critical care bed system for sri lanka
TRANSCRIPT
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ICU bed availability system for
Sri Lanka
2013
Ministry of Health
CRITICAL CARE BED SYSTEM FOR
SRI LANKA
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National Intensive Care Surveillance - 2013
ISBN 978-955-0505-43-2
National Intensive Care Surveillance
Room No. 15, Hotel Complex,
Health Education Bureau,
Ministry of Health
Kynsey Road,
Colombo 10.
Email:[email protected]
Website:www.nicslk.com
Telephone:+94 112679038,+94 112679039
Twitter: @nicslk
mailto:[email protected]:[email protected]:[email protected]://www.nicslk.com/http://www.nicslk.com/http://www.nicslk.com/http://www.nicslk.com/mailto:[email protected] -
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Partners
Ministry of Health, Sri Lanka College of Anaesthesiologists of Sri Lanka Department of Clinical Medicine, Faculty of Medicine, University
of Colombo
Mahidol Oxford Tropical Medicine Research Unit, Bangkok,Thailand (University of Oxford)
Collaborators
Ceylon College of Physicians Sri Lanka College of Paediatricians Sri Lanka College of Obstetricians and Gynecologists Government Medical Officers Association Information and Communications Technology Agency National Intensive Care Evaluation, Netherlands Department of Medical Informatics, University of Amsterdam,
Netherlands
Commercial partners
Sri Lanka Telecom Respere Lanka (pvt) ltd. Tektron Mobitel
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Dedicated to;
The critically unwell patients of Sri Lanka
NICS Team
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Steering committee of National Intensive Care Surveillance
Secretary, Health (Chairman) Director General of Health Services Deputy Director General (Medical Services)I Director, Tertiary Care Services Named nominees, Sri Lanka College of Anesthesiologist Dr Kumudini
Ranatunga, Dr Shirani Hapuarachchi and Dr Ramya Amarasena
Professor Saroj Jayasinghe, Department of Clinical Medicine, Faculty ofMedicine, University of Colombo
Nominee, Sri Lanka College of Paediatricians- Dr Srilal de Silva Nominee, Sri Lanka College of PhysicianDr M K Ragunathan Nominee, Sri Lanka College of Obstetricians and Gynecologists
Prof Hemantha Senanayake
President, GMOADr Anurudda Padeniya Dr. Rashan Haniffa, Project Coordinator, NICS
NICS Team
Project focal point / Director: Dr P Athapattu, Director, TCS Project coordinators Dr A Pubudu de Silva and Dr Rashan Haniffa Dr Janitha Jayawardena Dr Buddhika Mahesh Chathurani Sigera & Dilshan Jayanath Imelka Madushani, Tharaka Kalhari and Randi Ranasingha
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Table of contents
Contents Page
Executive summary 09
Section 1:ICU services in Sri Lanka and need for bed system
1.1 ICU services in Sri Lanka 121.2 ICU bed search: Current practice 191.3 ICU registries 21
Section 2:National Intensive Care Surveillance
2.1Objectives 292.2Benefits to Sri Lanka 302.3Stakeholders 322.4Governance 342.5NICS formation 352.6Responsibilities of parties as per MOU 352.7Sequence of events 372.8Methodology 452.9NICS network 602.10NICS data analysis and feedbacks 652.11NICS staff 66
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2.12NICS Funding 702.13Ethical review 712.14NICS Challenges 732.15Summary of Current state of NICS 75
Section 3:NICS Output
3.1Bed availability system 763.2Feedback reports from ICU registry of NICS 763.3Follow up information of ICU patients 803.4 ICU Fault and critical incident reporting system 813.5Publications 823.6 Information dissemination 833.7Collaborations 853.8Training 863.9Research 87
Section 4: Software development
4.1Rationale 904.2Essential features 904.3Process of development 954.4Challenges and future software development 106
Section 5:ICU bed availability system
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5.1Current practice 1085.2Bed availability from NICS 1095.3Aims of the ICU bed availability system 1105.4Benefits 1105.5Methodology 1115.6Few points to note 1135.7Pre-testing of bed availability system 114
Section 6:Evaluation and future
6.1Challenges 1156.2Evaluation 1156.3The future 116
References 118
Appendix
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EXECUTIVE SUMMARY
There are over 100 state intensive care units in Sri Lanka with over
500 beds and approximately 3000 admissions per month. More than
750 Doctors and nearly 2000 nurses serve in these ICUs.
No bed availability system or registry for critical care has existed
previously in Sri Lanka.
ICU beds are a precious resource, especially for developing countries
such as Sri Lanka costing well in excess of Rs 50,000 a day. It is
imperative that this resource is utilised in the most efficient manner
targeting those who are most likely to benefit from ICU care.
The current practice of searching for ICU beds by randomly calling
ICUs is inefficient and endangers patient survival. Only 18% of the
ICUs had direct telephone connections making even this search even
more difficult.
National intensive care surveillance (NICS) system was established in
late 2011 with the aim of implementing an ICU bed availability system
and improving the quality of care provided in the intensive care units.
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NICS is a multi disciplinary national and international collaboration
led by the Ministry of Health and including Academic Colleges and
Academic Institutions.
The ICU surveillance system gathers information of ICUs, patients,
staffing and available resources. The system captures information to
enable benchmarking of ICUs to show how ill ICU patients are
(severity scoring), their outcomes and diagnoses. This benchmarking
will allow ICU outcomes to be expressed relative to other units. This
process will facilitate learning from each other about methods,
procedures, techniques, policies, equipment, drug profiles and
training that have allowed some units to excel relative to others.
NICS will improve transparency, accountability and the ability to
direct scarce resources towards identified needs in a targeted
manner.
Such a locally developed system based on low cost, rapid feedback,
sustainable and locally integrated model is unique in a lower-middle
income country and possibly in any developing country.
The bed availability system will help patients directly by reducing the
time that is spent on searching a bed. This system will provide bed
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usage and bed pressure information to the MOH, which could be
used to improve access to critical care.
The system has already facilitated locally led research and audit
amongst the multi disciplinary ICU staff and stimulated ICU training
programmes. International collaborations are likely to follow.
A neonatal ICU network, a customised paediatric dataset, a more
clinically useful data capture system, improved diagnostic coding and
better audit functionality are some of the features expected shortly.
NICS has the potential to be a model to improve critical care in
resource poor settings and for Sri Lanka to be the setting in which this
was initiated.
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SECTION 1
Intensive Care Unit Services in Sri Lanka
1.1ICU services in Sri Lanka There are 113 Intensive Care Units (ICUs) in the state sector of Sri
Lanka (2013)*
The number of adult ICUs was 102 and paediatric ICUs were 11.*
Majority (>90%) of in-patient health care services to the SriLankan population are provided for by state sector hospitals (1).
* Source - NICS
Geographic scatter of
ICUs in Sri Lanka
Western
Southern
Central
Sabaragamuwa
Uva
North Western
North Central
Eastern
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The distribution of ICU services in the world
Australia has 8 ICU
beds per 100,000
populations.
The USA
has 20 ICU
beds per
100,000
populations
Europe has 5.38-
29.2 ICU beds per
100,000
populations.
Malaysia has 2.4
ICU beds per
100,000
populations.
China has 3.9
ICU beds per
100,000
o ulations.
Mongolia has
9.8 ICU beds
per 100,000
o ulations
Sri Lanka
2.5 ICU beds per 100,000
population
13 ICU beds per 1000 hospital
beds
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500 critical care beds in Sri Lanka* 38000 annual admissions* 6600 annual deaths* Each ICU bed costing at least Rs 50,000/= per night.**
Peadiatric ICUs
11 crtical care units* 64 functioning beds* 52 ventilators*
* NICS 2011 data
** Estimate
0
5
10
15
20
25
30
35
40
45
GICU MICU SICU PICU Special ICU
ICU categories in Sri Lanka
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Outcomes of Sri Lankan state ICUs
There is no data to understand how ill these patients were (severity
of illness) or what diagnoses they had. No specific Hospital
mortality/morbidity data or 28/30-day outcome data was available.
