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20% of COVID-19 patients become critically ill with hypoxia or respiratory failure (figure).1 Critical illness, describing any acute life-threatening condition, is receiving increased attention in global health because of its large disease burden and population impact.2 Before the COVID-19 pandemic, growing evidence suggested that the care of critical illness was overlooked in LRS—hospitals cannot, or do not, prioritise emergency and critical care.3 Most critically ill patients are cared for in emergency units and general wards and do not have access to advanced care in intensive care units (ICUs). [...]provision of essential care could prevent progression to multi-organ failure, reducing the burden on limited ICU capacity. DFM also reports personal fees from consultancy about acute respiratory disease for GlaxoSmithKline, Boehringer Ingelheim, and Bayer, unrelated to this Correspondence; in addition, DFM's institution has received funds from grants from the UK NIHR, Wellcome Trust, Innovate UK, and others, he has a patent issued to his institution for a treatment for acute respiratory distress syndrome, and he is Director of Research for the Intensive Care Society and NIHR Efficacy and Mechanism Evaluation Programme Director.

Critical illness results in millions of deaths each year. Care for those with critical illness is often neglected due to a lack of prioritisation, co-ordination, and coverage of timely identification and basic life-saving treatments. To improve care, we propose a new focus on essential emergency and critical care (EECC)—care that all critically ill patients should receive in all hospitals in the world. Essential emergency and critical care should be part of universal health coverage, is appropriate for all countries in the world, and is intended for patients irrespective of age, gender, underlying diagnosis, medical specialty, or location in the hospital. Essential emergency and critical care is pragmatic and low-cost and has the potential to improve care and substantially reduce preventable mortality.

ObjectiveAs ‘critical illness’ and ‘critical care’ lack consensus definitions, this study aimed to explore how the concepts’ are used, describe their defining attributes, and propose potential definitions.Design and methodsWe used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O’Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts’ defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents.ResultsNine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, ‘a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility’, and of critical care as, ‘the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.’ConclusionThe concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.

Critical illness is common throughout the world and has been the focus of a dramatic increase in attention during the COVID-19 pandemic. Severely deranged vital signs such as hypoxia, hypotension and low conscious level can identify critical illness. These vital signs are simple to check and treatments that aim to correct derangements are established, basic and low-cost. The aim of the study was to estimate the unmet need of such essential treatments for severely deranged vital signs in all adults admitted to hospitals in Malawi. We conducted a point prevalence cross-sectional study of adult hospitalized patients in Malawi. All in-patients aged [greater than or equal to]18 on single days Queen Elizabeth Central Hospital (QECH) and Chiradzulu District Hospital (CDH) were screened. Patients with hypoxia (oxygen saturation <90%), hypotension (systolic blood pressure <90mmHg) and reduced conscious level (Glasgow Coma Scale <9) were included in the study. The a-priori defined essential treatments were oxygen therapy for hypoxia, intravenous fluid for hypotension and an action to protect the airway for reduced consciousness (placing the patient in the lateral position, insertion of an oro-pharyngeal airway or endo-tracheal tube or manual airway protection). Of the 1135 hospital in-patients screened, 45 (4.0%) had hypoxia, 103 (9.1%) had hypotension, and 17 (1.5%) had a reduced conscious level. Of those with hypoxia, 40 were not receiving oxygen (88.9%). Of those with hypotension, 94 were not receiving intravenous fluids (91.3%). Of those with a reduced conscious level, nine were not receiving an action to protect the airway (53.0%). There was a large unmet need of essential treatments for critical illness in two hospitals in Malawi.

Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and a potential for reversibility.1 Surprisingly little is known about the incidence and prevalence of critical illness. Previous attempts to estimate the burden of critical illness have suffered from important methodological limitations when only including patients in Intensive Care Units (ICUs), with specific diagnoses or using extensive extrapolations.2 Important resource decisions such as the number of ICU- beds, High Dependency Unit beds and staffing levels are made without this knowledge. This study aimed to determine the prevalence and outcomes of critical illness throughout hospitals in contrasting settings in Malawi and Sweden. A prospective cohort study in six district and referral hospitals in Malawi and Sweden. On specified single days, all hospitalized adults were examined in a point prevalence assessment. Patients with one or more severely deranged vital sign (respiratory rate < 8 or ≥30/min; oxygen saturation < 90%, systolic blood pressure < 90 mmHg, heart rate < 40 or ≥130/min or Glasgow Coma Scale <9)) were classified as critically ill. Information on diagnosis and treatment limitations were extracted from medical records. The patients were followed-up to discharge or death, censored at 30 days. Primary outcomes were the hospital prevalence of critical illness and the mortality rate and risk of death for critically ill patients using logistic regression. In Sweden 133 of 1269 in-patients were critically ill (10.5%), with a median age of 76 years (IQR 69–87). In-hospital mortality for the critically ill was 29.3%, compared to 7.4% for stable patients (OR 5.2 [95% CI 3.4–8.2]). In Malawi 207 of 1135 patients were critically ill (18.2%), with a median age of 35 years (IQR 26–49). In-hospital mortality for the critically ill was 20.7%, compared to 4.6% for stable patients (OR 5.4 [95% CI 3.4–8.5]). Critical illness is common among hospitalized patients in Malawi and Sweden, markedly outnumbering ICU and HDU capacity in both settings. Critically ill patients have a high mortality rate and a significantly higher risk of dying in hospital compared to stable patients. This suggests a hidden burden of critical illness of potential public health, health system and hospital management significance. 1. Kayambankadzanja et al. BMJ Open 2022; 12(9): e060972. 2. Murthy S, Wunsch H. Crit Care 2012; 16(2): 218.

Background The burden of critical illness is a global issue. Healthcare systems often fail to provide essential emergency and critical care for deteriorating patients, and the optimal strategy for ensuring safe care is not fully known. This study aimed to explore the capability to identify and manage critical conditions and to evaluate how an interprofessional training intervention that included theory as well as high-fidelity simulation (proACT) in the short and long term affected the capability. Methods A questionnaire study was performed. A cross-sectional survey of all in-hospital nurses and physicians in a Swedish region (n538) and a longitudinal cohort of participants entering the proACT course during a six-month period (n99) were included. Descriptive and comparative statistics were generated. Additionally, qualitative content analysis was performed for free text answers. Results The findings demonstrated that the intervention improved the individual healthcare professionals’ competence with a sustained effect over time. The coverage of proACT trained staff increased from 13.2% to 26.5%, but no correlation was observed with workplace conditions that support safe care. Collaboration and workplace climate were perceived to be mainly positive, but for safer care, an overall need for improved competence and staffing was emphasized. Conclusions The present study confirms previously identified issues and the need for improvements in the care of critically ill patients in general hospital wards. It supports the notion that a training intervention, such as proACT, can increase the capability to identify and manage patients with critical conditions. All healthcare professions increased the competence. Hence, more effort is needed to enable staff of all professions to participate in such training. Studies of interventions cover higher number of trained staff in the setting are warranted to clarify whether the training can also improve workplace conditions that support safe care of deteriorating and critically ill patients.

Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and potential for reversibility(1). The burden of critical illness is high especially in low- and middle-income countries. Critical care can be provided as Essential Emergency and Critical Care (EECC) – the effective, low-cost, feasible, basic care that should be provided to all critically ill patients in all parts of all hospitals in the world(2) – and as advanced critical care that includes the more complex, resource-intensive care usually provided in an intensive care unit. Resources for the provision of care may be available in the hospital and yet not be ready in the wards for immediate use for critically ill patients. The ward readiness of these resources, although harder to evaluate, is likely to be more important than their availability at the hospital level. This study aimed to assess the ward readiness for EECC and the hospital availability of resources for EECC and for advanced critical care in hospitals in Tanzania. An in-depth, cross-sectional study was conducted in five purposively selected hospitals. Visits were made to all wards in the hospitals to collect data about all the 66 EECC and 161 advanced critical care resources as defined in previous studies. We defined hospital-availability as a resource that is present in the hospital and ward-readiness as a resource that is available, is functioning, and is present in the right place in sufficient amounts at the right time for its use for the care of critically ill patients in wards. Data were analyzed to calculate availability and readiness scores as proportions of the resources that were available at hospital level, and ready at ward level respectively. The availability of EECC resources in hospitals was 84% and the readiness for use in the wards was 56% (Fig. 1). Availability of advanced critical care resources was 31%. Hospitals in Tanzania lack readiness for the provision of EECC – the low-cost, life-saving care for critically ill patients. The resources for EECC were available in hospitals, but they were not ready for the immediate needs of critically ill patients in the wards. In order to provide effective EECC to all patients, improvements are needed around the essential, low-cost resources in hospital wards that are essential for decreasing preventable deaths.

