The provision of Critical Care Medicine: Where should we begin to address current global disparities?

Our goal for today…

Don't judge each day by the harvest you reap but by the seeds that you plant ― Robert Louis Stevenson

A great many people think they are thinking when they are merely rearranging their prejudices –William James

Is this critical care?

If you would lift me up you must be on higher ground --Ralph Waldo Emerson

Existential questions… • What is critical care? • Where is critical care delivered? • Who provides critical care?

• What defines a critical care unit?

CRITICAL (adjective): Extremely important or essential, synonym – indispensable

Most of us spend too much time on what is urgent and not enough time on what is important --Steven R. Covey

In conclusion…

“Things” (technology) is not a durable solution

The difference between a helping hand and an outstretched palm is a twist of the wrist. --Laurence Leamer, King of the Night

Where is the highest yield opportunity?

BADNESS

TECHNOLOGY DEPENDENT

TIME

Critical Care prevention is better than Critical Care treatment

In conclusion…

What are the LEAST interventions that will improve a patient’s survival curve?

Aim for the FLOOR, not the CEILING!

Where is the highest yield opportunity? ICU TECHNOLOGY-FOCUSED • SEPSIS

• TRAUMA • MALARIA

DIRECT CAUSES

• PREMATURE BIRTHS

PREVENTABLE DEATHS

NON-ICU PROCESS-FOCUSED • DELAY SEEKING CARE

ROOT CAUSES

• DELAY PROVIDING CARE • NON-ADHERENCE TO CARE PROTOCOLS

modified from: “IMPROVEMENT COLLABORATIVE REPORT ON NATIONAL SCALE-UP OF PROJECT FIVES ALIVE!,” 2014

In conclusion… GOALS

SHORT TERM

• • • •

MID TERM

RECOGNITION: Find and treat patients before they require advanced ICU care TREATMENT: earlier is better, least interventions that improve survival EDUCATION: non-ICU providers, protocols, procedures INFECTION CONTROL/ANTIBIOTIC STEWARDSHIP: (pre-ICU) prevention • • • •

RECOGNITION: prevention of hospital-acquired conditions TREATMENT: ICU-focused (sepsis, respiratory failure, hemodynamic support) EDUCATION: ICU providers, support devices, protocols, procedures, imaging techniques INFECTION CONTROL/ANTIBIOTIC STEWARDSHIP: ICU prevention

FIRST…we cope with disparities, LATER…we attempt to eliminate them!

Where is the highest yield opportunity? COMMUNITY

DISPENSARIES

HOSPITAL ICU

Critical Care is not a place…

In conclusion…

Bending the community survival curve does not happen (first) in the ICU, even for the critical care problems

Where to aim? HEALTHCARE HYGEINE

SEPSIS IDENTIFICATION

ANTIBIOTIC STEWARDSHIP The world hates change, yet it is the only thing that has brought progress – Charles Kettering

In conclusion…

PRIORITY 1 = SEPSIS PRIORITY 2 = SEPSIS PRIORITY 3 = SEPSIS

Navigating the maze Action expresses priorities --Mahatma Gandhi

Sepsis realities… Sepsis is the final common pathway in the majority of deaths from infection worldwide 1. World Health Organization estimates that sepsis accounts for 60–80% of lost lives per year in childhood 2. Over 75% of the global burden of infectious diseases, as assessed by mortality and disability adjusted life years lost, occurs in resource-limited countries

3. Infectious diseases make up six of the ten most frequent causes of death in resource-limited countries

If your lactate level is elevated, please raise your hand…

New sepsis definition… • Uses simple clinical features, available in any healthcare setting, without lab tests • The presence of 2 or more clinical features corresponds to a 10-50 fold increase in the likelihood of a poor outcome • Discrimination in internal and external cohorts in more than 800,000 suspected infected patients is excellent, equivalent to SOFA and improves upon SIRS • Serum lactate did not significantly improve overall discrimination

New sepsis definition…

DEVELOPED NATIONS

RESOURCE-LIMITED NATIONS

Not technology dependent…

Sepsis… • is not simply an acute diagnosis that is detected and treated • is not an ICU diagnosis, it is a community health problem • must be managed longitudinally, like hypertension or diabetes

Yesterday is gone. Tomorrow has not yet come. We have only today. Let us begin ―Mother Teresa Every day is a journey, and the journey itself is home --Matsuo Basho

Navigating Transitions of Care

DEVELOPMENT OF INFECTION

SEPSIS TRIAGE

ADVANCED CARE

How is this accomplished, where to start?? Where does systematic sepsis care begin?

s 5

Alive

A partnership to reduce under 5 mortality • Project Fives Alive! partnership between the Institute for Healthcare Improvement (IHI) and the National Catholic Health Service (NCHS) • GOAL: reduce morbidity and mortality in children less than five years old (under-5) in Ghana • COLLABORATION: The Ghana Health Service (GHS) is working with NCHS and IHI to achieve national spread

• FUNDING: The Bill & Melinda Gates Foundation

s 5

Alive

Project design WAVE 1

Rapid innovation and testing of change ideas on a small scale in four districts/dioceses in Northern Sector of Ghana

WAVE 2

Spread simplified package of successful changes to all 38 districts in three regions of the North

WAVE 3

Spread improvements within NCHS hospital system in the South

WAVE 4

Spread improvements to South and remainder of country

WIDESPREAD DISSEMINATION REFINE CONCENTRATE SIMPLIFY LARGER TESTS OF CHANGE REFINE CONCENTRATE SIMPLIFY SMALL TESTS OF CHANGE

s 5

Alive

Example results

SIMPLICITY!

