GAP between knowledge and skills for the implementation of the ACCM/PALS septic shock guidelines in India: Is the bridge too far?

Abstract

Objective:To determine whether physicians were aware of and had the skills to implement the American College of Critical Care Medicine/Pediatric Advanced Life Support Course septic shock protocol.Design:A cross-sectional questionnaire survey.Setting:Four academic institutions in Chennai, Manipal, Mangalore, and Trivandrum - cities representing the three southern states of Tamil Nadu, Karnataka, and Kerala, respectively, between February and April 2006.Interventions:Pre and post lecture questions. They were evaluated using 11 questions testing knowledge and 10 questions testing their comfort level in performing interventions related to the initial resuscitation in septic shock.Measurement and Main Result:The ACCM/PALS sepsis guidelines were taught during the PALS course conducted in the four academic institutions. A total of 118 delegates participated, of whom 114 (97%) were pediatricians and four (3%) were anaesthetists. The overall mean number of correct responses for the 11 questions testing knowledge before and after the lecture was 2.1 and 4.07, respectively P=0.001(paired t test). Although, 42% of the respondents (n=50) were aware of the ACCM guidelines, 88% (n=104) did not adhere to it in their practice. A total of 86% (n=101) and 66% (n=78) did not feel comfortable titrating inotropes or intubating in the ED; 78% (n=92) and 67% (n=78), respectively felt that central venous access (CVA) and arterial pressure (AP) monitoring were unimportant in the management of fluid refractory shock. Of the physicians, 20% (n=24) had never intubated a patient, 78% (n=92) had not introduced a central venous catheter, and 76% (n=90) had never introduced an intra-arterial catheter.Conclusions:In view of the lack of skills and suboptimal knowledge, the ACCM/PALS sepsis guidelines may be inappropriate in its current format in the Indian setting. More emphasis needs to be placed on educating community pediatricians with a simpler clinical protocol, which has the potential to save many more children.

Recommendations for sepsis management in resource-limited settings

“…Specific attention was paid to identify clinical evidence on sepsis management originating from resource-limited settings. Based on survey data on the availability of resources to implement the Surviving Sepsis Campaign guidelines and American College of Critical Care Medicine pediatric guidelines in middle- and low-income countries [ 12 – 15 ], scientific evidence was adjusted to resource-limited settings. In addition, expert opinion and clinical experience of the authors in providing sepsis care in middle- and low-income countries was considered.…”

“…The level of scientific evidence (LoE) of each recommendation was classified as high (LoE: A; supported by the results of randomized, controlled trials or meta-analyses), moderate (LoE: B; supported by the results of low-quality randomized controlled trials or high-quality observational studies), low (LoE: C; supported by the results of observational studies) or very low (LoE: D; supported by the results of case series or the opinion of experts). Since extrapolation of evidence from well-resourced to resource-limited countries is problematic given fundamental differences in sepsis epidemiology [ 2 , 4 ], the educational level of health care providers [ 15 , 16 ], health care facilities and resources [ 12 – 15 ], the level of evidence attributed to some recommendations differs from recommendations published by others [ 6 , 7 , 10 ].…”

“…Similar initiatives have been undertaken in children resulting in comparable improvements in outcome [ 10 , 11 ]. Despite their benefits, the Surviving Sepsis Campaign and the American College of Critical Care Medicine pediatric guidelines cannot be implemented in most middle- or low-income countries due to lacking resources [ 12 – 15 ]. This leaves those clinicians caring for the majority of sepsis patients worldwide without standardized and adoptable guidance for sepsis care.…”

Sepsis guideline implementation: benefits, pitfalls and possible solutions

“…Delayed recognition and delayed intravenous fluids and inotropes were also reported, along with a 36 % adherence to pre-PICU care, in a follow-up assessment of treatment guidelines for meningococcemia in the UK [ 15 ]. In India, a survey reported 12 % adherence to the ACCM guidelines among physicians; this low adherence was attributed mostly to lack of skills and knowledge [ 16 ]. Adherence to guidelines has also been poor in other parts of the world, including in Africa, where less than 50 % of the Surviving Sepsis Campaign guidelines were implemented; the predominant reasons were resource-limitations and lack of education [ 7 ].…”

Sepsis guideline implementation: benefits, pitfalls and possible solutions

“…Delayed recognition and delayed intravenous fl uids and inotropes were also reported, along with a 36 % adherence to pre-PICU care, in a follow-up assessment of treatment guidelines for meningococcemia in the UK [15]. In India, a survey reported 12 % adherence to the ACCM guidelines among physicians; this low adherence was attributed mostly to lack of skills and knowledge [16]. Adherence to guidelines has also been poor in other parts of the world, including in Africa, where less than 50 % of the Surviving Sepsis Campaign guidelines were implemented; the predomi nant reasons were resource-limitations and lack of education [7].…”