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. 2023 Jan 25;12(1):22799036231151762. doi: 10.1177/22799036231151762

Boosting ICU capacity during the COVID-19 pandemic in the western Balkan region, The Republic of Srpska experience

Pedja Kovacevic 1,2,✉, Vlado Djajic 1,2, Danica Momcicevic 1,2, Biljana Zlojutro 1, Milka Jandric 1, Tijana Kovacevic 1, Milan Latinovic 3, Alen Seranic 3, Dejan Bokonjic 4, Ranko Skrbic 2, Sasa Dragic 1,2
PMCID: PMC9880146  PMID: 36718459

Abstract

Background:

Response to the outbreak of poliomyelitis in mid-1950 led to recognition and consequent development of critical care. Seventy years later the humankind was struck by COVID-19, another major challenge for critical care medicine which was especially big in Low-Resources-Settings where more than two thirds of the world population live, including the population of the Republic of Srpska (RS).

Design and methods:

The main aim was to show an overview of all interventions in order to boost hospitals’ capacities to the level which is sufficient to manage high amount of critically ill COVID-19 patients in the RS. A before-after cohort study design was conducted to evaluate the effects of interventions for increase in preparedness and capacity of ICUs for admission and treatment of COVID-19 critically ill patients in nine hospitals in the RS. Results: Following interventions, the biggest and university affiliated hospital in the RS has increased ICU capacities: total number of ICU beds increased by 38% and number of ventilators by 114%. Availability of machines for veno-venous extracorporeal membrane oxygenation (vvECMO) increased by 100%. Number of doctors who were involved in treatment of critically ill patients increased by 47% and nurse/patient’s ratio reached 1:2.5. Similarly, all other hospitals experienced boosting of ICU beds by 189% and ventilators by 373% while number of doctors increased by 108% and nurse/patient’s ratio reached 1:4.

Conclusion:

All interventions implemented during COVID-19 pandemic outbreak in the RS resulted in increasing capacity for treatment of critically ill patients, but the education of health care professionals was identified as the most important conducted intervention.

Keywords: Critical care medicine, capacity boosting, low resources settings

Introduction

Basic information

Coronavirus disease 2019 (COVID-19) is a new infectious disease which affects respiratory system. It was first reported in China (Wuhan) and it has subsequently spread worldwide affecting almost every healthcare system globally with tremendous impact on global health, especially in low resources settings (LRS).1,2 Reports during the initial phase of the pandemic suggest that among those with COVID-19, up to 20% develop severe disease requiring hospitalization. Among those who are hospitalized, up to one-quarter need intensive care unit (ICU) admission, representing approximately 5%–8% of the total infected population.3–8 At the very beginning of COVID-19 pandemic, healthcare workers, stressed by large numbers of patients, insufficient supplies (ventilators and other ICU machines) and experiencing infection control concerns, have struggled to extract useful information from different valid sources into practical recommendations that can be readily implemented at the bedside. These challenges have been even more formidable in LRS.9,10

Critical care medicine in LRS, what have we learned so far?

Generally, the burden of critical illness in LRS is substantial and mortality rates remain unacceptably high when compared to high income countries (HIC). In pandemic period, the problem of mortality rates is probably even bigger in these settings. The main causes of poor outcome of critical illness are limited capacity for nonsurgical critically ill patients, small number of medical intensive care units (MICUs), insufficient number of ICU beds, lack of trained staff and poor academic and research resources in LRS. It is estimated that the number of ICU beds in low- and middle-income countries (LMICs) is 0.1–2.5 per 100,000 population. In contrast, HIC have as many as 30 ICU beds per 100,000 population. While data on structure, treatment and outcomes in LRS (LMICs) are scarce, data from HIC cannot be easily extrapolated.2,10,11

Health care challenges in the Republic of Srpska (Bosnia and Herzegovina)