ICU staffing2
Medical officers- 790 Nursing staff-1989 Healthcare assistants-626
0
10000
20000
30000
40000
2010 2011
Admissions
Deaths
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Services available in Sri Lankan ICUs (n=99)2
Services No. ICUs
Physiotherapy 91
Electrocardiogram (24/7) 74
Radiology (portable X ray 24/7) 81
Dietician/ Diet Clark 88
Cleaning staff- dedicated to ICU 78Bio medical technician 02
ICU facility profile (n=99)2
Facilities No. ICUs
Air conditioning 96Backup generator 97
Compressed air 88
Blood gas machine 65
Wall suction 64
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Equipment available (per 100 beds)2
Equipment AvailabilityVentilators 91
Infusion/syringe pumps 309
ECG Monitoring 103
Invasive arterial pressure 39
Capnography 33
Central Venous Pressure (Electronic) 27
Cardiac output monitoring 08
Neonatal ICU
These were not included in this profile.
Private sector
No similar data is available.
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The worldwide demand for critical care services is increasing
In developing countries this problem is higher due to Scarcity of resources- beds, equipment and staff Relatively younger critically ill patients Later hospital presentation Later recognition of critical illness
Critical care is expensive
Cost of ICU beds per night in different countries is as follows.
USA 1500 USD UK 2,500 USD India 168 USD Sri Lankan estimate > Rs 50,000.00 (370 USD)
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1.2ICU bed search: Current practiceThere has been no national ICU bed availability system in Sri Lanka
thus far.
When an ICU bed is needed the relevant Doctor (intern orregistrar) checks the local Hospital ICU.
If the local ICU is full the Doctor will have to find an ICU bedelsewhere.
The Doctor begins to telephone Hospitals in no particular order. Most ICUs do not have direct telephone lines and a directory to
find these numbers is not readily available.
Facilities to directly dial out of Hospitals too are limited. The critically unwell patient needs to be managed at the same
time as this bed search.
There are reports of many hours spent in the (often) futile searchfor an ICU bed.
Problems with current ICU bed searching method
Several hours are spent in finding an ICU bed. Many randomlydirected phone calls are also made (quite often more than 10
calls) before any progress is made.
Lives maybe lost due to delay/failure to find ICU beds intreatment of head injuries, cardiac arrests and other illnesses.
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National emergency bed system in other countries
England Maryland, USA- National Hospital Available Beds for Emergencies
and Disasters (HAvBED) System
Netherlands
Now one phone call will find you ICU bed availability in Sri Lanka!
1.3ICU registriesICU clinical registries gather information from each patient using ICU
services and then use the data to improve these services.
Clinical registries to improve ICU patient outcomes have been
implemented in developed countries but rarely in developing
countries.
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ICU registries help to improve intensive care and intensive care
outcomes. Their main functions are to
Collect patient data from participating units using predefined andinternationally accepted datasets
Clean and validate the data Analyse data according to predefined rules Provide reports and feedback on ICU performance Stimulate audit and research Work with ICUs to improve ICU practices
These national programs contribute to surveillance of the critically ill
population providing information on epidemiology, causes,
complications and outcomes in ICU patients.
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ICU registries are well established in developed countries, and in
high-middle income countries. UK-ICNARC (established in 1994) Netherlands-NICE (established in 1996) Australia and New Zealand-ANZICS Adult Patient Database
(established in 1997)
Malaysia-Malaysian Registry of Intensive Care (Established in2002)
No such system has existed so far in Sri Lanka.
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Barriers to implement ICU registries in developing health systems
Absence of a centralized health system Minimal ICU facilities with massive diversity of facilities Large geographic areas with poor transport Poor critical care training Poor communication channels Poor availability of internet Absence of experts Lack of awareness of need and benefits Lack of expertise in methodology Lack of IT resources Lack of data collectors
Sri Lanka is fortunate in that many of these difficulties do not apply
and is therefore a viable and excellent location for a clinical registry
and ICU bed availability system.
Sri Lanka has
A state health system controlled centrally or provincially More than 100 ICUs where minimum infrastructure and
equipment standards are met
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ICUs with resident skilled Doctors and excellent nurse patientratios
An understanding of the need for quality improvement processes. Safe and effective transport links between towns and cities A expanding capability to connect to the internet Widespread mobile phone coverage and penetrance Ability to understand and work in English Staff who can be easily trained to use new systems Experts in the areas of critical care, statistics, health economics
and administration
The scientific basis for an adapted ICU registry tailored to a
developing country
ICU performance tools and indicators developed in high-middleincome countries are of uncertain use in developing countries.
Methodologies from high-income countries cannot be directlytransplanted to low-income countries.
Clinical critical care scoring systems are used for categorizationand prognostication of ICU patients helping resource planning in
ICUs, comparing quality of patient care across ICUs, and
standardizing research in the field of critical care medicine (3).
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Presently available clinical scoring systems (APACHE, SAPS etc.)have almost exclusively been designed for, and validated in the
developed world (3).
Adapted scoring systems for critically ill patients in resource-poorsettings do not currently exist.
Parameters requiring advanced laboratory support are notcommonly available in a low-middle income setting.
Some diagnoses which are common in these settings (eg: snakebites) are not usually accommodated in the existing models.
When used in conjunction with valid scoring systems andaggregated patient outcome data (eg. standardized mortality
ratios) the registry enables a detailed description of ICUs and
provides key comparative data.
There is some evidence that the establishment of such a system,including feedback mechanisms and monitoring, improves critical
care services (4).
Sri Lanka lacks a critical care surveillance system. Capacity building is a recognized need in Sri Lanka, especially with
regard to critical care.
The country therefore needs an ICU surveillance system that iscomprehensive, structured and sustainable.
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Working with international experts and organizations inestablishing the registry will promote sustainable local capacity
building with regard to the registry itself. It will aid quality
improvement strategies and clinical audit.
The features of a successful ICU surveillance system in Sri Lanka
would include
Being relevant An early service delivery component Being low cost Use of simple technology Being sustainable Having a capacity building aspect Adaptability Having cross platform utility Having a quick feedback loop Having a validation component Being able to facilitate the gaining of any skill gaps amongst
clinical staff
Utilizing an easy to learn tool
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2.1 Ob ectives
SECTION 2
National Intensive Care Surveillance
Develop and operate an ICU bed availability system. Implement an audit of ICU patient outcomes mortality and
morbidity.
Improve effective use of ICU resources for patient care ICUfacilities and functional status reporting.
Standardization of ICUsprotocols, guidelines and standards ICU economic analysis and cost effectiveness for planning Local capacity building Improving the quality of audit and research in critical care
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2.2 Benefits to Sri Lanka
Bed availability system-24/7 Planning ICU services based on needs, capacity and resources
1. Plan and allocate new ICU beds2. Plan and allocate equipment3. Plan and allocate expensive medications4. Plan and allocate Staffing Doctors/ Nurses/ Allied health
professionals
Helps coordinate ICU resource management during any national /regional emergency or disaster
Improve quality of patient care1. Audit of ICU patient outcomes - morbidity and mortality2. ICU feedback on compliance with national and international
ICU clinical guidelines
3. Detect clinical and resource problems of ICUs early to takecorrective action outbreak of infection, equipment
malfunction etc
4. Help ICUs understand areas for improvement anddevelopment. Encourage and reinforce positive clinical or
management policies of individual ICUs.
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Improve cost effectiveness of critical care by carrying outeconomic analysis of staff and resource use.
