Out-of-hospital deaths in Mongolia: a nationwide cohort study on the proportion, causes, and potential impact of emergency and critical care services.

Background: Little is known about the proportion and causes of out-of-hospital deaths in Mongolia. In this study, we aimed to determine the proportion and causes of out-of-hospital deaths in Mongolia during a six-month observation period before the COVID-19 pandemic. Methods: In a retrospective study, the Mongolian National Death Registry was screened for all deaths occurring from 01 to 06/2020. The proportion and causes of out-of-hospital deaths, causes of out-of-hospital deaths likely treatable by emergency/critical care interventions, as well as sex, regional and seasonal differences in the proportion and causes of out-of-hospital deaths were determined. The primary endpoint was the proportion and causes of out-of-hospital death in children and adults. Descriptive statistical methods, the Fisher's Exact, multirow Chi2-or Mann-Whitney-U-rank sum tests were used for data analysis. Findings: Five-thousand-five-hundred-fifty-three of 7762 deaths (71.5%) occurred outside of a hospital. The proportion of out-of-hospital deaths was lower in children than adults (39.3% vs. 74.8%, p < 0.001). Trauma, chronic neurological diseases, lower respiratory tract infections, congenital birth defects, and neonatal disorders were the causes of out-of-hospital deaths resulting in most years of life lost in children. In adults, chronic heart diseases, trauma, liver cancer, poisonings, and self-harm caused the highest burden of premature mortality. The proportion of out-of-hospital deaths did not differ between females and males (70.5% vs. 72.2%, p = 0.09). The proportion (all, p < 0.001; adults, p < 0.001; children, p < 0.001) and causes (adults, p < 0.001; children, p < 0.001) of out-of-hospital deaths differed between Mongolian regions and Ulaanbaatar. The proportion of out-of-hospital deaths was higher during winter than spring/summer months (72.3% vs. 69.9%, p = 0.03). An expert panel estimated that 49.3% of out-of-hospital deaths were likely treatable by emergency/critical care interventions. Interpretation: With regional and seasonal variations, about 75% of Mongolian adults and 40% of Mongolian children died outside of a hospital. Heart diseases, trauma, cancer, and poisonings resulted in most years of life lost. About half of the causes of out-of-hospital deaths could be treated by emergency/critical care interventions. Funding: Institutional funding.

Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery.

OBJECTIVES: To inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country's ability to collect the indicators aided by a well-developed health information system. DESIGN: An 11-year retrospective analysis of the Mongolian surgical system using data from the Health Development Center, National Statistics Office and Household Socio-Economic Survey. Access estimates were based on travel time to capable hospitals. Provider density, surgical volume and postoperative mortality were calculated at national and regional levels. Protection against impoverishing and catastrophic expenditures was assessed against standard out-of-pocket expenditure at government hospitals for individual operations. SETTING: Mongolia's 81 public hospitals with surgical capability, including tertiary, secondary and primary/secondary facilities. PARTICIPANTS: All operative patients in Mongolia's public hospitals, 2006-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were national-level results of the indicators. Secondary outcomes include regional access; surgeons, anaesthesiologists and obstetricians (SAO) density; surgical volume; and perioperative mortality. RESULTS: In 2016, 80.1% of the population had 2-hour access to essential surgery, including 60% of those outside the capital. SAO density was 47.4/100 000 population. A coding change increased surgical volume to 5784/100 000 population, and in-hospital mortality decreased from 0.27% to 0.14%. All households were financially protected from caesarean section. Appendectomy carried 99.4% and 98.4% protection, external femur fixation carried 75.4% and 50.7% protection from impoverishing and catastrophic expenditures, respectively. Laparoscopic cholecystectomy carried 42.9% protection from both. CONCLUSIONS: Mongolia meets national benchmarks for access, provider density, surgical volume and postoperative mortality with notable limitations. Significant disparities exist between regions. Unequal access may be efficiently addressed by strengthening or building key district hospitals in population-dense areas. Increased financial protections are needed for operations involving hardware or technology. Ongoing monitoring and evaluation will support the development of context-specific interventions to improve surgical care in Mongolia.

Pragmatic Recommendations for the Management of Anticoagulation and Venous Thrombotic Disease for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries.

New studies of COVID-19 are constantly updating best practices in clinical care. Often, it is impractical to apply recommendations based on high-income country investigations to resource limited settings in low- and middle-income countries (LMICs). We present a set of pragmatic recommendations for the management of anticoagulation and thrombotic disease for hospitalized patients with COVID-19 in LMICs. In the absence of contraindications, we recommend prophylactic anticoagulation with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for all hospitalized COVID-19 patients in LMICs. If available, we recommend LMWH over UFH for venous thromboembolism (VTE) prophylaxis to minimize risk to healthcare workers. We recommend against the use of aspirin for VTE prophylaxis in hospitalized COVID-19 and non-COVID-19 patients in LMICs. Because of limited evidence, we suggest against the use of "enhanced" or "intermediate" prophylaxis in COVID-19 patients in LMICs. Based on current available evidence, we recommend against the initiation of empiric therapeutic anticoagulation without clinical suspicion for VTE. If contraindications exist to chemical prophylaxis, we recommend mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or graduated compression stockings (GCS) for hospitalized COVID-19 patients in LMICs. In LMICs, we recommend initiating therapeutic anticoagulation for hospitalized COVID-19 patients, in accordance with local clinical practice guidelines, if there is high clinical suspicion for VTE, even in the absence of testing. If available, we recommend LMWH over UFH or Direct oral anticoagulants for treatment of VTE in LMICs to minimize risk to healthcare workers. In LMIC settings where continuous intravenous UFH or LMWH are unavailable or not feasible to use, we recommend fixed dose heparin, adjusted to body weight, in hospitalized COVID-19 patients with high clinical suspicion of VTE. We suggest D-dimer measurement, if available and affordable, at the time of admission for risk stratification, or when clinical suspicion for VTE is high. For hospitalized COVID-19 patients in LMICs, based on current available evidence, we make no recommendation on the use of serial D-dimer monitoring for the initiation of therapeutic anticoagulation. For hospitalized COVID-19 patients in LMICs receiving intravenous therapeutic UFH, we recommend serial monitoring of partial thromboplastin time or anti-factor Xa level, based on local laboratory capabilities. For hospitalized COVID-19 patients in LMICs receiving LMWH, we suggest against serial monitoring of anti-factor Xa level. We suggest serial monitoring of platelet counts in patients receiving therapeutic anticoagulation for VTE, to assess risk of bleeding or development of heparin induced thrombocytopenia.

Pragmatic Recommendations for the Prevention and Treatment of Acute Kidney Injury in Patients with COVID-19 in Low- and Middle-Income Countries.

Current recommendations for the management of patients with COVID-19 and acute kidney injury (AKI) are largely based on evidence from resource-rich settings, mostly located in high-income countries. It is often unpractical to apply these recommendations to resource-restricted settings. We report on a set of pragmatic recommendations for the prevention, diagnosis, and management of patients with COVID-19 and AKI in low- and middle-income countries (LMICs). For the prevention of AKI among patients with COVID-19 in LMICs, we recommend using isotonic crystalloid solutions for expansion of intravascular volume, avoiding nephrotoxic medications, and using a conservative fluid management strategy in patients with respiratory failure. For the diagnosis of AKI, we suggest that any patient with COVID-19 presenting with an elevated serum creatinine level without available historical values be considered as having AKI. If serum creatinine testing is not available, we suggest that patients with proteinuria should be considered to have possible AKI. We suggest expansion of the use of point-of-care serum creatinine and salivary urea nitrogen testing in community health settings, as funding and availability allow. For the management of patients with AKI and COVID-19 in LMICS, we recommend judicious use of intravenous fluid resuscitation. For patients requiring dialysis who do not have acute respiratory distress syndrome (ARDS), we suggest using peritoneal dialysis (PD) as first choice, where available and feasible. For patients requiring dialysis who do have ARDS, we suggest using hemodialysis, where available and feasible, to optimize fluid removal. We suggest using locally produced PD solutions when commercially produced solutions are unavailable or unaffordable.

The Adaptation of Pain Assessment Tools from High-Income to Low- and Middle-Income Countries: Psychometric Properties of a Set of Chronic Pain Questionnaires in Mongolian and New Zealand Patient Samples.

OBJECTIVE: Chronic pain is a leading cause of disability in low- and middle-income countries; however, pain assessment tools have generally been developed and validated in high-income countries. This study examines the psychometric properties of a set of translated pain (and distress) questionnaires in Mongolia and documents the characteristics of people seeking treatment for chronic pain in Mongolia, compared with those in New Zealand, which is representative of high-income countries. DESIGN: Cross-sectional, observational. SETTING: Hospital-based pain treatment centers in New Zealand and Mongolia. SUBJECTS: People seeking treatment for chronic pain in Mongolia (N = 142) and New Zealand (N = 159). METHODS: The Brief Pain Inventory, the Depression Anxiety Stress Scale-21, the Pain Catastrophizing Scale, and the Pain Self-Efficacy Questionnaire were translated into Mongolian and administered to patients attending a hospital-based pain service. Questionnaires that were completed by patients in New Zealand were used for comparisons. Internal reliability, convergent validity, and factor structure were assessed in both groups. RESULTS: Patients in Mongolia were older and reported lower pain intensity, interference, and distress and higher pain self-efficacy than those in New Zealand. The translated questionnaires had good internal consistencies, and the relationships between pain variables were similar across both groups. The factor structure for the Pain Catastrophizing Scale was consistent across both groups, but this was not the case for the Brief Pain Inventory or the Depression Anxiety Stress Scale-21. CONCLUSIONS: Findings indicate that some pain outcome measures may be appropriate for use in Mongolia and should be investigated in other low- and middle-income countries.

Anesthesia Development in Mongolia: Strengthening Anesthesia Practice in Mongolia Through Education and Continuing Professional Development.

Anesthesia in Mongolia has undergone a period of major development over the past 17 years, thanks to the work of the Mongolian Society of Anesthesiologists (MSA) and the support of the World Federation of Societies of Anaesthesiologists and the Australian Society of Anaesthetists. The specialty has made major advances in training and in its standing among medical specialties in Mongolia. The MSA has produced members who are leaders in the development of anesthesia as well as emergency medicine and critical care. This has been achieved by engagement between the Ministry of Health and MSA, and with inexpensive but efficient programs to educate trainees and provide continuing professional development. There is now major work being done to achieve the Lancet Commission on Global Surgery goals of safe and accessible surgery for the population in a country that faces significant challenges of remote communities with vast distances.

Management of potentially life-threatening emergencies at 74 primary level hospitals in Mongolia: results of a prospective, observational multicenter study.

BACKGROUND: While the capacities to care for and epidemiology of emergency and critically ill patients have been reported for secondary and tertiary level hospitals in Mongolia, no data exist for Mongolian primary level hospitals. METHODS: In this prospective, observational multicenter study, 74 primary level hospitals of Mongolia were included. We determined the capacities of these hospitals to manage medical emergencies. Furthermore, characteristics of patients presenting with potentially life-threatening emergencies to these hospitals were evaluated during a 6 month period. RESULTS: An emergency/resuscitation room was available in 62.2% of hospitals. One third of the study hospitals had an operation theatre (32.4%). No hospital ran an intensive care unit or had trained emergency/critical care physicians or nurses available. Diagnostic resources were inconsistently available (sonography, 59.5%; echocardiography, 0%). Basic emergency procedures (wound care, 97.3%; foreign body removal, 86.5%; oxygen application, 85.2%) were commonly but advanced procedures (advanced cardiac life support, 10.8%; airway management, 13.5%; mechanical ventilation, 0%; renal replacement therapy, 0%) rarely available. During 6 months, 14,545 patients were hospitalized in the 74 study hospitals, of which 8.7% [n = 1267; median age, 34 (IQR 18-53) years; male gender, 54.4%] were included in the study. Trauma (excl. brain trauma) (20.4%), acute abdomen (16.9%) and heart failure (9.6%) were the most common conditions. Five-hundred-thirty patients (41.8%) were transferred to a secondary level hospital. The hospital mortality of patients not transferred was 3.2%. CONCLUSIONS: Capacities of Mongolian primary level hospitals to manage life-threatening emergencies are highly limited. Trauma, surgical and medical conditions make up the most common emergencies. In view of the fact that almost half of the patients with a potentially life-threatening emergency were transferred to secondary level hospitals and the mortality of those hospitalized in primary level hospitals was 3.2%, room for improvement is clearly evident. Based on our findings, improvements could be obtained by strengthening inter-hospital transfer systems, training staff in emergency/critical care skills and by making mechanical ventilation and advanced life support techniques available at the emergency rooms of primary level hospitals.

Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future.

BACKGROUND: Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome. AIM: To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU. FINDINGS: Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources. CONCLUSIONS: Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.

Potentially Preventable Deaths by Intensive Care Medicine in Mongolian Hospitals.

Purpose. To evaluate the portion of hospitalized patients dying without prior intensive care unit (ICU) admission and assess whether death could have been prevented by intensive care. Methods. In this prospective, observational, multicenter study, data of adults dying in and outside the ICU in 5 tertiary and 14 secondary hospitals were collected during six months. A group of experts categorized patients dying without prior ICU admission as whether their death was potentially preventable or not. Results. 617 patients died (72.9% in and 27.1% outside the ICU) during the observation period. In 54/113 patients (32.3%) dying in the hospital without prior ICU admission, death was considered potentially preventable. The highest number of these deaths was seen in patients aged 16-30 years and those who suffered from an infection (83.3%), underwent surgery (58.3%), or sustained trauma (52%). Potentially preventable deaths resulted in a total number of 1,078 years of life lost and 709 productive years of life lost. Conclusions. Twenty-seven percent of adults dying in Mongolian secondary and tertiary level hospitals do so without prior ICU admission. One-third, mostly young patients suffering from acute reversible conditions, may have potentially been saved by intensive care medicine.

The epidemiology and outcome of critical illness in Mongolia: A multicenter, prospective, observational cohort study.

CONTEXT: The epidemiology and outcome of critical illness in Mongolia remain undefined. AIM: The aim of this study was to evaluate the epidemiology and outcome of critical illness in Mongolia. SETTINGS AND DESIGN: This is a multicenter, prospective, observational cohort study including 19 Mongolian centers. MATERIALS AND METHODS: Demographic, clinical, and outcome data of patients >15 years admitted to the Intensive Care Units (ICUs) were collected during a 6-month period. STATISTICAL ANALYSIS: Descriptive methods, Mann-Whitney-U test, Fisher's exact or Chi-square test, and logistic regression analyses were used for statistical analysis. RESULTS: Two thousand and thirty-two patients (53.6% male) with a median age of 49 years (36-62 years) were included. The most frequent ICU admission diagnoses were stroke (17.4%), liver failure (9.2%), heart failure (9%), infection (8.3%), severe trauma (7.5%), traumatic brain injury (7.1%), acute abdomen (7%), pre-eclampsia/eclampsia (5.8%), renal failure (3.9%), and postoperative care following elective and emergency surgeries (3.2%). ICU mortality was 23.5% in the study population and 26.6% when maternal cases were excluded. The five ICU admission diagnoses with the highest ICU mortality were lung tuberculosis (51.9%), traumatic brain injury (42.1%), liver failure (33.7%), stroke (31.9%), and infection (30.8%). The five ICU admission diagnoses causing most death cases were stroke (n = 113), liver failure (n = 63), traumatic brain injury (n = 61), infection (n = 52), and acute abdomen (n = 38). CONCLUSION: Critical illness in Mongolia affects younger patients compared to high-income countries. ICU admission diagnoses are similar with a particularly high incidence of stroke and liver failure. ICU mortality is approximately 25% with most deaths caused by stroke, liver failure, and traumatic brain injury.

A Nationwide Census of ICU Capacity and Admissions in Mongolia.

In Mongolia, a Central Asian lower-middle income country, intensive care medicine is an under-resourced and-developed medical specialty. The burden of critical illness and capacity of intensive care unit (ICU) services in the country is unknown. In this nationwide census, we collected data on adult and pediatric/neonatal ICU capacities and the number of ICU admissions in 2014. All hospitals registered to run an ICU service in Mongolia were surveyed. Data on the availability of an adult and/or pediatric/neonatal ICU service, the number of available ICU beds, the number of available functional mechanical ventilators, the number of patients admitted to the ICU, and the number of patients admitted to the study hospital were collected. In total, 70 ICUs with 349 ICU beds were counted in Mongolia (11.7 ICU beds/100,000 inhabitants; 1.7 ICU beds/100 hospital beds). Of these, 241 (69%) were adult and 108 (31%) pediatric/neonatal ICU beds. Functional mechanical ventilators were available for approximately half of the ICU beds (5.1 mechanical ventilators/100,000 inhabitants). While all provincial hospitals ran a pediatric/neonatal ICU, only dedicated pediatric hospitals in Ulaanbaatar did so. The number of adult and pediatric/neonatal ICU admissions varied between provinces. The number of adult ICU beds and adult ICU admissions per 100,000 inhabitants correlated (r = 0.5; p = 0.02), while the number of pediatric/neonatal ICU beds and pediatric/neonatal ICU admissions per 100,000 inhabitants did not (r = 0.25; p = 0.26). In conclusion, with 11.7 ICU beds per 100,000 inhabitants the ICU capacity in Mongolia is higher than in other low- and lower-middle-income countries. Substantial heterogeneities in the standardized ICU capacity and ICU admissions exist between Mongolian provinces. Functional mechanical ventilators are available for only half of the ICU beds. Pediatric/neonatal ICU beds make up one third of the national ICU capacity and appear to meet or even exceed the demand of pediatric/neonatal critical care.

Rate and pattern of antibiotic resistance in microbiological cultures of sepsis patients in a low-middle-income country's ICU.

BACKGROUND: In this prospective, observational study, the rate of antibiotic resistance in cultures sampled from sepsis patients was determined in an intensive care unit of a low-middle income country. METHODS: Critically ill patients suffering from bacterial sepsis were eligible for enrollment. Aside from demographic, disease-related and sepsis-specific parameters, the type of microbiological sample and cultured microorganism as well as the resistance pattern (extensively resistant bacteria, multi-drug resistant bacteria) were documented. Descriptive statistical methods, parametric and non-parametric tests were used. RESULTS: 215 sepsis patients were included. 193 ofthe 410 cultured organisms (47.1%) showed antibiotic resistance [extensively resistant bacteria, n = 90 (11%); multi-drug resistant bacteria, n = 103 (25.1%)]. 51.6% of the patients were infected by > or = 1 resistant bacteria. Bacteria with an exceptionally high rate of antibiotic resistance were Acinetobacter baumannii (90%), Enterobacter spp (60%) and coagulase-negative Staphylococci (60%). Patients infected with resistant bacteria more often received inadequate empirical antibiotic therapy (36.9 vs. 13.5%, p < 0.001), required mechanical ventilation (66.7 vs. 42.3%, p < 0.001) and renal replacement therapy (28.8 vs. 9.6%, p < 0.001) more frequently, and had a longer stay in the intensive care unit [5 (3-9.5) vs. 5 (2-8)%, p < 0.001] than patients with sepsis due to non-resistant bacteria. There was a trend towards a higher mortality in patients with resistant bacteria (43.2 vs. 31.7%, p = 0.09). CONCLUSION: Resistant bacteria were detected in up to 50% of microbiological samples from critically ill sepsis patients in the intensive care unit of a low-middle-income country. Antibiotic resistance appears to be a relevant problem of sepsis management in a resource-limited setting.

Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia.

BACKGROUND: Provision of surgical care continues to receive little attention and funding despite the growing burden of surgical disease worldwide. In 2004, The World Health Organization (WHO) established the Emergency and Essential Surgical Care (EESC) program, which was designed to strengthen surgical services at the first-referral hospital. There are limited data documenting the implementation and scale-up of such services. We describe the nationwide implementation of the EESC program in Mongolia over a 6 year period. METHODS: Surgical services were increased in rural areas of Mongolia using the WHO Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit from 2004 to 2010. Fund of knowledge tests and program evaluation was done to measure uptake, response, and perceived importance of the program. Two years after the pilot sites were launched, programmatic impact on short-term process measures was evaluated using the WHO Monitoring and Evaluation form. RESULTS: The program was implemented in 14 aimags/provinces (66.67 %) and 178 soum hospitals (52.66 %). Fund of knowledge scores increased from 47.72 % (95 % confidence interval (CI) 40.7-54.7) to 77.9 % (95 % CI 70.1-85.7, p = 0.0001) after the training program. 1 year post-training, there was a 57.1 % increase in the availability of emergency rooms, 59.1 % increase in the supply of emergency kits, a 73.64 % increase in the recording of emergency care cases, and a 46.66 % increase in the provision of facility and instrument usage instructions at the pilot sites. CONCLUSIONS: The EESC program was successfully implemented and scaled up at a national level with improvements in short-term process measures.