PICU Use In Countries With Limited Resources

Duygu Sönmez Düzkaya, PhD, Supervisior NurseIstanbul University Istanbul Faculty of Medicine

Departmant of Nursing Administration

Pediatric intensive care units;

• Have improved a great deal in both developed and developing countries in the last quarter-century.

• Despite the fact that the use of PICUs in developing countries has increased over the years, it hasn’t reached the desired level

There are not enough PICUs.

An accessible and efficient pediatric intensive care service shows the quality of pediatric medical services of a country.

• While PICUs decrease the incidence of child death in developed countries, countries with limited resources should give priority to improving preventive health services rather than pediatric intensive care service.

The world's economic situation

In the world’s 66 high-income countries, the total annual expenditure on health averaged U.S. $4033 per capita in 2006

Which was 175 times the $23 per capita available in the 43 low-income countries

Countdown to 2015 2010 ReportShan et al. 2011

• In 2012, the under-five mortality rate in low-income countries was 82 deaths per 100 live births

• More than 13 times the average rate in high-income countries

• More than 98% of all child deaths occured in developing countries and 90% of these deaths were preventable

Countdown to 2015 2010 Report

Mortality in children

About half of under-five deaths occur in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan and China. India (22 percent) and Nigeria (13 percent) together account for more than a third of all under-five deaths.

Child Mortality Report 2013 (UNICEF)

Children die before the age of 5 years in low-income countries is more than 10 times compared to high-income countries .

Wold Health Statistic 2014

Causes of under-five child deaths

Malnutrition is a factor in more than half of the children who die after the first month of life.

malaria (8%), measles, (4%), HIV/AIDS (3%)

Gastroenterits (diarrhoea) (%18),

Acute lower respiratory infections, mostly pneumonia (19%),

Wold Health Statistic 2014Countdown to 2015 2010 Report

Source: Countdown to 2015 2010 Report

PYBÜ kullanımı

• Ideally, every child in the world should have access to an intensive care unit with facilities for endotracheal intubition and mechanical ventilation.

• Providing intensive care is not in the interest of a child if the prognosis is very poor because such care simply prolongs suffering, and it is not in the interests of health services if such care results in poor utilization of limited resources.

Shan, F., Argent, A.C. Ranjit, S. (2011) Pediatric İntensive Care in Developing Countries

• If the mortality rate in an intensive care unit is greater than 10%, patient selection probably is inappropriate.

• Shan, F., Argent, A.C. Ranjit, S. (2011) Pediatric İntensive Care in Developing Countries

• Çocuk Acil Tıp ve Yoğun Bakım Derneği, Turkiye’de Çocuk Yoğun Bakım Hizmetleri Mevcut Durum ve Öneriler (2006)

• When mortality in children younger than 5 years is greater than 30 per 1000, many deaths are caused by infections. A high proportion of these deaths can be prevented by immunization and primary health care, which are fa less expensive than intensive care.

• Shan, F., Argent, A.C. Ranjit, S. (2011) Pediatric İntensive Care in Developing

Countries• Çocuk Acil Tıp ve Yoğun Bakım Derneği, Turkiye’de Çocuk Yoğun Bakım Hizmetleri

Mevcut Durum ve Öneriler (2006)

Status of the pediatric intensive care unit in the world assessing with;

• ICU beds, • The number of patients per physician and nurse, • Patient characteristics, • Mortality rate, • Infection rate is considered.

In developing countries compared with developed countries;

• Insufficient number of pediatric intensive care unit and the distribution of inappropriate,

• More than the number of patients per nurse and physician,

• And high rates of infection and mortality • States that there is inadequate physical

infrastructure and equipment.

Köröğlu et al. 2008;Haque et al 2014; Bayrakçı et al. 2014

Structure/Organization of PICUs.

• Children under 14 years as compared to 1 bed/10,000 children in USA

Randolph et al (2004). Growth of pediatric intensive care units in the United States from1995 to 2001, Journal of Pediatrics

• 1/1000 in the UKMaybloom et al. (2002). Admissions for critically ill children: where and why? Intensive and Critical Care Nursing

• PICU bed to pediatric population ratio for İstanbul (1:268,000) is much lower than e.g., İzmir (1:30,000)

Köröğlu et al. (2008). A survey of pediatric intensive care services in Turkey. The Turkish Journal of Pediatrics

• In Pakistan under 14 years, this translates into only 1 PICU bed for approximately 500,000

Haque et al (2014). A National Survey of Pediatric Intensive Care Units in Pakistan. Journal of Critical Care Medicine.