Bosnia and Herzegovina (B&H) is one of countries that emerged after the dissolution of the Yugoslavia.12 As a result of the Dayton Peace Agreement, today’s Bosnia and Herzegovina consists of two parts, the Republic of Srpska and the Federation of Bosnia and Herzegovina. B&H is located in South Eastern Europe (West Balkan region). In its recent history, it has endured 4 years of war, international isolation (sanctions imposed by the international community) and severe social and economic devastation, including numerous refugees and displaced persons. Each of these events has left a deep scar in the Republic of Srpska’s (B&H’s) healthcare system, including critical care medicine.11–13 Currently, the World Bank classifies B&H (as well as RS) as an upper-middle income country,14 but it’s health care system and problems related to the treatment of critically ill patients are quite similar to LMICs and accordingly it can be defined as a LRS. When we talk or write about low resources countries, we have to be aware that these countries are not situated somewhere in Africa, but in the heart of Europe (the Western Balkan where is Bosnia and Herzegovina situated). The definition of LRS is used throughout this article to refer to health care systems in LMICs (as well as upper middle-income countries), acknowledging that LRS exist even in HICs.15 On the other hand, provision of critical care services in LRS are challenged with its high costs, insufficient numbers of ICU beds, lack of trained staff (doctors and nurses) and with insufficient academic and research resources.2,10,11 Before the COVID-19 outbreak, education of undergraduate medical students and residents in non-surgical branches (internal medicine, cardiology, neurology, and infectology) did not include obligatory rotation (or any theoretical knowledge) in the intensive care units. In the Republic of Srpska only pulmonology residents have critical care training and obligatory 6 months rotation in ICU. This was defined at the beginning of 2015 as a result of suggestion of pulmonologists from the MICU of UCC RS. Nine (9) hospitals operate in the Republic of Srpska; the biggest one and university affiliated, is the Clinical Centre of the Republic of Srpska, while other ones are general hospitals. One general hospital (Foča) is teaching hospital and serves as a teaching basis for Medical school of the University of East Sarajevo (Figure 1).

Figure 1.

Figure 1.

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Geographical distribution of all hospitals in The Republic of Srpska and paths of critically ill patients’ referrals.

UCC RS: University Clinical Centre of the Republic of Srpska; GH: general hospital; UH: University hospital.

Establishment of the very first modern Medical ICU in the Republic of Srpska (B&H)

Key authorities of UCC RS and Ministry of Health of the Republic of Srpska started the project of establishing the first modern MICU at UCC RS Banja Luka. The MICU started operating at the end of 2008.16 Over the next 14 years MICU has moved to the newly built north wing of UCC RS with staff expansion to 21 physicians (10 critical care specialists) and 60 nurses. The primary specialties of this multidisciplinary team include pulmonology (10 physicians), internal medicine (9 physicians), anesthesiology (1 physician), neurology (1 physician), and infectious diseases (1 physician). The new space and equipment (2019) allow admission and treatment of up to 28 critically ill patients, with provision of full support to all organ systems. At present, this MICU is the only level three and ISO 9001: 2015 certified MICU in the Republic of Srpska (and in B&H as well). MICU at UCC RS was defined as a referral center for treatment of critically ill patients for the region of the Republic of Srpska (approximately 1,000,000 inhabitants).10 Since the establishment of the MICU in Banja Luka, critically ill patients from the whole Republic of Srpska are being transferred to UCC RS’s MICU (Figure 1).

It is very important to notice that although no objective data from low resources settings are readily accessible, investigators from these countries are often under-represented in international non-governmental organizations responding to emergencies such as the present pandemic. The presumed inability of health care workers and researchers from LRS to implement improvement interventions and participate in observational and interventional research, creates a vicious cycle leading to lack of data, impractical guidelines and irrelevant research projects.

Because of everything mentioned above, a study was created with the aims to provide an overview of all activities (interventions) in order to capacitate (boost) hospitals to manage high amount of critically ill COVID-19 patients in the Republic of Srpska (LRS model country).

