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Development of a short course on management of critically ill patients with acute respiratory infection and impact on clinician knowledge in resource-limited intensive care units.

ABSTRACT: BACKGROUND:The 2009 influenza A (H1N1) pandemic caused surges of patients in intensive care units (ICUs) in resource-limited settings. Several Ministries of Health requested clinical management guidance from the World Health Organization (WHO), which had not previously developed guidance regarding critically ill patients. OBJECTIVE:To assess the acceptability and impact on knowledge of a short course about the management of critically ill patients with acute respiratory infections complicated by sepsis or acute respiratory distress syndrome delivered to clinicians in resource-limited ICUs. METHODS:Over 4 years (2009-2013), WHO led the development, piloting, implementation and preliminary evaluation of a 3-day course that emphasized patient management based on evidence-based guidelines and used interactive adult-learner teaching methodology. International content experts (n = 35) and instructional designers contributed to development. We assessed participants' satisfaction and content knowledge before and after the course. RESULTS:The course was piloted among clinicians in Trinidad and Tobago (n = 29), Indonesia (n = 38) and Vietnam (n = 86); feedback from these courses contributed to the final version. In 2013, inaugural national courses were delivered in Tajikistan (n = 28), Uzbekistan (n = 39) and Azerbaijan (n = 30). Participants rated the course highly and demonstrated increased immediate content knowledge after (vs before) course completion (P < .001). CONCLUSIONS:We found that it was feasible to create and deliver a focused critical care short course to clinicians in low- and middle-income countries. Collaboration between WHO, clinical experts, instructional designers, Ministries of Health and local clinician-leaders facilitated course delivery. Future work should assess its impact on longer-term knowledge retention and on processes and outcomes of care.

SUBMITTER: Diaz JV

PROVIDER: S-EPMC6086848 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Development of a short course on management of critically ill patients with acute respiratory infection and impact on clinician knowledge in resource-limited intensive care units.

Diaz Janet V JV Ortiz Justin R JR Lister Paula P Shindo Nahoko N Adhikari Neill K J NKJ

Influenza and other respiratory viruses 20180526 5

<h4>Background</h4>The 2009 influenza A (H1N1) pandemic caused surges of patients in intensive care units (ICUs) in resource-limited settings. Several Ministries of Health requested clinical management guidance from the World Health Organization (WHO), which had not previously developed guidance regarding critically ill patients.<h4>Objective</h4>To assess the acceptability and impact on knowledge of a short course about the management of critically ill patients with acute respiratory infections ...[more]

PMID: 29727522

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Project description:BackgroundPneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, current national guidelines for the treatment of hospital-acquired pneumonia (HAP) are several years old and the diagnosis of pneumonia in mechanically ventilated patients (VAP) has been subject to considerable recent attention. The optimal duration of antibiotic therapy for HAP in the critically ill is uncertain.ObjectivesTo assess the effectiveness of short versus prolonged-course antibiotics for HAP in critically ill adults, including patients with VAP.Search methodsWe searched CENTRAL (2015, Issue 5), MEDLINE (1946 to June 2015), MEDLINE in-process and other non-indexed citations (5 June 2015), EMBASE (2010 to June 2015), LILACS (1982 to June 2015) and Web of Science (1955 to June 2015).Selection criteriaWe considered all randomised controlled trials (RCTs) comparing a fixed 'short' duration of antibiotic therapy with a 'prolonged' course for HAP (including patients with VAP) in critically ill adults.Data collection and analysisTwo review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information.Main resultsWe identified six relevant studies involving 1088 participants. This included two new studies published after the date of our previous review (2011). There was substantial variation in participants, in the diagnostic criteria used to define an episode of pneumonia, in the interventions and in the reported outcomes. We found no evidence relating to patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, overall a short seven- or eight-day course of antibiotics compared with a prolonged 10- to 15-day course increased 28-day antibiotic-free days (two studies; N = 431; mean difference (MD) 4.02 days; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (one study; N = 110; odds ratio (OR) 0.44; 95% CI 0.21 to 0.95), without adversely affecting mortality and other recurrence outcomes. However, for cases of VAP specifically due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (two studies, N = 176; OR 2.18; 95% CI 1.14 to 4.16), though mortality outcomes were not significantly different. One study found that a three-day course of antibiotic therapy for patients with suspected HAP but a low Clinical Pulmonary Infection Score (CPIS) was associated with a significantly lower risk of superinfection or emergence of antimicrobial resistance, compared with standard (prolonged) course therapy.Authors' conclusionsOn the basis of a small number of studies and appreciating the lack of uniform definition of pneumonia, we conclude that for patients with VAP not due to NF-GNB a short, fixed course (seven or eight days) of antibiotic therapy appears not to increase the risk of adverse clinical outcomes, and may reduce the emergence of resistant organisms, compared with a prolonged course (10 to 15 days). However, for patients with VAP due to NF-GNB, there appears to be a higher risk of recurrence following short-course therapy. These findings do not differ from those of our previous review and are broadly consistent with current guidelines. There are few data from RCTs comparing durations of therapy in non-ventilated patients with HAP, but on the basis of a single study, short-course (three-day) therapy for HAP appears not to be associated with worse clinical outcome, and may reduce the risk of subsequent infection or the emergence of resistant organisms when there is low probability of pneumonia according to the CPIS.

