Carl Otto Schell

Introduction: Critical illness is a leading cause of mortality worldwide with the highest burden in low- and middle-income countries. Essential Emergency and Critical Care (EECC) is the foundational, low-cost care needed by all critically ill patients that is feasible to deliver in all health facilities globally. Unfortunately, EECC is often not provided. This study aimed to assess the determinants of non-provision of EECC in primary health care in the United Republic of Tanzania to inform a national EECC scale-up program.Methods: A convergent mixed-methods assessment was conducted in 24 purposively selected health facilities in five regions of mainland Tanzania and Zanzibar. Quantitative resource-readiness and clinical-process assessments were combined with 24 individual interviews and six focus group discussions, and converged using the capability, opportunity, motivation, behavior construct in the Consolidated Framework for Implementation Research: Findings Only 27%-34% of critically ill patients received EECC. Nine determinants of non-provision emerged: gaps in knowledge and skills; inefficient use of staff time; misperceived roles of lower-level facilities; emphasis on advanced care without EECC; poor availability and distribution of resources; oxygen not in place or in use; service organization barriers; low motivation and disincentives to care for the critically ill; and vertical programs determine managers’ priorities.Interpretation: Non-provision of EECC is not primarily an individual failing, but reflects how the foundational care of critical illness is poorly supported and prioritized within the health system, through a self-reinforcing cycle of limited knowledge, weak readiness and system-level acceptance. Strengthening care to reduce preventable mortality necessitates a targeting of context-specific determinants, and an embedding of EECC into health systems and patient management at all levels of health facilities.

Acute pain in hospitalised patients is common, yet African data are scarce. We conducted a prospective point-prevalence study of hospitalised adult patients across Africa to determine acute pain prevalence and severity and investigate associations of pain with critical illness and 7-day mortality. On a single day, investigators assessed patients' worst pain in the preceding 24 hours using a 0 to 10 visual-numerical scale and recorded vital signs. Critical illness was defined as ≥1 vital sign out of range, in line with an international consensus definition. In-hospital mortality was assessed at day 7. Data are presented as median [interquartile range], n (%), and odds ratios with 95% confidence intervals. Between September and December 2023, 19,438 patients from 180 hospitals in 22 African nations were included (age 40 [29; 59] years; 10,874 [56%] female). Pain prevalence [95% CI] was 67.9% [67.9-68.5], with 2795 (14.4%) patients reporting severe pain (≥7/10). Pain was more common among patients admitted for emergency or trauma care and in surgical and high-care wards. Pain severity did not differ meaningfully between sexes. There was no evidence of an association between pain severity and critical illness; however, increasing pain severity was associated with a higher likelihood of 7-day mortality. These findings are comparable to data from high-income countries despite substantial differences in healthcare resources, suggesting that acute pain remains a persistent and underaddressed problem globally. This study provides the first large-scale evidence of acute pain burden in African hospitals and lays a foundation for future research aimed at comprehensively characterising in-hospital pain.

Critical illness leads to millions of preventable deaths each year. Essential Emergency and Critical Care (EECC) is a pragmatic, globally relevant approach designed to address critical gaps in basic life-saving care. This study identified the top ten research priorities to guide the development of EECC over the next five years. At the first global EECC Research Conference in November 2024, 46 clinicians, researchers, and policymakers representing nine predominantly high-income countries participated in a structured priority-setting process. Participants formed four thematic groups focused on the current state, implementation, impact, and refinement of EECC. Throughout five sessions, groups developed sub-themes, generated research questions, and identified key priorities. An anonymous survey was used to rank questions within each theme, followed by a final selection of the top ten. Participants developed 28 research questions across four themes. The final top ten included four on EECC implementation, four on its current state, and two on impact. No top-ranked questions emerged from the refinement theme. The top ten EECC research priorities focused on estimating the burden of critical illness and on implementing programs effectively. Advancing these priorities through collaborative research is essential to strengthen health systems and improve outcomes for critically ill patients globally.