Methods

Study setting

The study was conducted in the Republic of Srpska, which health and educational systems are separately organized from the Federation of Bosnia and Herzegovina. The Republic of Srpska provides universal public health insurance to its inhabitants. Since the beginning of the pandemic, all COVID-19 patients have had full access to free healthcare, regardless of the basic pre-pandemic insurance status.

Study design and the analysis

Using a before-after cohort study design, the investigators evaluated the effects of interventions on the capacity building (boost) and preparedness increase of ICUs for admission and treatment of COVID-19 critically ill patients in nine hospitals in the Republic of Srpska. The survey recorded the following data: type of hospital, number of ICU beds, number of ventilators, nurse-to-patient ratio, number of intensivists, anesthesiologists, infectious disease specialists, pulmonary specialists, residents, and critical care fellows at the beginning of 2020 and at the beginning of 2022. Additionally, a survey was conducted among all doctors and main nurses who worked in these ICUs to evaluate the availability of basic and advanced critical care training programs (official and unofficial). The main source of data was the Ministry of Health and Social Welfare in the Republic of Srpska government. All data were recorded at the beginning of April 2022.

Interventions

Interventions were conducted by governmental and non-governmental organizations (NGOs), between May 2020 and April 2022. Governmental organizations which were involved in interventions were Ministry of health and social welfare of the Republic of Srpska, Health Insurance Fund of the Republic of Srpska, University Clinical Centre of Republic of Srpska (as the referral and biggest medical center), and Medical Faculties of Universities of Banja Luka and East Sarajevo. From the group of non-governmental organizations, interventions were supported by national society of intensivists named Medical intensive care society, World Health Organization (WHO), and Society of critical care medicine (SCCM). Intervention was conducted in several phases:

  • Phase 1—Purchase of equipment (ventilators, patient monitors, suction pumps, and infusion pumps). This intervention was realized by governmental organizations, mainly Health Insurance Fund of the Republic of Srpska and Ministry of health and social welfare of the Republic of Srpska.

  • Phase 2—Construction works in hospitals in order to increase the capacity to treat critically ill. These interventions were performed directly in cooperation of hospitals with Ministry of health and social welfare of the Republic of Srpska.

  • Phase 3—Education of health care workers (physicians and nurses) from the field of critical care. This intervention was carried out both by governmental and non-governmental organizations. Continuing medical education in our country is available in two forms, as official training within the form of specialization and subspecialization (fellowship), and as unofficial training in the form of courses or workshops. All forms of education are conducted at the bedside or via a video link. The two governmental organizations that provide official and unofficial training (education) are Ministry of health and social welfare of the Republic of Srpska and Medical faculties of Universities of Banja Luka and East Sarajevo. NGOs that took part in the process of unofficial education in the Republic of Srpska were: Medical intensive care society, WHO office in Sarajevo and SCCM (USA). All educational activities that required physical presence of physicians (at bedside) were organized and conducted exclusively at the Medical Intensive Care Unit (MICU) of the University Clinical Centre of Republic of Srpska—currently the most advanced multidisciplinary MICU in Bosnia and Herzegovina (level 3 ICU) with 10 officially trained intensivist and 3 professors from the field of critical care (Figure 2).

Figure 2.

Figure 2.

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Timeline of interventions performed to health care system of the Republic of Srpska in relation to pandemic waves.

1—Equipment purchase (ICU ventilators) 2—reorganization and construction works in UCC RS, 3—visiting the intensivists from MICU UCC RS to other hospitals in RS with an aim to evaluate organization of their ICU services, 4—beginning of reconstruction in order to create new ICUs for the treatment of COVID 19 critically ill patients, 5—starting the unofficial critical care training of doctors and nurses by critical care experts from MICU UCC RS, 6—start of the WHO support in unofficial critical care training for health care workers in the Republic of Srpska, 7—start of the very first criticall care education for undergraduate medical students at the Medical School in Foca (University East Sarajevo), 8—implementation of Fundamental Critical Care Support Course in MICU UCC RS for doctors from all hospitals of the Republic of Srpska, 1a—continued procurement of equipment, 9—creation of new department for treatment of COVID-19 critically ill patients, named NIV center, 10—implementation of the intensive care teaching curricula for medical students (Medical School in Foca), 11—adaptation of the curricula for all specializations in the field of non-surgical medicine branches (Medical schools in Banja Luka and Foca), 12—establishment of critical care department at the Medical School University of Banja Luka, 13—the very first textbook named: “Basics of critical care” published (Publisher: Medical School University of Banja Luka).

