Critical Foundations of Care – Global Assumptions Harm Critically Ill Patients

Critical illness is defined as any disease with a “high risk of imminent death, vital organ dysfunction, an urgent requirement for care to avoid death, and potential reversibility.” Critical care includes the “identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions” (BMJ Open 2022;12:e060972). Most envision intensive care units (ICUs), but critical care is time-critical care that should be delivered everywhere. Limiting critical care to ICUs harms patients. The expense of ICUs has historically excluded critical care from global priority lists and challenges the feasibility of improving capacity. In both low- and highly resourced settings, 90% of critically ill patients are found outside of ICUs (Eur J Med Res 2023;28:322). They are found in wards, postanesthesia care units, and emergency departments (Eur J Med Res 2023;28:322). As such, the majority of critically ill patients are neglected since most countries lack a comprehensive strategic plan for implementing the emergency, critical, and operative care resolution (asamonitor.pub/48o1JWQ).

Postoperative mortality remains the greatest challenge for the field of anesthesiology (Anesth Analg 2018;127:55-62; JAMA Netw Open 2021;4:e2131669). Intraoperative deaths have significantly decreased over time. Postoperative deaths have not (Anesthesiology 2013;119:1474-89). Essential care involves rapid recognition, quick response, and prompt rescue from life-threatening, reversible organ dysfunction (Figure 1) (JAMA Netw Open 2021;4:e2131669). The greatest needs are essentials – monitors, trained providers, policies, guidelines, and appropriate escalation of care. Essential care is missing in much of the world, including high-income countries like the U.S.

Integrating essential critical care into existing health care is the foundation for building stronger health systems. Essential emergency and critical care (EECC) is that fundamental solution (Figure 2). The contents of EECC are not new, but they define the foundation upon which all hospital care should be built (BMJ Glob Health 2021;6:e006585). Described as the care that should be provided to all critically ill patients in all hospitals in the world, EECC is composed of 40 clinical processes and 67 hospital readiness requirements.

Postoperative mortality is 50% higher on the continent of Africa (Lancet 2018;391:1589-98). Women undergoing emergent cesarian section are 50% more likely to die (Lancet Glob Health 2019;7:e513-22). People die from treatable illness everywhere. Patients are often lost in diagnosis-specific or specialty-specific solutions created by well-intentioned initiatives. Many critically ill patients in Sub-Saharan Africa are admitted with complications from HIV/AIDS, TB, malaria, and maternal health, yet to date, critical care is not integral to such programs. Patients die not from their disease; they die from a lack of EECC.

All hospitals must be equipped to provide essential care, but access is not the only issue. Quality improvement and assurance hold greater impact and could save over 8 million lives in some settings (Lancet Glob Health 2018;6:e1196-1252). EECC improves quality of care by improving ward care, postoperative care, maternal care, emergency care, and pandemic preparedness (Figure 3). EECC decreases the need for advanced ICU-level care while allowing discharge from the ICU sooner.

During the early outbreak of SARS-CoV-2, only 5% of patients needed an ICU. Yet resource-limited countries were flooded with ventilators (JAMA 2020;323:1239-42; Afr J Prim Health Care Fam Med 2020;12:e1-3). Most had no oxygen, no reliable electricity, and no trained providers of mechanical ventilation. In Lesotho, the World Bank built a fully functional ICU. This ICU still lacks providers. Expensive equipment arrives too delicate to endure non-climate-controlled environments and without service contracts. Equipment costs strain limited budgets – an opportunity cost for care that is more needed. On the contrary, fundamental interventions defined by EECC are as cost-effective as medications for malaria or HIV, a mere $14 per disability-adjusted life years averted (Pharmacoecon Open 2023;7:537-52). One million additional lives would be saved with EECC at a fraction of the cost of ICU-level care (Crit Care 2018;22:284).

Providers must be enticed to enter critical care medicine. Training is needed. Lack of interest among health workers may actually be related to fear of liability and a consequence of inadequate compensation. In Zambia, despite government commitment to support medical doctors’ specialization in critical care, most prefer internal medicine, surgery, obstetrics, and pediatrics, citing intense stress from life-threatening emergencies and patient deaths. The same reasons are given in Lesotho, leaving the World Bank’s eight-bed, fully equipped ICU unstaffed. Incentives must be context-specific to enhance critical care services at all levels of the health system.

In hospitals without specialty trained providers, physicians rely on guidelines and protocols. Professional societies issue evidence-based care protocols, assuming international adoption. Unfortunately, many are contextually incompetent. Evidence suggests poorer outcomes from international guidelines applied to dissimilar populations living in resource-constrained settings. Fluid resuscitation given to septic children with malaria in Africa led to worse outcomes (N Engl J Med 2011;364:2483-95). The same occurred for septic African adults (JAMA 2017;318:1233-40).

Clinical vignette: Four hours later, the patient sees a physician. She is prescribed an antibiotic and discharged home. Fortunately, an intensivist passing through noticed the breathless patient needing assistance to walk. He requested the patient’s vitals from the nurse and immediately recalled the patient. He resuscitates the patient, found to be profoundly hypoxic with elevated lactic acid, and admits her for further management. The patient is diagnosed with Pneumocystis pneumonia (PCP) and HIV with a CD4 count of 6.

Most assume that when ill, one can present to a hospital, have vital signs checked, be admitted to the appropriate ward, receive treatment, recover, and be discharged healthily back home. These are false assumptions. Despite readily available pulse oximetry, oxygen devices, and a PSA plant, this patient’s near-miss was a problem of early recognition, a key component of EECC. This vignette also demonstrates how one well-trained intensivist is able to quickly recognize, respond, rescue, and reverse a life-threatening illness. There are often resources available for resuscitating critically ill patients once identified; however, this still leaves two major gaps in the critical care continuum (Crit Care 2019;23:122). First is the problem of early recognition and immediate care. This is solved with universal EECC coverage. The second gap is seen in the ICU with unacceptably high mortality rates for resource-limited settings, which can be solved with additional trained intensivists (PLoS One 2021;16:e0251321). Challenging assumptions is paramount for building the critical foundations of care for patients both inside and outside of ICUs. Improving quality of care is essential for patient survival.