RESUMEN
OBJECTIVE: Critical illness affects health systems globally, but low- and middle-income countries (LMICs) bear a disproportionate burden. Due to a paucity of data, the capacity to care for critically ill patients in LMICs is largely unknown. Haiti has the lowest health indices in the Western Hemisphere. In this study, we report results of the first known nationwide survey of critical care capacity in Haiti. DESIGN: Nationwide, cross-sectional survey of Haitian hospitals in 2017-2018. SETTING: Haiti. SUBJECTS: All Haitian health facilities with at least six hospital beds. INTERVENTIONS: Electronic- and paper-based survey. RESULTS: Of 51 health facilities identified, 39 (76.5%) from all ten Haitian administrative departments completed the survey, reporting 124 reported ICU beds nationally. Of facilities without an ICU, 20 (83.3%) care for critically ill patients in the emergency department. There is capacity to ventilate 62 patients nationally within ICUs and six patients outside of the ICU. One-third of facilities with ICUs report formal critical care training for their physicians. Only five facilities met criteria for a Level 1 ICU as defined by the World Federation of Societies of Intensive and Critical Care Medicine. Self-identified barriers to providing more effective critical care services include lack of physical space for critically ill patients, lack of equipment, and few formally trained physicians and nurses. CONCLUSIONS: Despite a high demand for critical care services in Haiti, current capacity remains insufficient to meet need. A significant amount of critical care in Haiti is provided outside of the ICU, highlighting the important overlap between emergency and critical care medicine in LMICs. Many ICUs in Haiti lack basic components for critical care delivery. Streamlining critical care services through protocol development, education, and training may improve important clinical outcomes.
Asunto(s)
Cuidados Críticos/estadística & datos numéricos , Equipos y Suministros de Hospitales/estadística & datos numéricos , Instituciones de Salud/estadística & datos numéricos , Adolescente , Niño , Preescolar , Enfermedad Crítica , Estudios Transversales , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Salud Global/estadística & datos numéricos , Haití , Hospitales/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Médicos/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
PURPOSE: The World Health Organization (WHO) has developed a simplified algorithm specific to resource-limited settings for the treatment of severe sepsis emphasizing early fluids and antibiotics. However, this protocol's clinical effectiveness is unknown. We describe patient outcomes before and after implementation of an adapted WHO severe sepsis protocol at a community hospital in Haiti. MATERIALS AND METHODS: Using a before-and-after study design, we retrospectively enrolled 99 adult Emergency Department patients with severe sepsis from January through March 2012. After protocol implementation in January 2014, we compared outcomes to 67 patients with severe sepsis retrospectively enrolled from February to April 2014. We defined sepsis according to the WHO's Integrated Management of Adult Illness guidelines and severe sepsis as sepsis plus organ dysfunction. RESULTS: After protocol implementation, quantity of fluid administered increased and the physician's differential diagnoses more often included sepsis. Patients were more likely to have follow-up vital signs taken sooner, a radiograph performed, and a lactic acid tested. There were no improvements in mortality, time to fluids or antimicrobials. CONCLUSIONS: Use of a simplified sepsis protocol based primarily on physiologic parameters allows for substantial improvements in process measures in the care of severely septic patients in a resource-constrained setting.
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Antibacterianos/uso terapéutico , Protocolos Clínicos , Servicio de Urgencia en Hospital/normas , Evaluación de Resultado en la Atención de Salud , Sepsis/prevención & control , Adulto , Anciano , Antibacterianos/administración & dosificación , Benchmarking , Esquema de Medicación , Servicio de Urgencia en Hospital/organización & administración , Femenino , Haití , Mortalidad Hospitalaria , Humanos , Control de Infecciones , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Sepsis/mortalidad , Choque Séptico/mortalidad , Choque Séptico/prevención & control , Resultado del Tratamiento , Organización Mundial de la SaludRESUMEN
PURPOSE: Ultrasound (US) is a burgeoning diagnostic tool and is often the only available imaging modality in low- and middle-income countries (LMICs). However, bedside providers often lack training to acquire or interpret US images. We conducted a study to determine if a remote tele-intensivist could mentor geographically removed LMIC providers to obtain quality and clinically useful US images. MATERIALS AND METHODS: Nine Haitian non-physician health care workers received a 20-minute training on basic US techniques. A volunteer was connected to an intensivist located in the USA via FaceTime. The intensivist remotely instructed the non-physicians to ultrasound five anatomic sites. The tele-intensivist evaluated the image quality and clinical utility of performing tele-ultrasound in a LMIC. RESULTS: The intensivist agreed (defined as "agree" or "strongly agree" on a five-point Likert scale) that 90% (57/63) of the FaceTime images were high quality. The intensivist felt comfortable making clinical decisions using FaceTime images 89% (56/63) of the time. CONCLUSIONS: Non-physicians can feasibly obtain high-quality and clinically relevant US images using video chat software in LMICs. Commercially available software can connect providers in institutions in LMICs to geographically removed intensivists at a relatively low cost and without the need for extensive training of local providers.
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Educación a Distancia/normas , Personal de Salud/educación , Medios de Comunicación Sociales/normas , Telemedicina/normas , Ultrasonografía , Adulto , Educación a Distancia/métodos , Estudios de Factibilidad , Femenino , Haití , Humanos , Masculino , Persona de Mediana Edad , Sistemas de Atención de Punto , Pobreza , Programas Informáticos , Adulto JovenRESUMEN
PURPOSE: Developing countries carry the greatest burden of sepsis, yet few descriptive data exist from the Western Hemisphere. We conducted a retrospective cohort study to elucidate the presentation, treatment, and outcomes of sepsis at an urban referral hospital in Port-au-Prince, Haiti. MATERIALS AND METHODS: We studied all adult emergency department patient encounters from January through March 2012. We characterized presentation, management, and outcomes using univariable and multivariable analyses. RESULTS: Of 1078 adult patients, 224 (20.8%) had sepsis and 99 (9.2%) had severe sepsis. In-hospital mortality for severe sepsis was 24.2%. Encephalopathy was a predictor of intravenous fluid administration (adjusted odds ratio [OR], 5.63; 95% confidence interval [CI], 1.46-21.76; P=.01), and lower blood pressures predicted shorter time to fluid administration. Increasing temperature and lower blood pressures predicted antibiotic administration. Encephalopathy at presentation (adjusted OR, 6.92; 95% CI, 1.94-24.64; P=.003), oxygen administration (adjusted OR, 15.96; 95% CI, 3.05-83.59; P=.001), and stool microscopy (adjusted OR, 45.84; 95% CI, 1.43-1469.34; P=.03) predicted death in severe sepsis patients. CONCLUSIONS: This is the first descriptive study of sepsis in Haiti. Our findings contribute to the knowledge base of global sepsis and reveal similarities in independent predictors of mortality between high- and low-income countries.