Essential Emergency and Critical Care: a consensus among global clinical experts

Background Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. Methods In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC’s Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. Results The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. Conclusion The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.


INTRODUCTION
Critical illness, when defined as a state of ill health with vital organ dysfunction and a high risk of imminent death, is common in hospitals throughout the world. [1][2][3][4][5][6] It is the most severe form of acute illness due to any underlying condition and results in millions of deaths globally every year. 1 5 The COVID-19 pandemic has led to increased morbidity and mortality with a surge in critical illness worldwide. [7][8][9] Many of the deaths due to critical illness are potentially preventable. [10][11][12] In critical illness, the patient's airway, breathing or circulation may become compromised, and early identification of the problem and timely care can be lifesaving. Unfortunately, this care is frequently a neglected part of healthcare. The basic, life-saving clinical processes may be overlooked in specialised care 12 and in settings of both high [13][14][15] and low resources. [16][17][18] In hospitals all over the world, guidelines, equipment and routines focusing on the care of critically ill patients, are often missing for adult 19

Key questions
What is already known? ► Critical illness is common throughout the world and COVID-19 has caused a global surge of critically ill patients. ► There are large gaps in the quality of care for critically ill patients, especially in low-staffed and lowresourced settings, and mortality rates are high. ► Essential Emergency and Critical Care (EECC) is the effective lifesaving care of low-cost and lowcomplexity that all critically ill patients should receive in all wards in all hospitals in the world.
What are the new findings?
► The clinical processes that comprise EECC and the essential care of critically ill patients with COVID- 19 have been specified in a large consensus among clinical experts worldwide. ► The resource requirements for hospitals to be ready to provide this care has been described.
What do the new findings imply?
► The findings can be used across medical specialties in hospitals worldwide to prioritise and implement essential care for reducing preventable deaths. ► Inclusion of the EEEC processes could increase the impact of pandemic preparedness and response programmes and policies for health systems strengthening.
BMJ Global Health patients, 11 in emergency units, 20 in wards 21 and in intensive care units. 22 Improving the way healthcare manages critical illness could save many lives. 11 23 24 To improve outcomes for critically ill patients by means that are feasible to deliver in all hospital wards and settings, the Essential Emergency and Critical Care (EECC) concept was devised. 25 EECC is defined as the care that should be provided to all critically ill patients of all ages in all hospitals in the world. It is distinguished by three principles. First, priority to those with the most urgent clinical need, including both early identification and timely care. Second, provision of the life-saving treatments that support and stabilise failing vital organ functions. And third, a focus on effective care of low cost and low complexity.
The clinical processes that comprise the essential care of critically ill patients, and the resources required for those processes have not previously been specified. As critically ill patients can be suffering from any underlying condition, EECC is conceptualised to be integrated into all acute clinical specialties. We therefore sought consensus among a diverse group of global clinical experts with the aim of specifying the content of EECC. An additional aim, given the ongoing pandemic, was consensus around the essential diagnosis-specific care for critically ill patients with COVID-19.

METHODS
The study used three phases (figure 1). First, a consensus was sought about the treatments and actions (T&A) in EECC using a modified Delphi technique. 26 Second, the output from the Delphi was adjusted into a coherent, user-friendly and feasible package of clinical processes. And third, a list of requirements for hospitals to be ready to provide the care was developed.
Phase I An online, three-round modified Delphi process was conducted in November and December 2020. The Delphi method uses anonymous responses from an expert panel to iteratively posed questions and controlled feedback to reach consensus on the topic of interest. 26 A Delphi process was chosen for this study as EECC is new, its content has not been previously specified and a large group of diverse experts was required.
To be part of the panel, experts needed to have clinical experience of caring for critically ill patients. To ensure the involvement of a diverse range of experts, it was decided that at least 50% of the invitations to participate in the panel should be sent to experts with substantial experience working in low-income and middle-income countries, and there should be a balance between clinical experience (work in general wards, emergency units, intensive care units); specialty (paediatrics, obstetrics, medicine, surgery, intensive care, anaesthesia and emergency care); profession (doctors, nurses, other health professionals); location and gender. A list of potential participants was Figure 1 The study process. EECC, Essential Emergency and Critical Care; T&A, Treatment and actions.

