Essential care of critical illness

Background:

Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility. Patients of any age can become critically ill due to any underlying diagnosis and in any location. The critically ill patients require urgent support of failing vital organs - critical care - to improve their chance of survival.

Substantial unmet needs of critical care have been reported from hospitals both in high- and low-resource settings. Yet, most health policy attention is directed towards the care of specific diagnoses. Moreover, the policy attention in critical care is mostly directed towards advanced technology and high-cost intensive care. To be equitable and effective, however, critical care systems should focus on the most feasible lifesaving interventions - the essential care of critical illness. Such interventions can ensure that patients with critical illness are identified and that they are provided with urgent critical care.

There is surprisingly little epidemiological evidence to guide policy makers about the priority of critical illness and health systems require strategies for effective delivery of critical care.

Aim:

To assess the burden of critical illness in different global settings and to develop, evaluate and reach consensus around strategies to facilitate implementation of essential care of critical illness.

Methods:

Four studies were conducted in different global settings. To estimate the burden of critical illness, a novel method was applied in prospective point-prevalence and cohort studies in hospitals in Malawi, Sri Lanka and Sweden, and in the population of the whole Sörmland region of Sweden. The Vital-Signs Directed Therapy (VSDT) protocol for task-sharing critical care was implemented in an intensive care unit (ICU) in Tanzania and studied with a before-and-after design. The content of the Essential Emergency and Critical Care (EECC) concept to guide health system priorities, was specified in a large, diverse and global Delphi consensus. Statistical methods included univariate and multivariate regression models and Chi2-tests.

Results:

Critical illness was found in 12% of all hospital in-patients across the settings. In the substudy in Sörmland region, the population prevalence of critical illness was 19 per 100,000 people. Among hospital in-patients across all setting, critical illness was strongly associated with mortality (OR 7.5) and 19% died in hospital. More than 90% of the critically ill patients were cared for outside ICUs, in low- staffed general wards.

Implementation of VSDT increased acute treatments of critical illness and reduced mortality among patients presenting with shock from 92% to 69%, but not among all patients. The specified EECC package contains 40 lifesaving clinical processes that are effective, low-cost and feasible to implement in any hospital ward in the world, and the 66 resources that are required for providing this care.

Conclusions:

The results challenge three common misconceptions that have substantial consequences for patients around the world. First, critical illness is not uncommon - it is common. Second, critically ill patients are not always in ICUs - most critically ill patients are cared for in low-staffed general wards. Third, critical care is not limited to expensive and technologically sophisticated interventions. The work in this thesis has shown that critical care can be feasible and low-cost to be provided where most critically ill patients are cared for - in low-staffed or low-resourced settings. The findings can be used to inform priorities in health systems so critical care can be provided more effectively and reach more patients. A new focus on essential care of critical illness has potential to reduce mortality across medical disciplines.

List of scientific papers

I. Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country. Baker T, Schell CO, Lugazia E, Blixt J, Mulungu M, Castegren M, Eriksen J, Konrad D .. PLoS One. 2015 Dec 22;10(12):e0144801. https://doi.org/10.1371/journal.pone.0144801

II. The burden of critical illness among adults in a Swedish region-a population-based point-prevalence study. Schell CO, Wellhagen A, Lipcsey M, Kurland L, Bjurling-Sjöberg P, Stålsby Lundborg C, Castegren M, Baker T. European Journal of Medical Research. 2023 Sep 7;28(1):322. https://doi.org/10.1186/s40001-023-01279-0

III. The hospital burden of critical illness across global settings: a point-prevalence and cohort study in Malawi, Sri Lanka and Sweden. Carl Otto Schell, Raphael Kayambankadzanja, Abigail Beane, Andreas Wellhagen, Chamira Kodippily, Anna Hvarfner, Grace Banda-Katha, Nalayini Jegathesan, Christoffer Hintze, Wageesha Wijesiriwardana, Martin Gerdin Warnberg, Sujeewa Jayasingha Arachchilage, Mtisunge Kachingwe, Petronella Bjurling-Sjoberg, Iasaac Mbingwani, Annie Kalibwe Mkandawire, Hampus Sjostedt, Wezzie Kumwenda-Mwafulirwa, Surenthirakumaran Rajendra, Odala Kamandani, Cecilia Stalsby Lundborg, Samson Kwazizira Mndolo, Miklos Lipcsey, Rashan Haniffa, Lisa Kurland, Markus Castegren, Tim Baker. [Manuscript]

IV. Essential Emergency and Critical Care: a consensus among global clinical experts. Schell CO, Khalid K, Wharton-Smith A, Oliwa J, Sawe HR, Roy N, Sanga A, Marshall JC, Rylance J, Hanson C, Kayambankadzanja RK, Wallis LA, Jirwe M, Baker T; EECC Collaborators. BMJ Glob Health. 2021 Sep;6(9):e006585. https://doi.org/10.1136/bmjgh-2021-006585