Capacity building of critical care personnel and facilitate criticalcare training for ICU staff by identifying training needs of
1. Doctors2. Nurses3. Physiotherapists etc
Development of critical care epidemiologycapacity building Promotion of local and national level audit by collaborations with
various specialties (anaesthetists, physicians paediatricians) and
professions (nurses, physiotherapists etc)
Collaborations with nurses and other allied health professionalsfor training and practice development
Promotes local and international research Human resource development
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2.3 Stakeholders
NICS is the result of a multi disciplinary national and international
collaboration led by the Ministry of Health to improve ICU services in
Sri Lanka.
Participants
Ministry of Health, Sri Lanka Sri Lanka College of Anesthesiologists Department of Clinical Medicine, Faculty of Medicine, University
of Colombo, Sri Lanka
University of Oxford / Mahidol Oxford Tropical MedicineResearch Unit
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Collaborators
Ceylon College of Physicians Sri Lankan College of Paediatricians Sri Lanka College of Obstetricians and Gynaecologists Government Medical Officers Association (GMOA) Information and Communications Technology Agency (ICTA) of Sri
Lanka
National Intensive Care Evaluation (Dutch Critical Care ClinicalRegistry)
University of Amsterdam-Department of Medical Informatics/Department of Intensive Care medicine
Commercial Partners
Sri Lanka Telecom Respere Lanka Tektron Mobitel
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2.4 Governance
NICS is governed by a high level steering committee providing
strategic direction and guidance.
Steering committee
Secretary, Health (Chairman) Director General of Health Services Deputy Director General (Medical Services)I Director, Tertiary Care Services Named nominees, Sri Lanka College of Anesthesiologist Dr Kumudini
Ranatunga, Dr Shirani Hapuarachchi and Dr Ramya Amarasena
Professor Saroj Jayasinghe, Department of Clinical Medicine, Faculty ofMedicine, University of Colombo
Nominee, Sri Lanka College of Paediatricians- Dr Srilal de Silva Nominee, Sri Lanka College of PhysicianDr M K Ragunathan Nominee, Sri Lanka College of Obstetricians and Gynecologists
Prof Hemantha Senanayake
President, GMOADr Anurudda Padeniya Dr. Rashan Haniffa, Project Coordinator, NICS
rganization
NICS is under Director,
Tertiary Care Services,
Ministry of Health
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2.5 NICS formation
NICS was established in late 2011 based on a Memorandum of
understanding, after due diligence and legal approval, as a
collaboration led by the Ministry of Health, Sri Lanka and two
prestigious overseas academic institutions (University of Oxford via
the Mahidol Oxford Tropical Medicine Research Unit and the
University of Amsterdam)
2.6 Responsibilities of parties as per MOU
The MOU assigned tasks for the collaborators to achieve the
objectives of the collaboration
Activity Party responsible
Definitive location for NICS Ministry of Health (MOH)
Office furniture for NICS Ministry of Health
Staffing by MOH Doctors Ministry of Health
Solve administrative and logistics issues at
Hospitals/ICUs
Ministry of Health
Facilitate Drs / nursing staff at ICUs for NICS
data entry
Ministry of Health
Formal training of nurses for NICS Ministry of Health
Develop prototype Oxford/Amsterdam
Definitive software development Oxford/Amsterdam
Branding of NICS Oxford/Amsterdam
Staffing for NICS (non medical officer) Oxford/Amsterdam
Office equipment- PCs, telephone, fax, Oxford/Amsterdam
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stationary
Temporary office rent at MOH (HEB) Oxford/Amsterdam
Implement NICS in ICUs MOH/
Oxford/Amsterdam
Provide PCs to ICUs Oxford/Amsterdam
Provide telephone lines for ICUs Oxford/Amsterdam
Provide internet for ICUs Oxford/Amsterdam
Maintain network pay utilities, repair
equipment
Oxford/Amsterdam
Data validation / improve data quality MOH/Oxford/Amsterdam
Provide feedback reports- weekly/quarterly MOH/Oxford/Amsterdam
Provide data access for Ministry officials Oxford/Amsterdam
Comply with data requests from Ministry Oxford/Amsterdam
Apply for funding/grants Oxford/Amsterdam
Developing paediatric system- (extra
activity)
Oxford/Amsterdam
Promoting proposal for developing neonatal
system- (extra activity)
Oxford/Amsterdam
Formation of NICS steering committee Ministry of Health
Develop protocols and operating
procedures
Steering committee
Collaborate with national organisations/Colleges
MOH/Oxford/Amsterdam
Collaborate with international organisations Oxford/Amsterdam
Prepare publications MOH/Oxford/Amsterdam
Prepare scientific output MOH/Oxford/Amsterdam
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2.7 Sequence of events
The following pages illustrate the timeline of the entire NICS process.
The whole NICS process from 2010 is documented in the following
Ministry of Health files.
DDG(MS)I/69/2010: ICU Surveillance DDG(MS)I/13/2012: National Intensive Care Surveillance SAS(MS)/NICS/01/2012: National Intensive Care Surveillance SAS(MS)/NICS/02/2012: Minutes SAS(MS)/NICS/03/2012: NICS Equipment SAS(MS)/NICS/04/2012: NICS Travel DDG(MS) II - 431: National intensive Care Surveillance System for
Sri Lanka
WP/PD/PU/HI/0014: National ICU Surveillance System D/TCS/NICS/2013: National Intensive Care Surveillance
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2011 JulyJuneAprilMarchFebJan MayCompletion of National ICU Survey
Data collection and validation
Report writing
Completion of paper based surveillance
Data collection and validation
Report writing
GAMPAHA
CONSULTANTS
INFORMED
NORTH EAST
CONSULTANTS
INFORMED
NICS staffing
4
NICS staffing
5
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2011
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2012
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2013
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2.8MethodologyData collection
NICS data collection involves gathering information from ICUs
regarding the bed state, patient details and about logistics/facilities.
This data is analysed and used for service improvement.
1. ICU bed state dataCollected three times per day- 1000, 1700, 0000 (midnight)
Bed availability and reservation Ventilator availability Staffing information
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2. Patient dataNICS dataset was developed with input (local and international) from
experts in critical care, epidemiology and bio informatics to be able to
achieve NICS objectives and to have relevance with other settings.
With such internationally comparable data, NICS may be able to
provide, with the approval of the Ministry of Health, methodology
and analysed (not raw) information to other countries/settings to
improve ICU outcomes.
1. At admission- filled during the day of admission Demography Diagnosis Admission physiology Severity of illness
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2. At 24 hours- filled 24 after admission Diagnosis Physiology data Information to assess response to treatment
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3. Daily report- filled daily during ICU stay Assesses organ failure Level of treatment provided on a daily basis
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4. Discharge report-Filled on the day of discharge or death Status of discharge
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5. 30 day follow up Patient discharged from the ICUs are contacted 30 days later
to assess their Hospital outcomes and current outcome.
Currently being done in 10 ICUs at present
This will help assess and assist with any residual health issuesthe patient may have and possibly stimulate ICU follow up
clinics. Such services exist rarely even in the developed world
and are not known to currently operate in Sri Lanka.
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c. ICU functional status reportingIn discussions with clinicians working in the ICUs and other
nursing/allied health staff the need to understand and report the
equipment, staffing, medication, administrative matters affecting
clinical care and functioning of ICUs was apparent. This functionality
is now being rolled out so these requirements can be transmitted to
the Ministry of Health.
Logistical issues, equipment issues or staffing problems andadverse events in the ICU, equipment malfunction or
unavailability of medications can be reported to allow the
Hospital or central authorities to act to minimize patient harm
and promote staff well being.
