EPidemiology, clinical characteristics and Outcomes of 4546 adult admissions to high-dependency and intensive care units in Kenya (EPOK): a multicentre registry-based observational study.

Objective: to describe clinical, management and outcome features of critically ill patients admitted to intensive care units (ICUs) and high dependency units (HDUs) in Kenya. Design: prospective registry-based observational study. Setting: three HDUs and eight ICUs in Kenya. Patients: consecutive adult patients admitted between January 2021 and June 2022. Interventions: none. Measurements and main results: data was entered in a cloud based platform using a common data model. Study endpoints included case mix variables, management features and patient centred outcomes. Patients with Coronavirus disease 2019 (COVID-19) were reported separately. Of the 3892/4546 patients without COVID-19, 2445 patients (62.8%) were from HDUs and 1447 (37.2%) from ICUs. Patients had a median age of 53 years (interquartile range [IQR] 38-68), with HDU patients being older but with a lower severity (APACHE II 6 [3-9] in HDUs vs 12 [7-17] in ICUs; p<0.001). One out of four patients were postoperative with 604 (63.4%) receiving emergency surgery. Readmission rate was 4.8%. Hypertension and diabetes were prevalent comorbidities, with a 4.0% HIV/AIDS rate. Invasive mechanical ventilation (IMV) was applied in 3.4% in HDUs vs. 47.6% in ICUs (P<0.001), with a duration of 7 days (IQR 3-21). There was a similar use of renal replacement therapy (4.0% vs. 4.7%; P<0.001). Vasopressor use was infrequent while half of patients received antibiotics. Average length of stay was 2 days (IQR 1-5). Crude HDU mortality rate was 6.5% in HDUs versus 30.5% in the ICUs (P<0.001). Of the 654 COVID-19 admissions, most were admitted in ICUs (72.3%) with a 33.2% mortality. Conclusions: We provide the first multicenter observational cohort study from an African ICU national registry. Distinct management features and outcomes characterise HDU from ICU patients. Study registration: Clinicaltrials.gov (reference number NCT05456217, date of registration 07 Nov 2022).

Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units.

Background: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be led by local stakeholders, performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.

WHO O2CoV2: oxygen requirements and respiratory support in patients with COVID-19 in low-and-middle income countries-protocol for a multicountry, prospective, observational cohort study.

INTRODUCTION: SARS-CoV-2 has been identified as the cause of the disease officially named COVID-19, primarily a respiratory illness. COVID-19 was characterised as a pandemic on 11 March 2020. It has been estimated that approximately 20% of people with COVID-19 require oxygen therapy. Oxygen has been listed on the WHO Model List of Essential Medicines List and Essential Medicines List for Children for almost two decades. The COVID-19 pandemic has highlighted, more than ever, the acute need for scale-up of oxygen therapy. Detailed data on the use of oxygen therapy in low-and-middle income countries at the patient and facility level are needed to target interventions better globally. METHODS AND ANALYSIS: We aim to describe the requirements and use of oxygen at the facility and patient level of approximately 4500 patients with COVID-19 in 30 countries. Our objectives are specifically to characterise type and duration of different modalities of oxygen therapy delivered to patients; describe demographics and outcomes of hospitalised patients with COVID-19; and describe facility-level oxygen production and support. Primary analyses will be descriptive in nature. Respiratory support transitions will be described in Sankey plots, and Kaplan-Meier models will be used to estimate probability of each transition. A multistate model will be used to study the course of hospital stay of the study population, evaluating transitions of escalating respiratory support transitions to the absorbing states. ETHICS AND DISSEMINATION: WHO Ad Hoc COVID-19 Research Ethics Review Committee (ERC) has approved this global protocol. When this protocol is adopted at specific country sites, national ERCs may make require adjustments in accordance with their respective national research ethics guidelines. Dissemination of this protocol and global findings will be open access through peer-reviewed scientific journals, study website, press and online media. TRIAL REGISTRATION NUMBER: NCT04918875.

A health systems approach to critical care delivery in low-resource settings: a narrative review.

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Organisation, staffing and resources of critical care units in Kenya.

