Exploring medical and nursing students' perceptions about a patient safety course: a qualitative study.

BACKGROUND: Educating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students. METHODS: A dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021-2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo. RESULTS: The findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety. CONCLUSIONS: Student perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.

Burns in South Asia: Outcomes from South Asian Burn Registry (SABR).

BACKGROUND: South Asian region contributes 59 % to the global mortality due to burns. However, we find a paucity of literature on the outcomes of burns from low- and middle-income countries (LMICs). South Asian Burn Registry (SABR) is a facility-based burns registry that collected data on in-patient burn care. This study assesses factors associated with mortality, length of hospital stay at the burns center, and functional status of burn patients. METHODS: Prospective data was collected from two specialized public sector burn centers between September 2014 - January 2015 from Bangladesh and Pakistan. Multivariable logistic, linear, and ordinal logistic regression was conducted to assess factors associated with inpatient-mortality, length of hospital stay, and functional status at discharge, respectively. RESULTS: Data on 883 patients was analyzed. Increased association with mortality was observed with administration of blood product (OR:3, 95 % CI:1.18-7.58) and nutritional support (OR:4.32, 95 % CI:1.55-12.02). Conversely, antibiotic regimens greater than 8 days was associated with decreased mortality (OR:0.1, 95 % CI:0.03-0.41). Associated increase in length of hospital stay was observed in patients with trauma associated with their burn injury, history of seizures (CE:47.93, 95 % CI 12.05-83.80), blood product (CE:22.09, 95 % CI:0.83-43.35) and oxygen administration (CE:23.7, 95 % CI:7.34-40.06). Patients who developed sepsis (OR:6.89, 95 % CI:1.92-24.73) and received blood products during hospitalization (OR:2.55, 95 % CI:1.38- 4.73) were more likely to have poor functional status at discharge. CONCLUSION: This study identified multiple factors associated with worse clinical outcomes for burn patients in South Asia. Understanding these parameters can guide targeted efforts to improve the process and quality of burn care in LMICs.

Assessment of Patient Safety in a Low-Resource Health Care System: Proposal for a Multimethod Study.

BACKGROUND: The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources. OBJECTIVE: This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting. METHODS: We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization's Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility. RESULTS: The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs. CONCLUSIONS: A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non-resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50532.

Implementation and long-term efficacy of a multifaceted intervention to reduce central line-associated bloodstream infections in intensive care units of a low-middle-income country.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) pose a significant risk to critically ill patients, particularly in intensive care units (ICU), and are a significant cause of hospital-acquired infections. We investigated whether implementation of a multifaceted intervention was associated with reduced incidence of CLABSIs. METHODS: This was a prospective cohort study over nine years. We implemented a bundled intervention approach to prevent CLABSIs, consisting of a comprehensive unit-based safety program (CUSP). The program was implemented in the Neonatal ICU, Medical ICU, and Surgical ICU departments at the Aga Khan University Hospital in Pakistan. RESULTS: The three intervention ICUs combined were associated with an overall 36% reduction in CLABSI rates and a sustained reduction in CLABSI rates for > a year (5 quarters). The Neonatal ICU experienced a decrease of 77% in CLABSI rates lasting ∼1 year (4 quarters). An attendance rate above 88% across all stakeholder groups in each CUSP meeting correlated with a better and more sustained infection reduction. CONCLUSIONS: Our multifaceted approach using the CUSP model was associated with reduced CLABSI-associated morbidity and mortality in resource-limited settings. Our findings suggest that a higher attendance rate (>85%) at meetings may be necessary to achieve sustained effects post-intervention.

Factors associated with emergency department disposition among burn injury patients: Analysis of prehospital and emergency care characteristics using South Asia Burn Registry (SABR) data.

INTRODUCTION: Improvement in burn injury data collections and the quality of databanks has allowed meaningful study of the epidemiologic trends in burn care. The study assessed factors associated with disposition of burn injury patients from emergency department accounting for pre-hospital care and emergency care. METHODS: This prospective observational pilot study of the South Asia Burn Registry project was conducted at selected public sector burn centers in Bangladesh and Pakistan (September 2014 - January 2015). All age groups with an initial presentation to the burn centers were enrolled. Descriptive and regression analysis is presented. RESULTS: A total of 2749 patients were enrolled. The mean age was 21.7 ± 18.0 years, 55.3% were males, and about a quarter were children < 5 years. About 46.9% of the females were housewives. Scald burns were common among children (67.6%) while flame burns were common among adults (44.3%). About 75% of patients were brought in via non-ambulance mode of transport. More than 55% of patients were referrals from other facilities or clinics. The most common first aid given pre-hospital was the use of water or oil. About 25% were admitted for further care. The adjusted odds of being admitted compared to being sent home were highest for children < 5 yrs, those with higher total body surface area burnt, having arrived via ambulance, scald and electrical burn, having an associated injury and inhalational injury. CONCLUSION: The study provides insight into emergency burn care and associated factors that influenced outcomes for patients with burn injuries.