Results

University Clinical Centre of the Republic of Srpska (UCC RS)

Banja Luka, the capital of the Republic of Srpska has approximately 200,000 inhabitants. The University Clinical Centre of the Republic of Srpska is situated in Banja Luka and has 1198 hospital beds. At the beginning of 2020 there were five types of ICUs in the UCC RS (MICU, SICU, Pediatric ICU, Neonatal ICU, and Gynecological ICU) with 78 ICU beds and 58 ventilators. However, at the beginning of April 2022, UCC RS has six types of ICUs with 108 ICU beds and 124 modern ICU ventilators. Additional ICU was affiliated to MICU with a purpose of treating patients using non-invasive ventilation and high flow oxygen therapy (HFNC). Total number of ICU beds increased by 38% and ventilators by 114%. In these period, number of machines for veno-venous extracorporeal membrane oxygenation (vvECMO) increased by 100% (Table 1). At the beginning of 2020 treatment of critically ill patients in the UCC RS was performed in MICU and SICU (anesthesiology department). Number of doctors (residents, specialists, fellows, and subspecialists) who were involved in treatment of critically ill patients till the beginning of April 2022 increased by 47% (Table 2.) Nurse/patients ratio in ICUs of UCC RS was 1:4 at the beginning of 2020, however this ratio changed to 1:2.5 during 2 years of COVID pandemic.

Table 1.

Data on population distribution in the Republic of Srpska and comparison of hospitals’ capacities between years 2020 and 2022.

Cities in the Republic of Srpska Number of inhabitants Type of hospital Total number of beds Type of ICU in January 2020 Type of ICU in January 2022 Number of ICU beds in January 2020/2022 Number of ICU ventilators in January 2020/2022 Number of ECMO machines in January 2020/2022
Banja Luka ≈200,000 Tertiary—University affiliated Clinical Center 1198 1) Medical ICU
2) Surgical
3) Recovery
4) Gynecological
5) Pediatric		 1) Medical ICU
1a) NIV center
2) Surgical
3) Recovery
4) Gynecological
5) Pediatric		 28/28
0/26
20/20
14/18
8/8
8/8		 22/30
0/28
18/26
2/20
8/10
8/10		 MICU—2/4
Gradiska ≈67,000 General 200 1) Surgical/mix ICU 1) Surgical ICU/mix ICU
2) COVID ICU		 9/5
0/10		 5/7
0/14		 -
Prijedor ≈100,000 General 367 1) Surgical/mix ICU 1) Surgical ICU/mix ICU
2) COVID ICU		 10/10
0/14		 3/10
0/14		 -
Doboj ≈80,000 General 522 1) Surgical/mix ICU 1) Surgical ICU
2) COVID ICU/MICU		 5/6
0/14		 5/6
0/16		 -
Bijeljina ≈120,000 General 239 1) Surgical/mix ICU 1) Surgical ICU//mix ICU
2) COVID ICU		 10/10
0/40		 10/10
0/30		 -
Zvornik ≈64,000 General 210 1) Surgical/mix ICU 1) Surgical ICU//mix ICU
2) COVID HDU/MHDU		 7/7
0/16		 5/6
0/20		 -
Foca ≈10,000 Secondary—Teaching hospital 230 1) Surgical/mix ICU 1) Surgical ICU//mix ICU
2) COVID ICU/MICU		 6/6
0/10		 5/8
0/13		 -
East Sarajevo ≈61,000 General 180 1) Surgical/mix ICU 1) Mix ICU
2) COVID ICU		 13/13
0/13		 4/4
0/21		 -
Trebinje ≈32,000 General 168 1) Surgical/mix ICU 1) Surgical ICU//mix ICU
2) COVID ICU		 6/6
0/11		 4/4
0/11		 -
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Table 2.

