CRITICAL CARE BED SYSTEM FOR SRI LANKA

ICU bed availability system for Sri Lanka

Ministry of Health
2013

 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: info@nicslk.com Website: www.nicslk.com Telephone: +94 112679038, +94 112679039 Twitter: @nicslk

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

Dedicated to; The critically unwell patients of Sri Lanka

NICS Team

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 of Medicine, University of Colombo Nominee, Sri Lanka College of Paediatricians- Dr Srilal de Silva Nominee, Sri Lanka College of Physician Dr M K Ragunathan Nominee, Sri Lanka College of Obstetricians and Gynecologists Prof Hemantha Senanayake President, GMOA Dr 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

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 1.2 ICU bed search: Current practice 1.3 ICU registries 12 19 21

Section 2: National Intensive Care Surveillance 2.1 Objectives 2.2 Benefits to Sri Lanka 2.3 Stakeholders 2.4 Governance 2.5 NICS formation 2.6 Responsibilities of parties as per MOU 2.7 Sequence of events 2.8 Methodology 2.9 NICS network 2.10 NICS data analysis and feedbacks 2.11 NICS staff 29 30 32 34 35 35 37 45 60 65 66

2.12 NICS Funding 2.13 Ethical review 2.14 NICS Challenges 2.15 Summary of Current state of NICS

70 71 73 75

Section 3: NICS Output 3.1 Bed availability system 3.2 Feedback reports from ICU registry of NICS 3.3 Follow up information of ICU patients 3.4 ICU Fault and critical incident reporting system 3.5 Publications 3.6 Information dissemination 3.7 Collaborations 3.8 Training 3.9 Research 76 76 80 81 82 83 85 86 87

Section 4: Software development 4.1 Rationale 4.2 Essential features 4.3 Process of development 4.4 Challenges and future software development Section 5: ICU bed availability system 90 90 95 106

5.1 Current practice 5.2 Bed availability from NICS 5.3 Aims of the ICU bed availability system 5.4 Benefits 5.5 Methodology 5.6 Few points to note 5.7 Pre-testing of bed availability system

108 109 110 110 111 113 114

Section 6: Evaluation and future 6.1 Challenges 6.2 Evaluation 6.3 The future 115 115 116

References Appendix

118

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.

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

1.1 ICU 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.*

Geographic scatter of ICUs in Sri Lanka

Western

Southern
Central Sabaragamuwa Uva North Western North Central Eastern

Majority (>90%) of in-patient health care services to the Sri Lankan population are provided for by state sector hospitals (1).

* Source - NICS

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The distribution of ICU services in the world

The USA has 20 ICU beds per 100,000 populations . Europe has 5.3829.2 ICU beds per 100,000 populations. 100,000 populations. Australia has 8 ICU beds per 100,000 populations.

Mongolia has 9.8 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 populations.

Sri Lanka

2.5 ICU beds per 100,000 population 13 ICU beds per 1000 hospital beds

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ICU categories in Sri Lanka

45 40 35 30 25 20 15 10 5 0 GICU MICU SICU PICU Special ICU

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

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Outcomes of Sri Lankan state ICUs

40000 30000 20000 10000 Deaths 0 2010 2011 Admissions

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

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Services available in Sri Lankan ICUs (n=99)2 Services Physiotherapy Electrocardiogram (24/7) Radiology (portable X ray 24/7) Dietician/ Diet Clark Cleaning staff- dedicated to ICU Bio medical technician No. ICUs 91 74 81 88 78 02

ICU facility profile (n=99) 2 Facilities Air conditioning Backup generator Compressed air Blood gas machine Wall suction No. ICUs 96 97 88 65 64

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Equipment available (per 100 beds) 2 Equipment Ventilators Infusion/syringe pumps ECG Monitoring Invasive arterial pressure Capnography Central Venous Pressure (Electronic) Cardiac output monitoring Availability 91 309 103 39 33 27 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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1.2 ICU bed search: Current practice There has been no national ICU bed availability system in Sri Lanka thus far. When an ICU bed is needed the relevant Doctor (intern or registrar) checks the local Hospital ICU. If the local ICU is full the Doctor will have to find an ICU bed elsewhere. 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 search for an ICU bed.

