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. 2017 Mar 14;12(3):e0173483.
doi: 10.1371/journal.pone.0173483. eCollection 2017.

Impact of a structured ICU training programme in resource-limited settings in Asia

Rashan Haniffa  1 , Yoel Lubell  1   2 , Ben S Cooper  1   2 , Sanjib Mohanty  3 , Shamsul Alam  4 , Arjun Karki  5 , Rajya Pattnaik  3 , Ahmed Maswood  4 , R Haque  4 , Raju Pangeni  5 , Marcus J Schultz  6 , Arjen M Dondorp  1   2 ; ICU Training in South Asia Group
Affiliations

Impact of a structured ICU training programme in resource-limited settings in Asia

Rashan Haniffa et al. PLoS One. .

Abstract

Objective: To assess the impact on ICU performance of a modular training program in three resource-limited general adult ICUs in India, Bangladesh, and Nepal.

Method: A modular ICU training programme was evaluated using performance indicators from June 2009 to June 2012 using an interrupted time series design with an 8 to 15 month pre-intervention and 18 to 24 month post-intervention period. ICU physicians and nurses trained in Europe and the USA provided training for ICU doctors and nurses. The training program consisted of six modules on basic intensive care practices of 2-3 weeks each over 20 months. The performance indicators consisting of ICU mortality, time to ICU discharge, rate at which patients were discharged alive from the ICU, discontinuation of mechanical ventilation or vasoactive drugs and duration of antibiotic use were extracted. Stepwise changes and changes in trends associated with the intervention were analysed.

Results: Pre-Training ICU mortality in Rourkela (India), and Patan (Nepal) Chittagong (Bangladesh), was 28%, 41% and 62%, respectively, compared to 30%, 18% and 51% post-intervention. The intervention was associated with a stepwise reduction in cumulative incidence of in-ICU mortality in Chittagong (adjusted subdistribution hazard ratio [aSHR] (95% CI): 0.62 (0.40, 0.97), p = 0.03) and Patan (aSHR 0.16 (0.06, 0.41), p<0.001), but not in Rourkela (aSHR: 1.17 (0.75, 1.82), p = 0.49). The intervention was associated with earlier discontinuation of vasoactive drugs at Rourkela (adjusted hazard ratio for weekly change [aHR] 1.08 (1.03, 1.14), earlier discontinuation of mechanical ventilation in Chittagong (aHR 2.97 (1.24, 7.14), p = 0.02), and earlier ICU discharge in Patan (aHR 1.87 (1.02, 3.43), p = 0.04).

Conclusion: This structured training program was associated with a decrease in ICU mortality in two of three sites and improvement of other performance indicators. A larger cluster randomised study assessing process outcomes and longer-term indicators is warranted.

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Conflict of interest statement

Competing Interests: BSC was supported by The Medical Research Council and the Department for International Development (grant number MR/ K006924/1). All other authors declare that they have no competing interests. We can confirm that the grant held by BSC does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Common admission diagnoses (APACHE II diagnostic category) and mortality by site during study period.
Fig 2
Fig 2. Cumulative incidence function for ICU mortality in the three study sites.
P-values refer to the evidence for stepwise changes in adjusted subdistribution hazard ratio from the Fine-Gray model for the cumulative incidence of ICU mortality.
Fig 3
Fig 3. Median duration of ICU stay, mechanical ventilation, vasoactive drug use and antibiotic use in the three study sites by four-week period.
The trend line is a non-parametric locally weighted scatterplot smoother. The vertical line indicates the time that the training intervention started.
See this image and copyright information in PMC

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