Data on change in structure of critical care physicians in hospitals in 2022 compared to 2020.

Cities in the Republic of Srpska Type of hospital Number of critical care physicians January 2020/2022
Banja Luka Tertiary—University affiliated Clinical Center
(University Clinical Centre of the Republic of Srpska)		 MICU: Intensivists—5/7
On fellowship—5/3
Specialists—7/10
Residents—8/12
AD: Specialists—30/32
Residents—20/22
PD: Specialists—0/2
Residents—2/10
CD: Specialists—0/0
Residents—0/10
ID: Specialists—0/0
Residents—0/5
Gradiska General SICU/MixICU/COVID:
On fellowship—1/0
Intensivist—0/1 (anesthesiologist)
Specialists—3/3 (anesthesiologists)
Residents—0/3 (anesthesiology)
Prijedor General SICU/MixICU/COVID:
Specialists—5/5 (anesthesiologist)
Residents—0/1 (anesthesiology)
Doboj General SICU: On fellowship—0/1 (anesthesiologist)
Specialists—7/7 (anesthesiologist)
Residents—2/2
COVID/MICU: On Fellowship—0/2 (Anesthesiologist—1; pulmonologist—1)
Specialists—0/2 (Anesthesiologist—1; pulmonologist—1)
Residents—0/3 (Anesthesiology—1, pulmonology—1, internal medicine—3)
Bijeljina General SICU/MixICU/COVID:
Specialists—7/12 (anesthesiologists)
Residents—4/8 (Anesthesiology—4, pulmonology—1, internal medicine—1, and surgery—2)
Zvornik General SICU/MixICU:
Specialists—3/3 (anesthesiologists)
Residents—2/5 (anesthesiology)
COVID/HDU:
Specialists—0/6 (internal medicine—5 and cardiologist—1)
Residents—0/4 (internal medicine—1, infectology—1, and anesthesiology—2)
Foca Secondary—Teaching hospital SICU: Specialists—7/ 6 (anesthesiologists)
Residents—0/4 (anesthesiology)
COVID/MICU: On fellowship—0/1 (infectologist)
Specialist—0/5 (anesthesiologist)
Residents—0/2 (internal medicine)
East Sarajevo General SICU/MixICU/COVID:
Specialists—3/ 5 (anesthesiologists)
Residents—0/4
Trebinje General SICU/MixICU/COVID:
On Fellowship—0/1 (anesthesiologist)
Specialists—3/3 (anesthesiologists)
Residents—2/3
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Other general hospitals in the Republic of Srpska

In other eight (8) general hospitals just one type of ICU (SICU or mixed ICU) existed at the beginning of COVID-19 outbreak. Number of ICU beds at the beginning of the studied period in all general hospitals was 66 and it increased by 189% during 2 years (191). All hospitals had 41 ventilators in total at their disposal at the beginning of 2020 and after intervention of governmental institutions this number increased by 373% (194; Table 1). Number of critical care physicians at the beginning of 2020 was 49 (mostly anesthesiologist) and it increased by 108% in 2-year time (102; Table 2). Nurse/patient ratio in ICUs in general hospitals in the Republic of Srpska was 1:6 at the beginning of 2020, however this ratio changed to 1:4 during 2 years of COVID-19 pandemic.

