Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country

Tim Baker, Carl Otto Schell, Edwin Lugazia, Jonas Blixt, Moses Mulungu, Markus Castegren, Jaran Eriksen, David Konrad, Tim Baker, Carl Otto Schell, Edwin Lugazia, Jonas Blixt, Moses Mulungu, Markus Castegren, Jaran Eriksen, David Konrad

Abstract

Background: Global Critical Care is attracting increasing attention. At several million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LICs) have a disproportionally greater share of critical illness, and yet critical care facilities are scarce in such settings. Routines utilizing abnormal vital signs to identify critical illness and trigger medical interventions have become common in high-income countries but have not been investigated in LICs. The aim of the study was to assess whether the introduction of a vital signs directed therapy protocol improved acute care and reduced mortality in an Intensive Care Unit (ICU) in Tanzania.

Methods and findings: Prospective, before-and-after interventional study in the ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger levels of severely abnormal vital signs and stipulated acute treatment responses was implemented in a four week period using sensitisation, training, job aids, supervision and feedback. Acute treatment of danger signs at admission and during care in the ICU and in-hospital mortality were compared pre and post-implementation using regression models. Danger signs from 447 patients were included: 269 pre-implementation and 178 post-implementation. Acute treatment of danger signs was higher post-implementation (at admission: 72.9% vs 23.1%, p<0.001; in ICU: 16.6% vs 2.9%, p<0.001). A danger sign was five times more likely to be treated post-implementation (Prevalence Ratio (PR) 4.9 (2.9-8.3)). Intravenous fluids were given in response to 35.0% of hypotensive episodes post-implementation, as compared to 4.1% pre-implementation (PR 6.4 (2.5-16.2)). In patients admitted with hypotension, mortality was lower post-implementation (69.2% vs 92.3% p = 0.02) giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality rates were unchanged (49.4% vs 49.8%, p = 0.94).

Conclusion: The introduction of a vital signs directed therapy protocol improved the acute treatment of abnormal vital signs in an ICU in a low-income country. Mortality rates were reduced for patients with hypotension at admission but not for all patients.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Vital Signs Directed Therapy Protocol.
Fig 1. Vital Signs Directed Therapy Protocol.
Fig 2. Study flow chart.
Fig 2. Study flow chart.
Fig 3. Acute treatments in the ICU…
Fig 3. Acute treatments in the ICU over time.