OBJECTIVE: To describe the organisation, staffing patterns and resources available in critical care units in Kenya. The secondary objective was to explore variations between units in the public and private sectors. MATERIALS AND METHODS: An online cross-sectional survey was used to collect data on organisational characteristics (model of care, type of unit, quality- related activities, use of electronic medical records and participation in the national ICU registry), staffing and available resources for monitoring, ventilation and general critical care. RESULTS: The survey included 60 of 75 identified units (80% response rate), with 43% (n = 23) located in government facilities. A total of 598 critical care beds were reported with a median of 6 beds (interquartile range [IQR] 5-11) per unit, with 26% beds (n = 157) being non functional. The proportion of ICU beds to total hospital beds was 3.8% (IQR 1.9-10.4). Most of the units (80%, n = 48) were mixed/general units with an open model of care (60%, n = 36). Consultants-in-charge were mainly anesthesiologists (69%, n = 37). The nurse-to-bed ratio was predominantly 1:2 with half of the nurses formally trained in critical care. Most units (83%, n = 47) had a dedicated ventilator for each bed, however 63% (n = 39) lacked high flow nasal therapy. While basic multiparametric monitoring was ubiquitous, invasive blood pressure measurement capacity was low (3% of beds, IQR 0-81%), and capnography moderate (31% of beds, IQR 0-77%). Blood gas analysers were widely available (93%, n = 56), with 80% reported as functional. Differences between the public and private sector were narrow. CONCLUSION: This study shows an established critical care network in Kenya, in terms of staffing density, availability of basic monitoring and ventilation resources. The public and private sector are equally represented albeit with modest differences. Potential areas for improvement include training, use of invasive blood pressure and functionality of blood gas analysers.

Oxygen saturation targets for adults with acute hypoxemia in low and lower-middle income countries: a scoping review with analysis of contextual factors.

Knowing the target oxygen saturation (SpO2) range that results in the best outcomes for acutely hypoxemic adults is important for clinical care, training, and research in low-income and lower-middle income countries (collectively LMICs). The evidence we have for SpO2 targets emanates from high-income countries (HICs), and therefore may miss important contextual factors for LMIC settings. Furthermore, the evidence from HICs is mixed, amplifying the importance of specific circumstances. For this literature review and analysis, we considered SpO2 targets used in previous trials, international and national society guidelines, and direct trial evidence comparing outcomes using different SpO2 ranges (all from HICs). We also considered contextual factors, including emerging data on pulse oximetry performance in different skin pigmentation ranges, the risk of depleting oxygen resources in LMIC settings, the lack of access to arterial blood gases that necessitates consideration of the subpopulation of hypoxemic patients who are also hypercapnic, and the impact of altitude on median SpO2 values. This process of integrating prior study protocols, society guidelines, available evidence, and contextual factors is potentially useful for the development of other clinical guidelines for LMIC settings. We suggest that a goal SpO2 range of 90-94% is reasonable, using high-performing pulse oximeters. Answering context-specific research questions, such as an optimal SpO2 target range in LMIC contexts, is critical for advancing equity in clinical outcomes globally.

Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country.

Poor outcomes among the critically ill in low- and middle-income countries (LMICs) have been attributed in part to the challenge of diagnostic delays caused by lack of skilled personnel. Focused cardiac ultrasound (FoCUS) by non-cardiologists may mitigate the shortage of echocardiography experts to perform emergency echocardiography at the point of care in these settings. It is however crucial that FoCUS training for non-cardiologists in LMICs be based on robust evidence to support training delivery if diagnostic accuracy is to be assured.

Safe Thrombolysis During Pregnancy for Recurrent Acute Ischaemic Stroke Due to Concomitant Isolated Left Ventricular Non-Compaction and Bilateral Foetal Posterior Communicating Arteries.

Isolated left ventricular non-compaction (ILVNC) is a rare congenital cardiomyopathy and is associated with arrhythmias, heart failure and thromboembolism including ischaemic stroke. Pregnancy is a relative contraindication to thrombolysis for acute ischaemic stroke, although case reports suggest the treatment can be given in selected cases. We report a case of recurrent cryptogenic strokes in a 36-year-old female who was thrombolysed with good outcome at 37 weeks' gestation and was eventually found to have ILVNC as the cause. She had a predilection to recurrent posterior circulatory strokes due to foetal posterior communicating arteries. To our knowledge this is the first case report of safe thrombolysis for acute ischaemic stroke in pregnancy caused by ILVNC.