Objective To describe the lessons learnt during the promotion of a new approach to the care of critically ill patients in TanzaniaEssential Emergency and Critical Care (EECC). Design A descriptive qualitative study using thematic analysis of structured interviews. Setting and participants The study was conducted in Tanzania, involving 11 policymakers, researchers and senior clinicians who participated in the promotion of EECC in the country. Findings Five inter-related themes emerged from the promotion of EECC in Tanzania: (1) early and close collaboration with the government and stakeholders; (2) conduct research and use evidence; (3) prioritise advocacy and address misconceptions about EECC; (4) leverage events and embed activities in other health system interventions; and (5) employ a multifaceted implementation strategy. The themes map to the normalisation process theory domains of coherence, cognitive participation, collective action and reflexive monitoring. Conclusion The integration of EECC into Tanzania’s health policy is a result of a multidisciplinary collaboration including government and partners that has used evidence, advocacy and context and included multifaceted implementation strategies. The lessons from Tanzania’s experience provide guidance for adoption in similar settings to improve critical care systems, foster access to care and optimal outcomes for all critically ill patients.

Critical illness leads to millions of preventable deaths each year. Essential Emergency and Critical Care (EECC) is a pragmatic, globally relevant approach designed to address critical gaps in basic life-saving care. This study identified the top ten research priorities to guide the development of EECC over the next five years. At the first global EECC Research Conference in November 2024, 46 clinicians, researchers, and policy makers participated in a structured priority-setting process. Participants formed four thematic groups focused on the current state, implementation, impact, and refinement of EECC. Throughout five sessions, groups developed sub-themes, generated research questions, and identified key priorities. An anonymous survey was used to rank questions within each theme, followed by a final selection of the top ten. Participants developed 28 research questions across four themes. The final top ten included four on EECC implementation, four on its current state, and two on impact. No top-ranked questions emerged from the refinement theme. The top ten EECC research priorities focused on estimating the burden of critical illness and on implementing programs effectively. Advancing these priorities through collaborative research is essential to strengthen health systems and improve outcomes for critically ill patients globally.

Introduction: The burden of critical illness may have been underestimated. Previous analyses have used data from intensive care units (ICUs) only, and there is a lack of evidence about where in hospitals critically ill patients receive care. This study aims to determine the burden of critical illness among adult inpatients across hospitals in different global settings. Methods: We performed a prospective, observational, hospital-based, point prevalence and cohort study in countries of different socioeconomic levels: Malawi, Sri Lanka and Sweden. On specific days, all adult in-patients in the eight study hospitals were examined by the study team for the presence of critical illness and followed up for hospital mortality. Patients with at least one severely deranged vital sign were classified as critically ill. The primary outcomes were the presence of critical illness and 30-day hospital mortality. In addition, we determined where the critically ill patients were being cared for and the association between critical illness and 30-day hospital mortality. Results: Among 3652 hospitalised patients, we found a point prevalence of critical illness of 12.0% (95% CI 11.0 to 13.1), with a hospital mortality of 18.7% (95% CI 15.3 to 22.6). The crude OR of death of critically ill patients compared with non-critically ill patients was 7.5 (95% CI 5.4 to 10.2). Of the critically ill patients, 96.1% (95% CI 93.9 to 97.6) were cared for in the general wards outside ICUs. Conclusions: The study has revealed a substantial burden of critical illness in hospitals from different global settings. One in eight hospital in-patients was critically ill, 19% of the critically ill died in hospital, and 96% of the critically ill patients were cared for outside of ICUs. Implementing the most feasible and low-cost critical care in general wards throughout hospitals would impact a large number of high-risk patients and has the potential to improve outcomes across all acute care specialties.