Problems with current ICU bed searching method Several hours are spent in finding an ICU bed. Many randomly directed 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 in treatment of head injuries, cardiac arrests and other illnesses.

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The patient awaiting transfer to an ICU bed will often have suboptimal critical care.

Patients arrive at ICUs after a long wait for transfer and in a worse condition.

Many hours of Doctors time spent looking for beds Very stressful for health care providers ICUs receive random phone calls from staff looking for beds causing disruption.

By critically ill patients remaining in the ward/theatre/OPD awaiting transfer, the care for remaining patients is

compromised. Patients are transferred to remote Hospitals when nearby beds may have been available. This inconveniences patients and their relatives. Encourages Hospitals to unnecessarily close/reserve available beds in case a need arises. The actual demand for ICU beds is concealed from the Health care professionals and health care planners. This prevents targeted action to improve circumstances. Increases health care costs.

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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!

1.3 ICU registries ICU 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 and internationally 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 in 2002)

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 patient ratios

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-middle income countries are of uncertain use in developing countries. Methodologies from high-income countries cannot be directly transplanted to low-income countries. Clinical critical care scoring systems are used for categorization and 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-poor settings do not currently exist.

Parameters requiring advanced laboratory support are not commonly available in a low-middle income setting.

Some diagnoses which are common in these settings (eg: snake bites) are not usually accommodated in the existing models.

When used in conjunction with valid scoring systems and aggregated 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 is comprehensive, structured and sustainable.

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Working with international experts and organizations in establishing 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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SECTION 2 National Intensive Care Surveillance

2.1 Objectives 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 ICU facilities and functional status reporting. Standardization of ICUs protocols, 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 beds 2. Plan and allocate equipment 3. Plan and allocate expensive medications 4. 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 care 1. Audit of ICU patient outcomes - morbidity and mortality 2. ICU feedback on compliance with national and international ICU clinical guidelines 3. Detect clinical and resource problems of ICUs early to take corrective action outbreak of infection, equipment malfunction etc 4. Help ICUs understand areas for improvement and

development. Encourage and reinforce positive clinical or management policies of individual ICUs.

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Improve cost effectiveness of critical care by carrying out economic analysis of staff and resource use.

Capacity building of critical care personnel and facilitate critical care training for ICU staff by identifying training needs of 1. Doctors 2. Nurses 3. Physiotherapists etc

Development of critical care epidemiology capacity 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 professionals for 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 Medicine Research Unit

32

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 Clinical Registry) 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 of Medicine, University of Colombo Nominee, Sri Lanka College of Paediatricians- Dr Srilal de Silva Nominee, Sri Lanka College of Physician Dr M K Ragunathan Nominee, Sri Lanka College of Obstetricians and Gynecologists Prof Hemantha Senanayake President, GMOA Dr Anurudda Padeniya Dr. Rashan Haniffa, Project Coordinator, NICS Organization 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 Definitive location for NICS Office furniture for NICS Staffing by MOH Doctors Solve administrative and logistics issues at Hospitals/ICUs Facilitate Drs / nursing staff at ICUs for NICS data entry Formal training of nurses for NICS Develop prototype Definitive software development Branding of NICS Staffing for NICS (non medical officer) Office equipment- PCs, telephone, fax, Party responsible Ministry of Health (MOH) Ministry of Health Ministry of Health Ministry of Health Ministry of Health Ministry of Health Oxford/Amsterdam Oxford/Amsterdam Oxford/Amsterdam Oxford/Amsterdam Oxford/Amsterdam