NICS will allow each ICU to report this information at any time.This information will be used to provide context to the quality and
outcome reporting. This will also be used for summary reporting
and feedback to allow timely action at local, provincial and
national level.
Further details are in section 3.4 below.
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d. NICS related logistical issuesNICS gathers information related to any difficulties the ICU
encountered in providing data and whether we were able to resolve
them. Below is the snapshot of September and October 2013 for this
process.
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Administrative and staffing issues have proven to be difficult to
resolve. With the streamlining of the administration and with the
Secretary, Health declaring that NICS is a priority area we are hopeful
there will be progress in these areas.
Issues Type of Issue
Administrative Connection
related
Software Computer
related
Staff
September F S F S F S F S F S
1st
week 5 2 3 2 2 1 1 1 5 2
2nd
week 3 0 3 2 4 0 0 0 11 5
3rd
week 3 0 6 2 4 0 2 0 7 1
4th
week 3 0 4 3 5 5 3 2 11 2
October
1st
week 3 0 3 1 1 0 1 0 9 2
2nd
week 3 0 4 1 4 1 1 1 20 7
3rd
week 3 0 6 2 3 1 0 0 16 8
4th
week 3 0 11 7 4 2 2 2 16 8
F=Found, S=Solved
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e. Chasing up missing data
Missed data
List of missed BHT numbers
Will inform the record room
Facilitate the process of obtaining the missing BHTs
Enter the missed data to system
3. NICS data validationData validation occurs at several levels
a. Automated-at time of entry Field validation- text/numbers Field validation- limits to fields- for eg heart rate has upper
limit
Minimize typing- dropdown boxes or yes/no Required fields
NICS
A nominated nurse in
the ICU
The Director / MS
of the hospital Sister in charge ICU/
Consultant in
charge ICU
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b. Timed automated remindersFor 24-hour forms and daily reports- an alert is visible
c. Manually from NICS centreNICS staff contacts ICU if bed reports have not been filled to
obtain the bed state and verify admissions/ discharges/
deaths.
Admission and discharge reports are tallied daily with bed
state and ICU staff encouraged to fill out any missing forms.
New admission BHT numbers and discharge BHT numbers are
obtained to assess whether relevant forms are being received
daily.
d. Content validationHorizontal and vertical validation for content in the forms is
being developed.
For eg if many fields are marked as unknown, a trigger is
created to check verify the fields.
A random variable entered by an ICU is double checked to
assess accuracy of data
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e. Site visits Site visits, both arranged and unarranged will be undertaken
with the authorization of the Ministry of Health to assess
accuracy and completeness of data.
Training and logistical support can be provided to correct anydeficiencies.
Hello, we
did not
receive
yesterday
admissions
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4. Equipment and infrastructureEquipment and infrastructure have been provided to the ICUs in the
network by the National intensive Care Surveillance. A breakdown of
equipment is below.
Equipment Number
ICUs
Desktop computers 67
Dongles 79
SLT direct telephone lines 57
ADSL Modems 55
NICS Software (prototype) 01
NICS Main Software 01
NICS Office
Desktop computers 07
SLT direct telephone lines 02
Fax machine 01
Wireless ADSL Modems 01
Dongles 02
Furniture and electric items 03
5. MaintenanceThe following monthly recurrent expenditure is borne by NICS for
staffing, maintenance of equipment and infrastructure.
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Category Recurrent cost
Staffing at NICS Staff member salaries
Maintenance of hardware at ICUs 73 Computers in working
condition
Software maintenance IT team (currently off-site)
SLT telephone bill Maintain 75 SLT telecom
connections including payments
for rentals
SLT ADSL bills Maintain 50+ ADSL connections
Dongle top ups Providing top ups whennecessary for the dongles in ICUs
Stationary
Travel to ICUs Travel to ICUs for training,
monitoring and trouble shooting
6. Meetings conducted during and after formation of NICSNumerous meeting (formal and informal) and updates were held
among different stakeholders/authorities by NICS project
coordinators since 2010.
Listed below are approximate totals of these meetings.
Person Number of meetingsMinistry of Health Officials
Secretary/DGHS/SAS (MS)1 26
Deputy Director General (MS)I 04
Director Tertiary Care Services 32
Director Information 06
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Director MA/MS 04
Director Planning 02
Partners
College of Anaesthesiologists of Sri Lanka 16
Department of Clinical Medicine, Colombo 14
Collaborators
ICTA 12
Ceylon College of Physicians 08
Sri Lanka College of Paediatrics 08
Sri Lanka College of Obstetricians 04
Sri Lanka Telecom 08
NICE/AMC 15
Health professionals/organizations
Consultant Anaesthetists of ICUs 67
Hospital Directors 47Consultant Physicians of ICUs 14
Government Medical Officers Association 08
Provincial Directors of Health Services 05
Director NHSL 04
Postgraduate Institute of Medicine 02
Epidemiology Unit 05
Family Health Bureau 04
Non health organizations
Mobitel 02
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2.9 NICS network
The NICS network currently has 65 adult ICUs and 8 paediatric ICUs. A
summary of the type of adult ICUs follows. Their locations are
illustrated below
Adult ICUs Pediatric ICUs
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Adult ICUs in the NICS network
ICU CategoryWestern Province
Avissawella Base Hospital GICU
Gampaha Base Hospital MICU
Gampaha Base Hospital SICU
Homagama Base Hospital G ICU
Horana Base Hospital GICU
IDH Angoda Base Hospital GICU
Kalubovila Teaching Hospital MICU
Kalubovila Teaching Hospital SICU
Kaluthara Base Hospital GICU
Negambo Provincial General Hospital SICU
Negambo Provincial General Hospital MICU
NHSL Teaching Hospital SICUNHSL Teaching Hospital MICU
NHSL Teaching Hospital NTICU1
NHSL Teaching Hospital NTICU2
Panadura Base Hospital GICU
Ragama Teaching Hospital MICU
Ragama Teaching Hospital SICU
Sri Jayawardhanapura GICU
Southern ProvinceBalapitiya Base Hospital GICU
Hambanthota Base Hospital GICU
Karapitiya Teaching Hospital GICU
Karapitiya Teaching Hospital ETCICU
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Chilaw District General Hospital SICU
Kuliyapitiya Base Hospital GICU
Kurunagala Teaching Hospital GICU
Kurunagala Teaching Hospital ASICU
Kurunagala Teaching Hospital MICU
North Central ProvinceAnuradhapura Teaching Hospital SICU
Anuradhapura Teaching Hospital MICU
Anuradhapura Teaching Hospital NSICUPolonnaruwa General Hospital GICU
Eastern ProvinceKalmunai Base hospital GICU
Batticaloa Teaching hospital GICU
Batticaloa Teaching hospital GICU
Kanthale DGH GICU
Trincomalee District General Hospital GICU
Northern ProvinceJaffna Teaching Hospital SICU
Jaffna Teaching Hospital MICU
Mannar Base Hospital GICU
Vauniya District General Hospital GICU
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Paediatric ICUs
ICU CategoryWestern Province
Maharagama Cancer hospital PICU
Lady Ridgeway Childrens Hospital MICU
Southern Province
Karapitiya Teaching Hospital PICU
Central Province
Kandy Teaching Hospital PICU
Sirimavo Bandaranayake Childrens Hospital SICU
Sirimavo Bandaranayake Childrens Hospital MICU
North Western ProvinceKurunegala Teaching Hospital PICU
North Central ProvinceAnuradhapura Teaching Hospital PICU
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Individual ICUs Ministry of Health
3. Annual report ICU performance is compared annually using NICS
annual report.