Background:Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility. Patients of any age can become critically ill due to any underlying diagnosis and in any location. The critically ill patients require urgent support of failing vital organs - critical care - to improve their chance of survival.Substantial unmet needs of critical care have been reported from hospitals both in high- and low-resource settings. Yet, most health policy attention is directed towards the care of specific diagnoses. Moreover, the policy attention in critical care is mostly directed towards advanced technology and high-cost intensive care. To be equitable and effective, however, critical care systems should focus on the most feasible lifesaving interventions - the essential care of critical illness. Such interventions can ensure that patients with critical illness are identified and that they are provided with urgent critical care.There is surprisingly little epidemiological evidence to guide policy makers about the priority of critical illness and health systems require strategies for effective delivery of critical care.Aim:To assess the burden of critical illness in different global settings and to develop, evaluate and reach consensus around strategies to facilitate implementation of essential care of critical illness.Methods:Four studies were conducted in different global settings. To estimate the burden of critical illness, a novel method was applied in prospective point-prevalence and cohort studies in hospitals in Malawi, Sri Lanka and Sweden, and in the population of the whole Sörmland region of Sweden. The Vital-Signs Directed Therapy (VSDT) protocol for task-sharing critical care was implemented in an intensive care unit (ICU) in Tanzania and studied with a before-and-after design. The content of the Essential Emergency and Critical Care (EECC) concept to guide health system priorities, was specified in a large, diverse and global Delphi consensus. Statistical methods included univariate and multivariate regression models and Chi2-tests.Results:Critical illness was found in 12% of all hospital in-patients across the settings. In the substudy in Sörmland region, the population prevalence of critical illness was 19 per 100,000 people. Among hospital in-patients across all setting, critical illness was strongly associated with mortality (OR 7.5) and 19% died in hospital. More than 90% of the critically ill patients were cared for outside ICUs, in low- staffed general wards.Implementation of VSDT increased acute treatments of critical illness and reduced mortality among patients presenting with shock from 92% to 69%, but not among all patients. The specified EECC package contains 40 lifesaving clinical processes that are effective, low-cost and feasible to implement in any hospital ward in the world, and the 66 resources that are required for providing this care.Conclusions:The results challenge three common misconceptions that have substantial consequences for patients around the world. First, critical illness is not uncommon - it is common. Second, critically ill patients are not always in ICUs - most critically ill patients are cared for in low-staffed general wards. Third, critical care is not limited to expensive and technologically sophisticated interventions. The work in this thesis has shown that critical care can be feasible and low-cost to be provided where most critically ill patients are cared for - in low-staffed or low-resourced settings. The findings can be used to inform priorities in health systems so critical care can be provided more effectively and reach more patients. A new focus on essential care of critical illness has potential to reduce mortality across medical disciplines.List of scientific papersI. Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country. Baker T, Schell CO, Lugazia E, Blixt J, Mulungu M, Castegren M, Eriksen J, Konrad D .. PLoS One. 2015 Dec 22;10(12):e0144801. https://doi.org/10.1371/journal.pone.0144801II. The burden of critical illness among adults in a Swedish region-a population-based point-prevalence study. Schell CO, Wellhagen A, Lipcsey M, Kurland L, Bjurling-Sjöberg P, Stålsby Lundborg C, Castegren M, Baker T. European Journal of Medical Research. 2023 Sep 7;28(1):322. https://doi.org/10.1186/s40001-023-01279-0III. The hospital burden of critical illness across global settings: a point-prevalence and cohort study in Malawi, Sri Lanka and Sweden. Carl Otto Schell, Raphael Kayambankadzanja, Abigail Beane, Andreas Wellhagen, Chamira Kodippily, Anna Hvarfner, Grace Banda-Katha, Nalayini Jegathesan, Christoffer Hintze, Wageesha Wijesiriwardana, Martin Gerdin Warnberg, Sujeewa Jayasingha Arachchilage, Mtisunge Kachingwe, Petronella Bjurling-Sjoberg, Iasaac Mbingwani, Annie Kalibwe Mkandawire, Hampus Sjostedt, Wezzie Kumwenda-Mwafulirwa, Surenthirakumaran Rajendra, Odala Kamandani, Cecilia Stalsby Lundborg, Samson Kwazizira Mndolo, Miklos Lipcsey, Rashan Haniffa, Lisa Kurland, Markus Castegren, Tim Baker. [Manuscript]IV. Essential Emergency and Critical Care: a consensus among global clinical experts. Schell CO, Khalid K, Wharton-Smith A, Oliwa J, Sawe HR, Roy N, Sanga A, Marshall JC, Rylance J, Hanson C, Kayambankadzanja RK, Wallis LA, Jirwe M, Baker T; EECC Collaborators. BMJ Glob Health. 2021 Sep;6(9):e006585. https://doi.org/10.1136/bmjgh-2021-006585

