). The intervention was associated with earlier discontinuation of vasoactive drugs at Rourkela (adjusted hazard ratio for weekly change [aHR] 1.08 (1.03, 1.14), earlier discontinuation of mechanical ventilation in Chittagong (aHR 2.97 (1.24, 7.14), p = 0.02), and earlier ICU discharge in Patan (aHR 1.87 (1.02, 3.43), p = 0.04).
Conclusion:
This structured training program was associated with a decrease in ICU mortality in two of three sites and improvement of other performance indicators. A larger cluster randomised study assessing process outcomes and longer-term indicators is warranted.
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ICU Nurses job satisfaction, working hours and educational opportunities. Preliminary data from a multi-center survey in a lower middle income country setting (LMIC).
Sigera et al, 2017
Intensive Care Society – State of the Art Conference, Liverpool 2017
Show Abstract
Background:
Job satisfaction, opportunities for development and working environment (including working hours) for ICU nurses are increasingly linked to ICU mortality and morbidity. In Sri Lanka, a LMIC, where approximately 1989 nurses serve nearly 100 ICU’s as few as 11.4% of nurses have undergone critical care training.
Objective:
To describe working hours, job satisfaction, and support with career development in a cohort of ICU nurses in Sri Lanka.
Method:
Nurses who had recently completed a 2 day practical critical care skills training programme were invited to participate in this anonymised survey. The third American Association of Critical Care Nurses work environments standard survey was used to describe working hours, current job and overall career satisfaction including future job plans and support with continuing education.
Result:
Eighty eight of the 94 nurses invited to participate responded, representing 68 ICU’s. Of these, 78 (88.64%) respondents held a nursing diploma, 9 (10.23%) an undergraduate degree and 1 (1.14%) had an MSc.
Average weekly working hours were reported as being between 30-60 hours 57.95% (n=51), >61 hours 36.36% (n=32), and < 30 hours 5.68% (n=5). All nurses worked shifts with 51.69% (n=46) working 24 hour and 4.49% (n=4) working 48 hour duties. Overall career and current role satisfaction are described in table 1. Thirteen (15.29%) nurses would consider leaving their current role, and 23 (26.74%) reported recent resignation amongst colleagues. Support for continuing education is described in table 2.
Conclusions:
Nurses were reportedly satisfied with their jobs, despite long working hours, and limited academic opportunities. Work is ongoing to extend the survey to the wider ICU nursing population, to enable evaluation of the relationship between these factors and the processes and outcomes of patient care in ICU’s.
Table 3. Job satisfaction.
Very satisfied |
Somewhat satisfied |
Somewhat dissatisfied |
Very dissatisfied |
|
Career satisfaction |
32.18% (n=28) |
63.22% (n=55) |
4.60% (n=4) |
0.00% (n=0) |
Current role satisfaction |
21.42% (n=21) |
72.09% (n=62) |
3.49% (n=3) |
0.00% (n=0) |
Table 4.Support from employer for continuing education.
Inhouse training |
Yes (%) |
In house education |
70 (80.46) |
Paid study leave |
54 (62.07) |
Registration fees |
18 (20.69) |
Unpaid study leave |
65 (76.47) |
Travel reimbursement |
40 (45.98) |
No support |
14 (16.47) |
Academic qualifications |
|
Pays/reimburses initial examination fee |
7 (8.05) |
Professional recognition |
55 (63.22) |
Salary increment |
5 (5.75) |
Certification fee |
1 (1.15) |
Pays registration fees for courses to prepare for examination |
4 (4.60) |
Unpaid study leave |
24 (27.59) |
Paid study leave |
19 (21.84) |
No support |
45 (51.72) |
Hide Abstract
2016
Outcomes after in-hospital cardiac arrest in a LMIC hospital with a nurse led rescue team and availability of parameters for early warning scores.
De Silva et al, 2016
Presented on: 6th December 2016, Intensive Care Society State of the Art 2016, ExCeL, London.
Show Abstract
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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Critical care junior doctors profile in a low middle income country; a national cross sectional survey.
De Silva et al, 2016
Presented on: 6th December 2016, Intensive Care Society State of the Art 2016, ExCeL, London.
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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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Practical acute care skills training (ACST) for newly qualified doctors – a peer based model in a Low Middle Income Country.