Contents (at section 3) Secretary, Health Director General of Health Services Director/ Tertiary care services, Ministry of Health Directors of the hospitals Consultants in charge of the ICUs Individual ICUs
2.11 NICS staff
NICS is under Directorate, Tertiary care services
1. Project Focal Point/Convener- Dr. Priyantha Athapattu,
Director/Tertiary Care Services
Responsibilities
Reports to the steering committee on NICS activities Provides overall direction and guidance for NICS activities Coordinates NICS activities with other stakeholders Overseas all other staff at NICS
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2.a Project Coordinator from MOH
Coordinate NICS activities with MOH Coordinate NICS activities with collaborators Coordinate NICS activities with ICUs, Hospitals and
Consultants
Provide supervision to MOH staff working at NICS Arrange staffing appointments from MOH to NICS Coordinate with software team to ensure optimum software
function
Provide technical guidance on prognostic risk modelling tolocal setting
Dr A P de Silva is currently on overseas placement at ICNARC,the premier ICU registry in the world, but is involved in NICS
activities (no access to raw data) remotely.
2.b Project Coordinators from MORU /Oxford
Ensure overall objectives of NICS are met Provide strategic and research direction Facilitate the activities of participating organisations to
further NICS objectives
Be responsible for overall budgetary and funding aspects Raise profile of NICS and secure funding
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Audit and governance Be part of steering committee Dr Rashan Haniffa currently holds this post
3. Medical officers
Ensure day to day NICS activities Contribute to operational activities Work with IT and software team to support project activities. Troubleshoot IT, technical and logistics issues Prepare routine reports Ensure smooth running of participating sites with regard to IT
and data collection
Participate in research and audit Report to Director (TCS)Dr Mahesh Buddhika has held this post previously while Dr
Niswan Subaru Preena and Dr Habeeb Mohamed are expected to
involve fully from now onwards.
4. IT team
Work with local IT company/ICTA and AMC/NICE to ensurethe IT component of NICS functions smoothly.
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Ensure all hardware and software components are updatedand system integrity is maintained.
Troubleshoot any hardware, software issues utilising the localpersonnel/research assistants as resource persons while
liaising with local IT collaborator/AMC as needed.
Implement an IT/data protection/ data governance plan forNICS
Ensure data backup and data integrity Participate actively in report generation and research output Currently IT support is provided through Respere while
restructuring takes place. Nuwan Jayaratne and Manoj
Amaratunga have previously worked in this area.
5. Project officers
Function as bed availability system operators
Troubleshoot local level IT/data collection issues
Assist with reporting and analysis
Train ICU staff to use NICS software
Ensure appropriate data collection in ICUs
Ensure data quality
Work with staff in ICUs to facilitate and encourage data
collection
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Ms Chathurani Sigera and Mr Dilshan Jayanath function as
Project Officers
Dr Janitha Jayawardena functions as the Office Manager
6. Data validators
Ensure appropriate data collection in ICUs Ensure data quality Work with staff in ICUs to facilitate and encourage data
collection
Function as bed availability system operators Troubleshoot local level IT/data collection issues Act as data validators verifying data quality at ICU level Conduct telephone follow up Imelka Madushani, Tharaka Kalhari and Thilini Randi
Ranasinga are data validators
2.12 NICS Funding
Travel related expenses- borne by MOH Electricity and water- borne by MOH Mahidol Oxford Research Unit (Oxford) Some personal funding has been utilisedfor equipment, staffing
and recurrent costs
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MORU (Oxford) are committed to contributing to sustainabilityas per current and future MOUs with the Ministry of Health.
2.13 Ethical review
NICS is not a research project. However, there is a necessity toscientifically and accurately document the process the
scientifically to benefit Sri Lanka and elsewhere.
NICS provides an opportunity to answer important ICU questionswhich have not been possible to do so in developing countries.
These findings will have wide ranging benefit.
Audit and scientific research will enable funding to reach NICS toensure expansion and sustainability. This is similar to other
registries.
This activity has been explicitly declared and agreedin the MOUsigned in 2011. The following are some of the multi disciplinary
examples of processes for which ethical clearance has been
sought from accredited ethical review boards. In some cases, the
committee has exempted ethical review.
It is however, important to note that some of these studies werebeforethe formation of NICS but are significant as they have led
to its formation and provide justification.
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EC- 10-135A Descriptive study on critically ill patients admitted to intensive
care units in Sri Lanka
EC-11-175Profile of ICU patients in a several districts in Sri Lanka and
feasibility of validating basic prognostic models.
EC-13-090The effect of a structured nurse focused practical ICU training
course on the knowledge, attitudes and skills of critical care
nurses in Sri Lanka.
EC-11-175Validation of APACHE II and other severity scoring systems in Sri
Lankan critical care settings
EC-11-175A prospective observational study of critical care patients in the
developing world country (Sri Lanka) to develop a high quality
clinical registry leading to the construction of case mix
adjustment model tailored to the resource poor setting
EC-11-175Gather 30 day outcome for patients discharged from state ICU for
surveillance purposes- as part of National Intensive Care
Surveillance System
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NICS is NOTa tool to discipline/question anyone NOTan individualsresearch DOES NOTanalyze individual patient outcomes DOES NOT share identifiable individual data except with the
relevant Hospital and Ministry authorized officials. Does NOT share data with anyone except with permission
from Ministry of Health
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SECTION 3
NICS Output
3.1Bed availability systemThe bed availability system provides information regarding the
closest available adult and paediatric ICU beds to patients needing a
bed. The bed availability system will eventually function 24/7. This is
described in section 5.
3.2Feedback reports from the ICU registry of NICSNICS provides Sri Lanka an opportunity to be a role model for other
developing countries by implementing a low cost dynamic ICU
registry designed to optimize ICU outcomes.
1. Weekly Feedback Report (WFR)
The WFR (see snapshots below) provides individual feedback with
regional and national benchmarking for all the ICUs participating in
NICS regarding:
ICU bed usage for the week Summary on profiles of ICU patients admitted and how ill
they were (severity of illness)
Summary on patient outcome and quality indicators. Summary of ICU staffing during the week
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Operational Incidents and difficulties encountered in theperiod-per unit and regionally.
Logistics issues overview related NICS- connectivity, softwareissues, admin issues etc
Summary of data compliance and quality Continuous professional development for Doctors, nurses
and allied staff on ICU matters
NICS events and news
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2. Quarterly Feedback Report (QFR)
The QFR (see snapshots) is designed for each ICU individually. It
provides a 3 monthly summary of:
All the information in the weekly reports, as above,summarized for the quarter with regional and national
benchmarking
Detailed information on the patient profiles of each ICU inrelation to the regional and country profile.
A detailed analysis of the severity of illness and outcomes ofpatients admitted to the ICU
An analysis of the 30 day follows up data for the individualICU and in the national context (see below).
A detailed analysis of the quality indicators pertaining to therelevant ICU
Benchmarking of the ICUs on the basis of quality indicators inrelation to category, region, and nationally.
Staffing information in the ICU correlated to ICU workload ,individually and nationally
Any research activity carried out involving the individual ICUas part of the NICS network
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3. Annual report
The annual report will be designed for all ICUs and for theconsumption of a wider audience, as decided by the steering
committee of NICS. It provides an annual summary of:
All the information in the Quarterly Reports, as above,summarized for the year with regional and national
benchmarking
National benchmarking of data quality and compliance National profile of patient characteristics, outcomes & treatments in
ICUs
National profile of staffing information and staff workload in ICUs National bed utilization in ICUs
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Profile of hospital acquired infections Compliance figures for ICUs with national guidelines
3.3 Follow up information of ICU patients
Patients admitted to the ICUs are followed up after ICU discharge to
determine hospital and ICU outcome. This process is currently done in 10 ICUs
and will be implemented nationally. This will allow the quality of life of these
patients to be described in the future and economic benefits (QALY, DALY etc)
to be quantified. This may lead to the introduction of follow up clinics for ICU
patients to help them with their special problems.
