Defining the Need for Critical Care in Underserved Areas

2014 - 1 February – Critical Care in Underserved Areas
David J. Dries, MD, MSE, MCCM
Strategies to prevent and manage critical illness must be translated and applied to regions without the diagnostic, monitoring and therapeutic technologies widely available in high-income countries.
Historically, global health policy emphasized multiple vertically oriented programs concentrating on maternal and child health and the control of communicable diseases.(1) Unfortunately, vertically oriented programs do not encourage development of efficient and effective healthcare delivery systems. Their weakness is apparent during medical emergencies or incidents involving large numbers of casualties. Our global health community is beginning to take a more comprehensive view of health, including provision of emergency and acute care. The minimum package of health services advocated by the World Bank contains at least six cost-effective interventions, including a series of non-specialized interventions for emergencies.(2) The World Health Organization is placing substantial emphasis on strengthening triage and emergency care within the context of integrated management of a variety of illnesses.(1-3)

The role of critical care in healthcare delivery systems has also grown remarkably over recent decades. Unfortunately, much of the world lacks the resources to implement high-cost and resource-intensive management strategies, which demonstrate improved outcomes in high-income countries. Strategies to prevent and manage critical illness must be translated and applied to regions without the diagnostic, monitoring and therapeutic technologies widely available in high-income countries. Essential aspects of critical care implementation in low-resource conditions include context-specific clinical evidence, quality improvement and system development for care designed to prevent or limit the impact of critical illness.(4)

Regardless of location, critical care is a complex, interdisciplinary, high-technology endeavor. Monitoring and interventions are associated with significant costs including personnel, equipment and long-term support of critical care survivors. Minimum supplies for a critical care unit include functional equipment driven by electricity and oxygen. In addition to the fixed costs of critical care, an adequate number of well-trained personnel are essential. Training opportunities are scarce in many parts of the world; thus, many critical care units are staffed by providers with limited relevant experience. More-experienced providers, often trained in high-income areas, are more likely to immigrate given the opportunity. This continuing trend depletes underserved areas of essential personnel.(4-6)
Preventive Critical Care
Select, relatively inexpensive interventions and systems can reverse potentially lethal conditions such as sepsis, hemorrhage from trauma or obstetric catastrophes. Care strategies requiring prioritization include timely and reliable delivery of evidence-based or widely accepted interventions to acutely ill patients before resource-intensive organ failure can develop.(1-4) Addressing this need begins outside the critical care unit. Safe and effective patient transportation systems are essential to move patients to and between hospitals. Within hospitals, the emergency department, operating room and ward staffs must be structured to recognize and provide initial support for acutely ill patients. Examples include implementation of guidelines for sepsis management or stabilization and initial management of injury.(1,4,7) Local triage and critical care admission protocols must be in place so that limited resources are effectively distributed. Traditional scoring systems may be ineffective in settings with minimal resources. Quality improvement activities must be reevaluated in a region-specific context.(8) Practice support tools – protocols, checklists, standard order sets and guidelines – reflect substantial opportunities for development and provision of low-cost and high-yield care.
Skills and Populations
Millions are dying each year with preventable and reversible critical illness, including circulatory shock and respiratory failure. The World Health Organization estimates that each year, more than one-third of global deaths are from cardiovascular disease, and more than one-third of deaths in children younger than 5 years are due to acute respiratory failure and shock. Inadequate initial assessment, stabilization and monitoring contribute to poor outcomes in developing countries. Hospital-based care providers are frequently undertrained in life support techniques.(3)
Consensus-based strategies from the International Liaison Committee on Resuscitation are based on systematic reviews of resuscitation literature and include tools designed to improve team behavior, emphasize psychomotor functioning, and increase the knowledge of first responders and hospital-based providers.(3) Studies of newborn resuscitation demonstrate improved operational performance of residents, midwives and traditional birth attendants after this training. Similar outcomes were identified with resuscitation in the setting of injury.(3,9,10) Barriers to effective training included presentation of material that did not match the patient demographics, difficulty with translation and relatively short duration of instruction. Later courses have emphasized collaboration with local experts to optimize translation and scenarios tailored to the local clinical setting. Perhaps most important, general resuscitation training and emergency medical care based on physical examination and fundamental principles were not expensive, nor did they require high technology interventions.
Trauma is a clear opportunity for appropriately trained providers to improve outcomes without the utilization of expensive technologies. The fundamental approach to trauma care has changed little since the American College of Surgeons began dissemination of the Advanced Trauma Life Support program in the 1980s.(11) Rapid focused physical assessment identifies the extent and nature of injuries in a team-based approach. This coordinated team approach has been shown to improve provider expertise and clinical outcomes.(11-13) Effective function of trauma systems requires transportation resources to support timely referral of patients to a higher level of care if appropriate. Although the trauma literature has increasingly emphasized shock resuscitation using blood products, a specific role for blood product administration is seen in a small number of injured patients even in busy centers.(14)

Global guidelines for sepsis management also emphasize the importance of early recognition, fluid administration, source control measures and antibiotic therapy.(15-17) Many of these interventions require tools and monitoring capabilities which can be readily adapted to a resource-limited setting. For example, evidence from clinical trials does not support a choice of colloid over crystalloid solutions, so the latter may be recommended because of their availability and far lower cost.(4,18) Triage may be necessary to provide access to specialists capable of some forms of source control and units equipped for administration of recommended vasoactive drugs.
Support of the patient with respiratory failure is enhanced with simple pulse oximetry and cost-effective technologies, including oxygen concentrators capable of supporting multiple patients simultaneously. Mechanical ventilators and anesthesia machines designed for resource-limited settings are becoming available and less expensive. Shortages of trained clinicians and technical support are ongoing limitations. Management guidelines for the patient with respiratory failure are becoming widely available, but may require modification for low resource settings.(3,4,19,20)
Critical care medicine began in 1953 when Danish patients with poliomyelitis received invasive mechanical ventilation(21,22) in a common location with intensified nursing support and manual ventilation provided by students. Mortality rates declined with this model of care. The intensive care unit has become a crucial part of hospital care. Intensive care medicine and nursing are young specialties since critical care units were uncommon before the 1970s. Unlike other diseases, including cancer, cardiovascular disease, tuberculosis, and HIV/AIDS, reliable epidemiologic data on critical illness syndromes are scarce. Despite specific data and, in some cases, a definition of critical illness, it seems clear that the demand for critical care services will increase in both developed and underdeveloped countries while the ability to pay for these services will decrease. Thus, our experience with providing cost-effective and preventive critical care in underserved countries may become a model for all nations.(22,23)
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