Date Published: June 13, 2019
Publisher: Public Library of Science
Author(s): Lia I. Losonczy, Sean L. Barnes, Shiping Liu, Sarah R. Williams, Michael T. McCurdy, Vivienne Lemos, Jerry Chandler, L. Nathalie Colas, Marc E. Augustin, Alfred Papali, Lars-Peter Kamolz.
Critical illness affects health systems globally, but low- and middle-income countries (LMICs) bear a disproportionate burden. Due to a paucity of data, the capacity to care for critically ill patients in LMICs is largely unknown. Haiti has the lowest health indices in the Western Hemisphere. In this study, we report results of the first known nationwide survey of critical care capacity in Haiti.
Nationwide, cross-sectional survey of Haitian hospitals in 2017–2018.
All Haitian health facilities with at least six hospital beds.
Electronic- and paper-based survey.
Of 51 health facilities identified, 39 (76.5%) from all ten Haitian administrative departments completed the survey, reporting 124 reported ICU beds nationally. Of facilities without an ICU, 20 (83.3%) care for critically ill patients in the emergency department. There is capacity to ventilate 62 patients nationally within ICUs and six patients outside of the ICU. One-third of facilities with ICUs report formal critical care training for their physicians. Only five facilities met criteria for a Level 1 ICU as defined by the World Federation of Societies of Intensive and Critical Care Medicine. Self-identified barriers to providing more effective critical care services include lack of physical space for critically ill patients, lack of equipment, and few formally trained physicians and nurses.
Despite a high demand for critical care services in Haiti, current capacity remains insufficient to meet need. A significant amount of critical care in Haiti is provided outside of the ICU, highlighting the important overlap between emergency and critical care medicine in LMICs. Many ICUs in Haiti lack basic components for critical care delivery. Streamlining critical care services through protocol development, education, and training may improve important clinical outcomes.
Critical illness affects health systems across the world, but low- and middle-income countries (LMICs) bear a disproportionate burden . Due to a paucity of data, however, the capacity to care for critically ill patients in LMIC settings is largely unknown. In a recent systematic review, only 15 of 36 low-income countries had any published data regarding their ICU capacity . Only two low-income countries, Nepal and Uganda, had national critical care capacity statistics .
We conducted a cross-sectional nationwide survey of Haitian hospitals in 2017–2018. The study was approved by the St. Luke Hospital (Port-au-Prince, Haiti) Ethics Committee. Consent was not obtained by survey participants as the data were analyzed anonymously.
Of 53 health facilities identified and 48 with accurate contact information, 38 (79.2%) from all ten Haitian administrative departments completed the survey. Facility demographics are shown in Table 1. All facilities, including those that reported no ICU, reported caring for critically ill patients with a median of 12 (IQR 6–50) critically ill patients per week. Of hospitals without an ICU, 19 (82.6%) care for critically ill patients in the ED, five (21.7%) in a general medical ward, two (8.7%) in a postoperative ward, and four (17.4%) in other areas. For all facilities, only eight (21.1%) reported formal emergency or critical care training for physicians, and only five (13.2%) for nurses.
The major finding of our nationwide survey of Haitian critical care is that current capacity remains insufficient to meet need. A significant, country-wide demand for critical care services exists at baseline, with regional demand likely increasing significantly during natural disasters and epidemics. The general paucity of ICU beds, equipment, professional training, and material resources is similar to findings from other LMICs. For a country of over 10 million people, our study estimates a total of 124 ICU beds. By comparison to other low-income countries, Uganda has 10 beds and Nepal has 167 beds per 10 million people , whereas Sri Lanka (a lower middle-income country) has 250 beds , South Africa (an upper middle-income country) has 957 beds  and the United States (a high-income country) has 3,125 beds per 10 million people [17, 18]. Unfortunately, there is no “magic number” of ICU beds to provide optimal critical care services, as diverse economic, cultural, and political values shape national and regional opinions on the benefits of—and even the very necessity of—critical care services. For low-income countries, such as Haiti, much more national-level data are required to help inform political and financial stakeholders, who must weigh innumerable competing priorities before allocating scarce funding to critical care services, which many consider expensive.
The global critical care movement is rapidly advancing knowledge of the epidemiology and outcomes of critically ill patients in LMICs. To date, no comprehensive evaluation of critical care in Haiti has been performed. This study provides an important first look at critical care capacity in Haiti and establishes a baseline from which academicians, health facilities, and governmental and non-governmental organizations can coordinate an integrated and organized approach moving forward.