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3.4 ICU fault and critical incident reporting system
Benchmarking and analysis of quality/outcome indicators of ICUswill be incomplete without understanding the difficulties
encountered by these ICUs.
Clinicians and nurses working in these ICUs during feedbacksessions highlighted this fact. Gathering this information parallel
to the patient data will allow this to be reported and promote
timely action by the Hospital and Ministry (national or provincial)
to improve circumstances.
Some examples will include broken ventilators, out of stockmedications, lack of reagents for blood gas machines, issues with
staffing etc.
Adverse events in the ICU, such as drug errors, equipmentmalfunction can also be reported to allow the Hospital or central
authorities to act to minimize patient harm and promote staff
well being.
NICS will allow each ICU to report this information at any time.This information will be used to provide context to the quality and
outcome reporting. This will also be used for summary reporting
and feedback to allow timely action at local, provincial and
national level.
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The fault reporting system will be modified as per feedbackreceived
3. 5 Publications
1. Baseline survey of ICUs in Sri Lanka in 2011
ISBN 978-955-0505-25-8
The survey report (see snapshots below) describes geographical
distribution of ICU/HDU facilities & the resources available for the
ICU/HDU in Sri Lanka.
The distribution of ICU/HDU by different authority areas ,district & ICU category
The authority of admissions and referral policy to the ICU
Number of admissions & deaths in ICUs Characteristics of ICUs Human resources of ICU Equipments of the ICU Infection control of ICU Resource distribution of ICUs
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2. Telephone directory of ICUs
ISBN 978-955-0505-26-5
It provides contact details of all ICUs in Sri Lanka including available
direct phone lines.
3.6 Information dissemination
Information from NICS was disseminated to individuals/organisations
within MOH and outside the MOH, but all with the approval of the
relevant Ministry officials.
1. Ministry of Health (MoH)
Director IT - bed usage information
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Director/Planning- ICU numbers, bed numbers, patient load Director MA/MS (for allocation of doctors and nurses to
ICUs)- ICU numbers, bed numbers, patient load
Deputy Director General (ET & R)-ICU training courses Secretary, Health office- ICU bed state, information on
nonfunctioning beds, broken beds etc
2. Individuals
a. Dr. Bhagya Gunathilaka , Consultant Anaesthetist / Ragama-Information on sepsis for PGIM presentation
Distribution of sepsis among ICU patients
Prevalence of sepsis among ICU patients Characteristics of sepsis patients Distribution of sepsis patients Types of sepsis patients & characteristics Mortality & morbidity of sepsis patients Sepsis & previous medical condition Sepsis & organ failure
b. Prof Saroj Jayasinghe and Prof. Rezvi Sheriff Faculty ofMedicine, University of Colombo
Information on acute kidney disease in ICU patients.
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c. Dr. Bimal Kudavidanage, Anuradhapura Teaching HospitalICU patients details of Anuradapura Teaching Hospital
Summary of data compliance and quality in AnuradapuraICUs
Characteristics of patients in these ICUs Morbidity & mortality data of these ICUs
3. 7 Collaborations
1. Post Basic College of Nursing - Nurse Intensive Care SkillsTraining, as below
2. Deputy Director General (Education Training & Research) NurseIntensive Care Skills Training and physiotherapy skills training
workshop
3. Medical Education Development And Research Centre (MEDARC)of the Faculty of Medicine, University of Colombo - Nurse
Intensive Care Skills Training and Physiotherapists skills training
4. Government Physiotherapy Association National survey on ICUphysiotherapists and workshop on physiotherapy skills training.
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3.8TrainingFacilitating training program for ICU staff:
1. Nurses
Basic IT training and NICS software skills training for ICUnurses- arranged with our PC supplier and to be held on a
regular basis across several centers in the Districts. First
program in November 2013.
Nurse intensive care skills training program In associationwith the Post Basic College of Nursing, Deputy Director
General (Education, Training and Research) of the Ministry of
Health and Medical Education Development and Research
Centre of the Faculty of Medicine, University of Colombo,
have facilitated 6 courses of 2/3-day duration training over
220 ICU nurses using local nurse tutors, under the supervision
of overseas intensive care nursing consultants. Report to be
published.
2. Physiotherapists
In association with the Government PhysiotherapyAssociation a physiotherapy skills workshop for about 60
state physiotherapists were held facilitated by local
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physiotherapy tutors under the supervision of an overseas
Physiotherapy trainer. Report to be published.
3.9Research1. Completed
A Descriptive study on critically ill patients admitted tointensive care units in Sri Lanka
The physiotherapy services of ICUs in Sri Lanka a crosssectional survey with the Government Physiotherapy
Association.
Profile of ICU patients in a semi urban population in Sri Lankaand feasibility of validating basic prognostic models.
The effect of a structured nurse focused practical ICU trainingcourse on the knowledge, attitudes and skills of critical care
nurses in Sri Lanka.
Feasibility and conduct of ICU case mix description in postconflict areas by a paper based surveillance system
The effect of a structured physiotherapist focused ICUtraining workshop on the knowledge and attitudes of critical
care physiotherapists in Sri Lanka.
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2. Current
The effectiveness of ventilator care bundles in reducingmorbidity and mortality due to ventilator associated
pneumonia in critical care units - Dr Kumudini Ranatunga et
al.
Gather 30 day outcome for patients discharged from stateICU for surveillance purposes- as part of National Intensive
Care Surveillance System
Validation of APACHE II and other severity scoring systems inSri Lankan critical care setting
3. Proposed
Development and validation of model for estimation of bodymass index using waist and hip circumference- awaiting
ethical clearance.
Effect of BMI on intensive care morbidity and mortality- acollaborative study, awaiting ethical clearance.
A cross sectional survey of junior doctors working in ICUs ontraining and career pathways available in critical care
proposal stage. Proposed to be a collaborative study.
Social determinants of critical illness and outcomes An audit of the ICU bed availability system of NICS
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Critical care hyperglycaemia and late onset diabetes mellitus The quality of life in critically ill patients admitted to ICUs. A
collaborative study, to be submitted for ethical clearance.
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SECTION 4
Software Development
4.1RationaleThe scope was to develop a software application for a national adult
and paediatric bed availability system and a critical care clinical
registry for ICU patients.
4.2Essential featuresWe identified some essential features for the software that was to be
developed. This was based on the needs assessment carried out in the
ICUs in Sri Lanka (below), conversations with stakeholders especially
members of the College of Anaesthesiologists of Sri Lanka and onconversations with Ministry of Health officials as well as other subject
experts.
Entire application should be web based. The software should fully function online and offline The software should utilize open source technology No installation should be necessary The software can be enabled remotely The software should be adaptable easily ie fields to be
added/removed
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It should be possible to have asymmetric deployment of thesoftwareeg adult and paediatric
The software should support internal and external audit processes The software should be user friendly The software should enable secure data transmission A local copy of the data transmitted should be stored in a PDF
format for later reference
The software should enable and support data validationprocesses- at different levels, as described under methodology of
NICS section, above.
This data should be uploaded, when connected to the internet,centrally to the secure central database (Local Government
Community Cloud)
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Summary of software development
The software requirement specifications (SRS) were initiallydesigned by Marten Smith & Rick Bolten, University of
Amsterdam, under the supervision of Eric van der Zwan, senior
software engineer at NICE and Dr Nicolette de Keizer, Associate
Professor, Department of Medical Informatics, University of
Amsterdam.
This SRS document describes what is expected form the systemand how it will provide that functionality.
The SRS document was further developed with input from thelocal experts and Respere Lanka (a local software developer
specializing in open source development) under the guidance of
the ICTA.
The prototype software, described below, was developed by theDutch team working in partnership with Respere Lanka, based on
this SRS document
NICS prototype was then piloted mainly in the Wayamba District(with thanks to Dr Saman Ratnayake, PDHS Wayamba) from April
2012.
