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Interventions for improving critical care in low- and middle-income countries: a systematic review

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A Publisher Correction to this article was published on 03 June 2024

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Abstract

Purpose

To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs).

Methods

MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions’ effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesised using the Consolidated Framework for Implementation Research.

Results

78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with clinical workflows.

Conclusions

The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.

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Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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Acknowledgements

Guus ten Asbroek assisted with study design and data acquisition; Tiffany Gooden and Layoni Dullawe assisted with data collection. Covidence provided access to their online platform via their LMIC exceptions rate.

Funding

Resources to conduct the study are provided by the Wellcome Flagship Innovations award. (“Collaboration for Research, Implementation and Training in Critical Care in Asia and Africa”, reference 224048/Z/21/Z). Wellcome were not able to support making this paper Open Access in this journal.

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Contributions

All authors contributed to the study conception and design. Material preparation, data collection was performed by DW, SA, AK, PC and AB. Analyses were performed by DW, SA, AR and AB. The first draft of the manuscript was written by DW and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sumaiya Arfin.

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Conflicts of interest

The authors of this research work have no competing interests.

Ethical and regulatory considerations

Risk and harm: This systematic review uses existing data to analyse the effectiveness of quality improvement interventions. No harm is anticipated.

Informed consent

This study is a systematic review and as such does not include patient, provider, or public involvement. The data was collected from already published research. No consent was sought.

Benefits

This study synthesises existing evidence on approaches used, outcome measures employed to estimate effects and the nature of implementation challenges. This evidence will directly inform the design of future QI interventions internationally as part of CCAA (CRIT Care Asia; a Wellcome funded collaboration for registry enabled research, implementation, and training for critical and acute care in Asia and Africa)18. The beneficiaries of these published findings will thus be patients, clinicians, and researchers on critical care units in Asia, Africa and more globally.

Participant confidentiality

This study does not include patient identifiable data. Since all data used for analysis is freely accessible through the registries, no additional measures for data storage need to be taken. All collected data will remain the property of the contributing registries.

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The findings of this study are being disseminated through publication and aim to directly inform the design of future quality improvement interventions.

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Wagstaff, D., Arfin, S., Korver, A. et al. Interventions for improving critical care in low- and middle-income countries: a systematic review. Intensive Care Med 50, 832–848 (2024). https://doi.org/10.1007/s00134-024-07377-9

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