Surviving Sepsis in Uganda:   a Role for Patient Attendants in Task Shifting Shevin T Jacob, MD, MPH University of Washing...
Sepsis pathophysiology RS Hotchkiss,  et al .  NEJM  2003; 348:138-150.
RP Wenzel.  NEJM 2002; 347 (13): 966-967
Mortality and DALYs Lost in 2002, Adults 15-60 Yrs Old AC Cheng, et al.  PLoS Medicine ; 2008; 5(8):  1173-1179.
Sepsis management  <ul><li>Early Goal Directed Therapy </li></ul><ul><ul><li>Monitoring of parameters like central venous ...
PRISM-U :  P romoting  R esource-Limited  I nterventions for  S epsis  M anagement in  U ganda <ul><li>Co-Investigators: <...
PRISM-U, Part 1 <ul><li>Prospective observational study investigating the management and outcomes of patients admitted to ...
Study details <ul><li>Time frame: July 2006 to November 2006 </li></ul><ul><li>2 sites </li></ul><ul><ul><li>Mulago Hospit...
Methods:  Data collection <ul><li>Fulfillment of inclusion criteria assessed at A&E </li></ul><ul><li>Vital signs (temp, H...
Results:  Patient characteristics <ul><li>N : 385 eligible,  382  enrolled </li></ul><ul><ul><li>250  patients from Mulago...
Results:  Outcomes <ul><li>Mortality (in-hospital + post-discharge):  </li></ul><ul><ul><li>43.0%  (n=337) </li></ul></ul>...
Results:  Intravenous Fluid Resuscitation <ul><li>Recommended initial administration of fluid:  </li></ul><ul><ul><li>20 c...
Intravenous Fluid Resuscitation, cont IV fluid volume received within first 6 hours <ul><li>Mean volume of fluid (6 hours)...
PRISM-U1:  Summary points <ul><li>Admission for sepsis syndromes in Uganda is associated with  late stage HIV infection  a...
 
 
The next step… <ul><li>Major constraints to providing optimal sepsis care: </li></ul><ul><ul><li>Lack of skilled health wo...
PRISM-U, Part 2: Improving Management, Investigating Pathogenesis <ul><li>Management </li></ul><ul><li>When compared to hi...
PRISM-U2 Methodology: Enrollment criteria <ul><li>Inclusion </li></ul><ul><ul><li>Patients triaged to the Medical Casualty...
PRISM-U2 Methodology: Role of attendants <ul><li>Attendants trained by a study team member to identify empty IV fluid bott...
Interim analysis  (n=134 patients) Historic Control Group: Mortality 40% (s.e.=0.4) Fluid Intervention Group: Mortality 27...
The way forward... opportunities and challenges <ul><li>Advocate for hiring 1 additional “critical care” health worker for...
Acknowledgments <ul><li>PRISM-U Study Team </li></ul><ul><ul><li>Mulago Hospital </li></ul></ul><ul><ul><li>Masaka Hospita...
 
PRISM-U1, Mulago
PRISM-U2, Mulago
PRISM-U1, Masaka
PRISM-U2, Masaka
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GH Workforce Taskshifting: Shevin Jacob

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This session focuses on considerations and challenges in meeting the health care needs of a growing global population. Attention will be placed on task shifting – the delegation of health interventions to less specialized health workers.

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  • GH Workforce Taskshifting: Shevin Jacob

    1. 1. Surviving Sepsis in Uganda: a Role for Patient Attendants in Task Shifting Shevin T Jacob, MD, MPH University of Washington [email_address] 18th Annual GHEC/ 7 th Annual WRIH Conference 4 April 2009
    2. 2. Sepsis pathophysiology RS Hotchkiss, et al . NEJM 2003; 348:138-150.
    3. 3. RP Wenzel. NEJM 2002; 347 (13): 966-967
    4. 4. Mortality and DALYs Lost in 2002, Adults 15-60 Yrs Old AC Cheng, et al. PLoS Medicine ; 2008; 5(8): 1173-1179.