Project description:BackgroundCurrent critical care prognostic models are predominantly developed in high-income countries (HICs) and may not be feasible in intensive care units (ICUs) in lower- and middle-income countries (LMICs). Existing prognostic models cannot be applied without validation in LMICs as the different disease profiles, resource availability, and heterogeneity of the population may limit the transferability of such scores. A major shortcoming in using such models in LMICs is the unavailability of required measurements. This study proposes a simplified critical care prognostic model for use at the time of ICU admission.MethodsThis was a prospective study of 3855 patients admitted to 21 ICUs from Bangladesh, India, Nepal, and Sri Lanka who were aged 16 years and over and followed to ICU discharge. Variables captured included patient age, admission characteristics, clinical assessments, laboratory investigations, and treatment measures. Multivariate logistic regression was used to develop three models for ICU mortality prediction: model 1 with clinical, laboratory, and treatment variables; model 2 with clinical and laboratory variables; and model 3, a purely clinical model. Internal validation based on bootstrapping (1000 samples) was used to calculate discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer-Lemeshow C-Statistic; higher values indicate poorer calibration). Comparison was made with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II models.ResultsModel 1 recorded the respiratory rate, systolic blood pressure, Glasgow Coma Scale (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% confidence interval (CI) 0.800-0.835) for model 1, 0.767 (0.741-0.792) for TropICS, and 0.725 (0.688-0.762) for model 3. The Hosmer-Lemeshow C-Statistic p values were less than 0.05 for models 1 and 3 and 0.18 for TropICS. In comparison, when APACHE II and SAPS II were applied to the same dataset, AUC was 0.707 (0.688-0.726) and 0.714 (0.695-0.732) and the C-Statistic was 124.84 (p < 0.001) and 1692.14 (p < 0.001), respectively.ConclusionThis paper proposes TropICS as the first multinational critical care prognostic model developed in a non-HIC setting.

