Development of a quality indicator set to measure and improve quality of ICU care in low- and middle-income countries

PURPOSE: To develop a set of actionable quality indicators for critical care suitable for use in low- or middle-income countries (LMICs). METHODS: A list of 84 candidate indicators compiled from a previous literature review and stakeholder recommendations were categorised into three domains (foundation, process, and quality impact). An expert panel (EP) representing stakeholders from critical care and allied specialties in multiple low-, middle-, and high-income countries was convened. In rounds one and two of the Delphi exercise, the EP appraised (Likert scale 1–5) each indicator for validity, feasibility; in round three sensitivity to change, and reliability were additionally appraised. Potential barriers and facilitators to implementation of the quality indicators were also reported in this round. Median score and interquartile range (IQR) were used to determine consensus; indicators with consensus disagreement (median < 4, IQR ≤ 1) were removed, and indicators with consensus agreement (median ≥ 4, IQR ≤ 1) or no consensus were retained. In round four, indicators were prioritised based on their ability to impact cost of care to the provider and recipient, staff well-being, patient safety, and patient-centred outcomes. RESULTS: Seventy-one experts from 30 countries (n = 45, 63%, representing critical care) selected 57 indicators to assess quality of care in intensive care unit (ICU) in LMICs: 16 foundation, 27 process, and 14 quality impact indicators after round three. Round 4 resulted in 14 prioritised indicators. Fifty-seven respondents reported barriers and facilitators, of which electronic registry-embedded data collection was the biggest perceived facilitator to implementation (n = 54/57, 95%) Concerns over burden of data collection (n = 53/57, 93%) and variations in definition (n = 45/57, 79%) were perceived as the greatest barrier to implementation. CONCLUSION: This consensus exercise provides a common set of indicators to support benchmarking and quality improvement programs for critical care populations in LMICs

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Anaerobic digestion as a core technology in sustainable management of organic matter

In the past decades, anaerobic digestion (AD) has steadily gained importance. However, the technology is not regarded as a top priority in science policy and in industrial development at present. In order for AD to further develop, it is crucial that AD profits from the current fuel issues emerging in the international arena. AD can provide low-cost treatment of sewage and solid domestic wastes, which represents a vast application potential that should be promoted in the developing world. Furthermore, the developments in the last decades in the domain of anaerobic microbiology and technology have generated some interesting niches for the application of AD, such as anaerobic nitrogen removal and the treatment of chlorinated organics. Recently, AD has also generated some serendipities, such as the use of AD in processes for sulphur and calcium removal and the coupling of AD with microbial fuel cells. The international developments in terms of bio-refineries and CO2-emission abatement are of crucial importance with respect to the impetus that AD will receive in the coming decade. There should be little doubt that by placing the focus of AD on the production of green energy and clean nutrients, the future of AD will be assured

Health status and health seeking behaviour of the elderly persons in Dagoretti division, Nairobi

Objective: To determine the health status and the health seeking behaviour of the elderly people aged 65 years and above. Design:A descriptive cross sectional study of individuals interviewed through questionnaires and focus groups discussions. Setting:Dagoretti Division, Nairobi Province, Kenya. Subjects:Four hundred non-institutionalised elderly persons. Results:Four hundred people including 276(69%) women and 124(31%) males were interviewed; 44% had no independent source of livelihood and 51% were widowed. The majority 376(92.5%) of the respondents had been sick within the last three months, preceding the study with 111(27.8%) being sick all the time. The prevalent diseases included musculoskeletal (80%), respiratory (68%), sight (44%) and dental conditions(40%). Three hundred and sixteen (79%) of the respondents were functionally independent in activities of daily living. One hundred and sixty one (40.3%) were satisfied with their current way of life while (63%) perceived themselves as healthy, 24.8% of the respondents lived alone. The reported social problems included:- economic dependency (96%), poor housing (76%), loneliness (60%) and feeling not needed (42%) of the respondents. Only 26% were on treatment, lack of money hindered health care access to 73% of the respondents (

HEALTH STATUS AND HEALTH SEEKING BEHAVIOUR OF THE ELDERLY PERSONS IN DAGORETTI DIVISION, NAIROBI

ABSTRACTObjective: To determine the health status and the health seeking behaviour of the elderlypeople aged 65 years and above.Design: A descriptive cross sectional study of individuals interviewed throughquestionnaires and focus groups discussions.Setting: Dagoretti Division, Nairobi Province, Kenya.Subjects: Four hundred non-institutionalised elderly persons.Results: Four hundred people including 276(69%) women and 124(31%) males wereinterviewed; 44% had no independent source of livelihood and 51% were widowed. Themajority 376(92.5%) of the respondents had been sick within the last three months,preceding the study with 111(27.8%) being sick all the time. The prevalent diseasesincluded musculoskeletal (80%), respiratory (68%), sight (44%) and dentalconditions(40%). Three hundred and sixteen (79%) of the respondents were functionallyindependent in activities of daily living. One hundred and sixty one (40.3%) were satisfiedwith their current way of life while (63%) perceived themselves as healthy, 24.8% ofthe respondents lived alone. The reported social problems included:- economic dependency(96%), poor housing (76%), loneliness (60%) and feeling not needed (42%) of therespondents. Only 26% were on treatment, lack of money hindered health care accessto 73% of the respondents (p&lt;0.001). Sixty two per cent of the respondents were buyingover-the-counter drugs. Walking was under taken by 217(67%) as a physical exercise,and (26%) of the respondents consumed addictive drugs. The focus groups criticisedthe lack of health facilities for the elderly in the community.Conclusion: The effects of ageing, low economic status and inadequate access to healthcare contributed to the elderly poor health status. The use of over-the-counter drugswas indicative of the inefficient health facilities in meeting the health needs of the elderly.The study points out the need to formulate policies that will target on the health needsof the elderly

A ¤comparison of serum biochemical changes in two breeds of sheep (Red Masai and Dorper) experimentally infected with Fasciola gigantica

Twelve Red Masai and 12 Dorper sheep aged between 6 and 9 months, were acquired from a flukefree area and sheep of each breed divided into two equal groups of six. Each animal in one group of each breed was experimentally infected with 400 viable metacercariae of Fasciola gigantica. The other groups acted as uninfected controls. Blood samples were taken at weekly intervals for the determination of serum bilirubin, albumin, and gamma glutamyl transferase levels. Following the establishment of infection, albumin levels declined in both breeds of infected animals without any significant difference between the two breeds. However, serum bilirubin and gamma glutamyl transferase (GGT) in the infected animals were elevated significantly more in the Dorper than in the Red Masai sheep. Based on these findings, it would appear that Dorper sheep are more susceptible to the infection than Red Masai sheep.The articles have been scanned in colour with a HP Scanjet 5590; 600dpi. Adobe Acrobat v.9 was used to OCR the text and also for the merging and conversion to the final presentation PDF-format.Danish International Development Agency (DANIDA).mn201