Improving the quality of intensive care in middle-income countries
Authors: Amanda Quintairos, Fernando G Zampieri, Jorge IF Salluh
Journal: The Lancet Global Health (2022)

We applaud Luigi Pisani and colleagues (February, 2022)1Pisani L Algera AG Neto AS et al.Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies.Lancet Glob Health. 2022; 10: e227-e235Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar for their excellent study which compares outcomes for mechanically ventilated patients in high-income countries (HICs) and middle-income countries (MICs). The study shows that outcomes differ between health systems and especially with the contexts in which patients are mechanically ventilated. In the past 10 years, studies have analysed intensive care units (ICUs) in resource-poor settings and provided evidence, guidelines, and recommendations. However, few studies have focused on MICs. Several factors specific to MICs affect how ICUs in these countries are designed and managed and the outcomes for patients that are treated within them. Compared with low-income countries, MICs have more ICU beds and more equipment (eg, ventilators, renal replacement therapy, laboratory facilities, and therapeutic and monitoring resources). MICs also have a predominantly urban population, and consequently their case mixes are closer to those of HICs in terms of diagnosis, age, and comorbidities.2Epimed SolutionsThe Brazilian ICUs project.http://www.utisbrasileiras.com.br/en/covid-19/benchmarking-covid-19/Date accessed: December 20, 2021Google Scholar Some of the diagnoses that are often cited in the context of MICs—such as dengue, yellow fever, and leptospirosis among others—constitute a very low proportion of ICU admissions. In addition, the availability of more ICU beds poses challenges for MICs, especially in terms of staffing and process of care. We have shown that better staffing patterns (more nurses with autonomy, a higher number of intensivists, and the presence of a pharmacist) are associated with reduced mortality and reduced duration of mechanical ventilation.3Zampieri FG Salluh JIF Azevedo LCP et al.ICU staffing feature phenotypes and their relationship with patients' outcomes: an unsupervised machine learning analysis.Intensive Care Med. 2019; 45: 1599-1607Crossref PubMed Scopus (21) Google Scholar In addition, ICUs that more widely implement protocols to prevent ICU-acquired complications are associated with better outcomes.4Soares M Bozza FA Angus DC et al.Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study.Intensive Care Med. 2015; 41: 2149-2160Crossref PubMed Scopus (86) Google Scholar Notably, Pisani and colleagues1Pisani L Algera AG Neto AS et al.Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies.Lancet Glob Health. 2022; 10: e227-e235Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar showed that protective ventilation rates are similar for both HICs and MICs. However, caring for a ventilated patient is a complex task that encompasses not only avoiding ventilator-induced lung injury but also coordinating sedation, weaning, and prevention of ICU-acquired infection, among other interventions. We analysed data from a cluster-randomised trial that included nearly 7000 patients in 118 ICUs in Brazil, and observed that evidence-based practices and organisational characteristics related to better ICU performance, and that better staffing patterns are associated with increased adherence to the implementation of these practices.5Bastos LSL Hamacher S Zampieri FG Cavalcanti AB Salluh JIF Bozza FA Structure and process associated with the efficiency of intensive care units in low-resource settings: an analysis of the CHECKLIST-ICU trial database.J Crit Care. 2020; 59: 118-123Crossref PubMed Scopus (4) Google Scholar We believe that multiple strategies should be implemented simultaneously to improve outcomes for mechanically ventilated patients in MICs (figure). These strategies would improve timely access to an ICU bed for patients who are critically ill, while promoting better triage that avoids treating patients in an ICU if they will not benefit from it. The ICU should manage patients according to a specified protocol, avoiding variation in the delivery of care and reducing ICU-acquired complications (eg, oversedation, ventilator-associated pneumonia, and prolonged mechanical ventilation). Quality-improvement studies conducted in MICs should consider the factors that affect ICUs in these countries—eg, delayed access to critical care, number of ICU beds, processes of care, staffing patterns, and heterogeneity in health systems—to ensure better design of interventions and the expected effects on patient outcomes. JIFS is supported in part by individual research grants from the Brazilian National Council for Scientific and Technological Development and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro. We declare no competing interests. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studiesDespite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Full-Text PDF Open Access