title: Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country.
abstract: BACKGROUND
  Global Critical Care is attracting increasing attention. At several million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LICs) have a disproportionally greater share of critical illness, and yet critical care facilities are scarce in such settings. Routines utilizing abnormal vital signs to identify critical illness and trigger medical interventions have become common in high-income countries but have not been investigated in LICs. The aim of the study was to assess whether the introduction of a vital signs directed therapy protocol improved acute care and reduced mortality in an Intensive Care Unit (ICU) in Tanzania.
  
  
  RESULTS
  Prospective, before-and-after interventional study in the ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger levels of severely abnormal vital signs and stipulated acute treatment responses was implemented in a four week period using sensitisation, training, job aids, supervision and feedback. Acute treatment of danger signs at admission and during care in the ICU and in-hospital mortality were compared pre and post-implementation using regression models. Danger signs from 447 patients were included: 269 pre-implementation and 178 post-implementation. Acute treatment of danger signs was higher post-implementation (at admission: 72.9% vs 23.1%, p<0.001; in ICU: 16.6% vs 2.9%, p<0.001). A danger sign was five times more likely to be treated post-implementation (Prevalence Ratio (PR) 4.9 (2.9-8.3)). Intravenous fluids were given in response to 35.0% of hypotensive episodes post-implementation, as compared to 4.1% pre-implementation (PR 6.4 (2.5-16.2)). In patients admitted with hypotension, mortality was lower post-implementation (69.2% vs 92.3% p = 0.02) giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality rates were unchanged (49.4% vs 49.8%, p = 0.94).
  
  
  CONCLUSIONS
  The introduction of a vital signs directed therapy protocol improved the acute treatment of abnormal vital signs in an ICU in a low-income country. Mortality rates were reduced for patients with hypotension at admission but not for all patients.
authors.affiliation: Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.|Global Health, Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Tim
authors.initials: T
authors.lastname: Baker
authors.affiliation: Global Health, Health Systems & Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.|Department of Internal Medicine, Nyköping Hospital, Sörmland County Council, Nyköping, Sweden.
authors.forename: Carl Otto
authors.initials: CO
authors.lastname: Schell
authors.affiliation: Department of Anaesthesia and Intensive Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Edwin
authors.initials: E
authors.lastname: Lugazia
authors.affiliation: Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.|Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Jonas
authors.initials: J
authors.lastname: Blixt
authors.affiliation: Department of Anaesthesia and Intensive Care, Muhimbili National Hospital, Dar es Salaam, Tanzania.
authors.forename: Moses
authors.initials: M
authors.lastname: Mulungu
authors.affiliation: Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.|Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.
authors.forename: Markus
authors.initials: M
authors.lastname: Castegren
authors.affiliation: Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden.
authors.forename: Jaran
authors.initials: J
authors.lastname: Eriksen
authors.affiliation: Department of Anaesthesia, Intensive Care and Surgical Services, Karolinska University Hospital, Stockholm, Sweden.|Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: David
authors.initials: D
authors.lastname: Konrad
mesh_terms: D000328:Adult; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007022:Hypotension / Q000401:mortality; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011203:Poverty; D011446:Prospective Studies; D012044:Regression Analysis; D013636:Tanzania; D055986:Vital Signs / Q000502:physiology*