Implementing Vital Signs Directed Therapy in Intensive Care Muhimbili National Hospital, Dar es Salaam, Tanzania, February-May 2014

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1 Project Report Implementing Vital Signs Directed Therapy in Intensive Care Muhimbili National Hospital, Dar es Salaam, Tanzania, February-May 2014 Background Critical Care Critical Care can be defined as all care given in hospital to patients with serious and reversible disease. Highincome countries such as Sweden can afford resource-intensive and sophisticated critical care on dedicated Intensive Care Units (ICUs). This is not possible in countries with much lower healthcare spending and yet in such settings there is a great need for critical care. Indeed, the burden of critical illness is especially high in lowincome countries, with over 90% of maternal deaths, child deaths, deaths from sepsis and deaths from trauma occurring in such settings. While the lack of health workers, drugs and equipment in low-income countries forms a barrier to the provision of critical care, a recent survey we conducted in Tanzania suggests the main problems lie elsewhere. There is a striking lack of training for health workers in critical care and the routines for managing critically ill patients are scarce or non-existent. Processes for prioritising and caring for critically unwell patients are not used. The optimal ways of conducting Critical care when resources are limited has, as yet, not been investigated. Vital Signs A patient s vital signs (heart rate, respiratory rate, blood pressure, conscious level, oxygen saturation) are commonly used as markers of illness severity. Deranged vital signs have been shown to correlate with negative outcomes such as cardiac arrest and death. Vital Signs are used in ICUs in high income countries as triggers for modifying treatments and as goals for patient responses. Such goal directed therapy has been shown to reduce mortality rates, and shorten hospital stay in critically ill patients. Goal directed therapy has never been studied in a low-income setting. Tanzania Tanzania is a politically stable, low-income country in East Africa. With a population of 44 million, Tanzania is ranked 152 out of 187 countries in the Human Development Index. (See Table 1)

2 Table 1: Sweden and Tanzania Sweden Tanzania Population size 9 million 44 million No of doctors 34, No of nurses 108,000 9,400 No of Specialists in Anaesthesia & Critical Care 2, Life expectancy (years) Maternal mortality (per 100,000) Newborn mortality (per 1000) 2 26 Human Development Index Ranking Data sources: WHO Statistics 2012; UNDP Muhimbili Muhimbili National Hospital is a specialist referral hospital in Dar es Salaam. Although almost the same size as Karolinska University Hospital in Stockholm, it has far fewer resources (see Table 2). Muhimbili has a sixbedded ICU receiving critically ill patients from the emergency department, the wards and the operating theatres. Care on the unit involves regular observations by the nursing staff, and subjective judgements of when to call a doctor and when to change management. Table 2: Karolinska and Muhimbili Karolinska Muhimbili Number of beds Number of ICU beds 35 6 No of Specialists in Anaesthesia & Critical Care No of ICU nurses No of Anaesthetic Nurses Maternal mortality per 100, Newborn mortality per Data sources: personal communication MKAIC and Life Support Foundation In 2008 Muhimbili approached Karolinska and requested assistance to build capacity in Anaesthesia & Intensive Care. A partnership was started, the Muhimbili-Karolinska Anaesthesia & Intensive Care Collaboration (MKAIC) which aims to be long-term and sustainable. In 2013 MKAIC was incorporated into the Life Support Foundation.

3 What MKAIC and Life Support Foundation have done so far 2008: Muhimbili asks Karolinska for help, Needs assessment, MKAIC steering committees set up : Quality audits and research projects at Muhimbili and nationally in Tanzania reveal the huge need for improved routines and training in Critical Care and Anaesthesia : Seven training courses at Muhimbili. Knowledge levels improved by 30% : Ten exchanges of staff between Muhimbili and Karolinska : Delivery of 50 pulse oximeters and other medical equipment to Muhimbili and hospitals in Dar es Salaam 2013: Life Support Foundation set up. Start of VSDT project. VSDT As part of MKAIC and Life Support, a group of doctors and nurses at Muhimbili and Karolinska developed a new working routine for the ICU at Muhimbili. Called Vital Signs Directed Therapy (VSDT) it is based on a simplified assessment and treatment protocol employing appropriate indicators and treatments (See Appendix A). For each vital sign VSDT defines the triggers for intervention and directs appropriate actions, thereby task-shifting some of the emergency care from physicians to nurses. This report describes the implementation process in February-May 2014 when the VSDT protocol was introduced to the ICU at Muhimbili. Research studies are undergoing to evaluate the effect of this intervention on mortality rates of the critically ill patients.

4 Aim of the VSDT implementation To introduce the VSDT on to the ICU at Muhimbili so that it is correctly used for all adult patients Objectives By the end of the implementation we aim to: 1. Have secured approval for the VSDT protocol from the hospital authorities 2. Have trained all the nurses and doctors in the rationale behind VSDT and in the use of the protocol 3. Have informed other staff in the hospital about the VSDT protocol 4. Have introduced the VSDT protocol onto the ICU, so that every adult patient has a copy of the protocol attached to their observation chart everyday 5. Have introduced job aids into the ICU Method Planning During 2013 the implementation was planned. Ethical clearance for the research was secured, the final protocol was designed using a collaborative approach, and the schedule was prepared. Data was collected for all the patients admitted to the ICU before the implementation period. The implementation team from Sweden were Dr Tim Baker (International Principal Investigator), Dr Jonas Blixt, Dr Otto Schell, Dr Markus Castegren, RN Ulrica Mickelsson, RN Lotta Förars and RN Charlotte Linde. The team in Tanzania were Dr Edwin Lugazia (Local Principal Investigator), Dr Moses Mulungu, Mrs Agness Laizer, Mr Erasto Kalinga, Mrs Nazahed Richards and Ms Elizabeth Stephens. Finances Funding was required for travel costs of the Swedish Team, for training expenses, and for expenses for the Tanzanian Research Assistants. (See Table 3) Item Cost per item GBP Travel 7600 Accommodation 4600 Job aids 700 Training course costs (books, stationary, food, drink) 500 Research Assistants Expenses 700 Information Dissemination 200 Total 14,300 Table 3: Implementation Costs