Epidemiology of ophthalmic trauma in the United States from 2009-2018: A Nationwide Emergency Department Sample Analysis.

PURPOSE: To determine the incidence, characteristics, disposition, and economic burden of emergency department (ED) visits for ophthalmic trauma in the United States (US). DESIGN: Retrospective study. METHODS: The Nationwide Emergency Department Sample was used to calculate and characterize ED visits for ophthalmic trauma in the US from 2009 to 2018. Linear regression was used to estimate trends in annual incidence and mean inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission. RESULTS: There were over 7.3 million ED visits for ophthalmic trauma in the US over the 10 years, with an annual incidence of 233 per 100,000 population. Patients were predominantly male (65 %), 21-44 years old (39 %), and from low-income households (56 %). Only 1 % of patients were hospitalized. Older age, male sex, metropolitan teaching hospitals, and trauma centers were associated with significantly higher odds of inpatient admission. The mean inflation-adjusted ED charge per visit more than doubled over the decade ($1,333 to $3,187) with total charges exceeding $14 billion. Superficial injuries (44 %) and eyelid/orbit wounds (20 %) accounted for the majority of visits. Orbital floor fractures (4 %) and open globe injuries (2 %) accounted for a minority of visits but were responsible for most admissions (49 % and 29 %, respectively) and the highest mean ED charge ($7,157 and $6,808, respectively). CONCLUSIONS: Ophthalmic trauma represents an increasingly significant burden to EDs in the US. Preventive efforts should target young males from low socioeconomic backgrounds. Strategies to improve outpatient access and redirect non-urgent injuries may help alleviate costs.

Estimating the frequency of inpatient adverse events using a two-step retrospective chart review: a study protocol.

INTRODUCTION: Adverse events are a major cause of patient harm in the hospitalised setting. Low-income and middle-income countries account for a disproportionate share of the global burden of adverse events. However, patient safety research is still centred around high-income countries and high-resource health systems. The methods and data produced from these efforts are ill-suited to low-income and middle-income systems due to the social and technical differences between these settings. We aim to use our pilot-tested, locally developed methodology to estimate the frequency and characteristics of adverse events in hospitalised patients in a lower-middle-income country to inform patient safety policies and initiatives. METHODS AND ANALYSIS: This multi-centre study will employ a two-step chart review methodology to identify adverse events in a representative sample of patients admitted at five hospitals between 1 January 2019 and 31 December 2019. The first step will include assessing patient files against a list of triggers to detect adverse events and the second step will involve an in-depth review of the events to capture pertinent characteristics. The triggers have been adapted from validated tools used in other studies. The reviewing team will be trained on the use of research tools and operational definitions to ensure that data are collected uniformly. The main outcome of interest is the rate at which adverse events occur in hospitalised patients. Further analysis will look to identify and quantify associations between the main outcome of interest and a variety of variables such as patient age and gender using tests of independence and regression techniques. ETHICS AND DISSEMINATION: This study protocol has been approved by the Ethics Review Committee at Aga Khan University (Reference number: 2023-6324-24566). The findings of this study will be published in a peer-reviewed journal and disseminated to the public through national and international conferences, workshops, websites and social media.

Covid-19 co-infection with Crimean Congo haemorrhagic fever (CCHF) in a CCHF endemic country: a case report.

Covid-19 pandemic affected the health care systems globally. In many countries, healthcare services were overwhelmed by the huge number of Covid cases; hence, shifting the focus from locally endemic infectious diseases. Such a case presented to us that was initially managed along the lines of critical Covid pneumonia with steroids, Remdesivir, and supplemental oxygen for hypoxic respiratory failure. The patient also received Baricitinib, to which he was non-responsive and thus offered invasive mechanical ventilation. Post intubation, the patient was managed for Covid-associated ARDS with lung protective ventilation. He later also developed liver dysfunction, renal failure, coagulation derangements, and shock. Workup for malaria and dengue were negative. Later, Crimean Congo PCR was sent which came positive; a possible cause of progressive deterioration. In CCHF endemic areas, it is crucial to rule out the CCHF infection among patients presenting with critical Covid pneumonia due to similar clinical presentation in both the infections.