Personal

• Low nurse-patient ratios are known to increase nosocomial infection rates and patient mortality.

• The number of patients per nurse - In USA 1:2.9-3.2 (Odetola et al.2005)

- In Europe 1:1 (Ferdinande et al. 1997)

- In Turkey 1:3.5-4.4 (Köröğlu et al. 2008; Bayrakçı et al. 2014)

- Only 37% of PICUs had a nurse to bed ratio of 1 :1 or 1 :2 (Haque et al

2014)

Personal

• The physicians;

- In USA 94%, In Europa 98% (Ferdinande et al. 1997)

- In Turkey 12 (35%) PICUs had a full-time intensivist on staff. (Köröğlu et al. 2008)

- There were only 3 out of 16 pediatricians (19%)who had advanced training in pediatric critical care medicine. (Haque et al 2014)

• The number of patients per physician - In Turkey 1:31.7 (Bayrakçı et al. 2014)

- In USA 1:2- 1:4.5 (Odetola et al.2005)

- In Australia 1:3-1:5 (Ferdinande et al. 1997)

Patient Characteristics

Diagnosis is assessed; • In low-income countries is higher than level 3 number of intensive

care patients, • Respiratory diseases, neurological diseases, infectious diseases, heart

diseases Khositseth et al 2012; Goh et al 2003; Khajeh et al. 2013

Patient Characteristics

• In developing countries patients stay with mechanical ventilation longer and duration of stay in intensive care longer

• Hospital stay longer, finally the cost increases.

• Nearly 18% of patients were being ventilated for more than 14 days (Köröğlu et al. 2008)

The causes of prolonged hospitalization in intensive care

• Insufficient number of trained staff

• Increase the rate of infection due to lack of material

• The extension of the discharge process due to lack of home

care services

Patient Outcome

Mortality rate;• In USA 2.9 % (Randolph et al. 2004), In Europa 5.6% (Nipshagen et al 2002)

• In Thailand 8% (Khositseth et al 2012)

• In Pakistan 12% (Haque et al 2014)

• In Malasia 12.1% (Goh et al 2003)

• In Spain 13.2% (Campos-Mi˜no et al 2012)

• In Turkey 14.6% (Köröğlu et al. 2008)

• South America, India and South Africa have reported mortality rates between 18-32% Singhal et al. 2001

• In Iran 21.3% (Khajeh et al. 2013)

Catheter-associated urinary tract infection

• Catheter-associated urinary tract infection rates were higher in lower middle-income countries than high-income countries or upper middle-income countries (5.9 vs. 0.6 catheter-associated urinary tract infection per 1,000 catheter-days (Rosenthal ve ark. 2012).

Ventilator-associated pneumonia

• Lower middle-income countries had higher ventilator-associated pneumonia rates than high-income countries or upper middle-income countries: (9.0 vs. 0.5 per 1,000 ventilator-days)

• Low income countries VAP rate %14.4-%45.4 (Patra ve ark. 2007;Dey and Bairy 2007;Broughton et al. 2012;Awasthi ve ark. 2013;Rosenthal ve ark. 2012)

• High income countries VAP rate %3-10 (Elward ve ark 2002; Foglia ve ark. 2007; Rosenthal ve ark. 2012)

Central line-associated bloodstream infection

• Central line-associated bloodstream infection rates in lower middle-income countries were higher than high-income countries or upper middle-income countries (12.2 vs. 5.5 central line-associated bloodstream infections per 1,000 catheter-days) (Rosenthal ve ark. 2012).

Ethical issues

• Access to intensive care,

• Inadequate number of beds,

• Acute / chronic patient selection,

• The decision to terminate resuscitation,

• Euthanasia practices

In Countries With Limited Resources

• Insufficient number of beds,

• The small number of nurses,

• The small number of specialist physicians,

• The greater mortality and infection rates

• Physical conditions, lack of technical equipment and materials

Respect and affection ….