Ideal Critical Care Setup Dr Tim Baker Stockholm, Sweden Blantyre, Malawi SATA Conference, Tanzania, May 2016

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3 Summary What is critical care The need for critical care What is the ideal critical care setup?

4 Case Pregnant mother: week 40 Seizure at home. Arrives to hospital unconscious. Diagnosed as ”Eclampsia.” Emergency Caesarean. A healthy baby is delivered. Post op Diazepam infusion started. Dies on the ward overnight.

What could be the cause of death? 5

6 A - Airway B - Breathing C - Circulation D – Disability (Neurological) E – Everything Else

What is critical care? 7

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Infections MaternalTraumaSurgeryOther ( burns, paediatrics, cardiovascular, diabetes, substance abuse) Critical Illness Illness severity Care for any patient with acute, life-threatening, reversible illness For all ages, all specialties Focus on disease severity, not diagnosis or specialty

10 Is critical care needed in low- income countries? 90% of maternal deaths (Requejo 2011) 75% of sepsis deaths (Cheng 2008) 90% of trauma deaths(Mock 2005) 75% of child deaths in Africa&Asia (Liu 2012)

11 Current state Critical Care is often lacking No ER No ICU Lack of emergency drugs and equipment Lack of trained staff (Baker 2012) Lack of treatment modifications when critical illness is identified (Baker 2015)

12 Critical care is too expensive and advanced! No! Critical Care need not be expensive Simple things are needed first New triage & emergency care for children in Malawi cost $1.75 per patient Reduced hospital mortality by 50% Oxygen costs ~1 cent per hour (WHO) Reduced child deaths in Papua New Guinea by 35% (Duke 2008)

13 A - Airway B - Breathing C - Circulation D – Disability (Neurological) E – Everything Else Lateral position. Oropharyngeal airways. Chin lift. Oxygen. Salbutamol Positioning. Fluids. Stop bleeding. BT Protect airway. Dextrose. Anti-convulsants. Supportive care. Pain-relief. Diagnosis…

14 Triage Senior nurse quickly evaluates each patient – use ABC Critically ill patients seen first Senior review Hospital-wide triage OPD, admissions, wards, post-op What is needed for a good critical care service 1.Identify the critically ill patients

15 Resuscitation room / ER Emergency drugs and equipment always available Senior review ICU Hospital-wide triage: Wards, post-op, Medical Emergency Team Standardised treatments and guidelines 2. Hospital system What is needed for a good critical care service

16 All Nurses / clinical officers / doctors trained in basic Critical Care Guidelines for managing critically ill patients Continuing education Supervision – internally, externally 3. Training, guidelines, supervision What is needed for a good critical care service

17 Discuss with policy makers Research Training – more specialists, task-shifting National guidelines, standards Links with hospitals in high income countries 4. Health policy: prioritise the critically ill What is needed for a good critical care service

What would you like to have on your critical care ward? 18

19 Increased staff ratios – nurses / clinicians Closer observation – nurses / ward rounds Emergency equipment and treatments on hand (no need to fetch or pay) Optimise basic treatments for ABCD – no need for ventilators or dialysis! 5. Focus on simple things What is needed for a good critical care service

20 6. ABC approach What is needed for a good critical care service

21 1.Trained staff 2.Triage at admission 3.Triage on the wards 4.Critically ill patients on HDU/ICU 5.More nurses for the sickest patients 6.Regular obs 7.Emergency drugs & equipment always available 8.Guidelines 9.Collaboration between anaesthetists & ward doctors 10.Good routines - Ward rounds twice per day 11.(Monitors, syringe drivers, ventilators … ) An ideal Critical Care Setup

No Critical Care Eclampsia Unconscious Caesarean Died 22

Good Critical Care 23 Triage on admission: Very Sick! Resus Room ABC: emergency box Senior Review Immediately to ICU ABC Airway maintained Oxygen Fluids Magnesium

Good Critical Care 24 ABC Emergency Caesarean ABC Post-op ICU ABC SURVIVED!

Summary -Critical Care is care for any patient with acute, life- threatening, reversible illness -Critical illness is common -Critical Care is often neglected -Hospitals should prioritise the critically ill -Simple systems and treatments can make a big difference A new focus on Critical Care in all hospitals in low-income countries could save thousands of lives