The Impact of Short Intensive Care Rotation on Residents' Experience in the COVID-19 Pandemic: A Mixed-Methods Study.

Objectives: To assess the impact and utility of an intensive care unit (ICU) rotation during the coronavirus disease 2019 (COVID-19) pandemic and the need for mandatory ICU rotations in training for all clinical specialties. Methods: A mixed methods study was conducted from January to September 2021 at the Aga Khan University Hospital, including resident doctors who rotated through COVID ICU between May and September 2020. An online survey was undertaken, followed by two focused group discussions (FGDs). Results: Fifty-nine complete responses out of a total of 86 were analyzed. Around 42.3% (n = 25) of doctors belonged to medicine/allied specialties and 57.6% (n = 34) had previous ICU experience. Both groups, with and without prior ICU experience, found the rotation equally challenging (82.3% (n = 28) versus 84% (n = 21), P = .776) and gained similar practical skills (35.3% (n = 12) versus 16% (n = 4), P = .072), however, those with experience gained significantly more knowledge (58.5% (n = 20) versus 32% (n = 8), P = .047). On opinion regarding mandatory ICU rotation, the majority agreed to have a mandatory rotation (82% (n = 28) versus 72% (n = 18), P = .421)) with an optimal duration of 1 to 2 months. The FGDs found that all residents encouraged the idea of mandatory training in ICU which must be tailored to their training specialty and suggested extending the duration beyond 1 week to ensure learning. Conclusions: COVID ICU rotation was a good avenue for learning and the idea of mandatory ICU training was supported. Mandating ICU rotation might theoretically enhance response to emergencies. More research is needed to understand for feasible incorporation of ICU training in the curriculum.

Estimating access to surgical care: A community centered national household survey from Pakistan.

Pakistan is a lower middle-income country in South Asia with a population of 225 million. No estimate for surgical care access exists for the country. We postulate the estimated access to surgical care is less than the minimum 80% to be achieved by 2030. We conducted a randomized, stratified two-stage cluster household survey. A sample of 770 households was selected using 2017 census frames from the Pakistan Bureau of Statistics. Data was collected on choice of hospital and travel time to the chosen hospital for C-section, laparotomy, open fracture repair (OFR), and specialized surgery. Analysis was conducted using Stata 14. Access to all Bellwether surgeries (C-section, laparotomy, and open fracture repair) in Pakistan is estimated to be 74.8%. However, estimated access in rural areas and the provinces of Balochistan, Khyber Pakhtunkhwa (KP) and Sindh is far less than in urban areas and in Punjab and Islamabad. Estimated access to C-sections is more compared to OFR, laparotomy, and specialized surgery. Health system strengthening efforts should focus on improving surgical care access in rural areas and in Balochistan, KP, and Sindh. More focus is required on standardizing the availability and quality of surgical services in secondary-level hospitals.

Ease of Intubation with McGrath Videolaryngoscope and Incidence of Adverse Events During Tracheal Intubation in COVID-19 Patients: A Prospective Observational Study.

Background: Tracheal intubation in critically ill patients remains high-risk despite advances in equipment, technique, and clinical guidelines. Many patients with COVID-19 were in respiratory distress and required intubation that is considered an aerosol-generating procedure (AGP). The transition to videolaryngoscopy as a routine first line option throughout anesthetic and ICU practice has been reported. We evaluated the ease of intubation, success rate, use of accessory maneuvers and adverse outcomes during and 24 hours after intubation with the McGrath videolaryngoscope. Methods: This was a prospective, observational single center study conducted at non-operating room locations that included all adults (>18 years old) with suspected or confirmed COVID-19 infection and were intubated by McGrath videolaryngoscope. The anesthesiologist performed tracheal intubation were requested to fill online data collection form. A co-investigator was responsible to coordinate daily with assigned consultants for COVID intubation and follow up of patients at 24 hours after intubation. Results: A total of 105 patients were included in our study. Patients were predominantly male (n=78; 74.3%), their COVID status was either confirmed (n=97, 92.4%) or suspected (n=8, 7.6%). Most were intubated in the COVID ward (n=59, 56.2%) or COVID ICU (n=23, 21.9%). The overall success rate of intubation with McGrath in the first attempt was 82.9%. The glottic view was either full (n=85, 80.95%), partial (n=16, 15.24%) or none (n=4, 3.81%). During intubation, hypoxemia occurred in 18.1% and hypotension in 16.2% patients. Within 24 hours of intubation, pneumothorax occurred in 1.9%, cardiac arrest and return of spontaneous circulation in 6.7% and mortality in 13.3% of patients. Conclusion: These results illustrate the ease and utility of the McGrath videolaryngoscope for tracheal intubation in COVID-19 patients. Its disposable blade is of significant value in protectin during tracheal intubation.