The prototype then moved through more than 8 main versionstaking on board changing requirements, user feedback and
methodological needs.
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The ICTA took the NICS software development under their wingto provide funding for the project, project management,
oversight and ensure compliance with national and international
standards.
The software design document was then prepared by RespereLanka working with the Dutch team and under the guidance of
ICTA. This document describes how the system would be built
including system architectural features.
The definitive NICS software, described below, was thendeveloped by Respere Lanka under the guidance of ICTA, working
in partnership with NICS and NICE based on the SRS and design
documents. The experiences and feedback from the prototype
was extensively used to make the definitive software provide the
functionality.
The software development process was overseen by a ProjectSteering Committee appointed by the Ministry of Health. This
comprised a Consultant Anaesthetist, Director Information at the
Ministry of Health, project manager/coordinator from NICS and
ICTA and Director reengineering from ICTA were responsible for
project oversight.
The software project was completed on time and on budgetthanks to the commitment of the parties involved, even if one
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extension was needed for document submission and payment
processing.
We wish to note here the tremendously supportive andcollaborative roles played by Respere Lanka, NICE and the ICTA to
enable knowledge transfer, internalization and then
implementation.
The ICTA has also generously offered to help with securing anyconcerns related to security or design and have helped initiated
the process to achieve SLCERT accreditation.
The stages of the software development cycle
Requirement analysis Infrastructure/architecture of the system: This includes the client
server infrastructure, the design of the database and the
clarification of interconnections with other systems
Prototyping of the system Development of the system Implementation in clinical practice Improvements and maintenance
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4.3The process of developmentNICE (Netherlands Intensive Care Evaluation) and AMC (Academic
Medical Centre)
The group responsible for developing and maintaining the Dutch
critical care registry were centrally involved in the NICS software
development. Their enthusiastic (and unpaid for) contribution for the
development of the NICS application was invaluable.
We wish to place on record our appreciation to them here.
They were responsible for
Providing methodological and technical support for NICS
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Liaising with Information Technology counterparts based atMinistry of Health and elsewhere
Providing researchers to develop the software and otheroperating procedures for NICS
Helping with the software algorithms necessary for feedbackprocesses
Ongoing methodological and technological assistance Ensuring NICS maintains international standards in
governance, data validity and audit
Requirement analysis for NICS software
The Dutch bed availability system (NICE) zorgcapiciteit.nl andthe English Emergency bed service were analyzed by using
document archaeology.
The founder, a developer and a user of the Dutch systemwere interviewed.
Based on functionality of these western bed availabilitysystems and interviews the mock ups of the Sri Lankan
system were created.
12 of Sri Lankan ICUs were visited, which were situated in 6provinces of the country.
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Date Hospital ICU
19.03.2012 Kurunegala Teaching Hospital General ICU
19.03.2012 Kurunegala Teaching Hospital Paediatric ICU
19.03.2012 Kurunegala Teaching Hospital Accident Service ICU
20.03.2012 Kuliyapitiya Base Hospital General ICU
20.03.2012 Chilaw Base Hospital General ICU
21.03.2012 Nawalapitiya Base Hospital General ICU
23.03.2012 National Hospital of Sri Lanka Neuro Surgery ICU
23.03.2012 National Hospital of Sri Lanka Cardio Thoracic ICU
27.03.2012 Batticaloa Teaching Hospital Medical ICU
27.03.2012 Batticaloa Teaching Hospital Surgical ICU
29.03.2012 Ratnapura General Hospital General ICU
02.04.2012 Avissawella Base Hospital General ICU
At each ICU, interviewed the available nurses, doctors,consultants and sisters/nurses in charge.
Based on the paper based surveillance findings and NICEdataset, a minimal dataset for Sri Lanka was designed with
input from the local experts
In the interview showed them the mock ups of the proposedsystem and explained how it would work.
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Feedback on the system was collected from them. Based on their feedback minimal dataset were adapted and
developed a prototype.
Prototype was installed in three ICUs to find out if theproposed system could work in practice.
Prototype
The prototype was a web based system developed with HTML,
Javascript, and PHP and MySQL databases.
Development stages of the prototype
Date version Main changes
29.04.2012 1 As designed
12.05.2012 2 Mandatory fields, Date for daily report,
Date of discharge, Date for midnight report
27.05.2012 3 Added fields to the midnight report
Mandatory fields- The apache diagnosis
26.07.2012 4 Option to send full database
05.09.2012 5 Join admission page one and two
Add new fields to dataset
15.09.2012 6 Change daily item page and discharge page
27.09.2012 6.1 Name of the nurse and doctor included in all
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the forms
29.09.2012 6.2 Corrected the error of admission page 2missing
03.10.2012 7 Removed some fields in discharge form
24.10.2012 7.1 24 report alert on home page in bright red
color
03.11.2012 7.2 Add some fields to daily items report
01.11.2012 8.1 Add some fields to daily items report
Software requirement specification and design documents
These documents necessary for the NICS software were finalized by
Respere Lanka in working closely with Department of MedicalInformatics of the University of Amsterdam and the NICS Team.
ICTA (Information and Communication Technology Agency of Sri
Lanka)
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Facilitated funding for the software developer and to provideNICS with methodology, quality assurance and project
management support to deliver the product. Also provided
support to obtain Lanka Government Community Cloud (secure
database), initiated the SLCERT process and is expected to
facilitate the maintenance arrangement.
Mr Wasantha Deshapriya, Director, Re-engineering GovernmentProgramme, Mr Shriyananda Rathanayake (Project Manager)
were responsible for initiation, oversight and delivery of the NICS
software project on behalf of the ICTA.
Professor P. W. Epasinghe, Chairman of ICTA, was behind the far-sighted decision to provide the ICTA umbrella, guidance and
financing for the project.
We wish to note our appreciation for their essential contribution.
Respere
Respere Lanka is the software company chosen by the ICTA to
develop the NICS software. They have worked closely with NICS from
the conception stage of the prototype to the development and
maintenance of the definitive NICS software. They worked very
closely with NICE, NICS and ICTA.
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Darmendra Pradeeper, Joseph Priyanga Fonseka, Mifan Careem and
their team are responsible for the past and current contributions
from Respere.
NICS Software development
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NICS software
The definitive NICS software was built by Respere Lanka using the
prototype and the SRS/design documentation. NICE and NICS
provided the methodological, feasibility and scientific input needed.
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Development versions of the new software
Date Version Main changes
19.02.2013 1 Compulsory- 24 hour report
Adjust minimum & maximum values of data
21.02.2013 2 Changes in discharge & daily forms
05.03.2013 3 Slowness of the system was corrected
Changes in daily form
20.05.2013 4 Conversion of units of measurements using
radio buttons (Body temperature)
18.04.2013 5 Validation from admin side
22.04.2013 6 Corrected the error with data synchronization
21.05.2013 7 Corrected bugs, errors, spelling issues
27.06.2013 8 ICU roster for contact
02.07.2013 9 Help menu
18.07.2013 10 Staging of NICS for test data
12.08.2013 11 Increase the time out for the synchronization
process
21.08.2013 12 Corrected the issue of not saving daily reports
Corrected the issue of unloading APACHE II
drop down menu
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Software maintenance needs
The NICS software maintenance and development is a cyclical
process. Troubleshooting and maintenance needs of the software are
provided by a two-tier approach.
Training, basic troubleshooting, and simple maintenanceExpected to be undertaken by a NICS team. This area is being
currently restructured. Dilshan Jayaratne, Nuwan Jayaratne,
Manoj Amaratunga were handling this area but with the software
moving to the maintenance phase, the latter two are no longer
with NICS.
