56 SECTION I Pediatric Critical Care The Discipline Programs Organization Program Details Fellowships The African Paediatric Fellowship Programme University of Cape Town, South Africa African doctors[.]
56 S E C T I O N I Pediatric Critical Care: The Discipline TABLE Examples of Pediatric Critical Care Education Available in Lower-Middle-Income Countries 8.1 Programs Organization Program Details The African Paediatric Fellowship Programme University of Cape Town, South Africa African doctors spend months to years training in a pediatric subspecialty, including pediatric critical care Graduates then return to their home institution to build a practice, training, research, and advocacy Pediatric Emergency and Critical Care–Kenya University of Nairobi and AIC Kijabe Hospital, Kenya in collaboration University of Washington, Seattle, Washington Two-year program in pediatric emergency and critical care for African pediatricians Curriculum based on East African disease spectrum and resources Emergency, triage, assessment and treatment (ETAT) World Health Organization Teaches health workers of all levels to appropriately triage sick children on arrival to a health facility and to provide emergency treatment for lifethreatening conditions Pediatric basic assessment and support intensive care (BASIC) Created by leaders in pediatric critical care education Teaches nonintensivists the essential principles of recognizing and initiating care for the critically ill child in the absence of an intensivist; low cost Pediatric fundamentals of critical care study (PFCCS) Society of Critical Care Medicine Teaches nonintensivists the essential principles of recognizing and initiating care for the critically ill child in the absence of an intensivist Tiered course pricing based on a country’s gross domestic income Pediatric advanced life support (PALS) American Heart Association Teaches pediatric healthcare provider in developing the knowledge and skills necessary to efficiently and effectively manage critically ill infants and children; targeted toward pediatricians, emergency physicians, family physicians, physician assistants, nurses, nurse practitioners, and paramedics Pediatric, emergency, assessment, recognition and stabilization (PEARS) American Heart Association Teaches assessment, early recognition, prompt communication, and initial intervention in pediatric critical illness by using high-performance team dynamics; targeted toward physicians and nurses not specializing in pediatrics, nurse practitioners, and physician assistants Trauma team training (TTT) Canadian Network for International surgery grants access to course materials Low-cost course designed to teach a multidisciplinary team approach to trauma evaluation and resuscitation with the limited resources found at African rural hospitals and health centers Fellowships Short Courses LMICs, such as Trinidad, India, Ecuador, and Tanzania.94–97 In fields such as pediatric surgery and obstetrics, short-term, specialized training courses have been correlated to increased knowledge retention.98,99 Training of Kenyan doctors taking the Fundamental Critical Care Study course has been shown to increase their knowledge of and confidence in new critical care skills.100 A Cochrane review assessed the effects of in-service emergency care training on health professionals’ treatment of severely ill newborns and children in LICs.101 It included only two neonatal resuscitation studies, both of which suggested a beneficial effect on health provider outcomes (resuscitation practices, assessment of breathing, resuscitation preparedness) in the short term However, the effects on neonatal mortality outcomes were inconclusive, and improvement in health provider practices after training was not generalizable Therefore, decisions to scale up life support courses in LICs “must be based on consideration of costs and logistics associated with their implementation, including the need for adequate numbers of skilled instructors, appropriate locally adapted training materials and the availability of basic resuscitation equipment.”101 With the broad availability of mobile technology in LMICs, there are increasing opportunities for mobile apps to improve training of healthcare providers, for example, as a mode for continued medical education or to assistance with resuscitation algorithms.102 In addition, the use of telemedicine can be beneficial for LMICs, both for improved access to basic and subspecialty care and to promote learning and professional development.103 The global community can help by supporting country-led processes of reform and capacity building in education and by helping to create a stronger evidence base that contributes to cross-country learning Critical Illness During Public Health Emergencies As past H1N1 influenza, severe acute respiratory syndrome, and Ebola outbreaks have clearly illustrated, improved preventive and disease surveillance strategies are necessary in LMICs, but also coordinated emergency and critical care resources are critical for saving lives during epidemics Globally, increasing urbanization, ease of travel, natural disasters, and regional war and conflict increase the risk of infectious outbreaks and need for critical care resources for potentially large numbers of seriously ill patients within a short period of time.104 Mass critical care preparedness in resource-limited settings is only recently being more systematically addressed.105 Use of technology to identify and communicate outbreaks may limit the impact of outbreaks and facilitate triage to critical care resource locations.106,107 Further, an international consensus statement emphasizes the need to develop resilient CHAPTER 8 Challenges of Pediatric Critical Care in Resource-Poor Settings healthcare systems to prepare for disaster and mass critical care preparedness in resource-poor settings.108 Recommendations include strengthening the primary care, basic emergency care, and public health systems and building critical care capacity in the fields with the highest burden of disease—such as surgery, obstetrics, internal medicine, and pediatrics.108 District- and regionallevel health centers should develop at least a minimal level of critical care Therefore, to improve capacity building and quality of care at district hospitals, performance improvement activities should be instituted Prehospital care and transport of the critically ill could be improved through community-level education of medical and nonmedical laypersons Highlighting implementation of these ideas, regional capacity building, emergency preparedness training, and other public health efforts to improve future response to outbreaks were recently described for West African nations affected by Ebola.109 How to Develop an ICU in Low- to MiddleIncome Countries Organizing a PICU in resource-poor settings is associated with many challenges necessitating appropriate planning and proper utilization of limited available resources The building blocks of pediatric critical care services in any setting comprise specialized training of healthcare professionals, including nursing staff, in terms of knowledge, skills and teamwork, resource-appropriate equipment selection, and adequate space for each patient Also key is support of administration and leaders