35

stationary Temporary office rent at MOH (HEB) Implement NICS in ICUs

Oxford/Amsterdam 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 Oxford/Amsterdam equipment 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) Promoting proposal for developing neonatal system- (extra activity) Formation of NICS steering committee Develop protocols and operating procedures Collaborate with national organisations/ Colleges Collaborate with international organisations Prepare publications Prepare scientific output Oxford/Amsterdam Oxford/Amsterdam Ministry of Health Steering committee MOH/ Oxford/Amsterdam Oxford/Amsterdam MOH/Oxford/Amsterdam 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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38

2011
Jan Feb March April May June July
Completion of National ICU Survey Data collection and validation Report writing

Aug

Com 2 2 2 2 2 2

NICS staffing

NICS staffing

Completion of paper based surveillance Data collection and validation Report writing
GAMPAHA CONSULTANTS INFORMED NORTH EAST CONSULTANTS INFORMED

Deve De Ob

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2011

40

41

2012

42

43

2013

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2.8 Methodology Data 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 data Collected three times per day- 1000, 1700, 0000 (midnight) Bed availability and reservation Ventilator availability Staffing information

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2. Patient data NICS 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

47

3. Daily report- filled daily during ICU stay Assesses organ failure Level of treatment provided on a daily basis

48

4. Discharge report-Filled on the day of discharge or death Status of discharge

49

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 issues the 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 reporting In 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 and adverse 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 issues NICS 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 Software Computer Staff related related S 2 2 2 3 F 2 4 4 5 S 1 0 0 5 F 1 0 2 3 S 1 0 0 2 F 5 S 2

September 1st week 2nd week 3rd week 4th week October 1st week 2nd week 3rd week 4th week

F 5 3 3 3

S 2 0 0 0

F 3 3 6 4

11 5 7 1

11 2

3 3 3 3

0 0 0 0

3 4 6 11

1 1 2 7

1 4 3 4

0 1 1 2

1 1 0 2

0 1 0 2

20 7 16 8 16 8

F=Found, S=Solved

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e. Chasing up missing data NICS Missed data The Director / MS of the hospital List of missed BHT numbers Will inform the record room

Sister in charge ICU/ Consultant in charge ICU

Facilitate the process of obtaining the missing BHTs Enter the missed data to system A nominated nurse in the ICU

3. NICS data validation Data 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

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b. Timed automated reminders For 24-hour forms and daily reports- an alert is visible

c. Manually from NICS centre NICS 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 validation Horizontal 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 any deficiencies.

Hello, we did not receive yesterday admissions

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4. Equipment and infrastructure Equipment and infrastructure have been provided to the ICUs in the network by the National intensive Care Surveillance. A breakdown of equipment is below. Equipment ICUs Desktop computers Dongles SLT direct telephone lines ADSL Modems NICS Software (prototype) NICS Main Software NICS Office Desktop computers SLT direct telephone lines Fax machine Wireless ADSL Modems Dongles Furniture and electric items Number 67 79 57 55 01 01

07 02 01 01 02 03

5. Maintenance The following monthly recurrent expenditure is borne by NICS for staffing, maintenance of equipment and infrastructure.

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Category Staffing at NICS Maintenance of hardware at ICUs Software maintenance SLT telephone bill

SLT ADSL bills Dongle top ups Stationary Travel to ICUs

Recurrent cost Staff member salaries 73 Computers in working condition IT team (currently off-site) Maintain 75 SLT telecom connections including payments for rentals Maintain 50+ ADSL connections Providing top ups when necessary for the dongles in ICUs Travel to ICUs for training, monitoring and trouble shooting

6. Meetings conducted during and after formation of NICS Numerous 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 Ministry of Health Officials Secretary/DGHS/SAS (MS)1 Deputy Director General (MS)I Director Tertiary Care Services Director Information Number of meetings 26 04 32 06

