Priyantha Lakmini Athapattu

Nursing intensive care skills training: A nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting☆

PURPOSE To assess the impact of a nurse-led, short, structured training program for intensive care unit (ICU) nurses in a resource-limited setting. METHODS A training program using a structured approach to patient assessment and management for ICU nurses was designed and delivered by local nurse tutors in partnership with overseas nurse trainers. The impact of the course was assessed using the following: pre-course and post-course self-assessment, a pre-course and post-course Multiple Choice Questionnaire (MCQ), a post-course Objective Structured Clinical Assessment station, 2 post-course Short Oral Exam (SOE) stations, and post-course feedback questionnaires. RESULTS In total, 117 ICU nurses were trained. Post-MCQ scores were significantly higher when compared with pre-MCQ (P < .0001). More than 95% passed the post-course Objective Structured Clinical Assessment (patient assessment) and SOE 1 (arterial blood gas analysis), whereas 76.9% passed SOE 2 (3-lead electrocardiogram analysis). The course was highly rated by participants, with 98% believing that this was a useful experience. CONCLUSIONS Nursing Intensive Care Skills Training was highly rated by participants and was effective in improving the knowledge of the participants. This sustainable short course model may be adaptable to other resource-limited settings.

Applicability of the APACHE II model to a lower middle income country

Purpose: To determine the utility of APACHE II in a low‐and middle‐income (LMIC) setting and the implications of missing data. Materials and methods: Patients meeting APACHE II inclusion criteria admitted to 18 ICUs in Sri Lanka over three consecutive months had data necessary for the calculation of APACHE II, probabilities prospectively extracted from case notes. APACHE II physiology score (APS), probabilities, Standardised (ICU) Mortality Ratio (SMR), discrimination (AUROC), and calibration (C‐statistic) were calculated, both by imputing missing measurements with normal values and by Multiple Imputation using Chained Equations (MICE). Results: From a total of 995 patients admitted during the study period, 736 had APACHE II probabilities calculated. Data availability for APS calculation ranged from 70.6% to 88.4% for bedside observations and 18.7% to 63.4% for invasive measurements. SMR (95% CI) was 1.27 (1.17, 1.40) and 0.46 (0.44, 0.49), AUROC (95% CI) was 0.70 (0.65, 0.76) and 0.74 (0.68, 0.80), and C‐statistic was 68.8 and 156.6 for normal value imputation and MICE, respectively. Conclusions: An incomplete dataset confounds interpretation of prognostic model performance in LMICs, wherein imputation using normal values is not a suitable strategy. Improving data availability, researching imputation methods and developing setting‐adapted and simpler prognostic models are warranted. HighlightsAn incomplete dataset confounds interpretation of APACHE II performance in LMICs.Imputation of missing data with normal values is not appropriate for LMICs.Developing a setting‐adapted and simpler prognostic model for LMICs is warranted.

Capacity building for critical care training delivery: Development and evaluation of the Network for Improving Critical care Skills Training (NICST) programme in Sri Lanka

OBJECTIVES To deliver and evaluate a short critical care nurse training course whilst simultaneously building local training capacity. RESEARCH METHODOLOGY A multi-modal short course for critical care nursing skills was delivered in seven training blocks, from 06/2013-11/2014. Each training block included a Train the Trainer programme. The project was evaluated using Kirkpatricks Hierarchy of Learning. There was a graded hand over of responsibility for course delivery from overseas to local faculty between 2013 and 2014. SETTING Sri Lanka. MAIN OUTCOME MEASURES Participant learning assessed through pre/post course Multi-Choice Questionnaires. RESULTS A total of 584 nurses and 29 faculty were trained. Participant feedback was consistently positive and each course demonstrated a significant increase (p≤0.0001) in MCQ scores. There was no significant difference MCQ scores (p=0.186) between overseas faculty led and local faculty led courses. CONCLUSIONS In a relatively short period, training with good educational outcomes was delivered to nearly 25% of the critical care nursing population in Sri Lanka whilst simultaneously building a local faculty of trainers. Through use of a structured Train the Trainer programme, course outcomes were maintained following the handover of training responsibility to Sri Lankan faculty. The focus on local capacity building increases the possibility of long term course sustainability.

A data platform to improve rabies prevention, Sri Lanka.

Abstract Problem In Sri Lanka, rabies prevention initiatives are hindered by fragmented and delayed information-sharing that limits clinicians’ ability to follow patients and impedes public health surveillance. Approach In a project led by the health ministry, we adapted existing technologies to create an electronic platform for rabies surveillance. Information is entered by trained clinical staff, and both aggregate and individual patient data are visualized in real time. An automated short message system (SMS) alerts patients for vaccination follow-up appointments and informs public health inspectors about incidents of animal bites. Local setting The platform was rolled out in June 2016 in four districts of Sri Lanka, linking six rabies clinics, three laboratories and the public health inspectorate. Relevant changes Over a 9-month period, 12 121 animal bites were reported to clinics and entered in the registry. Via secure portals, clinicians and public health teams accessed live information on treatment and outcomes of patients started on post-exposure prophylaxis (9507) or receiving deferred treatment (2614). Laboratories rapidly communicated the results of rabies virus tests on dead mammals (328/907 positive). In two pilot districts SMS reminders were sent to 1376 (71.2%) of 1933 patients whose contact details were available. Daily SMS reports alerted 17 public health inspectors to bite incidents in their area for investigation. Lessons learnt Existing technologies in low-resource countries can be harnessed to improve public health surveillance. Investment is needed in platform development and training and support for front-line staff. Greater public engagement is needed to improve completeness of surveillance and treatment.