Background:Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility. Patients of any age can become critically ill due to any underlying diagnosis and in any location. The critically ill patients require urgent support of failing vital organs - critical care - to improve their chance of survival.Substantial unmet needs of critical care have been reported from hospitals both in high- and low-resource settings. Yet, most health policy attention is directed towards the care of specific diagnoses. Moreover, the policy attention in critical care is mostly directed towards advanced technology and high-cost intensive care. To be equitable and effective, however, critical care systems should focus on the most feasible lifesaving interventions - the essential care of critical illness. Such interventions can ensure that patients with critical illness are identified and that they are provided with urgent critical care.There is surprisingly little epidemiological evidence to guide policy makers about the priority of critical illness and health systems require strategies for effective delivery of critical care.Aim:To assess the burden of critical illness in different global settings and to develop, evaluate and reach consensus around strategies to facilitate implementation of essential care of critical illness.Methods:Four studies were conducted in different global settings. To estimate the burden of critical illness, a novel method was applied in prospective point-prevalence and cohort studies in hospitals in Malawi, Sri Lanka and Sweden, and in the population of the whole Sörmland region of Sweden. The Vital-Signs Directed Therapy (VSDT) protocol for task-sharing critical care was implemented in an intensive care unit (ICU) in Tanzania and studied with a before-and-after design. The content of the Essential Emergency and Critical Care (EECC) concept to guide health system priorities, was specified in a large, diverse and global Delphi consensus. Statistical methods included univariate and multivariate regression models and Chi2-tests.Results:Critical illness was found in 12% of all hospital in-patients across the settings. In the substudy in Sörmland region, the population prevalence of critical illness was 19 per 100,000 people. Among hospital in-patients across all setting, critical illness was strongly associated with mortality (OR 7.5) and 19% died in hospital. More than 90% of the critically ill patients were cared for outside ICUs, in low- staffed general wards.Implementation of VSDT increased acute treatments of critical illness and reduced mortality among patients presenting with shock from 92% to 69%, but not among all patients. The specified EECC package contains 40 lifesaving clinical processes that are effective, low-cost and feasible to implement in any hospital ward in the world, and the 66 resources that are required for providing this care.Conclusions:The results challenge three common misconceptions that have substantial consequences for patients around the world. First, critical illness is not uncommon - it is common. Second, critically ill patients are not always in ICUs - most critically ill patients are cared for in low-staffed general wards. Third, critical care is not limited to expensive and technologically sophisticated interventions. The work in this thesis has shown that critical care can be feasible and low-cost to be provided where most critically ill patients are cared for - in low-staffed or low-resourced settings. The findings can be used to inform priorities in health systems so critical care can be provided more effectively and reach more patients. A new focus on essential care of critical illness has potential to reduce mortality across medical disciplines.List of scientific papersI. Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country. Baker T, Schell CO, Lugazia E, Blixt J, Mulungu M, Castegren M, Eriksen J, Konrad D .. PLoS One. 2015 Dec 22;10(12):e0144801. https://doi.org/10.1371/journal.pone.0144801II. The burden of critical illness among adults in a Swedish region-a population-based point-prevalence study. Schell CO, Wellhagen A, Lipcsey M, Kurland L, Bjurling-Sjöberg P, Stålsby Lundborg C, Castegren M, Baker T. European Journal of Medical Research. 2023 Sep 7;28(1):322. https://doi.org/10.1186/s40001-023-01279-0III. The hospital burden of critical illness across global settings: a point-prevalence and cohort study in Malawi, Sri Lanka and Sweden. Carl Otto Schell, Raphael Kayambankadzanja, Abigail Beane, Andreas Wellhagen, Chamira Kodippily, Anna Hvarfner, Grace Banda-Katha, Nalayini Jegathesan, Christoffer Hintze, Wageesha Wijesiriwardana, Martin Gerdin Warnberg, Sujeewa Jayasingha Arachchilage, Mtisunge Kachingwe, Petronella Bjurling-Sjoberg, Iasaac Mbingwani, Annie Kalibwe Mkandawire, Hampus Sjostedt, Wezzie Kumwenda-Mwafulirwa, Surenthirakumaran Rajendra, Odala Kamandani, Cecilia Stalsby Lundborg, Samson Kwazizira Mndolo, Miklos Lipcsey, Rashan Haniffa, Lisa Kurland, Markus Castegren, Tim Baker. [Manuscript]IV. Essential Emergency and Critical Care: a consensus among global clinical experts. Schell CO, Khalid K, Wharton-Smith A, Oliwa J, Sawe HR, Roy N, Sanga A, Marshall JC, Rylance J, Hanson C, Kayambankadzanja RK, Wallis LA, Jirwe M, Baker T; EECC Collaborators. BMJ Glob Health. 2021 Sep;6(9):e006585. https://doi.org/10.1136/bmjgh-2021-006585