Beane et al, 2016
Presented on: 6th December 2016, Intensive Care Society State of the Art 2016, ExCeL, London.
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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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External validation of the quick sequential organ failure assessment (qSOFA) and Systemic inflammatory response syndrome (SIRS) scores in a lower middle income country (LMIC) setting.
De Silva et al, 2016
Presented on: 6th December 2016, Intensive Care Society State of the Art 2016, ExCeL, London.
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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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Practices and perspectives in cardiopulmonary resuscitation attempts: a cross-sectional survey in a low middle income country.
Beane et al, 2016
PMCID: PMC5042925
Presented on: 5th October 2016 at ESICM Saving Lives. Milan, Italy.
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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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A comparison of rescue and primary percutaneous coronary interventions for acute ST elevation myocardial infarction
Faslur Rahuman M B, Jayawardena J B, Francis G R, Niraj M, Wasantha Kumara A H T, Wijesinghe U A D, Haniffa R, Ariyapperuma R, Paramanayakam A, and De Silva A P.
11th Annual Cardiology Summit
September 12-13, 2016 Philadelphia, USA
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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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Outcomes following laparotomy and laparoscopic abdominal surgeries: preliminary data from 3 surgical units in National Hospital Sri Lanka.
Yatawara et al, 2016
Presented on: 18-20 August 2016, Annual Academic Sessions (AAS) 2016,The College of Surgeons, Cinnamon Grand, Colombo, Sri Lanka.
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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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Outcome of early coronary intervention for acute ST elevation myocardial infarction in a tertiary care cardiac centre in Sri Lanka.
Rahuman MB, Jayawardana JB, Francis GR, Niraj M, Kumara AH, Wijesinghe UA, Haniffa R, Ariyapperuma R, Anuruddha C, de Silva AP
March 2016
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OBJECTIVES: To describe the outcomes of early percutaneous coronary intervention (PCI) for the treatment of acute ST elevation myocardial infarction (STEMI) in a tertiary care cardiac centre in Colombo, Sri Lanka.
METHODS: Medical records of 139 consecutive patients presenting to Cardiology Unit 5, National Hospital of Sri Lanka from March 2013 to June 2014 with acute STEMI, and treated with early PCI as a mode of reperfusion were reviewed. These patients were then followed up for 6 months to determine survival, target-vessel revascularization, in-stent thrombosis and other major adverse cardiac events (MACE).
RESULTS: Of 139 patients, 116 (83.5%) were male. Mean age was 52.3±SD11.1 years. Eighty eight (63.3%) patients underwent primary PCI and 51 (36.7%) underwent rescue PCI. There were six deaths (4.3%). One occurred on-table and three occurred after discharge. Four patients who died had cardiogenic shock. Mean door-to-balloon (DTB) time was 147 minutes for the primary PCI patients who were transferred from ETU. At six months, of 106 patients who attended follow up, two had been re-hospitalised for heart failure but none underwent coronary artery bypass grafting (CABG).
CONCLUSIONS: This report from the national tertiary care cardiology referral centre in Sri Lanka, found that the study population was relatively younger, similar to other Asian countries. There was high rate of initial success (98.6%) and good short-term survival (95.7%), particularly in the subset presenting without cardiogenic shock (98.4%) despite the long DTB time. Loss to follow up at 6 months in this centre was 23.7% (33 patients).
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A sustainable approach to training nurses in acute care skills in a resource limited setting (Network for Intensive Care Skills Training, NICST).
Beane et al. Resuscitation 2016
PMID: 26875989
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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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Capacity building for critical care skills training provision in resource limited settings: the nursing intensive care skills training (NICST) project
Stephens et al, Intensive and Critical Care Nursing. 2016
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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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National profile of critical care physiotherapy services in Sri Lanka; a low-middle income country.
Sigera PC et al. Physical therapy. 2016.
PMID: 26893503
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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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2015
A survey on socioeconomic determinants of diabetes mellitus management in a lower middle income setting
Ambepitiyawaduge Pubudu De SilvaEmail author, Sudirikku Hennadige Padmal De Silva, Rashan Haniffa, Isurujith Kongala Liyanage, Kosala Saroj Amarasiri Jayasinghe, Prasad Katulanda, Chandrika Neelakanthi Wijeratne, Sumedha Wijeratne and Lalini Chandika Rajapakse
24 Dec 2015
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Background: Information on socioeconomic determinants in the management of diabetes mellitus is scarce in lower middle income countries. The aim of this study is to describe the socioeconomic determinants of management and complications of diabetes mellitus in a lower middle income setting.