National Profile of Physical Therapists in Critical Care Units of Sri Lanka: Lower Middle-Income Country

Background The availability and role of physical therapists in critical care is variable in resource-poor settings, including lower middle-income countries. Objective The aim of this study was to determine: (1) the availability of critical care physical therapist services, (2) the equipment and techniques used and needed, and (3) the training and continuous professional development of physical therapists. Methods All physical therapists working in critical care units (CCUs) of state hospitals in Sri Lanka were contacted. The study tool used was an interviewer-administered telephone questionnaire. Results The response rate was 100% (N=213). Sixty-one percent of the physical therapists were men. Ninety-four percent of the respondents were at least diploma holders in physical therapy, and 6% had non–physical therapy degrees. Most (n=145, 68%) had engaged in some continuous professional development in the past year. The majority (n=119, 56%) attended to patients after referral from medical staff. Seventy-seven percent, 98%, and 96% worked at nights, on weekends, and on public holidays, respectively. Physical therapists commonly perform manual hyperinflation, breathing exercises, manual airway clearance techniques, limb exercises, mobilization, positioning, and postural drainage in the CCUs. Lack of specialist training, lack of adequate physical therapy staff numbers, a heavy workload, and perceived lack of infection control in CCUs were the main difficulties they identified. Limitations Details on the proportions of time spent by the physical therapists in the CCUs, wards, or medical departments were not collected. Conclusions The availability of physical therapist services in CCUs in Sri Lanka, a lower middle-income country, was comparable to that in high-income countries, as per available literature, in terms of service availability and staffing, although the density of physical therapists remained very low, critical care training was limited, and resource limitations to physical therapy practices were evident.

Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting

Objective This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. Design Longitudinal observational cohort study. Setting District General Hospital Monaragala. Participants All adult (age >17 years) admitted patients. Main outcome measures Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. Statistical analysis Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve. Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). Results Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). Conclusion There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients. Trial registration number NCT02523456; Results.

A retrospective study of physiological observation-reporting practices and the recognition, response, and outcomes following cardiopulmonary arrest in a low-to-middle-income country

Background and Aims: In Sri Lanka, as in most low-to-middle-income countries (LMICs), early warning systems (EWSs) are not in use. Understanding observation-reporting practices and response to deterioration is a necessary step in evaluating the feasibility of EWS implementation in a LMIC setting. This study describes the practices of observation reporting and the recognition and response to presumed cardiopulmonary arrest in a LMIC. Patients and Methods: This retrospective study was carried out at District General Hospital Monaragala, Sri Lanka. One hundred and fifty adult patients who had cardiac arrests and were reported to a nurse responder were included in the study. Results: Availability of six parameters (excluding mentation) was significantly higher at admission (P < 0.05) than at 24 and 48 h prior to cardiac arrest. Patients had a 49.3% immediate return of spontaneous circulation (ROSC) and 35.3% survival to hospital discharge. Nearly 48.6% of patients who had ROSC did not receive postarrest intensive care. Intubation was performed in 46 (62.2%) patients who went on to have ROSC compared with 28 (36.8%) with no ROSC (P < 0.05). Defibrillation, performed in eight (10.8%) patients who had ROSC and eight (10.5%) in whom did not, was statistically insignificant (P = 0.995). Conclusions: Observations commonly used to detect deterioration are poorly reported, and reporting practices would need to be improved prior to EWS implementation. These findings reinforce the need for training in acute care and resuscitation skills for health-care teams in LMIC settings as part of a program of improving recognition and response to acute deterioration.

Capacity building for critical care skills training provision in resource limited settings: the nursing intensive care skills training (nicst) project

The availability of high quality critical care is increasingly recognised as a global health problem [1, 2]. The ability of any health system to scale-up delivery of effective critical care services will be limited by critical care training capacity.

A COLLABORATIVE APPROACH TO TRAINING WARD NURSES IN ACUTE CARE SKILLS IN RESOURCE LIMITED SETTINGS: THE NURSING INTENSIVE CARE SKILLS TRAINING (NICTS) PROJECT

Early recognition and prevention of deterioration of ward patients can improve patient outcomes and reduce critical care admissions [1]. In low and middle income countries (LMICs), with often minimal access to critical care therapies, the benefit may be even greater. However training to assist ward nurses develop acute care skills remains limited in such settings. As part of the NICST portfolio of acute care training, the Sri Lankan nursing faculty sought assistance to deliver a 2 day course for ward nurses [2].

Practices and perspectives in cardiopulmonary resuscitation attempts and the use of do not attempt resuscitation orders: A cross-sectional survey in Sri Lanka

Objective: The objective of this study is to describe the characteristics of in-hospital cardiopulmonary resuscitation (CPR) attempts, the perspectives of junior doctors involved in those attempts and the use of do not attempt resuscitation (DNAR) orders. Methods: A cross-sectional telephone survey aimed at intern doctors working in all medical/surgical wards in government hospitals. Interns were interviewed based on the above objective. Results: A total of 42 CPR attempts from 82 hospitals (338 wards) were reported, 3 of which were excluded as the participating doctor was unavailable for interview. 16 (4.7%) wards had at least 1 patient with an informal DNAR order. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt, of which 6 occurred on wards with an informal DNAR order in place. 39 resuscitations were attempted. Survival at 24 h was 2 (5.1%). In 5 (13%) attempts, CPR was the only intervention reported. On 25 (64%) occasions, doctors were “not at all” or “only a little bit surprised” by the arrest. Conclusions: CPR attempts before death in hospitals across Sri Lanka is prevalent. DNAR use remains uncommon.