Recommendations for sepsis management in resource-limited settings, Intensive Care Med (2012) 38:557–574

Must legislate the “don’ts”

Recommendations for sepsis management in resource-limited settings, Intensive Care Med (2012) 38:557–574, DOI 10.1007/s00134-012-2468-5

Uncomplicated, uncluttered, understandable

A provocative challenge: How much is required to make a measurable difference?

1 antibiotic

1 hour

1 L fluids

Changing a survival curve…

Scan-Teach-Treat ENVIRONMENTAL SCAN

SEPSIS FIRST AID KIT

SEPSIS EDUCATION

Pilot Project •

Funded by the Hellman Family Foundation & an ESICM Life-Priority Grant

•

Focuses on sepsis initiatives at Gitwe Hospital Rwanda

•

The study aims to: •

Evaluate the impact of a focused training program on sepsis on the clinical management of patients suffering from sepsis treated at the Gitwe Hospital

•

Validate the environmental scan tool to evaluate essential aspects of sepsis care in the region

•

Evaluate the clinical usefulness and practicality of the ‘Sepsis First Aid’ kit in the management of patients with sepsis in the catchment area served by the Gitwe Hospital and in the Gitwe Hospital.

REGION

COMMUNITY DISPENSARY HOSPITAL ICU

TIME?

How and where do sepsis patients present for care?

Gitwe Hospital in Rwanda

Beyond sepsis: Improving critical care

Major road accident trauma cases in Tu Liem district of Hanoi, Viet Nam •

31% of casualties receive first aid at the accident site

•

71% of patients die before reaching the hospital

•

Int. J. Care Injured (2008), 39: 1026-1033

Why do so many patients die at the scene?

1. Asphyxia (head trauma ➔ airway obstruction)

2. Blood loss (exsanguination)

All difficult things have their origin in that which is easy, and great things in that which is small. --Lao Tsu

Role of technology…

It is a mistake to think you can solve any major problems just with potatoes --Douglas Adams

Technology is not a substitute for education, infrastructure, discipline, culture change, ownership

ICU MEDICAL DEVICES

SMART DEVICES

ROLE OF TECHNOLOGY

TELEEVERYTHING DISTANCE LEARNING

Technology is not a substitute for education, infrastructure, discipline, culture change, ownership

Advanced medical devices = solutions?

Introducing more high technology devices does not inherently solve problems or make things better • Education and training

• Medical maintenance • Cost

Educational reality: “Giving the people what they want versus what they need...”

WHAT THE PEOPLE WANT

•

Advanced critical care topics

•

Eminent lectures and symposia

•

A gathering of many...

It is not the mountain we conquer but ourselves --Edmund Hillary

Educational reality: “Giving the people what they want versus what they need...”

WHAT THE PEOPLE NEED • Needs-based curricula/education • Exercises that develop analysis and synthesis skills • Case-based learning • Care protocolization and standardization • Team training, communications skills, and leadership development

• Repetition, repetition, repetition You can only elevate individual performance by elevating that of the entire system --W. Edwards Deming

CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness and iNjury) • GOAL: standardize the approach to the evaluation and treatment of acutely decompensating patients • DESIGN & CONTENT: survey of clinicians from diverse international settings

• FORMAT: electronic (laptop/mobile) and paper • TOOLS: evidence-based diagnostic checklists, clinical decision support, educational modules on performing critical procedures

CERTAIN = predictable, timely, reliable choreography

Smartphones as a ‘Point-of-Care’ knowledge acquisition tool…

• • • •

Ubiquitous device availability Front line care protocols Regional care algorithms 30-90 second videos – Demonstrations – “How to” techniques

Breathing pattern with severe metabolic acidosis

Assessing capillary refill

OPTIMAL USE OF "TOOLS" Pragmatism…

Aim for the FLOOR, not the CEILING!

What are the elements of an ‘essential’ curriculum? • This is not for ICU personnel ONLY! • Early recognition of impending “badness”

• Defining and sequencing clinical priorities • Common (basic) principles of organ system support

• Infection control, HCW hygiene, antibiotic stewardship

How to think, problem solve, and “DO,” Not lists of “facts” about “things”

Team behaviors: What (which) should we teach?

In conclusion…

The best way out is always through ― Robert Frost

In conclusion… • “Things” (technology) is not a durable solution • What are the LEAST interventions that will improve a patient’s survival curve? • Bending the community survival curve does not happen (first) in the ICU, even for the critical care problems • PRIORITY 1 = SEPSIS Keep your eyes on the stars, and your feet on the ground --Theodore Roosevelt

AN ACTION PLAN

I wish you enough… sun to keep your attitude bright rain to appreciate the sun more happiness to keep your spirit alive

pain so that the smallest joys in life appear much bigger gain to satisfy your wanting loss to appreciate all that you possess hellos to get you through the final good-bye