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Director MA/MS Director Planning Partners College of Anaesthesiologists of Sri Lanka Department of Clinical Medicine, Colombo Collaborators ICTA Ceylon College of Physicians Sri Lanka College of Paediatrics Sri Lanka College of Obstetricians Sri Lanka Telecom NICE/AMC Health professionals/organizations Consultant Anaesthetists of ICUs Hospital Directors Consultant Physicians of ICUs Government Medical Officers Association Provincial Directors of Health Services Director NHSL Postgraduate Institute of Medicine Epidemiology Unit Family Health Bureau Non health organizations Mobitel

04 02 16 14 12 08 08 04 08 15 67 47 14 08 05 04 02 05 04 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 Western Province Avissawella Base Hospital Gampaha Base Hospital Gampaha Base Hospital Homagama Base Hospital Horana Base Hospital IDH Angoda Base Hospital Kalubovila Teaching Hospital Kalubovila Teaching Hospital Kaluthara Base Hospital Negambo Provincial General Hospital Negambo Provincial General Hospital NHSL Teaching Hospital NHSL Teaching Hospital NHSL Teaching Hospital NHSL Teaching Hospital Panadura Base Hospital Ragama Teaching Hospital Ragama Teaching Hospital Sri Jayawardhanapura Southern Province Balapitiya Base Hospital Hambanthota Base Hospital Karapitiya Teaching Hospital Karapitiya Teaching Hospital Category GICU MICU SICU G ICU GICU GICU MICU SICU GICU SICU MICU SICU MICU NTICU1 NTICU2 GICU MICU SICU GICU GICU GICU GICU ETCICU

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Matara General Hospital Matara General Hospital Tangalle Base Hospital Central Province Gampola Base Hospital Kandy Teaching Hospital Kandy Teaching Hospital Kandy Teaching Hospital Kandy Teaching Hospital Kandy Teaching Hospital Mathale Base Hospital Nawalapitiya District General Hospital Nuwaraeliya General Hospital Peradeniya Teaching Hospital Sabaragamuwa Province Balangoda Base Hospital Embilipitiya Base Hospital Kegalle Teaching Hospital Mawanella Base Hospital Rathnapura Provincial General Hospital Uva Province Badulla District General Hospital Badulla District General Hospital Diyathalawa Base Hospital Mahiyangaya Base Hospital Moneragala DGH North Western Province Chilaw District General Hospital

MICU SICU GICU GICU MICU NSICU1 CTICU SICU NSICU2 GICU GICU GICU GICU GICU GICU GICU GICU GICU SICU MICU GICU GICU GICU MICU

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Chilaw District General Hospital Kuliyapitiya Base Hospital Kurunagala Teaching Hospital Kurunagala Teaching Hospital Kurunagala Teaching Hospital North Central Province Anuradhapura Teaching Hospital Anuradhapura Teaching Hospital Anuradhapura Teaching Hospital Polonnaruwa General Hospital Eastern Province Kalmunai Base hospital Batticaloa Teaching hospital Batticaloa Teaching hospital Kanthale DGH Trincomalee District General Hospital Northern Province Jaffna Teaching Hospital Jaffna Teaching Hospital Mannar Base Hospital Vauniya District General Hospital

SICU GICU GICU ASICU MICU SICU MICU NSICU GICU GICU GICU GICU GICU GICU SICU MICU GICU GICU

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Paediatric ICUs ICU Western Province Maharagama Cancer hospital Lady Ridgeway Childrens Hospital Southern Province Karapitiya Teaching Hospital Central Province Kandy Teaching Hospital Sirimavo Bandaranayake Childrens Hospital Sirimavo Bandaranayake Childrens Hospital North Western Province Kurunegala Teaching Hospital North Central Province Anuradhapura Teaching Hospital Category PICU MICU PICU PICU SICU MICU PICU PICU

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2.10 NICS data analysis and feedbacks 1. Weekly report ICU activity is summarised using weekly report in the form of the Weekly epidemiological review of the Epidemiology Unit. Contents (at section 3) Delivered to: 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. Quarterly reports ICU performance individually is reviewed by quarterly reports every 3 months. Individual ICU performance and ICU performances in the context of similar ICUs, the region and nationally. Contents (at section 3) Delivered to: Consultant in charge of the ICU Director of the hospital

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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 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 to local 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. NICS activities with ICUs, Hospitals and

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 ensure the IT component of NICS functions smoothly.