Discussion

The main finding of this study shows that acquisition of medical equipment, performing additional construction works in hospital wards and establishment of new ICUs are goals easier to achieve (even in pandemic and emergencies situations) than creating well educated critical care professionals. The impact of previously established modern multidisciplinary MICU in the Republic of Srpska to all described interventions was tremendous. All activities (interventions) conducted throughout the Republic of Srpska which led to increase of capacities for the treatment of critically ill COVID-19 were coordinated by experts from MICU at UCC RS. Support by medical experts (intensivists) was equally provided to governmental and non-governmental organizations. Literature source (data) of similar experiences in the Western Balkan countries are scarce and knowledge is limited (especially in LMICs and in low resource settings generally). Due to many differences in health care systems, a regional (area of Balkans—South-East Europe) analysis may be helpful. To the best of our knowledge, our study is the only one conducted in the area of Balkans that determines interventions conducted with an aim to increase capacities for treatment of COVID-19 critically ill patients during pandemic. All described interventions are mostly performed in COVID-19 free periods (in-between pandemic waves).

Interventions performed in the health care system of the Republic of Srpska

Immediately after the outbreak of the COVID-19 pandemic in the world, the health care authorities in the Republic of Srpska realized that the capacities for the treatment of the critically ill patients are insufficient. The first intervention was purchasing medical equipment, mostly ICU ventilators. Governmental institutions finalized the purchase of equipment and delivery of all ventilators throughout the Republic of Srpska started at the beginning of Jun 2020. This intervention was a great success for governmental institutions because the Republic of Srpska is very small market and in the chaotic first months of the pandemic COVID-19 the procurement of ICU ventilators was extremely difficult.17–19 Group of experts from the field of critical care (MICU at UCC RS) visited all general hospitals in the Republic of Srpska during the summer of 2020, when the number of COVID-19 patients temporarily decreased. Main aim of this exploration (visiting and screening) was to identify problems but also the opportunities for the implementation of critical care and establishment of the new ICUs. Shortly after providing suggestions by the experts, almost all hospitals in the health care system of the Republic of Srpska started construction works with main aim to establish new ICU departments especially for the treatment of COVID-19 critically ill patients. Main aim of construction works in the UCC RS was to increase oxygen supplies throughout the hospital pipelines to supply increasing number of ICU ventilators. In addition to oxygen, a pipeline was made for the supply of compressed air. After this intervention Pulmonary Department (PD) was capable to treat 26 critically ill patients using ICU ventilators. Similar expert recommendations followed by construction activities were performed worldwide.20–23

Procurement of equipment and reconstruction of hospital walls were done relatively fast, whereupon health care authorities recognized a much bigger and more significant problem—the lack of trained staff.24 At the very beginning of the pandemic crisis WHO identified education as a major priority especially in LRS, but distance and resources remained significant barriers to rapid education dissemination.25 In the pre-pandemic period treatment of critically ill patients was conducted by intensivist (subspecialists) only in the MICU UCC RS. In the rest of the Republic of Srpska, care of these patients was provided only by anesthesiologists. This was very similar to other low resources countries.26 Dominant intervention in observed, 2-year period, in the Republic of Srpska was education. In the beginning, unofficial type of education from the field of critical care was used mainly in the forms of certified courses (e.g. Fundamental Critical Care Support Course) and continuous medical education (CME). Official education in the form of specialization and critical care fellowship began exactly 1 year after the COVID-19 outbreak. Both types of education were recognized and supported by governmental institutions (Medical School University of Banja Luka and Ministry of Health and Welfare of the Republic of Srpska) and NGOs (The National society of critical care, WHO, and SCCM). The impact of the 2 years interventions on educational system is positive in the long run: (a) curriculum for undergraduate medical students has been changed and intensive medicine became obligatory course (subject) in the final year of studies for all Medical Schools in the Republic of Srpska, (b) curriculum for residents of non-surgical brunches (internal medicine, pulmonology, cardiology, infective diseases, and neurology) was changed and practical and theoretical critical care training became obligatory; all residents in the Republic of Srpska have to spend 3–6 months at the MICU, (c) for the very first-time textbook “Basics of critical care” was published by Medical School University of Banja Luka and by the National society of critical care, (d) in two hospitals (GH Doboj and UH Foča) COVID-19 ICU was converted to MICU with multidisciplinary team of physicians, (e) five doctors (form GH Doboj, GH, Trebinje, and UH Foča) started critical care fellowship at the MICU (UCC RS), (f) Health care authorities in the Republic of Srpska decided to build completely new hospitals (UH Doboj and UH Trebinje) with two types of ICU, surgical and medical, increasing the number of ICU beds, (g) recognized and partially resolved problem of transportation of critically ill patients from general hospitals to UCC RS, (h) recognized and partially resolved problem of delayed recognition of critically Ill COVID-19 patients treated at the emergency departments and regular wards. Similar programs of educations (FCCS), redeployment and involvement of residents in the treatment critically ill COVID-19 patients were performed in other settings.27–29

