Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study

Abstract

Introduction: As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes.

Methods: This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test.

Results: From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant.

Conclusion: Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.

Keywords: Barriers; Care capacity; Critical care; Medical ward.

Fig. 1

Box plots of percentage of times the six most common barrier categories were identified. The numerator was calculated as the number of times each category of barrier was identified by a participant at a unit for the signal functions included in the essential bundles*. The denominator was the number of times participants at a unit were asked to identify barriers (i.e. the number of times participants rated any of these signal functions as generally unavailable or somewhat available). *Mental status exam, perform manual maneuvers to open the airway manual maneuvers (e.g. jaw thrust, chin lift), use of suction, placement of oro- or nasopharyngeal airway device, availability of oxygen, bag-valve mask ventilation, external control of bleeding, administration oral rehydration solution, administration of IV fluids, administration of adrenaline, protect unconscious patient from secondary injury, diagnose and treat hypoglycemia, administration of benzodiazepine for seizure, management of extreme temperatures, place peripheral IV, place intraosseous line, administration of IV or IM antibiotics, administration IV opioid, administer appropriate therapeutics for agitation, administration of enteral nutrition, and reposition patient every four hours