Key Points Question: What is the burden of critical illness in hospitals in different global settings, and where are critically ill patients being cared for? Findings: Among 3652 hospitalized patients in countries of different socio-economic levels (Malawi, Sri Lanka, and Sweden) we found a point-prevalence of critical illness of 12.0% (95% CI, 11.0-13.1), with a hospital mortality of 18.7% (95% CI, 15.3-22.6). The odds ratio of death of critically ill compared to non-critically ill patients was 7.5 (95% CI, 5.4-10.2). Of the critically ill patients 3.9 % (95% CI, 2.4-6.1) were cared for in Intensive Care Units (ICUs). Meaning: Critical illness is common in hospitals and has a high mortality. Ensuring that feasible critical care interventions are implemented throughout hospitals including in general wards where more than nine in ten critically ill patients are cared for, has potential to improve outcomes across all medical specialties. Abstract Importance: Large unmet needs of critical care have been identified globally, but evidence to guide policy priorities is scarce. Available studies into the burden of critical illness have important limitations. Objective: To assess the adult burden of critical illness in hospitals across global settings. Design, Setting, and Participants: This was a prospective, observational, international, hospital-based, point-prevalence and cohort study in Malawi, Sri Lanka, and Sweden. On specific days, all adult in-patients in the eight study hospitals were examined for the presence of critical illness and followed up for hospital mortality. Exposure: Patients with one or more severely deranged vital sign were classified as critically ill. Main Outcomes and Measures: The primary study outcomes were the point-prevalence of critical illness and 30-day in-hospital mortality. In addition, we assessed the proportion of critically ill patients who were cared for in Intensive Care Units (ICU)s, and the association between critical illness and 30-day in-hospital mortality. Results: Among 3652 hospitalized patients in countries of different socio-economic levels we found a point-prevalence of critical illness of 12.0% (95% CI, 11.0-13.1), with a hospital mortality of 18.7% (95% CI, 15.3-22.6). The odds ratio of death of critically ill compared to non-critically ill patients was 7.5 (95% CI, 5.4-10.2). Of the critically ill patients 3.9 % (95% CI, 2.4-6.1) were cared for in ICUs. Conclusions and Relevance: The study has revealed a substantial burden of critical illness in hospitals from different global settings. One in eight hospital in-patients were critically ill, 19% of them died in hospital, and 96% of the critically ill patients were cared for outside ICUs. Implementing feasible, low-cost, critical care in general wards and units throughout hospitals would impact all critically ill patients and has potential to improve outcomes across all acute care specialties.