    5. 5. Sepsis management <ul><li>Early Goal Directed Therapy </li></ul><ul><ul><li>Monitoring of parameters like central venous pressure and oxygen and Hct resulted in increased volume resuscitation , RBC transfusion, inotrope usage </li></ul></ul><ul><ul><li>Significant decrease in mortality in EGDT arm compared to standard therapy arm </li></ul></ul><ul><ul><li>Limited applicability to resource-constrained countries because of lack of monitoring technology and cardiovascular support medications </li></ul></ul><ul><li>Sepsis in sub-Saharan Africa </li></ul><ul><ul><li>IMAI and ETAT (pediatric) guidelines address the triage aspect of management </li></ul></ul><ul><ul><li>No prospective studies on the management and outcome of severely septic patients </li></ul></ul><ul><li>Further studies are needed to evaluate feasible strategies for sepsis management in resource-constrained settings </li></ul>E Rivers, et al. NEJM 2001; 345(19): 1368-1377. Cheng, et al. PLoS Medicine 2008; 5(8):1173-1179.
    6. 6. PRISM-U : P romoting R esource-Limited I nterventions for S epsis M anagement in U ganda <ul><li>Co-Investigators: </li></ul><ul><li>Shevin T Jacob (UW) </li></ul><ul><li>Patrick Banura (Masaka Hospital) </li></ul><ul><li>Christopher C Moore (UVA) </li></ul><ul><li>David Meya (IDI) </li></ul><ul><li>Steven J Reynolds (RHSP/NIH) </li></ul><ul><li>Pius Opendi (RHSP) </li></ul><ul><li>Relana Pinkerton (UVA) </li></ul><ul><li>Principal Investigators: </li></ul><ul><li>Nathan Kenya-Mugisha (Uganda MOH) </li></ul><ul><li>Harriet Mayanja-Kizza (Makerere) </li></ul><ul><li>W Michael Scheld (UVA) </li></ul>
    7. 7. PRISM-U, Part 1 <ul><li>Prospective observational study investigating the management and outcomes of patients admitted to medical wards with severe sepsis </li></ul>
    8. 8. Study details <ul><li>Time frame: July 2006 to November 2006 </li></ul><ul><li>2 sites </li></ul><ul><ul><li>Mulago Hospital </li></ul></ul><ul><ul><li>Masaka Regional Referral Hospital </li></ul></ul><ul><li>Inclusion </li></ul><ul><ul><li>Suspected infection </li></ul></ul><ul><ul><li>2 of the following: </li></ul></ul><ul><ul><ul><li>Body temperature >37.5°C or <35.5°C </li></ul></ul></ul><ul><ul><ul><li>Heart rate >90 beats/min </li></ul></ul></ul><ul><ul><ul><li>Respiratory rate >20 breaths/min </li></ul></ul></ul><ul><ul><li>Systolic Blood Pressure ≤ 100 mmHg </li></ul></ul><ul><li>Exclusion </li></ul><ul><ul><li>Age <18yo </li></ul></ul><ul><ul><li>Acute cerebrovascular event </li></ul></ul><ul><ul><li>GI bleed </li></ul></ul><ul><ul><li>Need for triage to surgery or OB/GYN ward </li></ul></ul>
    9. 9. Methods: Data collection <ul><li>Fulfillment of inclusion criteria assessed at A&E </li></ul><ul><li>Vital signs (temp, HR, RR, BP)—enrollment and 6 and 24 hours afterwards </li></ul><ul><li>Patients followed from emergency ward to medical wards at both sites until discharge or death </li></ul><ul><li>Recorded in the first 6 and 24 hrs: </li></ul><ul><ul><li>Amount of IV fluid resuscitation provided </li></ul></ul><ul><ul><li>Type of empiric antimicrobial agents administered </li></ul></ul><ul><li>Laboratory and culture results provided to primary medical team to assist in care of patients </li></ul><ul><li>Outcomes measured: </li></ul><ul><ul><li>Length of hospitalization </li></ul></ul><ul><ul><li>In-hospital mortality </li></ul></ul><ul><ul><li>30-day mortality </li></ul></ul>