Oxygen is a low-cost and life-saving therapy for patients with COVID-19. Yet, it is a limited resource in many hospitals in low income countries and in the 2020 pandemic even hospitals in richer countries reported oxygen shortages. An accurate understanding of oxygen requirements is needed for capacity planning. The World Health Organization estimates the average flow-rate of oxygen to severe COVID-19-patients to be 10 l/min. However, there is a lack of empirical data about the oxygen provision to patients. This study aimed to estimate the oxygen provision to COVID-19 patients with severe disease in a Swedish district hospital. A retrospective, medical records-based cohort study was conducted in March to May 2020 in a Swedish district hospital. All adult patients with severe COVID-19 –those who received oxygen in the ward and had no ICU-admission during their hospital stay–were included. Data were collected on the oxygen flow-rates provided to the patients throughout their hospital stay, and summary measures of oxygen provision calculated. One-hundred and twenty-six patients were included, median age was 70 years and 43% were female. On admission, 27% had a peripheral oxygen saturation of ≤91% and 54% had a respiratory rate of ≥25/min. The mean oxygen flow-rate to patients while receiving oxygen therapy was 3.0 l/min (SD 2.9) and the mean total volume of oxygen provided per patient admission was 16,000 l (SD 23,000). In conclusion, the provision of oxygen to severely ill COVID-19-patients was lower than previously estimated. Further research is required before global estimates are adjusted.

Global Critical Care is attracting increasing attention. At several million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LICs) have a disproportionally greater share of critical illness, and yet critical care facilities are scarce in such settings. Routines utilizing abnormal vital signs to identify critical illness and trigger medical interventions have become common in high-income countries but have not been investigated in LICs. The aim of the study was to assess whether the introduction of a vital signs directed therapy protocol improved acute care and reduced mortality in an Intensive Care Unit (ICU) in Tanzania. Prospective, before-and-after interventional study in the ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger levels of severely abnormal vital signs and stipulated acute treatment responses was implemented in a four week period using sensitisation, training, job aids, supervision and feedback. Acute treatment of danger signs at admission and during care in the ICU and in-hospital mortality were compared pre and post-implementation using regression models. Danger signs from 447 patients were included: 269 pre-implementation and 178 post-implementation. Acute treatment of danger signs was higher post-implementation (at admission: 72.9% vs 23.1%, p<0.001; in ICU: 16.6% vs 2.9%, p<0.001). A danger sign was five times more likely to be treated post-implementation (Prevalence Ratio (PR) 4.9 (2.9-8.3)). Intravenous fluids were given in response to 35.0% of hypotensive episodes post-implementation, as compared to 4.1% pre-implementation (PR 6.4 (2.5-16.2)). In patients admitted with hypotension, mortality was lower post-implementation (69.2% vs 92.3% p = 0.02) giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality rates were unchanged (49.4% vs 49.8%, p = 0.94). The introduction of a vital signs directed therapy protocol improved the acute treatment of abnormal vital signs in an ICU in a low-income country. Mortality rates were reduced for patients with hypotension at admission but not for all patients.

Background Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and potential for reversibility. The burden of critical illness is high, especially in low- and middle-income countries. Critical care can be provided as Essential Emergency and Critical Care (EECC)– the effective, low-cost, basic care that all critically ill patients should receive in all parts of all hospitals in the world– and advanced critical care– complex, resource-intensive care usually provided in an intensive care unit. The required resources may be available in the hospital and yet not be ready in the wards for immediate use for critically ill patients. The ward readiness of these resources, although harder to evaluate, is likely more important than their availability in the hospital. This study aimed to assess the ward readiness for EECC and the hospital availability of resources for EECC and for advanced critical care in hospitals in Tanzania. Methods An in-depth, cross-sectional study was conducted in five purposively selected hospitals by visiting all wards to collect data on all the required 66 EECC and 161 advanced critical care resources. We defined hospital-availability as a resource present in the hospital and ward-readiness as a resource available, functioning, and present in the right place, time and amounts for critically ill patient care in the wards. Data were analyzed to calculate availability and readiness scores as proportions of the resources that were available at hospital level, and ready at ward level respectively. Results Availability of EECC resources in hospitals was 84% and readiness in the wards was 56%. District hospitals had lower readiness scores (less than 50%) than regional and tertiary hospitals. Equipment readiness was highest (65%) while that of guidelines lowest (3%). Availability of advanced critical care resources was 31%. Conclusion Hospitals in Tanzania lack readiness for the provision of EECC– the low-cost, life-saving care for critically ill patients. The resources for EECC were available in hospitals, but were not ready for the immediate needs of critically ill patients in the wards. To provide effective EECC to all patients, improvements are needed around the essential, low-cost resources in hospital wards that are essential for decreasing preventable deaths.