Advanced troubleshooting and maintenance of the NICS softwareis handled by the Respere team.
Maintenance issues
The common issues handled on a day-to-day basis relating to the
software and associated hardware/connectivity requirements are
listed below.
1. Internet connection issues Solution provided by Sri Lanka Telecom (ADSL) and mobile
phone network providers (USB dongles)
Solved by NICS and SLT Reloads for mobile broadband
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2. Software issues Viewed by TEAM VIEWER- remote desktop application Solved by technical officers at NICS Advanced issues handled by Respere
3. Computer issues Troubleshoot remotely by NICS team Repair computers by Tektron, our PC provider. Replace computers using courier services to minimize down
time.
4. User Training NICS conducts user training for all staff at ICUs by remote
methods as well as scheduled local traning sessions.
Apart from this, special training is given when requests arisefrom ICU staff (at the ICU or through team viewer).
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4.4 Challenges and future software development
1. Data connection abuse ICU staff have been to a large extentvery cooperative in protecting the data connection and usage
allowances. We have deployed methods to reinforce the message
and requirements when needed.
SLT usage meter Follow up of usage by NICS
2. Levels of access to datalevels of user privilege to access data asneeded will be developed.
3. Data definitions are to be uploaded to help to improve datavalidity. Help menu in NICS software is now ready and will be
deployed shortly.
4. ICU facilities and difficulty reporting system is now live This willallow these critical matters to be conveyed to the Ministry to
allow timely action. This two way process will breed trust and
make the ICUs appreciate the usefulness of the system thus
enforcing the process.
5. Data validation processes are being developed to improve dataquality. They involve both horizontal and vertical data validation
methods.
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SECTION 5
ICU Bed Availability System
5.1 Current practice
PCV
.
denugue shock
. ICU
.
Dr. Janaka
Kegalle hospital ICU
?
Sorry doctor
beds full
Sorry Doctor
ICU
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5.3 Aims of the ICU bed availability system
Provide a reliable island wide 24/7 ICU bed availability system foradult and paediatric critical care patients.
5.4 Benefits
For patients:
Reduced morbidity and mortality due to-
More chances of finding an ICU-bed quickly Ability to find an appropriate ICU for the requirementIncreased satisfaction of patients and careers
Improved quality of life
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For service providers:
Minimize wastage of time Survival monitoring system Capacity development Improvement of ICU facilities A mechanism to inform break-downs Easy retrieval of past records Quicker communication of patient issues
For the health system:
Evaluation of performance A forum for resource allocation Research and audit Can be utilized to evaluate costing A model for other developing countries
5.5 Methodology
Bed updates will be obtained, from each ICU in the NICS networkthrough the NICS software three times a day; 1000, 1700 and
2400 (midnight).
If the bed update is not received from the ICU at the specifiedtime a telephone bed update will be obtained
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Any Doctor in a state Hospital requiring an ICU bed for a patientcan contact NICS hotline on 112679039
The following information will be obtained from the Doctor Name of the Doctor Contact details of the Doctor Location of patient; Hospital, ward/clinic, Hospital telephone number Name of the patient Type of ICU bed required- adult/paediatric/specialist
The system will be used to determine the three closest availableICU beds based on the last bed update with age group and
speciality requested also considered.
The Doctor will be contacted through the Hospital telephonesystem and provided with the three locations and their telephone
numbers.
The Doctor will be informed that this does not guarantee a bedbeing available (local circumstances may have changed) or that
the ICU has accepted the patient.
It will be clarified that they would have to discuss the patient withthe ICU Consultant.
Two hours after the bed request the Doctor/Ward/Hospital willbe contacted again to determine whether the patient was being
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transferred; if being transferred the destination will be
requested. If not being transferred, reason for this would be
inquired- no bed available, patient died, patient not accepted by
ICU etc
If patient has been transferred to an ICU, 8 hours after theinitial call, the particular ICU will be contacted to determine
the arrival time of the patient.
5.6 Few points to note:
NICS will NOT allocate any ICU beds. NICS will NOT guarantee/ promise any ICU beds. ICUs can close and reserve their beds as per local needs; NICS will
NOT question this.
ICU Consultants can decline or accept patients based on clinicalsituation; NICS will not interfere with this.
NICS will not provide information to the private sector. The performance, strengths and weaknesses will be evaluated by
the NICS steering committee.
The bed availability mechanism is implemented by
The National Intensive Care Surveillance under Director Tertiary Care
Services, Ministry of Health.
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5.7 Pre-testing of bed availability system
Six rounds of pre-tests conducted 26thFebruary 2013 and 01stof March 2013. Over the phone the ICUs were contacted Bed-related updates were taken. This data was compared with the data available in the database
of the NICS.
Results
The proportion of ICUs sending the updates
The validity of data - 61% to 70%
Recommendations
Bed availability system could be launched with the scheduled time.
0%
10%
20%
30%
40%
50%
6:00 PM 10:00 AM Midnight
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SECTION 6
Evaluation and Future
6.1 Challenges
NICS has been a successful and pioneering collaboration with the
objective of improving ICU services in Sri Lanka. Moving forward
there is an opportunity to contribute to further enhance critical care
in this country and to allow Sri Lanka to be seen as a role model to
improve ICU services in a developing world country.
The process will inevitably face challenges, both internal and external.
Benchmarking of ICUs is a complicated process that will inevitably
lead to controversy, debate and vested interests. The process isunlikely to be straightforward and likely to be emotially charged.
However, if ICU services need to be improved and this valuable and
very expensive resource is to be utilized in a manner which will best
benefit patients of this country, then this process is essential.
6.2 Evaluation
The NICS process needs to be evaluated to see how far the objectives
are being achieved. Our annual report will provide internal quality
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control data but an external independent evaluation, as agreed by
the Steering committee, is needed.
6.3 The future
Work closely with all stakeholders to achieve NICS objectiveswhile ensuring the stakeholders have ownership
Ensure that stakeholder objectives are met to ensuresustainability
Ensure that individual ICUs feel that they have some tangibleearly benefit from the process to improve data compliance and
participation.
Ensure the sustainability of NICS in terms of funding and staffing Secretary Health has assured that this is important for the
Ministry.
Contribute to development of critical care epidemiology Document and publish methodology, implementation and
findings of NICS to improve awareness and help other developing
countries.
Obtain funding from agencies to undertake other serviceimprovement strategies through NICS eg auditing clinical
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guideline and bundle compliance, conduct targeted training
programs to reduce ICU complications etc.
Make ICU bed service 24/7. ICU bed system being now active! Secretary, Health has declared this a priority.
Develop and sustain an audit and research team at NICS Modify dataset for neonatal system and recruit neonatal ICUs Recruit remaining adult and paediatric ICUs Secretary, Health
has instructed to achieve this.
Secure MO (Bio informatics) and general to NICS- Secretary,Health has instructed this.
Encourage medical staff to use system by providing more clinicalapplicability system under development and will be rolled out
gradually.
Enhance training of Doctors and nursing staff- clinical, IT and inuse of NICS system.
Develop and implement 2 way validation system through NICS toimprove data quality
Data validation visits to assess quality of ICU data
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References
1. Central bank of Sri Lanka. Annual Report 2012. 2012.
2. De Silva AP, Haniffa R. A Survey Report on Intensive Care
Units of The Government Hospitals in Sri Lanka. 2012.
3. Vincent J-L, Moreno R. Clinical review: scoring systems in the
critically ill. [Internet]. Crit. Care. 2010. page 207. Available
from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2
887099&tool=pmcentrez&rendertype=abstract
Accesed on 12th
October 2013.
3. Firth P, Ttendo S. Intensive care in low-income countries--a
critical need. [Internet]. N. Engl. J. Med. 2012. pages 19746.
Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23171093
Accesed on 12th
October 2013.
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