    10. 10. Results: Patient characteristics <ul><li>N : 385 eligible, 382 enrolled </li></ul><ul><ul><li>250 patients from Mulago Hospital </li></ul></ul><ul><ul><li>132 patients from Masaka Hospital </li></ul></ul><ul><li>Sex : 59.2% female </li></ul><ul><li>Age : mean, 34 yo (range 18 to 80) </li></ul><ul><li>HIV : </li></ul><ul><ul><li>Seropositive: 84.9% (320/377) </li></ul></ul><ul><ul><li>CD4: median, 52 (range 1-999) </li></ul></ul><ul><ul><li>On HAART: 11.9% (38/320) </li></ul></ul><ul><ul><li>Unaware of serostatus: 32.5% (104/320) </li></ul></ul>
    11. 11. Results: Outcomes <ul><li>Mortality (in-hospital + post-discharge): </li></ul><ul><ul><li>43.0% (n=337) </li></ul></ul><ul><li>Median length of stay (days): </li></ul><ul><ul><li>6 (range, 1-55) </li></ul></ul><ul><li>Lost to follow-up (post-discharge): </li></ul><ul><ul><li>14.8% (43/290) </li></ul></ul>
    12. 12. Results: Intravenous Fluid Resuscitation <ul><li>Recommended initial administration of fluid: </li></ul><ul><ul><li>20 cc/kg as a fluid challenge </li></ul></ul><ul><ul><li>Subsequent fluid challenges every 30 min to 1 hour for refractory hypotension (within the first 6 hours) </li></ul></ul><ul><li>Timing of fluid administration: </li></ul><ul><ul><li>53% received at least some IV crystalloid within the first hour of presentation </li></ul></ul><ul><ul><li>28% waited between 1 to 6 hours for fluid </li></ul></ul><ul><ul><li>14% of patients received no fluid within the first 6 hours of presentation </li></ul></ul>SurvivingSepsisCampaign. http://www.survivingsepsis.org/bundles/individual_changes/treat_hypotension .
    13. 13. Intravenous Fluid Resuscitation, cont IV fluid volume received within first 6 hours <ul><li>Mean volume of fluid (6 hours) : 671 cc </li></ul><ul><li>Mean volume of fluid (24 hours): 1075 cc </li></ul>
    14. 14. PRISM-U1: Summary points <ul><li>Admission for sepsis syndromes in Uganda is associated with late stage HIV infection and high mortality </li></ul><ul><li>Bacteremia-associated in-hospital mortality in Mulago Hospital has not improved in the last 10 years (28%  33%) </li></ul><ul><li>Fluid resuscitation is inadequate </li></ul><ul><li>Future studies are needed to evaluate approaches to managing critically ill patients in resource constrained settings </li></ul>
    15. 17. The next step… <ul><li>Major constraints to providing optimal sepsis care: </li></ul><ul><ul><li>Lack of skilled health workers —on a 50-bed ward where the number of patients can approach 100, the nurse to patient ratio was less than 1:20 </li></ul></ul><ul><ul><li>Insufficient fluid supplies —the volume of intravenous fluids provided to the ward/day was limited to 20 L </li></ul></ul><ul><li>In Uganda, family members accompany patients for the duration of their hospital stay </li></ul><ul><ul><li>Provide limited assistance for daily patient needs such as feeding, bathing and toileting </li></ul></ul><ul><ul><li>91.6% patients in PRISM-U1 accompanied by an attendant </li></ul></ul><ul><li>Patient attendants may be an untapped resource for contributing to patient care in busy Ugandan hospitals </li></ul>
    16. 18. PRISM-U, Part 2: Improving Management, Investigating Pathogenesis <ul><li>Management </li></ul><ul><li>When compared to historic controls, </li></ul><ul><ul><li>Patients receiving aggressive fluid resuscitation will have improved survival </li></ul></ul><ul><ul><li>Utilization of patient attendants as an alert mechanism for IV fluid provision will provide a model for improving sepsis management </li></ul></ul>
