Global Challenges in Continuity of Critical Care. A Mixed-Methods Study

Abstract

Integrated health services are embedded in a process that provides a continuum of care and have been advocated by the World Health Organisation (WHO) as the vehicle to improve health outcomes worldwide (Regional Office for Europe of the WHO, 2016). The health loss to injuries, conditions and risk factors are quantified using an index called the global burden of disease (GBD). The three leading causes of GBD in the 1990-2016 period have been ischaemic heart disease, cerebrovascular disease, and lower respiratory infections (GBD 2016 DALYs and HALE Collaborators, 2017), all conditions that often need intensive care. The GBD and sequelae in Intensive Care Unit (ICU) survivors depends on the number of critically ill patients, the resources available to treat them and the morbidity protracted after discharge (Stevens et al., 2014). It is hypothesised that low resources limit the possibility of admitting patients to intensive care units and the services offered after ICU discharge. Objectives To identify how critically ill patients are triaged in Low-Middle-Income Country (LMIC) compared to High-Income Country (HIC) to determine whether triage practice is linked to resource settings; To evaluate which post discharge services are available to critically ill patients in LMIC compared to HIC to detect if there is a difference in service provision; To explore barriers and facilitators of continuity of critical care and identify potential opportunities for quality improvement initiatives driven by crosscountry learning. Methods 14 intensive care doctors from Europe, Africa, America and Asia participated in a online survey and five of them in in-depth interviews. The survey included three sections in order to collect data on the services’ context, the triage and the post ICU practice. The interviews were conducted to explore barriers and facilitators of ICU triage and post ICU care in different settings. Descriptive statistics and thematic analysis have been used to analyse data. Triangulation has been applied to identify convergence, complementarity or discrepancy between data collected via the two research methods. Results Nine of the 14 participants who completed the questionnaire described practice in a LMIC, while five respondents provided examples of HIC practice. Globally, there are several models of care: public, governmental funding (6 LMIC and 4 HIC study units); private funding (1 LMIC unit); fee-for-service model where family/relatives contributes (2 LMIC units); access to health insurance (1 HIC unit). According to study results, when family needs to contribute financially there may be no other choice than limit treatment during and after intensive care. Also, lack of standardised end of life procedures in LMIC make triage a challenging process. Post discharge services are limited by resources according to the majority of participants with a tendency to holistic care in the LMIC units. Staffing, bed availability, and infrastructures (equipment, logistics) have been named as potential barriers to triage and discharges from ICU in all resource settings. Outreach services have been advocated for appropriate triage and after discharge monitoring Conclusions Barriers and facilitators of triage are similar between LMIC and HIC study units despite resources available. Capacity of triage and post discharge services are limited in settings where relatives need to contribute to cost of care. Indeed, triage may be easier in the context of low resources because there may be no other choice than refusing admission. Therefore deciding which patient to admit or not should be planned as soon as possible. Outreach and post discharge services could facilitate the prevention of deterioration and therefore help to decrease the global burden of critical illness.