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Ensure all hardware and software components are updated and system integrity is maintained.

Troubleshoot any hardware, software issues utilising the local personnel/research assistants as resource persons while liaising with local IT collaborator/AMC as needed.

Implement an IT/data protection/ data governance plan for NICS

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 utilised for equipment, staffing and recurrent costs

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MORU (Oxford) are committed to contributing to sustainability as 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 to scientifically and accurately document the process the

scientifically to benefit Sri Lanka and elsewhere. NICS provides an opportunity to answer important ICU questions which 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 to ensure expansion and sustainability. This is similar to other registries. This activity has been explicitly declared and agreed in the MOU signed 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 were before the formation of NICS but are significant as they have led to its formation and provide justification.

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EC- 10-135 A Descriptive study on critically ill patients admitted to intensive care units in Sri Lanka

EC-11-175 Profile of ICU patients in a several districts in Sri Lanka and feasibility of validating basic prognostic models.

EC-13-090 The effect of a structured nurse focused practical ICU training course on the knowledge, attitudes and skills of critical care nurses in Sri Lanka.

EC-11-175 Validation of APACHE II and other severity scoring systems in Sri Lankan critical care settings

EC-11-175 A 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-11-175 Gather 30 day outcome for patients discharged from state ICU for surveillance purposes- as part of National Intensive Care Surveillance System

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EC- 12-087 The effectiveness of ventilator care bundles in reducing morbidity and mortality due to ventilator associated pneumonia in critical care units - Dr Kumudini Ranatunga et al

EC-13-021

The physiotherapy services of ICUs in Sri Lanka a cross sectional survey with the Government Physiotherapy Association

2.14 NICS challenges Multiple stakeholders Staffing in ICUs Computer literacy Compliance Sustainability Data security

NICS
Will store data in a secure Sri Lankan Government database with the best available security. Will work with our participants, partners and collaborators to improve methodology, processes and technology Will work with stakeholders to improve critical care audit and research processes, subject to ethical approval and due process

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NICS is
NOT a tool to discipline/question anyone NOT an individuals research DOES NOT analyze 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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2.15 Summary of current state of NICS 73 ICUs currently connected to the network Support of all stakeholders obtained New software system developed under ICTA guidance and deployed NICS database in Lanka Government Community Cloud (LGCC), a secure cloud under ICTA supervision Weekly and Quarterly ICU performance reports prepared for each ICU and provided ICU bed availability system ready to function 24/7- System ready since March 2013 Arranged national and regional training days for ICU staff Expanded to Northern and Eastern provinces Deployed system in most pediatric ICUs 30 day follow up services was commenced Dedicated paediatric dataset being incorporated in software. Diagnostic coding system being upgraded to Read CTV3. Software is being made more clinically useful- can print discharge summary, can view ICU summary etc.

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SECTION 3 NICS Output

3.1 Bed availability system The 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.

3.2 Feedback reports from the ICU registry of NICS NICS 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 the period-per unit and regionally.

