ICU Structures and Protocols in Ecuador: A Peri-Pandemic Nationwide Assessment

ABSTRACT

Rationale Ecuador was among the top fifth of countries affected by the COVID-19 pandemic worldwide. Intensive care units (ICUs), and health system resilience form key elements of the health system to prepare for meeting needs of its population, both during surge needs, and for postpandemic planning. There is limited evaluation of the existing ICU infrastructure, processes and protocols within ICUs. Our study sought to perform an assessment of the ICU practices across Ecuador. Methods: During December, 2020, we conducted an observational, cross-sectional study using questionnaires developed in Spanish, that were deployed in 42 Ecuadorian medical facilities, using trained physicians. The questionnaires were developed by experts, covering domains including hospital characteristics, utilization, and structural factors, such as human resources, and staffing practices. ICUs were categorized by the degree of global resource availability. The primary outcomes were availability and access to equipment, personnel, protocols, and therapies relevant to the practice of critical care. Secondary outcomes were mortality, admissions in the emergency department and ICU annually. Results: Thirty-six hospitals (85.7%) agreed to participate and were enrolled in the study. Annual average ICU mortality in 2019 was 20% (IQR 14-30), which in 2020 increased to 40.5% (IQR 28.9-49.8), in the facilities evaluated. Annual average ICU admissions were 311 (154-404), with an average annual bed capacity of 120 (82-221.5). Sepsis, deep venous thromboprophylaxis, and glucose monitoring protocols were most commonly reported (96%), while protocols for massive transfusion (48%), targeted temperature management (41%), and palliative care (30%) were less common. In a multivariable linear regression adjusting for ICU level, annual ICU mortality was significantly lower in hospitals that reported higher use of respiratory protocols (- 3.4%, 95% CI-5.4 to -1.3;p=0.003) and sepsis protocols (-8.4%, 95% CI -14.1 to -2.7);p= 0.006). Conclusions: To our knowledge, this is the first study describing the ICU structure, process and components of different facilities across Ecuador. These may help guide decision-making policymakers, and health service communities to understand Ecuador's health system resilience, and key avenues for improvement and planning.