Critical Care Nursing resource limited

Essential Emergency and Critical Care

This concept was first mentioned by (Schell et al., 2018); a medically-diverse group of researchers and clinicians from Global Helth (Health Systems & Policy), Tropical Research and Critical Care departments at various Universities,formed an unusual alliance. Until this paper was published, there was no concept or framework (or striking pneumonic) for critical care as part of the Global Health movement.

In fact, acute care, surgery and especially critical care were not considered part of Global Health which was focused on public health and primary care with a notional acknowledgement of hospital-based care.

Professor Paul Farmer,an anthropologist and MD from USA was a staunch advocate of Global Health but around 2008-2010 he also started to campaign for Global Surgery to be included in Global Health thinking and considered as a worldwide concern. This culminated in the Lancet Commission on Global Surgery which addressed the lack of safe, affordable surgical and anaesthesia care throughout much of the world. Interestingly, this report had no mention or acknowledgement of critical care or Intensive Care Units (Meara et al., 2015)

If you look at any public health / global health textbook or paper before 2014-2015 you will not find any recognition of the contribution of critical care speciality. Even now, the campaign for Universal Health Care does not directly refer to surgery and likewise, critical care as proponents of UHC.

Many researchers have argued the case for surgery, anaesthesia and critical care to be a worldwide phenomenon and there have been ethical and economic arguments for LMIC’s to develop some critical care services. Overall, proponents for critical care in the global arena are apologist and they remain aware that the competition for funding is a big issue in all health systems but is complex and has conflicts of interest in LMICs. Therefore when Schell, Warnberg, Hvarfner, Hoog, U Baker, Castegren and T Baker wrote ‘The global need for essential emergency and critical care’in 2018, it was seen as a breakthrough document. Although written by clinicians and researchers from the global north, it is recognised that they all and extensive experience or interest in LMIC and were particularly focused on low-resource settings.

Clear (international) definitions are needed for:

Emergency care

Critical Care

Essential care is partly-defined as WHO guidelines for trauma and pregnancy, childbirth, postpartum and newborn care have established the terminology as a ‘minimum set of actions that should always be implemented’. Like these reports ‘essential services for all is the foundation of critical care systems (Baker et al., 2015)

Some key aspects of EECC are:

EECC should be part of universal health coverage

EECC has the potential to improve the care given to critically ill patients throughout the world and can have a real impact on mortality.

Critically ill patients should at least receive fundamental care throughout the hospital(Schell et al., 2019)

Essential is a keyword because the EECC plan is to define a minimum set of actions that should be implemented and is concerned with raising the level of care throughout the whole hospital and not just the ICU. In the UK, this approach was seen as breaking down the walls of the ICU and encouraging the ICU team to be more involved with deterioration outside of ICU. The UK pioneered ‘critical care outreach’ where nurses with advanced skills would be available to provide immediate assessment and treatment and coordinate the care of deteriorating / critically ill patients outside of the ICU.

Organisational changes like ‘outreach’ are a way of implementing a system-wide approach to critical care

System-wide changes can be low cost and all countries have to interpret EECC according to their own situation i.e. how can each country ensure that a minimum set of actions is available to its population?

Innovation should be aimed at basic provision of care

EECC is the obvious way to organise a hospital as critically ill  patients can be stabilised and treated outside of the ICU – avoiding admission to ICU that can be left to deal with the sickest patients in the hospital

Essential Emergency Critical Care Nursing

Why Nursing?

Florence Nightingale implemented some nursing measures that are the foundation stones of critical care:

• The sickest patients were grouped together usually around the nurses’ station to increase observation
• Nightingale continued triage within the hospital by assessing and prioritising patients
• Select nurses were chosen to look after the sickest patients and they provided a continuation of care
• All patients were undressed and had a head – to -toe assessment by a nurse

Nurses have always had a crucial role in critical care and provide the majority of the workforce. We don’t always have full representation or a ‘seat at the table’.

Nurses have their own patient-care issues and EECCN is important as nurses need to be involved in the EECC process as it becomes further defined and accepted by global organisations.

Nurses are innovative and enterprising in LIC, these initiatives need to be captured and good practices should be highlighted and published in open access resources.

Nurses throughout the world should develop true partnerships and avoid bias towards the global north (developed world). Many partnerships and health links between the GlobalNorth/ South appear to have a colonial-type approach (Gomersall, 2010). Every country must develop its own response to implementing EECC and this must be keeping with the health budget and resources available within each country.