Logistics issues overview related NICS- connectivity, software issues, 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 in relation to the regional and country profile. A detailed analysis of the severity of illness and outcomes of patients admitted to the ICU An analysis of the 30 day follows up data for the individual ICU and in the national context (see below). A detailed analysis of the quality indicators pertaining to the relevant ICU Benchmarking of the ICUs on the basis of quality indicators in relation 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 ICU as part of the NICS network

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3. Annual report The annual report will be designed for all ICUs and for the consumption 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 ICUs will be incomplete without understanding the difficulties encountered by these ICUs. Clinicians and nurses working in these ICUs during feedback sessions 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 stock medications, lack of reagents for blood gas machines, issues with staffing etc. Adverse events in the ICU, such as drug errors, equipment malfunction 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 feedback received

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 / RagamaInformation 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 of Medicine, University of Colombo Information on acute kidney disease in ICU patients.

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c. Dr. Bimal Kudavidanage, Anuradhapura Teaching Hospital ICU patients details of Anuradapura Teaching Hospital Summary of data compliance and quality in Anuradapura ICUs Characteristics of patients in these ICUs Morbidity & mortality data of these ICUs

3. 7 Collaborations 1. Post Basic College of Nursing - Nurse Intensive Care Skills Training, as below 2. Deputy Director General (Education Training & Research) Nurse Intensive 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 ICU physiotherapists and workshop on physiotherapy skills training.

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3.8 Training Facilitating training program for ICU staff: 1. Nurses Basic IT training and NICS software skills training for ICU nurses- 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 association with 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 Physiotherapy

Association 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.

3.9 Research 1. Completed A Descriptive study on critically ill patients admitted to intensive care units in Sri Lanka The physiotherapy services of ICUs in Sri Lanka a cross sectional survey with the Government Physiotherapy Association. Profile of ICU patients in a semi urban population in Sri Lanka and feasibility of validating basic prognostic models. The effect of a structured nurse focused practical ICU training course on the knowledge, attitudes and skills of critical care nurses in Sri Lanka. Feasibility and conduct of ICU case mix description in post conflict areas by a paper based surveillance system The effect of a structured physiotherapist focused ICU training 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 reducing morbidity and mortality due to ventilator associated pneumonia in critical care units - Dr Kumudini Ranatunga et al. Gather 30 day outcome for patients discharged from state ICU for surveillance purposes- as part of National Intensive Care Surveillance System Validation of APACHE II and other severity scoring systems in Sri Lankan critical care setting

3. Proposed Development and validation of model for estimation of body mass index using waist and hip circumference- awaiting ethical clearance. Effect of BMI on intensive care morbidity and mortality- a collaborative study, awaiting ethical clearance. A cross sectional survey of junior doctors working in ICUs on training 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

4.1 Rationale The 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.

4.2 Essential features We 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 on conversations 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 the software eg 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 validation processes- 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 initially designed 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 system and how it will provide that functionality. The SRS document was further developed with input from the local 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 the Dutch 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 versions taking on board changing requirements, user feedback and methodological needs.

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The ICTA took the NICS software development under their wing to provide funding for the project, project management, oversight and ensure compliance with national and international standards.

The software design document was then prepared by Respere Lanka 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 then developed 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 Project Steering 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 budget thanks 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 and collaborative 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 any concerns 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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4.3 The process of development NICE (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 at Ministry of Health and elsewhere

Providing researchers to develop the software and other operating procedures for NICS

Helping with the software algorithms necessary for feedback processes

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 and the English Emergency bed service were analyzed by using document archaeology. The founder, a developer and a user of the Dutch system were interviewed. Based on functionality of these western bed availability systems and interviews the mock ups of the Sri Lankan system were created. 12 of Sri Lankan ICUs were visited, which were situated in 6 provinces of the country.

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Date 19.03.2012 19.03.2012 19.03.2012 20.03.2012 20.03.2012 21.03.2012 23.03.2012 23.03.2012 27.03.2012 27.03.2012 29.03.2012 02.04.2012

Hospital Kurunegala Teaching Hospital Kurunegala Teaching Hospital Kurunegala Teaching Hospital Kuliyapitiya Base Hospital Chilaw Base Hospital Nawalapitiya Base Hospital National Hospital of Sri Lanka National Hospital of Sri Lanka Batticaloa Teaching Hospital Batticaloa Teaching Hospital Ratnapura General Hospital Avissawella Base Hospital

ICU General ICU Paediatric ICU Accident Service ICU General ICU General ICU General ICU Neuro Surgery ICU Cardio Thoracic ICU Medical ICU Surgical ICU General ICU General ICU

At each ICU, interviewed the available nurses, doctors, consultants and sisters/nurses in charge.