References

    1. Riviello ED, Letchford S, Achieng L, Newton MW. Critical care in resource-poor settings: lessons learned and future directions. Critical care medicine. 2011;39(4):860–7. 10.1097/CCM.0b013e318206d6d5
    1. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet. 2010;376(9749):1339–46. 10.1016/S0140-6736(10)60446-1
    1. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015.
    1. Hirshon JM, Risko N, Calvello EJ, Stewart de Ramirez S, Narayan M, Theodosis C, et al. Health systems and services: the role of acute care. Bulletin of the World Health Organization. 2013;91(5):386–8. 10.2471/BLT.12.112664
    1. Mock C, Kobusingye O, Joshipura M, Nguyen S, Arreola-Risa C. Strengthening trauma and critical care globally. Current opinion in critical care. 2005;11(6):568–75.
    1. Requejo JH, Merialdi M, Bustreo F. Improving global maternal health: progress, challenges, and promise. Current opinion in obstetrics & gynecology. 2011;23(6):465–70.
    1. Cheng AC, West TE, Limmathurotsakul D, Peacock SJ. Strategies to reduce mortality from bacterial sepsis in adults in developing countries. PLoS medicine. 2008;5(8):e175 10.1371/journal.pmed.0050175
    1. Fowler RA, Fletcher T, Fischer WA, Lamontagne F, Jacob S, Brett-Major D, et al. Caring for Critically Ill Patients with Ebola Virus Disease Perspectives from West Africa. American journal of respiratory and critical care medicine. 2014;190(7):733–7. 10.1164/rccm.201408-1514CP
    1. Murthy S, Leligdowicz A, Adhikari NK. Intensive care unit capacity in low-income countries: a systematic review. PloS one. 2015;10(1):e0116949 10.1371/journal.pone.0116949
    1. Kwizera A, Dunser M, Nakibuuka J. National intensive care unit bed capacity and ICU patient characteristics in a low income country. BMC research notes. 2012;5:475 10.1186/1756-0500-5-475
    1. Baelani I, Jochberger S, Laimer T, Otieno D, Kabutu J, Wilson I, et al. Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers. Critical care (London, England). 2011;15(1):R10.
    1. WHO. World Health Statistics. Geneva: 2015.
    1. Baker T, Lugazia E, Eriksen J, Mwafongo V, Irestedt L, Konrad D. Emergency and critical care services in Tanzania: a survey of ten hospitals. BMC health services research. 2013;13:140 10.1186/1472-6963-13-140
    1. Stafford RE, Morrison CA, Godfrey G, Mahalu W. Challenges to the provision of emergency services and critical care in resource-constrained settings. Global heart. 2014;9(3):319–23. 10.1016/j.gheart.2014.08.005
    1. Gosselin RA, Heitto M. Cost-effectiveness of a district trauma hospital in Battambang, Cambodia. World journal of surgery. 2008;32(11):2450–3. 10.1007/s00268-008-9708-4
    1. Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World journal of surgery. 2006;30(4):505–11.
    1. McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet. 2003;81(1):83–92.
    1. Baker T. Critical care in low-income countries. Trop Med Int Health. 2009;14(2):143–8. 10.1111/j.1365-3156.2008.02202.x
    1. Dunser MW, Baelani I, Ganbold L. A review and analysis of intensive care medicine in the least developed countries. Critical care medicine. 2006;34(4):1234–42.
    1. Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia. 1999;54(9):853–60.
    1. Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation. 2004;62(3):275–82.
    1. Bleyer AJ, Vidya S, Russell GB, Jones CM, Sujata L, Daeihagh P, et al. Longitudinal analysis of one million vital signs in patients in an academic medical center. Resuscitation. 2011;82(11):1387–92. 10.1016/j.resuscitation.2011.06.033
    1. Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation. 2013;84(4):465–70. 10.1016/j.resuscitation.2012.12.016
    1. Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Annals of internal medicine. 2013;158(5 Pt 2):417–25. 10.7326/0003-4819-158-5-201303051-00009
    1. Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cooper DJ, et al. Goal-directed resuscitation for patients with early septic shock. The New England journal of medicine. 2014;371(16):1496–506. 10.1056/NEJMoa1404380
    1. Andrews B, Muchemwa L, Kelly P, Lakhi S, Heimburger DC, Bernard GR. Simplified Severe Sepsis Protocol: A Randomized Controlled Trial of Modified Early Goal-Directed Therapy in Zambia. Critical care medicine. 2014;42(11):2315–24. 10.1097/CCM.0000000000000541
    1. Konrad D, Jaderling G, Bell M, Granath F, Ekbom A, Martling CR. Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Intensive care medicine. 2010;36(1):100–6. 10.1007/s00134-009-1634-x