Incorporating Patient Safety and Quality Course Into the Nursing Curriculum: An Assessment of Student Gains.

BACKGROUND: Training nursing students on quality and patient safety (PS) is crucial to ensuring safe healthcare practices given the key role nurses play on the healthcare team. The aim of this study was to evaluate the impact of quality and PS course on the knowledge, and system thinking of students at different stages of the undergraduate nursing course. METHODS: A 4.5-day quality improvement and PS course was conducted at the Aga Khan University School of Nursing and Midwifery for 146 second- and 139 fourth-year students. Students' knowledge, self-assessment of knowledge and skills, and system thinking were assessed using pretest and posttest. RESULTS: Of the total of 20 points, the course significantly improved students' knowledge by a mean of 4.91 points for second-year students (95% confidence interval [CI], 4.32-5.51) and 3.46 points for fourth-year students (95% CI, 2.90-4.02) between pretest and posttest. For systems thinking, the Systems Thinking Scale scores increased by 0.41 points (95% CI, 0.29-0.52) for second-year students and 0.33 points (95% CI, 0.22-0.44) for fourth-year students out of the total of 5 points. The self-assessment scores significantly increased on postcourse assessment for second (P < 0.05) and fourth-year students (P < 0.001). Positive experience reported by students in the narrative reflections complemented these results. CONCLUSIONS: There was a significant increase in nursing students' knowledge, self-efficacy, and system thinking after participating in this short PS course. Replication at a national level may improve safety knowledge and skills among nursing students with subsequent gains in the safety of healthcare delivery in Pakistan.

Confronted With Death: Factors Affecting End of Life Decisions in the Intensive Care Unit.

To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.

Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan.

OBJECTIVES: To evaluate nationwide pediatric critical care facilities and resources in Pakistan. DESIGN: Cross-sectional observational study. SETTING: Accredited pediatric training facilities in Pakistan. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring. CONCLUSIONS: There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.

Measuring the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC).

BACKGROUND: Patient safety is a top priority for many healthcare organisations worldwide. However, most of the initiatives aimed at the measurement and improvement of patient safety culture have been undertaken in developed countries. The purpose of this study was to measure the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC). METHODS: The HSOPSC was used to measure the patient safety culture across 12 dimensions at Aga Khan University Hospital, Karachi. 2,959 individuals, who had been working at the hospital, were administered the HSOPSC in paper form between June and September 2019. RESULTS: The response rate of the survey was 50%. In the past 12 months, 979 respondents (33.1%) had submitted at least one event report. Results showed that the personnel viewed the patient safety culture at their hospital favourably. Overall, respondents scored highest in the following dimensions: 'feedback and communication on error' (91%), 'organisational learning and continuous improvement' (85%), 'teamwork within units' (83%), 'teamwork across units' (76%). The dimensions with the lowest positive per cent scores included 'staffing' (40%) and 'non-punitive response to error' (41%). Only the reliability of the 'handoffs and transitions', 'frequency of events reported', 'organisational learning' and 'teamwork within units' was higher than Cronbach's alpha of 0.7. Upon regression analysis of positive responses, physicians and nurses were found to have responded less favourably than the remaining professional groups for most dimensions. CONCLUSION: The measurement of safety culture is both feasible and informative in developing countries and could be broadly implemented to inform patient safety efforts. Current data suggest that it compares favourably with benchmarks from hospitals in the USA. Like the USA, high staff workload is a significant safety concern among staff. This study lays the foundation for further context-specific research on patient safety culture in developing countries.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

BACKGROUND AND OBJECTIVE: The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS: In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS: Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS: Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Development of an emergency airway response system for COVID-19 at a tertiary care hospital in resource limited country.