Based on the paper based surveillance findings and NICE dataset, a minimal dataset for Sri Lanka was designed with input from the local experts

In the interview showed them the mock ups of the proposed system 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 the proposed 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 29.04.2012 12.05.2012 version 1 2 Main changes As designed 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 05.09.2012 4 5 Option to send full database Join admission page one and two Add new fields to dataset 15.09.2012 27.09.2012 6 6.1 Change daily item page and discharge page 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 2 missing 03.10.2012 24.10.2012 7 7.1 Removed some fields in discharge form 24 report alert on home page in bright red color 03.11.2012 01.11.2012 7.2 8.1 Add some fields to daily items report 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 Medical Informatics 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 provide NICS 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 Government Programme, 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 farsighted 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 19.02.2013 Version 1 Main changes Compulsory- 24 hour report Adjust minimum & maximum values of data 21.02.2013 05.03.2013 2 3 Changes in discharge & daily forms 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 22.04.2013 21.05.2013 27.06.2013 02.07.2013 18.07.2013 12.08.2013 5 6 7 8 9 10 11 Validation from admin side Corrected the error with data synchronization Corrected bugs, errors, spelling issues ICU roster for contact Help menu Staging of NICS for test data 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 maintenance Expected 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 software is 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 arise from 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 extent very 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 data levels of user privilege to access data as needed will be developed. 3. Data definitions are to be uploaded to help to improve data validity. Help menu in NICS software is now ready and will be deployed shortly. 4. ICU facilities and difficulty reporting system is now live This will allow 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 data quality. They involve both horizontal and vertical data validation methods.

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6. The software is being made more clinically useful for ICU staff to aid the day-to-day management of ICU patients and allow ICU consultants remote access to their patient data.

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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 ICU

Sorry beds full

doctor

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5.2 Bed availability from NICS

PCV . denugue shock . ICU .

Dr. Janaka Kegalle hospital , ward number 02 30 dengue patient shock hospital ICU beds ICU beds hospital ?

Doctor ICU bed Mawanella GICU , Matale GICU & Kuliyapitiya GICU . 109

5.3 Aims of the ICU bed availability system Provide a reliable island wide 24/7 ICU bed availability system for adult 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 requirement Increased 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 network through the NICS software three times a day; 1000, 1700 and 2400 (midnight). If the bed update is not received from the ICU at the specified time a telephone bed update will be obtained

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Any Doctor in a state Hospital requiring an ICU bed for a patient can 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 available ICU beds based on the last bed update with age group and speciality requested also considered.

The Doctor will be contacted through the Hospital telephone system and provided with the three locations and their telephone numbers.

The Doctor will be informed that this does not guarantee a bed being 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 with the ICU Consultant.

Two hours after the bed request the Doctor/Ward/Hospital will be 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 the initial 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 clinical situation; 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 26th February 2013 and 01st of 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

50% 40% 30%

20%
10% 0%

6:00 PM

10:00 AM

Midnight

The validity of data - 61% to 70%

Recommendations Bed availability system could be launched with the scheduled time.

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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 is unlikely 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 objectives while ensuring the stakeholders have ownership Ensure that stakeholder objectives are met to ensure sustainability Ensure that individual ICUs feel that they have some tangible early 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 service improvement 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 clinical applicability system under development and will be rolled out gradually. Enhance training of Doctors and nursing staff- clinical, IT and in use of NICS system. Develop and implement 2 way validation system through NICS to improve 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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