    1. Rylance J, Baker T, Mushi E, Mashaga D. Use of an early warning score and ability to walk predicts mortality in medical patients admitted to hospitals in Tanzania. Trans R Soc Trop Med Hyg. 2009;103(8):790–4. 10.1016/j.trstmh.2009.05.004
    1. Baker T, Blixt J, Lugazia E, Schell CO, Mulungu M, Milton A, et al. Single Deranged Physiologic Parameters Are Associated With Mortality in a Low-Income Country. Critical care medicine. 2015;43(10):2171–9. 10.1097/CCM.0000000000001194
    1. Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC research notes. 2015;8:313 10.1186/s13104-015-1275-9
    1. Thompson ML, Myers JE, Kriebel D. Prevalence odds ratio or prevalence ratio in the analysis of cross sectional data: what is to be done? Occupational and environmental medicine. 1998;55(4):272–7.
    1. Savu A, Liu Q, Yasui Y. Estimation of relative risk and prevalence ratio. Stat Med. 2010;29(22):2269–81. 10.1002/sim.3989
    1. Howell MD, Ngo L, Folcarelli P, Yang J, Mottley L, Marcantonio ER, et al. Sustained effectiveness of a primary-team-based rapid response system. Critical care medicine. 2012;40(9):2562–8. 10.1097/CCM.0b013e318259007b
    1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. The New England journal of medicine. 2001;345(19):1368–77.
    1. Marik PE, Desai H. Goal directed fluid therapy. Current pharmaceutical design. 2012;18(38):6215–24.
    1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical care medicine. 2013;41(2):580–637. 10.1097/CCM.0b013e31827e83af
    1. Castellanos-Ortega A, Suberviola B, Garcia-Astudillo LA, Holanda MS, Ortiz F, Llorca J, et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study. Critical care medicine. 2010;38(4):1036–43. 10.1097/CCM.0b013e3181d455b6
    1. Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock. The New England journal of medicine. 2015.
    1. Chew M, Oldner A. [In Process Citation]. Lakartidningen. 2015;112.
    1. Dunser MW, Festic E, Dondorp A, Kissoon N, Ganbat T, Kwizera A, et al. Recommendations for sepsis management in resource-limited settings. Intensive care medicine. 2012;38(4):557–74. 10.1007/s00134-012-2468-5
    1. Jacob ST, Lim M, Banura P, Bhagwanjee S, Bion J, Cheng AC, et al. Integrating sepsis management recommendations into clinical care guidelines for district hospitals in resource-limited settings: the necessity to augment new guidelines with future research. BMC medicine. 2013;11:107 10.1186/1741-7015-11-107
    1. Jacob ST, Banura P, Baeten JM, Moore CC, Meya D, Nakiyingi L, et al. The impact of early monitored management on survival in hospitalized adult Ugandan patients with severe sepsis: a prospective intervention study*. Critical care medicine. 2012;40(7):2050–8. 10.1097/CCM.0b013e31824e65d7
    1. Human resources for health in the low-resource world: collaborative practice and task shifting in maternal and neonatal care. Int J Gynaecol Obstet. 2009;105(1):74–6. 10.1016/j.ijgo.2008.11.007
    1. Callaghan M, Ford N, Schneider H. A systematic review of task- shifting for HIV treatment and care in Africa. Hum Resour Health. 2010;8:8 10.1186/1478-4491-8-8
    1. Lavy C, Sauven K, Mkandawire N, Charian M, Gosselin R, Ndihokubwayo JB, et al. State of surgery in tropical Africa: a review. World J Surg. 2011;35(2):262–71. 10.1007/s00268-010-0885-6
    1. Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. The New England journal of medicine. 2011;364(26):2483–95. 10.1056/NEJMoa1101549
    1. Riviello ED. Improving outcomes for severe sepsis in Africa: one step closer. Critical care medicine. 2014;42(11):2439–40. 10.1097/CCM.0000000000000591
    1. Baker T, Blixt J, Lugazia E, Schell O, Mulungu M, Milton A, et al. Single Deranged Physiologic Variables Are Associated With Mortality in a Low-Income Country. Critical care medicine. 2015.
    1. Schell C, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an ICU in a Low-income country (manuscript undergoing peer review). 2015.
    1. Ayieko P, Ntoburi S, Wagai J, Opondo C, Opiyo N, Migiro S, et al. A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomised trial. PLoS medicine. 2011;8(4):e1001018 10.1371/journal.pmed.1001018
    1. Chaudoir SR, Dugan AG, Barr CH. Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures. Implementation science: IS. 2013;8:22 10.1186/1748-5908-8-22
    1. Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation science: IS. 2013;8:35 10.1186/1748-5908-8-35
    1. Papali A, McCurdy MT, Calvello EJ. A "three delays" model for severe sepsis in resource-limited countries. Journal of critical care. 2015.

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