Microbial coinfections and superinfections in critical COVID-19: a Kenyan retrospective cohort analysis.

Objectives: The aim of our study was to outline the burden, risk factors, and outcomes for critical COVID-19 patients with coinfections or superinfections. Methods: This was a retrospective descriptive study of adults who were admitted with critical COVID-19 for ≥ 24 hours. Data collected included demographic profiles and other baseline characteristics, laboratory and radiological investigations, medical interventions, and clinical outcomes. Outcomes of interest included the presence or absence of coinfections or superinfections, and in-hospital mortality. Differences between those with and without coinfections or superinfections were compared for statistical significance. Results: In total, 321 patient records were reviewed. Baseline characteristics included a median age (IQR) of 61.4 (51.4-72.9) years, and a predominance of male (71.3%) and African/black (66.4%) patients. Death occurred in 132 (44.1%) patients, with a significant difference noted between those with added infections (58.2%) and those with none (36.6%) (p = 0.002, odds ratio (OR) = 2.41). One patient was coinfected with pulmonary tuberculosis. Approximately two-thirds of patients received broad-spectrum antimicrobial therapy. Conclusion: Added infections in critically ill COVID-19 patients were relatively uncommon but, where present, were associated with higher mortality. Empiric use of broad-spectrum antimicrobials was common, and may have led to the selection of multidrug-resistant organisms. More robust local data on antimicrobial susceptibility patterns may help in appropriate antibiotic selection, in order to improve outcomes without driving up rates of drug-resistant pathogens.

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact.

BACKGROUND: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally. METHODS: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa >0.6 indicative of good inter-rater agreement. RESULTS: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties. CONCLUSIONS: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives.

Investigating SOFA, delta-SOFA and MPM-III for mortality prediction among critically ill patients at a private tertiary hospital ICU in Kenya: A retrospective cohort study.

BACKGROUND: Outcomes in well-resourced, intensive care units (ICUs) in Kenya are thought to be comparable to those in high-income countries (HICs) but risk-adjusted mortality data is unavailable. We undertook an evaluation of the Aga Khan University Hospital, Nairobi ICU to analyze patient clinical-demographic characteristics, compare the performance of Sequential Organ Failure Assessment (SOFA), delta-SOFA at 48 hours and Mortality Prediction Model-III (MPM-III) mortality prediction systems, and identify factors associated with increased risk of mortality. METHODS: A retrospective cohort study was conducted of adult patients admitted to the ICU between January 2015 and September 2017. SOFA and MPM-III scores were determined at admission and SOFA repeated at 48 hours. RESULTS: Approximately 33% of patients did not meet ICU admission criteria. Mortality among the population of critically ill patients in the ICU was 31.7%, most of whom were male (61.4%) with a median age of 53.4 years. High adjusted odds of mortality were found among critically ill patients with leukemia (aOR 6.32, p<0.01), tuberculosis (aOR 3.96, p<0.01), post-cardiac arrest (aOR 3.57, p<0.01), admissions from the step-down unit (aOR 3.13, p<0.001), acute kidney injury (aOR 2.97, p<0.001) and metastatic cancer (aOR 2.45, p = 0.04). The area under the receiver-operating characteristic (ROC) curve of admission SOFA was 0.77 (95% CI, 0.73-0.81), MPM-III 0.74 (95% CI, 0.69-0.79), delta-SOFA 0.69 (95% CI, 0.63-0.75) and 48-hour SOFA 0.83 (95% CI, 0.79-0.87). The difference between SOFA at 48 hours and admission SOFA, MPM-III and delta-SOFA was statistically significant (chi2 = 17.1, 24.2 and 26.5 respectively; p<0.001). Admission SOFA, MPM-III and 48-hour SOFA were well calibrated (p >0.05) while delta-SOFA was borderline (p = 0.05). CONCLUSION: Mortality among the critically ill was higher than expected in this well-resourced ICU. 48-hour SOFA performed better than admission SOFA, MPM-III and delta-SOFA in our cohort. While a large proportion of patients did not meet admission criteria but were boarded in the ICU, critically ill patients stepped-up from the step-down unit were unlikely to survive. Patients admitted following a cardiac arrest, and those with advanced disease such as leukemia, stage-4 HIV and metastatic cancer, had particularly poor outcomes. Policies for fair allocation of beds, protocol-driven admission criteria and appropriate case selection could contribute to lowering the risk of mortality among the critically ill to a level on par with HICs.

