Impact of a structured ICU training programme in resource-limited settings in Asia

Abstract

ObjectiveTo assess the impact on ICU performance of a modular training program in three resource-limited general adult ICUs in India, Bangladesh, and Nepal.MethodA 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.ResultsPre-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).ConclusionThis 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.

Current Challenges in the Management of Sepsis in ICUs in Resource-Poor Settings and Suggestions for the Future

“…The mean age of adult patients admitted to ICUs in HICs is consistently higher than those reported in LMICs. For example, in European ICUs, the mean age of adult admissions is typically 55-66 years, much higher than the median age of 34 years in a Rwandan ICU [68], the mean age of 32 years in one of the few ICUs in Uganda [1], and the median age of 37, 51, and 49 years in ICUs in Bangladesh, Nepal, and India [69]. Although not specified for admission diagnoses, it likely also reflects the younger age of sepsis patients.…”

“…For this reason it is imperative that basic standards of care are in place prior to introduction of costly interventions whose effect might otherwise be compromised. Training programs to improve the general quality of care that require no costly interventions have been shown to have beneficial effects [69]. Second, while hypothetically cost-effectiveness should correspond with affordability, in LMICs where health systems are often fragmented and divided between the private and public sector and an abundance of vertically funded health programs, this is often not the case.…”

“…Critical care could be ripe for this at times called "frugal innovation" or "reverse innovation" concept [95]. Also, in our personal experience [69], nurses from HICs who have worked in LMICs, and even for a short time, are more cost-conscious than their colleagues.…”

The effect of an educational intervention on nurses’ knowledge of managing endotracheal tube cuff pressure in intensive care units: A quasi-experimental study

“…Hence, this could explain the generally low knowledge scores obtained for questions regarding nursing care practices for the management of ETT cuff pressure by the nurses in this study. According to Haniffa et al 34 , quality training is imperative for good quality care in the ICU. Therefore, it is recommended that nurses in ICUs should be formally trained before positioning them in these units and/or that a structured training programme should be provided to those currently without formal training but working in ICUs.…”

Infrastructure and Organization of Adult Intensive Care Units in Resource-Limited Settings

“…Reports from India and Africa confirm the feasibility of noninvasive ventilation in resource-limited settings [157,158]. A randomized controlled trial including four rural hospitals in Ghana found that continuous positive airway pressure application by local nurses significantly reduced respiratory rate and was not associated with complications in 70 children with respiratory distress [159].…”