A comment in today's The Lancet states: 'Timely access to critical care saves lives in *any* health-care context [my emphasis]... Components of such emergency and critical care interventions include recognition of organ dysfunction, early clinical diagnosis, and emergency management (consisting of oxygen therapy, intravenous fluids, simple manoeuvres to maintain airway patency, and vasoactive medication). These are low-cost interventions that do not require highly specialist training to deliver...'
The comment links to a research paper in the same issue that finds: '55·6% (1369/2461) of critically ill patients received partial or no essential emergency and critical care treatment...'
Comment: Understanding the scale of critical illness in Africa and the need for universal access to emergency and critical care
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02843-5/fulltext?dgcid=raven_jbs_etoc_email
CITATION: The African Critical Illness Outcomes Study (ACIOS): A Point Prevalence Study of Critical Illness in 22 Nations in Africa
T Baker, J Scribante, M Elhadi, AO Ademuyiwa, B Osinaike, C Owoo, D Sottie, K Khalid…
https://www.sciencedirect.com/science/article/pii/S0140673624028460?ssrn...
Abstract
Background: Critical illness represents a major global healthcare burden and critical care is an essential component of hospital care. There are few data describing the prevalence, treatment and outcomes of critically ill patients in African hospitals.
Methods: International prospective point-prevalence study in acute hospitals across Africa. Investigators examined all in-patients ≥ 18 years, regardless of location, to assess the co-primary outcomes of critical illness and seven-day mortality. Patients were classified as critically ill if≥ 1 vital signs were severely deranged. Data were collected describing available resources and care provided to patients. Data are presented as mean (SD), median (IQR), n (%) and odds ratios (OR) with 95% confidence intervals.
Findings: We included 19872 patients from 180 hospitals in 22 African countries between September and December 2023. The median age was 40 (29-59) years, and 11078/19862 (55·8%) patients were women. There were 967/19780 (4·9%) deaths. On census day, 2461/19743 (12·5%) patients were critically ill, with 1688/2459 (68·6%) cared for in general wards. Among the critically ill, 507/2450 (20· 7%) patients died in hospital. Mortality for non-critically ill patients was 458/17205 (2·7%). Critical illness on census day was independently associated with subsequent in-hospital mortality (adjusted OR 7· 59 [6·50-8·79]). Of the critically ill patients with respiratory failure, 557/1151 (48·4%) were receiving oxygen, of those with circulatory failure 521/965 (54·0%) were receiving intravenous fluids or vasopressors and of those with low conscious level, 387/784 (49·4%) were receiving an airway intervention or placed in the recovery position.
Interpretation: One in eight patients in hospitals in Africa are critically ill, of whom one in five dies within seven days. Most critically ill patients are cared for in general wards, and most do not receive the essential emergency and critical care treatments they require. Our findings suggest a high incidence of preventable deaths due to critical illness in Africa.
COMMENT (NPW): I am reminded of Margaret Kruk et al's research in The Lancet that estimated 5m excess deaths in 2016 due to poor quality care - at the time HIFA noted the true picture is worse than this because the research only looked at deaths at the facility level. Similarly, the true picture is almost certainly worse than the authors describe in the current study, which again looks at care only in the facility setting. It excludes healthcare decisions and actions (and associated morbidity and mortality) at the level of the home and community (pre-facility). Poor pre-facility decisions and actions contribute to avoidable critical illness and death before reaching a facility. Whether pre-facility or in-facility, lack of reliable healthcare information or knowledge is a substantial (though unquantified) driver of poor quality care.
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org