A “three delays” model for severe sepsis in resource-limited countries☆,☆☆,★
Introduction
Severe sepsis is a global phenomenon affecting high- and low-income countries alike; however, the developing world carries the greatest burden of sepsis-related mortality [1]. A recent audit of 730 intensive care units (ICUs) from 84 countries spanning 9 geographic regions across the world demonstrated in-hospital mortality among septic patients as high as 47.2% in Africa compared with 13.1% in North America [2]. Studies from individual nations paint a stark picture, with sepsis-related mortality ranging from 43% among hospitalized patients in Uganda [3], to nearly 50% in Thailand [4], to as high as 87% among ICU patients in Turkey [5]. Thus far, global health organizations have given priority to primary care, prevention, and public health. Now efforts are underway to improve cooperation, facilitate research, and build a greater focus on severe sepsis in the broader context of the acute care movement [6], [7].
The management of severe sepsis in developed countries has undergone revolutionary transformation in the past decade [8], [9], [10], [11], but similar improvements in the developing world have not yet occurred. New international sepsis management guidelines call for resource-intensive methodologies impractical in most developing countries [12]. Moreover, most investigations from resource-constrained environments highlight limitations in institutional and human resources rather than protocol development. However, a recent prospective study demonstrating a 12.7% reduction in mortality rate with early intervention using noninvasive techniques in severely septic adults in Uganda [13] indicates the incredible potential impact of further research in this area. Developing sustainable models for the diagnosis and management of severe sepsis in resource-limited environments should be urgent priorities.
A “three delays” model has been developed to describe factors influencing perinatal mortality in developing nations [14]. This model suggests that maternal mortality is influenced by (1) a delay in patient recognition of an obstetric emergency, (2) a delay in the patient reaching a medical facility, and (3) a delay in receiving appropriate and timely medical intervention after arrival to the facility. The three delays model has been validated across different World Health Organization (WHO) regions [15], [16], [17] and has provided the framework for policymakers to plan targeted interventions and provide uniform monitoring indicators [18].
We propose a three delays model for severe sepsis in adults in resource-limited countries (RLCs) using a framework specifically adapted to identify delays in treatment after patients arrive at a medical facility. This model assumes that delays in patients' recognition of severe illness and their arrival at a care facility can be reduced only with national and international efforts that increase health literacy, enhance a country's infrastructure, and provide innovative solutions to prehospital care shortfalls. The model highlights limitations in the three basic pillars of sepsis management (Fig. 1): (1) sepsis recognition and diagnosis at the time of triage, (2) initial focused resuscitation, and (3) postresuscitation clinical monitoring and reassessment. Characterizing these barriers frames the problem in a language common in global health circles and allows for further study of effective, targeted interventions that could streamline treatment of severe sepsis and reduce sepsis-related mortality in the developing world.
Section snippets
Triage and diagnosis
Timely recognition of the critically ill patient is the first and most important step in acute care medicine. In severe sepsis and septic shock, delayed treatment correlates directly to increased mortality [19]. In RLCs, multiple factors including limited training about sepsis, lack of standardized triage protocols, insufficient staffing, and equipment problems conspire to delay effective triage.
Poor training in sepsis recognition is one of the most important of these problems. A multinational
Resuscitation
Multinational efforts over the past 15 years have markedly improved the treatment for septic patients. Cornerstones of resuscitation include the timely administration of intravenous fluids (IVFs), antimicrobials, and oxygen, when needed, and imaging to identify an infectious source. Most hospitals in the developed world use resource-intensive approaches to identify and treat severe sepsis and septic shock; these targeted methods often do not exist in RLC health facilities. These delays in
Monitoring and reassessment
The third pillar of sepsis management, postresuscitation monitoring and reassessment, involves ensuring adequate tissue perfusion, maintaining hemodynamic stability, achieving source control for the culprit infection, and responding appropriately when signs and symptoms suggest clinical decompensation. In developed countries, modern facilities use numerous invasive and resource-intensive modalities to achieve these goals. In resource-poor environments, however, myriad limitations, such as
Building a new paradigm for sepsis care in resource-limited settings
First used to describe factors contributing to maternal mortality in Haiti, the three delays model has provided the reproductive health movement with a common platform applicable to disparate regions of the world [14], [15], [16], [17]. It has created a universal language used widely by academics and policymakers to improve women's health in nonindustrialized settings [18]. Adapting the three delays model for sepsis similarly creates a common language for clinicians from different socioeconomic
Conclusion
The monumental impact of severe sepsis and septic shock suggests the need for a swift and multipronged approach to its management. Specific to countries with limited resources, a multifaceted framework must first be developed to facilitate research, treatment, and management end points germane to these environments, where both human and technological capacity are lacking. Adaptation of the three delays model to address severe sepsis and septic shock provides one pathway that academicians,
Acknowledgments
The authors thank Linda J. Kesselring for her valuable assistance.
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2022, International Emergency NursingCitation Excerpt :Based on a global audit of intensive care units (ICUs), sepsis-related mortality was found to be 47.2% in Africa, compared to 13.1% in North America[3]. Over the past decade, developed countries have seen improvements in sepsis management and outcomes through targeted therapies and implementation of care bundles [2,4]; however, resource-restricted countries have not seen corresponding improvements [3]. Data from various single-nation studies indicate a much higher sepsis-related mortality rate ranging from 43% to 50% in Uganda and Thailand, respectively, and even higher at 87% in Turkey[3].
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Contributors: E.J.B.C. conceived the study. A.P. created the conceptual framework, performed the literature review, and wrote the first draft of the report. M.T.M. and E.J.B.C. revised the report for content. All authors approved the final version of the manuscript.
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Conflicts of interest: We have no competing interests.
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Role of the funding source: We received no funding for this study.