Limitations and the strength

The most important limitation of the study can be found in the fact that it was a single-country (single-republic) design. The lack of data regarding the outcome of the treatment of critically ill patients in the Republic of Srpska after the intervention represents a significant limitation. Additionally, presence of negligible number of scientific research in low-resources countries and lack of reporting about response (interventions) to the COVID-19 pandemic in these settings might be seen as invisible limitations. This type of research sometimes can be accompanied by political and public impact, hence response outcomes in these countries are often much worse, compared to HICs. Main strength of this study is that it showed the outcomes of the interventions implemented the Republic of Srpska (typical represent of Western Balkan) with the main aim to increase ICU capacities. Any study published in low resources countries and LMICs can stimulate other researchers from these settings to publish their results, this is invisible strength as well.

Conclusion

In conclusion, all interventions implemented during COVID-19 pandemic outbreak in the Republic of Srpska resulted in increased capacity for treatment of critically ill patients. Procurement of equipment and reconstruction of hospital walls were done relatively fast, (approximately in several months), but education of doctors and nurses took a longer period of time. Organization of educational activities performed during pandemic was the most difficult intervention to implement and initially included unofficial education (workshop courses), and then official education (specialization and fellowship). All these interventions resulted in rapid development of critical care medicine as a medical branch generally, but we identified education of health care professionals as the most important conducted intervention with long term effects on health care and educational systems of the Republic of Srpska. Existence of modern multidisciplinary MICU in pre-pandemic period accelerated all described processes. The interventions assessed in this study offers an excellent model for increasing capacity for treatment of critically ill patients generally and can be especially valuable to low resources settings where critical care expertise is lacking.

Footnotes

Author contributions: SD participated in the analysis and interpretation of the data and drafted the manuscript. DM, BZ, MJ, TK, DB, ML, and AS participated in the collection of the data and revised the manuscript. VDj and RS participated in the design of the study and coordination. PK had primary responsibility for study design, data analysis, interpretation of data, and writing the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Pedja Kovacevic Inline graphic https://orcid.org/0000-0001-6654-5351

Availability of data and materials: The datasets used and/or analyzed in the present study are available from the corresponding author on reasonable request.

References

  • 1. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; 382: 1708–1720. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Salluh JIF, Burghi G, Haniffa R. Intensive care for COVID-19 in low- and middle-income countries: research opportunities and challenges. Intensive Care Med 2021; 47: 226–229. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020; 8: 475–481. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; 323: 1061. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA 2020; 323: 1488. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Liu K, Fang YY, Deng Y, et al. Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. Chin Med J 2020; 133: 1025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8. Chen T, Wu D, Chen H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020; 368: m1091. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Vukoja M, Rivello E, Gavrilovic S, et al. A survey on critical care resources and practices in low-and middle-income countries. Glob Heart 2014; 9: 337–342. [DOI] [PubMed] [Google Scholar]
  • 10. Kovacevic P, Meyer FJ, Gajic O. Successful implementation of modern critical care in the low-resources country Bosnia and Herzegovina: single-center experience. Med Klin Intensivmed Notfmed 2022; 117: 269–275. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11. Vukoja M, Riviello ED, Schultz MJ. Critical care outcomes in resource-limited settings. Curr Opin Crit Care 2018; 24: 421–427. [DOI] [PubMed] [Google Scholar]
  • 12. Kunitz SJ. The making and breaking of Yugoslavia and its impact on health. Am J Public Health 2004; 94: 1894–904. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Tokalić R, Viđak M, Kaknjo MM, et al. Antifragility of healthcare systems in Croatia and Bosnia and Herzegovina: Learning from man-made and natural crises. Lancet Reg Health Eur 2021; 9: 100216. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. GDP per capita (current US$). World Bank national accounts data, and OECD National Accounts data files, https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=BA (accessed July 1, 2022).
  • 15. Losonczy LI, Papali A, Kivlehan S, et al. White paper on early critical care services in low resource settings. Ann Glob Health 2021; 87: 105. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16. Thiery G, Kovacević P, Straus S, et al. From mechanical ventilation to intensive care medicine: a challenge for Bosnia and Herzegovina. Bosn J Basic Med Sci 2009; 9: 69–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Mantena S, Rogo K, Burke TF. Re-examining the race to send ventilators to low-resource settings. Respir Care 2020; 65: 1378–1381. [DOI] [PubMed] [Google Scholar]
  • 18. McMahon DE, Peters GA, Ivers LC, et al. Global resource shortages during COVID-19: Bad news for low-income countries. PLoS Negl Trop Dis 2020; 14: e0008412. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19. Aggarwal R, Trikha A. Acquiring ventilators: fighter planes without high-octane fuel and pilots: Indian perspective in COVID Era. Indian J Crit Care Med 2020; 24: 735–736. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20. Al-Dorzi HM, Aldawood AS, Almatrood A, et al. Managing critical care during COVID-19 pandemic: the experience of an ICU of a tertiary care hospital. J Infect Public Health 2021; 14: 1635–1641. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21. Phua J, Weng L, Ling L, et al.; Asian Critical Care Clinical Trials Group. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med 2020; 8: 506–517. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22. Haldane V, De Foo C, Abdalla SM, et al. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med 2021; 27: 964–980. [DOI] [PubMed] [Google Scholar]
  • 23. Chen Y, Zhou M, Hu L, et al. Emergency reconstruction of large general hospital under the perspective of new COVID-19 prevention and control. Wien Klin Wochenschr 2020; 132(21–22): 677–684. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Brotherton BJ, Mbugua E, Halestrap P, et al. COVID-19 and the need for global critical care training. Why ventilators alone are not the answer. ATS Sch 2020; 2: 13–18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Kodama C, Kuniyoshi G, Abubakar A. Lessons learned during COVID-19: Building critical care/ICU capacity for resource limited countries with complex emergencies in the World Health Organization Eastern Mediterranean Region. J Glob Health 202; 11: 03088. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Metogo JAM, Tochie JN, Etoundi PO, et al. Anaesthesiologist-intensivist phycisians at the core of the management of critically ill COVID-19 patients in Africa: persistent challenges, some resolved dilemma and future perspective. Pan Afr Med J 2020; 37(Suppl 1): 44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. Camputaro LA, Bello Quezada ME, Hoyos Arango WA, et al. Intensive competency-based training strategy in a National Hospital in times of Pandemic. Medicine 2021; 100(39): e27152. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28. Baptista FVD, Aguiar MRA, Moreira JA, et al. Contributions of residents from multiple specializations in managing the COVID-19 pandemic in the largest public hospital Brazil. Clinics 2020; 75: e2229. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29. Vera San Juan N, Clark SE, Camilleri M, et al. Training and redeployment of healthcare workers to intensive care units (ICUs) during the COVID-19 pandemic: a systematic review. BMJ Open 2022;12(1): e050038. [DOI] [PMC free article] [PubMed] [Google Scholar]

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