critical care bed system for sri lanka

8/12/2019 CRITICAL CARE BED SYSTEM FOR SRI LANKA

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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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