The ongoing coronavirus (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare due to highly transmissible and contagious nature. Aerosol generating procedures such as tracheal intubation is of particularly high risk. This mandates some advice on processes and techniques required to protect staff and uniform approach during airway management. We hereby share our experience in development of an emergency response system to deal with COVID airway management at a frontline hospital which particularly consider the local demands and resources. This includes a change in working dynamics with 24/7 consultant coverage for emergent or urgent tracheal intubation of COVID patients at non-operating room locations. Other steps include prepackaging intubation baskets, availability of videolaryngoscope, standard personal protective equipment including powered air purifying respirator, and use of modified intubation checklist.

Association Between the Site of Infection and Mortality Analysis in Critically Ill Surgical Patients.

Background Sepsis remains a critical global health concern, leading to a high mortality rate. Existing literature suggests a potential correlation between infection site and mortality. Mortality data from Pakistan, especially in the context of the infection site, is notably scarce. Purpose The study aimed to explore the relationship between the site of infection and clinical features in deceased septic patients in the surgical intensive care unit. Methods In this retrospective study conducted at the Aga Khan University Hospital, data from patients admitted to the surgical intensive care unit and meeting Sepsis 3 criteria over a five-year period (2016-2020) were analyzed. We analyzed the relation between the infection site and clinical characteristics using analysis of variance (ANOVA), chi-square, or Fisher's exact tests. Multivariable logistic regression models were applied using stepwise forward selection. A p-value of ≤ 0.05 was considered statistically significant. Results A total of 2472 ICU admissions were screened, out of which 170 patients were included in this study. Demographic analysis showed a predominantly male population with a mean age of 47 years. The most prevalent site of infection was the abdomen. Logistic regression analysis identified on-admission septic shock and high Acute Physiology and Chronic Health Evaluation (APACHE) II scores as significant risk factors for 48-hour mortality while colistimethate sodium usage and admission through the operating room were protective. Conclusion Our study provides a comprehensive analysis, outlining infection sites and identifying early mortality-influencing factors within our region. The distinct demographic profile, characterized by younger age, and the prevalence of abdominal infections in the Pakistani cohort contradict established medical literature. Early initiation of broad-spectrum antibiotics, coupled with prompt source control, confers a protective effect upon individuals afflicted with sepsis.

Prophylactic Recombinant Factor VIIa for Preventing Massive Transfusion During Orthotopic Liver Transplantation.

OBJECTIVES: RecombinanthumanactivatedfactorVIIahas been usedprophylactically to mitigate requirements for transfusion in liver transplant. We explored its effectiveness andrisks amonglivertransplantrecipients at high risk for massive transfusion. MATERIALS AND METHODS: We performed a retrospective study of recipients who underwent liver transplant from 2012 to 2015. Patients considered at risk for massive transfusion received up to two 20 µg/kg doses of recombinant human activated factor VIIa, with rescue use permitted for other patients. We used propensity matching to determine the average treatment effectson patients who received recombinant human activated factor VIIa prophylactically to prevent massive transfusion. We determined thromboembolic events from medical record review. RESULTS: Of 234 liver transplant recipients, 38 received prophylactic and 2 received rescue recombinant human activated factor VIIa. We used a prediction model to readily identify those who would receive prophylactic recombinant human activated factorVIIa (C statistic = 0.885; 95% CI, 0.835-0.935). Propensity matching achieved balance, particularly for massive transfusion. Twenty-three of 38 patients (60.5%) who received recombinant human activated factorVIIa and 47 of 76 matched controls (61.8%) experienced massive transfusion. The coefficient for the average treatment effect of prophylactic administration was - 0.013 (95% CI, -0.260 to 0.233; P = .92). The cohorts exhibited no difference in number ofthromboembolic events (P > .99), although fatal events occurred in 1 patient who had prophylactic and 1 patient who had rescue recombinant human activated factor VIIa. CONCLUSIONS: Prophylactic recombinanthumanactivated factor VIIa use in patients at elevated risk of massive transfusion did not affect incidence of massive transfusion and was not associated with an increase in thromboembolic events overall. The lack of clinical benefit and the potential for fatal throm-boembolic events observed with recombinant human activated factor VIIa precluded its prophylactic use in liver transplant recipients.

Disparities in adult critical care resources across Pakistan: findings from a national survey and assessment using a novel scoring system.

BACKGROUND: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan's baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities. METHODS: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles. RESULTS: A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public-private and metropolitan-rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks. CONCLUSION: Pakistan has an underdeveloped critical care network with significant inequity between public-private and metropolitan-rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities.