A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Commentary: Challenges and priorities for pediatric critical care clinician-researchers in low- and middle-income countries

Von Saint Andre-Von Arnim and colleagues noted that LMIC clinicians should be empowered to influence local and global research agendas for critically unwell children (1). We too can report that clinicians trained in LMIC acknowledge the need for systematic gathering of outcome data in improving services and endorse the role that non-LMIC collaborators can play in contributing to training, surveillance, and research (2). Interestingly, these perceptions were more strongly held when compared to High Income Country (HIC) counterparts with experience in LMIC settings. These findings perhaps point to untapped opportunities to upskill LMIC clinicians to build equitable research and training partnerships with their non-LMIC counterparts

To: The Epimed Monitor ICU Database®: a cloud-based national registry for adult intensive care unit patients in Brazil

We congratulate the Epimed collaborators(1) on their impressive results from a privately owned registry in Brazil, an upper-middle income country. In addition to the examples from high income countries cited by the authors, Sri Lanka - a lower-middle-income country in South Asia - has implemented a national cloud-based intensive care unit (ICU) registry,(2) directly overseen by the Ministry of Health and Information and Communications Technology Agency (ICTA), in partnership with other national and overseas collaborators, including the Dutch National Intensive Care Evaluation (NICE) foundation. Founded in 2012, the cloud-based critical care unit registry, as part of a codesigned agile mobile data platform, the so called Network for Improving Critical Care Systems and Training (NICST; www.nicst.com), encompasses almost the entire network of state ICUs island-wide and includes pediatric, neonatal and specialized units

To: The Epimed Monitor ICU Database®: a cloud-based national registry for adult intensive care unit patients in Brazil

We congratulate the Epimed collaborators(1) on their impressive results from a privately owned registry in Brazil, an upper-middle income country. In addition to the examples from high income countries cited by the authors, Sri Lanka - a lower-middle-income country in South Asia - has implemented a national cloud-based intensive care unit (ICU) registry,(2) directly overseen by the Ministry of Health and Information and Communications Technology Agency (ICTA), in partnership with other national and overseas collaborators, including the Dutch National Intensive Care Evaluation (NICE) foundation. Founded in 2012, the cloud-based critical care unit registry, as part of a codesigned agile mobile data platform, the so called Network for Improving Critical Care Systems and Training (NICST; www.nicst.com), encompasses almost the entire network of state ICUs island-wide and includes pediatric, neonatal and specialized units

Addressing the information deficit in global health: lessons from a digital acute care platform in Sri Lanka

Lack of investment in low-income and middle-income countries (LMICs) in systems capturing continuous information regarding care of the acutely unwell patient is hindering global efforts to address inequalities, both at facility and national level. Furthermore, this of lack of data is disempowering frontline staff and those seeking to support them, from progressing setting-relevant research and quality improvement. In contrast to high-income country (HIC) settings, where electronic surveillance has boosted the capability of governments, clinicians and researchers to engage in service-wide healthcare evaluation, healthcare information in resource-limited settings remains almost exclusively paper based. In this practice paper, we describe the efforts of a collaboration of clinicians, administrators, researchers and healthcare informaticians working in South Asia, in addressing the inequality in access to patient information in acute care. Harnessing a clinician-led collaborative approach to design and evaluation, we have implemented a national acute care information platform in Sri Lanka that is tailored to priorities of frontline staff. Iterative adaptation has ensured the platform has the flexibility to integrate with legacy paper systems, support junior team members in advocating for acutely unwell patients and has made information captured accessible to diverse stakeholders to improve service delivery. The same platform is now empowering clinicians to participate in international research and drive forwards improvements in care. During this journey, we have also gained insights on how to overcome well-described barriers to implementation of digital information tools in LMIC. We anticipate that this north–south collaborative approach to addressing the challenges of health system implementation in acute care may provide learning and inspiration to other partnerships seeking to engage in similar work

A data platform to improve rabies prevention, Sri Lanka.

Problem In Sri Lanka, rabies prevention initiatives are hindered by fragmented and delayed information-sharing that limits clinicians’ ability to follow patients and impedes public health surveillance. Approach In a project led by the health ministry, we adapted existing technologies to create an electronic platform for rabies surveillance. Information is entered by trained clinical staff, and both aggregate and individual patient data are visualized in real time. An automated short message system (SMS) alerts patients for vaccination follow-up appointments and informs public health inspectors about incidents of animal bites. Local setting The platform was rolled out in June 2016 in four districts of Sri Lanka, linking six rabies clinics, three laboratories and the public health inspectorate. Relevant changes Over a 9-month period, 12 121 animal bites were reported to clinics and entered in the registry. Via secure portals, clinicians and public health teams accessed live information on treatment and outcomes of patients started on post-exposure prophylaxis (9507) or receiving deferred treatment (2614). Laboratories rapidly communicated the results of rabies virus tests on dead mammals (328/907 positive). In two pilot districts SMS reminders were sent to 1376 (71.2%) of 1933 patients whose contact details were available. Daily SMS reports alerted 17 public health inspectors to bite incidents in their area for investigation. Lessons learnt Existing technologies in low-resource countries can be harnessed to improve public health surveillance. Investment is needed in platform development and training and support for front-line staff. Greater public engagement is needed to improve completeness of surveillance and treatment.</p

A data platform to improve rabies prevention, Sri Lanka.

Problem In Sri Lanka, rabies prevention initiatives are hindered by fragmented and delayed information-sharing that limits clinicians’ ability to follow patients and impedes public health surveillance. Approach In a project led by the health ministry, we adapted existing technologies to create an electronic platform for rabies surveillance. Information is entered by trained clinical staff, and both aggregate and individual patient data are visualized in real time. An automated short message system (SMS) alerts patients for vaccination follow-up appointments and informs public health inspectors about incidents of animal bites. Local setting The platform was rolled out in June 2016 in four districts of Sri Lanka, linking six rabies clinics, three laboratories and the public health inspectorate. Relevant changes Over a 9-month period, 12 121 animal bites were reported to clinics and entered in the registry. Via secure portals, clinicians and public health teams accessed live information on treatment and outcomes of patients started on post-exposure prophylaxis (9507) or receiving deferred treatment (2614). Laboratories rapidly communicated the results of rabies virus tests on dead mammals (328/907 positive). In two pilot districts SMS reminders were sent to 1376 (71.2%) of 1933 patients whose contact details were available. Daily SMS reports alerted 17 public health inspectors to bite incidents in their area for investigation. Lessons learnt Existing technologies in low-resource countries can be harnessed to improve public health surveillance. Investment is needed in platform development and training and support for front-line staff. Greater public engagement is needed to improve completeness of surveillance and treatment.</p

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 &gt;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.</p

Experiences of ICU survivors in a low middle income country - A multicenter study

Background Stressful patient experiences during the intensive care unit (ICU) stay is associated with reduced satisfaction in High Income Countries (HICs) but has not been explored in Lower and Middle Income Countries (LMICs). This study describes the recalled experiences, stress and satisfaction as perceived by survivors of ICUs in a LMIC. Methods This follow-up study was carried out in 32 state ICUs in Sri Lanka between July and December 2015.ICU survivors’ experiences, stress factors encountered and level of satisfaction were collected 30 days after ICU discharge by a telephone questionnaire adapted from Granja and Wright Results Of 1665 eligible ICU survivors, 23.3% died after ICU discharge, 49.1% were uncontactable and 438 (26.3%) patients were included in the study. Whilst 78.1% (n = 349) of patients remembered their admission to the hospital, only 42.3% (n = 189) could recall their admission to the ICU. The most frequently reported stressful experiences were: being bedridden (34.2%), pain (34.0%), general discomfort (31.7%), daily needle punctures (32.9%), family worries (33.6%), fear of dying and uncertainty in the future (25.8%). The majority of patients (376, 84.12%) found the atmosphere of the ICU to be friendly and calm. Overall, the patients found the level of health care received in the ICU to be “very satisfactory” (93.8%, n = 411) with none of the survivors stating they were either “dissatisfied” or “very dissatisfied”. Conclusions In common with HIC, survivors were very satisfied with their ICU care. In contrast to HIC settings, specific ICU experiences were frequently not recalled, but those remembered were reported as relatively stress-free. Stressful experiences, in common with HIC, were most frequently related to uncertainty about the future, dependency, family, and economic concerns.</p

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.</p