    17. 19. PRISM-U2 Methodology: Enrollment criteria <ul><li>Inclusion </li></ul><ul><ul><li>Patients triaged to the Medical Casualty Units of Mulago Hospital and Masaka Regional Referral Hospital with: </li></ul></ul><ul><ul><ul><li>Suspected underlying infection </li></ul></ul></ul><ul><ul><ul><li>2 of the following: </li></ul></ul></ul><ul><ul><ul><ul><li>Tachycardia > 90 beats per minute </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tachypnea > 20 bpm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thermodysregulation (body temperature < 35.5° or > 37.5° C) </li></ul></ul></ul></ul><ul><ul><ul><li>Systolic Blood Pressure ≤ 100 mm Hg </li></ul></ul></ul><ul><ul><ul><li>Accompanied by an attendant </li></ul></ul></ul><ul><li>Exclusion </li></ul><ul><ul><li>Patients presenting to the Accident and Emergency unit of Mulago Hospital or Masaka Regional Referral Hospital with: </li></ul></ul><ul><ul><ul><li>< 18 years of age </li></ul></ul></ul><ul><ul><ul><li>History of fluid overload-associated disease (i.e., congestive heart failure, hepatic failure, nephrotic syndrome) </li></ul></ul></ul><ul><ul><ul><li>Signs of fluid overload on physical exam </li></ul></ul></ul><ul><ul><ul><li>Acute cerebrovascular event </li></ul></ul></ul><ul><ul><ul><li>Gastrointestinal bleed </li></ul></ul></ul><ul><ul><ul><li>Need for triage to the Surgical Casualty Unit or Obstetrics and Gynecology Unit </li></ul></ul></ul>
    18. 20. PRISM-U2 Methodology: Role of attendants <ul><li>Attendants trained by a study team member to identify empty IV fluid bottles </li></ul><ul><li>Once resuscitation begins, attendant alerts the study team medical officer (STMO) when fluid bottles need changing </li></ul><ul><li>Sufficient bottles of normal saline provided for appropriate early fluid resuscitation within the first 6 hours of presentation </li></ul><ul><li>Role of ward STMO: </li></ul><ul><ul><li>To assist attendants who need help with their patient </li></ul></ul><ul><ul><li>To assess whether fluid bottles are empty every 30 minutes </li></ul></ul><ul><ul><li>If bottle empty and STMO not alerted by attendant, STMO will replace fluid bottle and document reason why attendant did not alert him/her </li></ul></ul><ul><ul><li>To monitor vital signs every hour (i.e., RR, O2 sats, BP) for the first 6 hours of hospital admission </li></ul></ul>
    19. 21. Interim analysis (n=134 patients) Historic Control Group: Mortality 40% (s.e.=0.4) Fluid Intervention Group: Mortality 27% (s.e.=0.7)
    20. 22. The way forward... opportunities and challenges <ul><li>Advocate for hiring 1 additional “critical care” health worker for busy Ugandan hospital wards </li></ul><ul><ul><li>Health worker will work with attendants to provide fluid resuscitation and monitor “critically ill” patients </li></ul></ul><ul><ul><li>Model can span management of critical illness across disciplines (e.g., trauma, obstetrics, DKA) </li></ul></ul><ul><li>Research-based evidence m otivates MOH to prioritize programs that improve health outcomes by: </li></ul><ul><ul><li>Decreasing the health worker gap </li></ul></ul><ul><ul><li>Increasing resources in places where they are needed </li></ul></ul>
    21. 23. Acknowledgments <ul><li>PRISM-U Study Team </li></ul><ul><ul><li>Mulago Hospital </li></ul></ul><ul><ul><li>Masaka Hospital </li></ul></ul><ul><li>Dr. Jackie Mabweijano (head of casualty, Mulago) </li></ul><ul><li>Nurses and Red Cross workers of the Mulago and Masaka Casualty Departments </li></ul><ul><li>Rakai Health Sciences Project (Kalisizo), Ebenezer Labs (Kampala), AID Child (Masaka), and Uganda Cares (Masaka) for laboratory support </li></ul><ul><li>Infectious Diseases Institute (Kampala) </li></ul><ul><li>UVA Center for Global Health—Pfizer Initiative for International Health </li></ul>
    22. 25. PRISM-U1, Mulago
    23. 26. PRISM-U2, Mulago
    24. 27. PRISM-U1, Masaka
    25. 28. PRISM-U2, Masaka
    26. 29. Thank you

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