Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting.

OBJECTIVE: This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. DESIGN: Longitudinal observational cohort study. SETTING: District General Hospital Monaragala. PARTICIPANTS: All adult (age >17 years) admitted patients. MAIN OUTCOME MEASURES: Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. STATISTICAL ANALYSIS: Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve.Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). RESULTS: Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). CONCLUSION: There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients. TRIAL REGISTRATION NUMBER: NCT02523456.

Critical Care Junior Doctors' Profile in a Lower Middle-income Country: A National Cross-sectional Survey.

BACKGROUND AND AIMS: Retention of junior doctors in specialties such as critical care is difficult, especially in resource-limited settings. This study describes the profile of junior doctors in adult state intensive care units in Sri Lanka, a lower middle-income country. MATERIALS AND METHODS: This was a national cross-sectional survey using an anonymous self-administered electronic questionnaire. RESULTS: Five hundred and thirty-nine doctors in 93 Intensive Care Units (ICUs) were contacted, generating 207 responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Most junior doctors (150, 75.8%) had no previous exposure to anesthesia and 134 (67.7%) had no previous ICU experience while 116 (60.7%) ICU doctors wished to specialize in critical care. However, only a few (12, 6.3%) doctors had completed a critical care diploma course. There was a statistically significant difference (P < 0.05) between the self-assessed confidence of anesthetic background junior doctors and non-anesthetists. The overall median competency for doctors improves with the length of ICU experience and is statistically significant (P < 0.05). ICU postings were less happy and more stressful compared to the last non-ICU posting (P < 0.05 for both). The vast majority, i.e., 173 (88.2%) of doctors felt the care provided for patients in their ICUs was good, very good, or excellent while 71 doctors (36.2%) would be happy to recommend the ICU where they work to a relative with the highest possible score of 10. CONCLUSION: Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed.

Practices and Perspectives in Cardiopulmonary Resuscitation Attempts and the Use of Do Not Attempt Resuscitation Orders: A Cross-sectional Survey in Sri Lanka.

OBJECTIVE: The objective of this study is to describe the characteristics of in-hospital cardiopulmonary resuscitation (CPR) attempts, the perspectives of junior doctors involved in those attempts and the use of do not attempt resuscitation (DNAR) orders. METHODS: A cross-sectional telephone survey aimed at intern doctors working in all medical/surgical wards in government hospitals. Interns were interviewed based on the above objective. RESULTS: A total of 42 CPR attempts from 82 hospitals (338 wards) were reported, 3 of which were excluded as the participating doctor was unavailable for interview. 16 (4.7%) wards had at least 1 patient with an informal DNAR order. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt, of which 6 occurred on wards with an informal DNAR order in place. 39 resuscitations were attempted. Survival at 24 h was 2 (5.1%). In 5 (13%) attempts, CPR was the only intervention reported. On 25 (64%) occasions, doctors were "not at all" or "only a little bit surprised" by the arrest. CONCLUSIONS: CPR attempts before death in hospitals across Sri Lanka is prevalent. DNAR use remains uncommon.

Capacity building for critical care training delivery: Development and evaluation of the Network for Improving Critical care Skills Training (NICST) programme in Sri Lanka.

OBJECTIVES: To deliver and evaluate a short critical care nurse training course whilst simultaneously building local training capacity. RESEARCH METHODOLOGY: A multi-modal short course for critical care nursing skills was delivered in seven training blocks, from 06/2013-11/2014. Each training block included a Train the Trainer programme. The project was evaluated using Kirkpatrick's Hierarchy of Learning. There was a graded hand over of responsibility for course delivery from overseas to local faculty between 2013 and 2014. SETTING: Sri Lanka. MAIN OUTCOME MEASURES: Participant learning assessed through pre/post course Multi-Choice Questionnaires. RESULTS: A total of 584 nurses and 29 faculty were trained. Participant feedback was consistently positive and each course demonstrated a significant increase (p≤0.0001) in MCQ scores. There was no significant difference MCQ scores (p=0.186) between overseas faculty led and local faculty led courses. CONCLUSIONS: In a relatively short period, training with good educational outcomes was delivered to nearly 25% of the critical care nursing population in Sri Lanka whilst simultaneously building a local faculty of trainers. Through use of a structured Train the Trainer programme, course outcomes were maintained following the handover of training responsibility to Sri Lankan faculty. The focus on local capacity building increases the possibility of long term course sustainability.

A cross-sectional survey of critical care services in Sri Lanka: a lower middle-income country.

PURPOSE: To describe the extent and variation of critical care services in Sri Lanka as a first step towards the development of a nationwide critical care unit (CCU) registry. MATERIALS AND METHODS: A cross-sectional survey was conducted in all state CCUs by telephone or by visits to determine administration, infrastructure, equipment, staffing, and overall patient outcomes. RESULTS: There were 99 CCUs with 2.5 CCU beds per 100000 population and 13 CCU beds per 1 000 hospital beds. The median number of beds per CCU was 5. The overall admissions were 194 per 100000 population per year. The overall bed turnover was 76.5 per unit per year, with CCU mortality being 17%. Most CCUs were headed by an anesthetist. There were a total of 790 doctors (1.6 per bed), 1,989 nurses (3.9 per bed), and 626 health care assistants (1.2 per bed). Majority (87.9%) had 1:1 nurse-to-patient ratio, although few (11.4%) nurses had received formal intensive care unit training. All CCUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (such as electronic monitoring and infusion pumps). CONCLUSION: Sri Lanka, a lower middle-income country has an extensive network of critical care facilities but with inequalities in its distribution and facilities.