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made from a mapping of stakeholders, the literature across all acute medical specialties, the researchers' networks and additional purposive and snowball sampling for under-represented groups. Additionally, a link to a screening survey was sent to global professional networks, specialist societies and on social media to identify further potential participants. A total of 895 experts were invited to participate, and those who accepted provided written informed consent.
EECC consists of clinical processes of care. To enable rating by the Delphi panel, clinical processes were disassembled into individual T&A. The T&A concern the identification of critical illness; care of critical illness, and the diagnosis-specific care of critically ill patients with COVID-19. To be included, all T&A were required to meet two a priori defined criteria: effectiveness i and feasibility. i Additionally, universality i was required for the identification and care of critical illness and relevance i was required for the diagnosis-specific care of critically ill patients with COVID-19. A draft list of potential T&A was developed based on clinical guidelines and tools from related specialties [27][28][29][30][31][32][33][34][35][36][37][38] and aligned with the WHO/ International Committee of the Red Cross's (ICRC) Basic Emergency Care. 39 The draft list was revised by specialist reviewers-a group of senior clinicians, researchers and policy makers, with expertise in paediatrics, medicine, emergency medicine, anaesthesia and intensive care, critical care nursing, obstetrics and gynaecology, and surgery.
Three Delphi rounds were deemed sufficient to address the aim while avoiding attrition and poor response rates. A 4-point Likert scale (strongly disagree, disagree, agree, strongly agree) with a 'do-not know' option was used for the panel to rate their opinion about the inclusion of each T&A in EECC. [40][41][42] Consensus was achieved when more than 90% of respondents selected 'agree' or 'strongly agree', excluding 'don't know' responses. The experts were able to provide free-text comments, which were analysed to identify appropriate, relevant changes to the wording of T&A for clarity of understanding, and to identify newly proposed T&A. After the first round, newly proposed T&A that fulfilled the EECC criteria for potential inclusion were revised after input from the specialist reviewers and included for assessment by the panel. T&A that did not reach consensus in the previous round were presented for i Effectiveness: established or proven to be safe and to reduce mortality (compression to stop bleeding is effective; treating with leech therapy is not). Feasibility: low-cost and low complexity. Possible to provide in a low-staffed, low-resourced setting without the immediate presence of a doctor (placing a comatose patient in the recovery position (lateral position) is feasible; continuous haemodialysis is not). Universality: supports vital organ function rather than being the definitive care of a diagnosis (intravenous fluids for shock are universal; thrombolytic therapy is not). Relevance: established or proven to be a treatment for COVID-19. reassessment in rounds two and three, together with a visual representation of the spread of previous responses.
As the Delphi panel was diverse, it was considered that there may be different opinions about the inclusion of T&As between experts with particular a priori defined characteristics. These subgroups of experts were those with work experience in a low-income country or not; those who are doctors or not; those with clinical experience in emergency care and those without; and those with clinical experience in intensive care and those without. The levels of agreement in each subgroup were assessed and presented for all the T&As that reached consensus. *As the experts were asked to select all that apply, the sum of the percentages may exceed 100.

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Phase II After the Delphi, slight adjustments were made to the wording of the T&A that had reached consensus to ensure language consistency. The T&A were reassembled back into clinical processes to increase overall coherence and feasibility of the EECC package, with the goal of user-friendliness for health system implementation and quality improvement work. The adjustments were done in an iterative process with the same specialist reviewers as in Phase I to ensure relevance for all acute medical specialties. The final package of clinical processes was organised into those relevant for identification, for care and general processes.

Phase III
A provisional list of hospital readiness requirements for the provision of the clinical processes were developed using existing WHO tools, guidelines for related specialties, facility preparedness lists 29 32 34 35 37-39 43 44 and the experience and knowledge of the study team. The specialist reviewers provided iterative input into the provisional list, approving suggested items, adding relevant items from their clinical specialties and suggesting modifications. Based on previous work and following consultation with health economists and procurement experts, the final list of requirements was agreed and arranged into eight categories: equipment, consumables, drugs, human resources, training, routines, guidelines and infrastructure.

Patient and public involvement
Patients and the public were not involved in the design and conduct of the research.

Phase I
Of the 895 invited experts, 269 participated in the first round of the Delphi when the majority of the decisions were made (30% response rate). In round 2, 228 experts participated (85% of those in round 1) and round 3 included 194 experts (85% of those in round 2). The panel comprised experts from diverse resource settings, clinical settings, specialties and professions (table 1). The panel included experts from 59 countries (figure 2) and 38% were female. Of the 57 T&A for EECC in round 1, consensus was reached for 49. In round 2, 29 newly proposed T&A were added to the eight remaining from round 1, of which two had been reworded for clarity. Out of these 37, consensus was reached for 17. The remaining 20, of which another two had been reworded for clarity, were included in round 3. Consensus was reached for nine of the final 20 T&A. In total, consensus was reached for 75 out of 86 proposed T&A, including 54 of the original 57 (online supplemental table 1).
Of the seven T&A for the essential diagnosis-specific care of critically ill COVID-19 in round 1, all reached consensus for inclusion. In round 2, two newly proposed T&A were added. Neither of these reached consensus in round 2 or round 3.
Analyses of participant subgroups did not reveal substantial divergence from the overall results. For the T&A that reached 90% agreement in the panel, agreement was not below 80% in any subgroup (online supplemental tables 2-4).

Phase II and III
After the Delphi, the T&A that had reached consensus were reassembled into a final user-friendly and feasible  Table 2 The clinical processes of Essential Emergency and Critical Care

Identification of critical illness
Critical illness is identified as soon as possible so timely care can be provided  The essential diagnosis-specific care of critically ill patients with COVID-19 consisted of an additional seven clinical processes and nine hospital readiness requirements (table 4).