Knowledge and Perceptions Regarding Palliative Care Among Religious Leaders in Uasin Gishu County, Kenya: Survey and Focus Group Analysis.

Spirituality and religion are at the core of Kenyan life. Pastoral leaders play a key role in shaping the individual and community's response to living with chronic and life-threatening illnesses. Involvement of religious leaders would therefore be critical in advocacy and education efforts in palliative care (PC) to address the needs of this population. The goal of this study was to evaluate the knowledge and perceptions of religious leaders in Western Kenya regarding PC. This was a mixed-methods study with 86 religious leaders utilizing a 25-question survey followed by 5-person focus group discussions. Eighty-one percent of participants agreed that pastors should encourage members with life-threatening illnesses to talk about death and dying. However, almost a third of participants (29%) also agreed with the statement that full use of PC can hasten death. The pastors underscored challenges in end-of-life spiritual preparation as well as the importance of traditional beliefs in shaping cultural norms. Pastors supported the need for community-based PC education and additional training in PC for religious leaders. The results of this study confirm the dominant role of religion and spirituality in PC in Kenya. This dominant role in shaping PC is tied closely to Kenyan attitudes and norms surrounding death and dying.

The history of critical care in Kenya.

Critical care is a young specialty in Kenya. From its humble beginnings in the 1960s to present day Kenya, the bulk of this service has largely been provided by anaesthetists. We provide a detailed account of the growth and development of this specialty in our country, the attempts made by our people to grow this service within our borders and the vital role our international partners have played throughout this process. We also share a selection of our successes over the years, the challenges we have faced and our aspirations as we look to the future.

Building focused cardiac ultrasound capacity in a lower middle-income country: a single centre study to assess training impact

Background: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agree-ment between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training pro-gramme locally. Methods: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were as-sessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa > 0.6 indicative of good inter-rater agreement. Results: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties. Conclusions: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives

Intensive Care Outcomes and Mortality Prediction at a National Referral Hospital in Western Kenya.

RATIONALE: The burden of critical care is greatest in resource-limited settings. Intensive care unit (ICU) outcomes at public hospitals in Kenya are unknown. The present study is timely, given the Kenyan Ministry of Health initiative to expand ICU capacity. OBJECTIVES: To identify factors associated with mortality at Moi Teaching and Referral Hospital and validate the Mortality Probability Admission Model II (MPM0-II). METHODS: A retrospective cohort of 450 patients from January 1, 2013, to April 5, 2015, was evaluated using demographics, presenting diagnoses, interventions, mortality, and cost data. RESULTS: ICU mortality was 53.6%, and 30-day mortality was 57.3%. Most patients were male (61%) and at least 18 years old (70%); the median age was 29 years. Factors associated with high adjusted odds of mortality were as follows: age younger than 10 years (adjusted odds ratio [aOR], 3.59; P ≤ 0.001), ages 35-49 years (aOR, 3.13; P = 0.002), and age above 50 years (aOR, 2.86; P = 0.004), with reference age range 10-24 years; sepsis (aOR, 3.39; P = 0.01); acute stroke (aOR, 8.14; P = 0.011); acute respiratory failure or mechanical ventilation (aOR, 6.37; P < 0.001); and vasopressor support (aOR, 7.98; P < 0.001). Drug/alcohol poisoning (aOR, 0.33; P = 0.005) was associated with lower adjusted odds of mortality. MPM0-II discrimination showed an area under the receiver operating characteristic curve of 0.78 (95% confidence interval, 0.72-0.82). The result of the Hosmer-Lemeshow test for calibration was significant (P < 0.001). CONCLUSIONS: In a Kenyan public ICU, high mortality was noted despite the use of advanced therapies. MPM0-II has acceptable discrimination but poor calibration. Modification of MPM0-II or development of a new model using a prospective multicenter global collaboration is needed. Standardized triage and treatment protocols for high-risk diagnoses are needed to improve ICU outcomes.