for logistics and appropriate settings to provide services.30 Team-based training is essential for the success of intensive care programs The aim should be to master the basic skills and knowledge essential for pediatric critical care, such as resuscitation skills, with effective communication among team members Simulation-based training has been shown to reinforce skills and teamwork, improving outcomes, and is feasible in LMICs.14,30,61 The bed space as per PICU guidelines in HICs may not be feasible in LMICs because of lack of infrastructure and manpower Judicious use of space is needed for appropriate care of high patient burden and to prevent cross-infection at the same time Low-cost substitutes for expensive equipment may be used as appropriate and preferably with locally available technological services.30,61,110 As mentioned earlier, in order to improve outcomes and judicious use of resources, it is important to establish patient selection criteria for admission and discharge for every PICU along with policies for end-of-life care decisions.111 Other key important aspects in PICU development in LMICs are to have (1) infection control policies, (2) continuous supply of consumable items and medications, (3) laboratory and radiology support, and (4) data collection systems for measurement of PICU outcomes and complications.111 The success of an intensive care program depends on early recognition, timely referral, safe transport, good triage, and emergency care Hence, it is important to strengthen these aspects of care at the community level as well as improving emergency services.30 Importance of Critical Care Research in Limited Resource Settings A large majority of published critical care research occurs in HICs However, research findings in HICs may not directly translate into improved outcomes in LRSs Recent breakthroughs in 57 pediatric resuscitation and critical care interventions in research programs conducted in LRSs have impacted clinical care in the following conditions: severe sepsis, in terms of fluid management; the benefits of early norepinephrine in patients with vasodilatory septic shock; the increased risk of dopamine (vs epinephrine) as a first-line vasoactive agent in fluid refractory septic shock; and insights into the pathophysiology of cerebral malaria that informed an active clinical trial.112–118 There continues to be a vital need for investment in quality research programs that serve the unique needs of these children, as the limited evidence in this field hinders effective and efficient care and advocacy for resources.10,61 Reasons for this gap in evidence include lack of funding; lack of local critical care providers, researchers, and research staff; lack of academic mentorship, infrastructure, and training to research; and barriers to producing publishable research.119 Additionally, establishing research networks in LRSs should be explored to leverage resources to support training, science quality, and capacity to accomplish more than would be done by individuals The research agenda should prioritize increasing evidence regarding critical illness epidemiology and its outcomes in LRSs A more accurate estimate of the potential lives saved through critical care would serve to prove its role in healthcare systems in resource-poor settings.18 Efficacy must be measured and validated for critical care interventions, with limited resources targeted to those practices that save lives, time, and resources Dissemination of evidence and experience from successes and failures could help accelerate the pace of critical care infrastructure improvements Data on critical care capacity and access to both critical care resources and healthcare professionals are essential for health system planning but generally are lacking for pediatrics Recognizing that implementation of clinical care guidelines created using evidence from and for critical care provided in higher-resources settings may not be feasible, efforts should be made to generate and evaluate critical care guidelines for LRSs, especially for common conditions such as sepsis and coma.29,120 Cost-effectiveness analyses of current and proposed critical care practices need to be emphasized.61 Patient triage and clinical research would benefit from simple severity of illness scoring systems adapted and validated for resource-poor settings With increased survival from pediatric critical illness has come the realization of post-ICU sequelae and late mortality and thus the need for services to support continued recovery from critical illness and successful community reintegration For example, children admitted to the hospital in Uganda with infections had a 4.9% increased risk of mortality in the first months following discharge.121 Further, in severely malnourished Bangladeshi children initially treated in the PICU for severe pneumonia, postdischarge (3 months) mortality was 8.6%.122 Identifying risk factors of children at high risk or morbidity and late mortality before hospital discharge and providing effective interventions should be another research priority Low-cost critical care technology, such as noninvasive positivepressure ventilation, is much needed to support critical care in LRSs Locally available, ubiquitous technology such as cell phones should be used to enable better healthcare seeking and delivery and solve clinical challenges While mobile apps for critical care and resuscitation are becoming available, there is significant need for quality control.123,124 Technology development must be tightly woven into solving implementation challenges that result from not only technology cost and availability but also complexity of the political, social, and professional systems in LMICs.120 58 S E C T I O N I Pediatric Critical 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JAMA 2014;312:1297-1298 87 Mormina M, Pinder S A conceptual framework for training of trainers (ToT) interventions in global health Global Health 2018;14:100 88 Barasa EW, Ayieko P, Cleary S, English M A multifaceted intervention to improve the quality of care of children in district hospitals in Kenya: a cost-effectiveness analysis PLoS Med 2012;9:e1001238 89 Wright SW, Steenhoff AP, Elci O, et al Impact of contextualized pediatric resuscitation training on pediatric healthcare providers in Botswana Resuscitation 2015;88:57-62 90 Joynt GM, Zimmerman J, Li TST, Gomersall CD A systematic review of short courses for nonspecialist education in intensive care J Crit Care 2011;26:533 e1-e10 91 Meaney PA, Sutton RM, Tsima B, et al Training hospital providers in basic CPR skills in Botswana: acquisition, retention and impact of novel training techniques Resuscitation 2012;83:1484-1490 ... needs of these children, as the limited evidence in this field hinders effective and efficient care and advocacy for resources.10,61 Reasons for this gap in evidence include lack of funding; lack... Norheim OF End-of-life decisions as bedside rationing An ethical analysis of life support restrictions in an Indian neonatal unit J Med Ethics 2010;36:473-478 52 Beerenahally TS No free bed with... openlabel, cluster, crossover trial Lancet Glob Health 2017;5:e615-e623 The full reference list for this chapter is available at ExpertConsult.com e1 References Databank Agriculture & Rural Development