Challenges for the care delivery for critically ill COVID-19 patients in developing countries: the Brazilian perspective
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COMMENTARY
Open Access
Challenges for the care delivery for critically ill COVID-19 patients in developing countries: the Brazilian perspective Jorge I. F. Salluh1,2*, Thiago Lisboa3,4 and Fernando A. Bozza1,5 Background The delivery of critical care is a major challenge for developing countries [1]. The inequity of access to an ICU bed, heterogeneous triage policies, a low staff/patient ratio and suboptimal adherence to evidence-based practices contribute to disproportionally high mortality of sepsis and acute respiratory distress syndrome in these countries [2–5]. In addition, limited step-down and specialized ward beds’ availability further widens the gap between critical and non-critical care inside hospitals. As the COVID-19 pandemic spreads through the world, developing countries are challenged with the surge of pneumonia cases where up to 30% of all hospitalized cases will require ICU admission [6]. In August 2020, Brazil is a hotspot of COVID-19 with more than 100,000 deaths. Other Latin American countries such as Mexico, Peru, Colombia, and Chile are also among the 10 countries with most cases worldwide. Several factors seem to have contributed to the dramatic progress of the epidemic in the country. Initial measures of social distancing were adopted at the beginning of the epidemic in several states. However, the lack of central coordination and, at a certain point, the denial of the pandemic by a populist government meant that more effective measures such as lockdown were not adopted whereas use of unproven therapies such as hydroxychloroquine was encouraged. Also, the low availability of tests and progression towards the interior and * Correspondence: [email protected] 1 Department of Critical Care and Postgraduate Program in Translational Medicine, D’Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 – 3º andar, Rio de Janeiro 22281-100, Brazil 2 Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil Full list of author information is available at the end of the article
peripheries of large cities made the epidemic hard to control causing overwhelming hospitals and ICUs.
What are the challenges? Despite its high absolute number of ICU beds [7], even in comparison with western European countries, the heterogeneous regional distribution and payor-based access are major barriers for a more equitable delivery of critical care. Although increases in the number of ICU beds were recently made across the country as preparation for the pandemic, they are still insufficient to compensate regional differences (the North region has 50% fewer ICU beds per capita as compared with the Southeast) or the imbalances between the public and private sector. The number of public ICU beds per capita is 72% lower than private sector ones, and only 22% of the population has access to private healthcare. Additionally, ICU staffing is an important shortcoming in the COVID-19 pandemic in developing countries. First, the ICU staffing can be considered
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