5 The implementation was made possible by generous donations by the Laerdal Foundation, the Association of Anaesthetists of Great Britain and Ireland, the Swedish Society for Medical Research, the Einhorn Family Foundation, Mrs Birgitta Ericsson and Karolinska Institutet Travel Grant. Karolinska donated 50 USB-memory sticks and Muhimbili supplied teaching facilities and refreshments during the training. Timeplan Implementation began in Week with training of the local facilitators. In weeks all the ICU nurses and doctors were trained, the protocol and job aids were introduced. A supervision visit was conducted in week 20. During the implementation period there was close contact between the research team and the ICU staff. (see Figure 1) Securing hospital support and permission Training of local facilitators Training of ICU nurses & doctors Introduction of protocol Bedside teaching Introduction of job aids Information to hospital doctors Daily contact, supervision & feedback Supervision visit Figure1: Implementation timeplan 2014 week Securing hospital support The Executive Head of Muhimbili, the Director of Surgical Services, the Head of Department of Anaesthesia & Intensive Care and the Head Nurse on ICU were all approached and gave their support for the VSDT project. A new Standard Operating Procedure for the ICU was officially introduced to the ICU. (See Appendix B)

6 Training Training was conducted for three nurses and six doctors in Week 11. (See Appendix C) In Week 13 & 14 thirty-six nurses and doctors on the ICU were trained (See Appendix C and D) Introduction of the protocol The protocol was introduced at the start of week 13 so that the nurses could modify the care of every adult patient on the ICU depending on the vital signs. (See Appendix A)

7 Bedside teaching Throughout weeks 13 & 14 and again in week 20 bedside teaching reinforced the formal training and increased the nurses and doctors confidence in using the protocol. Job aids Posters were put up on the walls of ICU and information booklets were distributed. Information Presentations were held to doctors in other departments in the hospital and at MUHAS University so that everyone was aware of the change to routines on the ICU.

8 Results The five implementation objectives were achieved. 1. Approval for the VSDT protocol has been secured from the hospital authorities 2. All the nurses and doctors have been trained in the rationale behind VSDT and in the use of the protocol 3. Other staff in the hospital have been informed about the VSDT protocol 4. The VSDT protocol has been introduced onto the ICU, every adult patient has a copy of the protocol attached to their observation chart everyday 5. Job aids have been introduced onto the ICU Next steps for VSDT Collection of the after-implementation data (approx 1 year) Analysis of the intervention research has our implementation reduced mortality rates? Dissemination of these results to stakeholders in Tanzania, to the International research community in peer-reviewed journals and to funders Sustainability research are the effects sustained on the ICU over the following 2-3 years? If positive results implementation to other hospitals in Tanzania and other low-income countries Continue MKAIC and Life Support Foundation s other activities aiming at improving the quality of critical care and anaesthesia and saving lives in Tanzania and other low-income countries Report written by Dr Tim Baker, Principal Investigator, May tim@lifesupportfoundation.org

9 Appendix A VSDT Protocol

10 Appendix B SOP

11 Appendix C Training Timetable 8:00 Welcome. Pre-course test 9:30 Chai 9:30 What is good intensive care? Lecture 9:45 Background to MKAIC & VSDT Lecture 10:00 The VSDT concept Lecture 10:20 VSDT - A Lecture 10:30 VSDT - B Lecture 10:40 VSDT - C Lecture 10:50 Cases individual & with charts Discussion 11:50 Difficult cases Discussion 12:30 Barriers to adopting VSDT Discussion 13:00 Lunch 13:30 Summing up. Questions. Feedback Discussion 13:40 Post-course test 14:00 Finish

12 Appendix D List of staff trained Name Cadre 1 Paul Masua Doctor 2 Nazahed Richard Nurse 3 Erasto Kalinga Nurse 4 Faustina Mbuya Doctor 5 Sunil Laxman Doctor 6 Rita Doctor 7 Lugazia Doctor 8 Tiku Doctor 9 Agness Nurse 10 Jane Mwakitosi Nurse 11 Happiness Damas Mdangu Nurse 12 Mtage Kabweta Nurse 13 Happyness Laizer Nurse 14 Edwin Damas Nurse 15 Agnes Mhando Nurse 16 Debora Mwanja nurse 17 Festo Komba Nurse 18 Joel Simbeye Nurse 19 Dotto Ally Nurse 20 Joyce William Nurse 21 Florence Chizazi Nurse 22 Salome Maghembe Nurse 23 Hilda Kwezi Nurse 24 Nicholas Gervas Nurse 25 Eva Nzigilwa Nurse 26 Agnes Kaberege Nurse 27 Namghama Said Nurse 28 Herieth Rugemalira Nurse 29 Hadija Magogo Nurse 30 Richard Nurse 31 Rehema Nyandoro Nurse 32 Elizabeth Stephen Nurse 33 Elizabeth Fidelis Nurse 34 David Misiwa Nurse 35 Kalumelina Asenga Nurse 36 Aida Adamson Nurse