EECC is an understanding and a loose framework that needs to be discussed and developed. It needs research and resources that are realistic and implementable. The lowest common denominator is an important feature of EECC and EECCN. It needs to repeatedly state the case for critical care to be considered in the UHC movement.

References

Baker, T. et al. (2015) ‘Vital Signs directed therapy: Improving care in an intensive care unit in a low-income country’, PLoS ONE. doi: 10.1371/journal.pone.0144801.

Gomersall, C. D. (2010) ‘Critical care in the developing world – a challenge for us all’, Critical Care. doi: 10.1186/cc8871.

Meara, J. G. G. et al. (2015) Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development, The Lancet. Lancet Publishing Group. doi: 10.1016/S0140-6736(15)60160-X.

Schell, C. O. et al. (2018) ‘The global need for essential emergency and critical care’, Critical Care. BioMed Central Ltd. doi: 10.1186/s13054-018-2219-2.

Schell, C. O. et al. (2019) ‘Global critical care: Add essentials to the roadmap’, Annals of Global Health, 85(1), pp. 1–2. doi: 10.5334/aogh.2546.

About Me

BVM continues to prove itself. Safe and effective. Less hypoxaemia and less aspiration.
https://www.nejm.org/doi/full/10.1056/NEJMoa1812405

Freely Accessible Nurse Education education

Freely Accessible Nurse Education critical care

The FANEed and FANEcc acronyms are designated to learning resources and information that can be accessed via limited bandwidth. They are also aimed at nurses (#FANE) and critical care nurses (#FANEcc) who work in Developing Health Systems, especially sub-Saharan Africa and sub-regions within SE Asia. In these regions, the internet is typically accessed by health professionals via a smartphone with limited memory / storage and a restrictive data plan.

YouTube The mobile version of YouTube only receives low-quality videos that are surprisingly easy to download in a low-bandwidth environment. You Tube is avidly used by Registered Nurses in LMIC’s to learn about physical  assessment and advanced practice. When I am doing teaching and training in resource-limited environments, I make a point of finding out which You Tube videos are being downloaded and used to develop the nurses clinical skills. My experience within Uganda and The Gambia is that Registered Nurses invariably discover legitimate sources of information, albeit the videos may contain information about equipment that is not available within the locale.

Facebook Lite An Android app, this version of Facebook is designed to work smoothly with poor data connections and low-end phones. For example the download is under 1MB and typically takes up 3 MB of space on the device. In contrast, the Android app for Facebook can take between 195-200 MB. Facebook lite has various settings that are designed to give a satisfactory experience with smartphones that have a limited amount of RAM andlow CPU power. For example, low-resolution versions of photos are downloaded. These can become higher resolution photos by tapping the low-resolution version. The basic tabs from the full version are all available.

Facebook Messenger Lite The core messaging function is integral and effective, but additional features such as Stickers are scaled down and not fully featured. The video-chat tool usually provides good quality display but uses less battery power and I have found it to work well compared to Skype (Android version).

WhatsApp This ubiquitous software works in locations with low-bandwidth. The chat and video call functions are used extensively by all health professions in countries with well-known low-bandwidth provision.

 To clear secretions in patient’s mouth in a resource-constrained area. I use a 60 ml syringe and a naso-gastric tube of different size, according to the age of the patient. I insert the tube in the patients mouth as far as i can see. I then attach a 60ml sryinge to the tube and was able to withdraw out secretions. This is done periodically to maintain a patent airway for critically ill patients

Alhagie MM Baldeh

The Gambia

 

 

Do you use Twitter?

Look out for #FANE Free Accessible Nurse Education and #FANEcc Free Accessible Nurse Education critical care . Both Twitter hashtags are for nurses who work in resource constrained environments or Developing Health Systems. They will be emphasising resources that are low bandwidths or that have been ammended to reduce the size of the content..

Patients become critically ill before they appear on ICU. Ideally, a pre-hospital life support is available within a local ambulance service. In reality, many deteriorating patients simply arrive at a clinic or hospital and join a queue of people waiting to be seen by a doctor or a nurse.

The SATS system is an effective and evidence-based method of sorting and prioritising adults and children according to the severity of their illness. It provides a way of screening the severity of illness of adults and children as they arrive at a clinic or hospital.

http://emssa.org.za/sats/

The above website contains a large collection of clinical guidelines and learning resources.

The manual is currently under review and a revised version is scheduled for late 2017.

The SATS system has been designed and tested in resource limited environments and the literature and audio-visual guides are full of practical content.

The silent emergency – the critically ill child. What are the oxygen requirements?