Project description:IntroductionCorticosteroids are one of the most promising therapeutic agents for critically ill patients with coronavirus disease 2019 (COVID-19). Despite emerging data, assessed populations and regimens vary, and there are patient subgroups whose response to steroids remains unclear. We aimed to evaluate the outcomes of COVID-19 patients admitted to the intensive care unit (ICU) and treated with a short dexamethasone course to determine which patient categories derive the highest benefit.MethodsA retrospective cohort study was conducted using a prospectively collected single-center ICU database (April 1-October 1, 2020). Adult COVID-19 patients were assigned to dexamethasone (12 mg × 3 days) and usual care groups. Patient, management, and outcome data were extracted. The primary outcome was the 28-day ICU mortality. Subgroup analysis was performed to assess the impact of dexamethasone on mortality in patients with invasive mechanical ventilation (IMV).ResultsOf 233 patients, 220 (median age: 65 years, 38% female) were included: 83 patients received dexamethasone and 137 received usual care. Overall, 28 (33.7%) and 54 (39.4%) patients in the dexamethasone and usual care groups, respectively, died within 28 days since ICU admission (rate ratio (RR) 0.86; 95% confidence interval (95% CI): 0.59-1.23; p=0.405). In the IMV cohort, dexamethasone did not decrease the 28-day mortality compared with usual care (47.5% vs. 62.0%; RR 0.78; 95% CI: 0.57-1.09; p=0.107). A subgroup analysis revealed significantly lower 28-day mortality in IMV patients <65 years receiving dexamethasone vs. usual care (22.6% vs. 48.5%; RR 0.47; 95% CI: 0.22-0.98; p=0.043), which was not seen in IMV patients ≥65 years (75.0% vs. 71.1%; RR 1.06; 95% CI: 0.79-1.42; p=0.719). Patients ≥65 years experienced hyperglycemia, bacterial infection, and septic shock significantly more often than younger patients who received dexamethasone (p=0.002, p=0.025, and p < 0.001, respectively).ConclusionsA 3-day dexamethasone course is not associated with lower 28-day mortality in critically ill COVID-19 patients, either in the entire ICU cohort or in the IMV. Dexamethasone may significantly reduce the 28-day mortality in IMV patients <65 years, but not in the older IMV subgroup. Dexamethasone administration in patients ≥65 years is associated with a significantly higher rate of adverse events than that in younger patients.

Project description:IntroductionRecent evidence suggests that choice of fluid used for resuscitation may influence mortality in critically ill patients.MethodsWe conducted a cross-sectional study in 391 intensive care units across 25 countries to describe the types of fluids administered during resuscitation episodes. We used generalized estimating equations to examine the association between patient, prescriber and geographic factors and the type of fluid administered (classified as crystalloid, colloid or blood products).ResultsDuring the 24-hour study period, 1,955 of 5,274 (37.1%) patients received resuscitation fluid during 4,488 resuscitation episodes. The main indications for administering crystalloid or colloid were impaired perfusion (1,526/3,419 (44.6%) of episodes), or to correct abnormal vital signs (1,189/3,419 (34.8%)). Overall, colloid was administered to more patients (1,234 (23.4%) versus 782 (14.8%)) and during more episodes (2,173 (48.4%) versus 1,468 (32.7%)) than crystalloid. After adjusting for patient and prescriber characteristics, practice varied significantly between countries with country being a strong independent determinant of the type of fluid prescribed. Compared to Canada where crystalloid, colloid and blood products were administered in 35.5%, 40.6% and 28.3% of resuscitation episodes respectively, odds ratios for the prescription of crystalloid in China, Great Britain and New Zealand were 0.46 (95% confidence interval (CI) 0.30 to 0.69), 0.18 (0.10 to 0.32) and 3.43 (1.71 to 6.84) respectively; odds ratios for the prescription of colloid in China, Great Britain and New Zealand were 1.72 (1.20 to 2.47), 4.72 (2.99 to 7.44) and 0.39 (0.21 to 0.74) respectively. In contrast, choice of fluid was not influenced by measures of illness severity (for example, Acute Physiology and Chronic Health Evaluation (APACHE) II score).ConclusionsAdministration of resuscitation fluid is a common intervention in intensive care units and choice of fluid varies markedly between countries. Although colloid solutions are more expensive and may possibly be harmful in some patients, they were administered to more patients and during more resuscitation episodes than crystalloids were.

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Development of a short course on management of critically ill patients with acute respiratory infection and impact on clinician knowledge in resource-limited intensive care units.

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Development of a short course on management of critically ill patients with acute respiratory infection and impact on clinician knowledge in resource-limited intensive care units.

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