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 HbA1C, 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.
Conclusions: Diabetes mellitus patients, irrespective of their socioeconomic status, are poorly managed and have high rates of complications. Most depend on the private healthcare system with overall poor access to care in the estate sector.
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Nursing intensive care skills training; a structured, practical, nurse led training programme, developed and tested in a resource limited setting.
De Silva et al, Journal of critical care. 2015 Apr 30;30(2): 438-e7.
PMID: 24929445
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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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A collaborative approach to training ward nurses in acute care skills in resource limited settings: the nursing intensive care skills training (NICTS) project
Beane et al, 2015. Intensive Care Medicine Experimental (Suppl 1): A445
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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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A cross sectional survey on social, cultural and economic determinants of obesity in a low middle income setting
De Silva AP, De Silva SH, Haniffa R, Liyanage IK, Jayasinghe KS, Katulanda P, Wijeratne CN, Wijeratne S, Rajapakse LC
Jan 17, 2015
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INTRODUCTION:
Obesity is an increasing problem in South Asian countries and Sri Lanka is no exception. The socioeconomic determinants of obesity in Sri Lanka, and in neighbouring countries are inadequately described. Aim was to describe social, cultural and economic determinants of obesity in a representative sample from Kalutara District in Sri Lanka.
METHODS:
This was a cross sectional descriptive study conducted among adults aged 35-64 years. A representative sample was selected using stratified random cluster sampling method from urban, rural and plantation sectors of Kalutara District. Data were collected using a pre-tested questionnaire. A body mass index of 23.01 kg/m(2)-27.50 kg/m(2) was considered as overweight and ≥27.51 kg/m(2) as obese. Waist circumference (WC) of ≥ 90 cm and ≥80 cm was regarded as high for men and women respectively. Significance of prevalence of obesity categories across different socio-economic strata was determined by chi square test for trend.
RESULTS:
Of 1234 adults who were screened, age and sex adjusted prevalence of overweight, obesity and abdominal obesity (high WC) were 33.2% (male 27.3%/female 38.7%), 14.3% (male 9.2%/female 19.2%) and 33.6% (male 17.7%/female 49.0%) respectively. The Muslims had the highest prevalence of all three obesity categories. Sector, education, social status quintiles and area level deprivation categories show a non linear social gradient while income shows a linear social gradient in all obesity categories, mean BMI and mean WC. The differences observed for mean BMI and mean WC between the lowest and highest socioeconomic groups were statistically significant.
CONCLUSION:
There is a social gradient in all three obesity categories with higher prevalence observed in the more educated, urban, high income and high social status segments of society. The higher socioeconomic groups are still at a higher risk of all types of obesity despite other public health indicators such as maternal and infant mortality displaying an established social gradient.
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2014
The characteristics of critically ill patients admitted to the intensive care units in a resource scarce setting.
De Silva et al, 2014
Presented on: 13th – 18th October 2012, 44th Asia Pacific Academic Consortium for Public Health, Bandaranaike Memorial International Conference Hall, Colombo, Sri Lanka.
Critical care and severe sepsis in resource poor settings
Arjen M. Dondorp, Rashan Haniffa
August 2014
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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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Impact of a practical ICU workshop on the knowledge, attitudes and skills of critical care physiotherapist in Sri Lanka.
Tunpattu et al, 2014
Presented on: 15th to 18th July 2014, 127th Anniversary International Medical Congress of SLMA, Bandaranayake Memorial International Conference Hall, Colombo, Sri Lanka.
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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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2013
National Intensive Care Surveillance (NICS): An innovative public health e-intervention from Sri Lanka for the developing world in critical care medicine.
De Silva AP, 2013
Presented on: 02nd – 04th May 2013, International Conference on Public Health Innovations, National Institute of Health Sciences, Kalutara, Sri Lanka.
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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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Nursing intensive care skills training: A nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting. National Intensive Care Surveillance, Ministry of Health. 2013.
ISBN 978-955-0505-44-9
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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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A critical care bed system for Sri Lanka. National Intensive Care Surveillance. 2013.
ISBN 978-955-0505-43-2