DISCUSSION
We have specified the content of EECC based on consensus among global clinical experts. While the EECC approach is new, the included clinical processes are commonly used in the care of sick patients and can be seen in WHO publications and specialist society standards and guidelines. 29 32-35 38 39 45 The contribution of this study is the specification of a baseline bundle of care interventions that should be provided when needed to all critically ill patients in all hospitals in the world. This marks a break from previous guidelines that tend to be specialty-specific, condition-specific or location-specific, or that specify care that may be too complex and costly to provide in all hospital settings.
The EECC approach EECC is an approach that supports priority-setting in health systems. In this regard, it has parallels to the approaches used in the WHO's Essential Medicines List, 37 Interagency Integrated Triage Tool, 29 Emergency Triage and Treatment for Children 32 and Universal Health Coverage. 36 EECC emphasises the identification and care of the critically ill, and the provision of the life-saving supportive care that is of low cost and of low complexity. 25 EECC can be seen as a unifying concept for such aspects of patient management found in WHO and specialist guidelines, triage, early warning systems and rapid response teams. 28 29 39 46 47 To maintain focus on life-saving supportive care and to be useful across all specialties, EECC does not include the definitive care of the underlying diagnoses. Instead, EECC is intended to complement specialty-based care and existing guidelines and does not aim to include all the care a patient needsas well as EECC, patients should receive diagnostics, definitive and symptomatic care of their condition, additional nursing care, and if available, higher levels of emergency and critical care. EECC seeks to bridge the quality gap that is commonly found between the current care of critical illness and best-practice guidelines. 12 48 49 To ensure feasibility in settings with restricted human resources, EECC is designed to enable task-sharing between health professionals. 50 It should be noted that not all the EECC clinical processes will be needed in the care of every critically ill patient-they should be seen as essential 'tools in the tool-box' for health workers to use when required. To operationalise the EECC approach, it is intended that the content specified here is used to develop tools for quality monitoring, teaching and integration into other guidelines and recommendations.

EECC complements the current healthcare organisation
The basic clinical processes specified in EECC have been overlooked in healthcare. 11 13-15 18 20 51 52 In UK hospitals, half of the patients received substandard basic vital organ support prior to intensive care and 31% of preventable deaths were associated with absent clinical monitoring. 13 14 In Malawi, 89% of adult hypoxic patients and 75% of children dying from pneumonia in hospital did not receive oxygen. 17 18 The usual organisational set-up of health services may be one underlying reason for this. Specialist units with a primary function of delivering the definitive management for one disease group may underestimate the effort needed to maintain core processes and competences in the supportive management of critically ill patients. Innovative and specialised treatments and technologies may become preferred to those that are basic and long-standing. 53 By targeting a feasible, lowest baseline quality for critically ill patients throughout hospital settings, EECC provides a complimentary approach to the current organisation that safeguards the provision of basic life-saving actions, enhancing the impact of hospital care for all acute conditions. EECC in the COVID-19 pandemic EECC has added importance in a situation causing a substantial amount of severe disease and the Delphi panel agreed that EECC should be part of the care of critically ill patients with COVID-19. In addition, the agreed essential diagnostic-specific care for COVID-19 can assist in decisions about the priorities of care when the pandemic threatens to overwhelm available resources. All of the COVID-19 specific processes are well established and are included in the WHO COVID-19 clinical management guidance. 30 The WHO guidance, and others, 54 additionally include recommendations for advanced critical care (such as mechanical ventilation, vasopressors and extracorporeal oxygenation), which may be difficult to rapidly scale-up in settings of low resources. Advanced critical care can be necessary to save the lives of some patients, but has a

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high cost per recovery and risks diverting scarce resources to a few individuals. [55][56][57][58][59][60] Fortunately, the focus has shifted in the global pandemic response from advanced critical care towards securing basic oxygen delivery systems 61 62 underscored by statements from the WHO and other partners. 63 Table 3 Continued Table 4 The essential diagnosis-specific care for critically ill patients with COVID-19 Clinical processes  39 and developed by a diverse specialist team, but the possibility remains that alternative methods would have led to a different output. The study did not address the underlying evidence-base for the included clinical processes, the impact, or the potential opportunity costs of increasing the coverage of EECC in hospitalssuch system-wide effects warrant careful evaluation during EECC implementation. It should be noted that, while policy makers were involved throughout the process, the EECC content has not been ratified by the WHO or governmental ministries of healththe method has been primarily scientific. The findings should be seen as the first version of the EECC content, as recommended by global clinicians and researchers, one that could be incorporated into WHO and other global and national programmes and that should subsequently be improved and updated as new knowledge arises.

Implications
Implementation of EECC could be an effective strategy as part of the current calls to save lives through improved quality of care in health systems 65   Provenance and peer review Not commissioned; externally peer reviewed.
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