Open Journal of Anesthesiology, 2013, 3, 315-319
doi:10.4236/ojanes.2013.37069 Published Online September 2013 (http://www.scirp.org/journal/ojanes)
315
Challenges of Improving Intensive Care Medicine in
Eritrea: Impact of an Italian Cooperative Project of
Educational and Clinical Support*
Valentina Anichini1, Giovanni Zagli1#, Hagos Goitom2, Giovanni Cianchi1, Andrea Cecchi1,
Lucia Perretta1, Emanuele Bigazzi1, Barbara Gazzini1, Simone Proietti1, Alessandro Di Filippo3,
Simone Toccafondi4, Gianfranco Gensini5, Giancarlo Berni6, Adriano Peris1
1Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Florence, Italy; 2Department Intensive
Care Unit, Orotta National Referral Hospital, Asmara, Eritrea; 3Anesthesia and Intensive Care, Faculty of Medicine, University of
Florence, Florence, Italy; 4First Aid of Emergency Department, Careggi Teaching Hospital, Florence, Italy; 5Department of Critical
Care Medicine and Surgery, Careggi Teaching Hospital, Florence, Italy; 6Tuscany Region Sanitary System, Florence, Italy.
Received June 8th, 2013; revised July 8th, 2013; accepted July 31st, 2013
Copyright © 2013 Valentina Anichini et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Intensive care in Africa is available only in teaching or referral hospitals. Here we report the experience of a multidisci-
plinary collaboration between physicians and nurses of the Emergency Department (First Aid and Intensive Care Unit)
of a tertiary referral hospital (Careggi Teaching Hospital, Florence, IT) and physicians and nurses of Orotta National
referral Hospital in Asmara, Eritrea. The project was aimed at performing clinical assistance and training on the job to
the local staff to improve the standard of care in the local Emergency Department. The duration of the project was ini-
tially planned to be 30 months, but unfortunately it was interrupted after 18 months because of lack of funds. The Italian
staff was composed of two physicians and two nurses per period. To monitor local ICU activity, a retrospective survey
of 36 months was performed. During the 36 months of data collection, 1169 patients were admitted to the ICU. In-
tra-ICU mortality rate resulted comparable before, during, and after Italian presence. On the contrary, the 28-day mor-
tality resulted significantly lower bo th during and after the Italian stay. After project interruption, the Italian staff main-
tained contact with the Eritrean ICU personnel, who were invited to attend the Italian ICU for one month per year, and
collected information about Orotta ICU activities.
Keywords: Intensive Care Unit; Developing Countries; MEWS
1. Introduction
Intensive care in Eritrea is available only in teaching or
referral hospitals, even if in developing countries acute
critical illness is often potentially reversible with ade-
quate intensive care treatment. Expensive technologies,
maintenance inadequacy, and shortage of health person-
nel can explain the difficulties in having a high level
standard of care.
The Eritrean State has been independent since 1993.
The population is about 5 million. Inhabitants have a life
expectancy of 61 - 65 years (male-female), and the infant
mortality rate is 7.4%. Gross national income per capita
is $680, and total expenditure on health per capita is $28.
(WHO statistics:
http://www.afro.who.int/en/eritrea/country-health-profile
.html). Information on the Eritrean population health
status is available on the world health statistics site
(http://www.who.int/whosis/en/). Another important pa-
per describing the health status of the Eritrean population
reports the prevalence of non-communicable disease risk
factors [1]. Here we report the experience of a multidis-
ciplinary collaboration among physicians and nurses of
the Emergency Department (First Aid and Intensive Care
Unit) of a tertiary referral hospital (Careggi Teaching
Hospital, Florence, IT). The collaboration project, sus-
tained by the Eritrean Health Ministry and the Tuscan
Region, took place in the Orotta National referral Hospi-
*Conflicts of Interest: The authors declare that they do not have any
conflicts of interest.
#Corresponding author.

Challenges of Improving Intensive Care Medicine in Eritrea: Impact of an Italian Cooperative Project
of Educational and Clinical Support
316
tal in Asmara, Eritrea.
In a recent review, critical care improvement as a fun-
damental aspect of healthcare in the developing world
has been emphasised [2]. In their article, Riviello and
co-authors correctly underlined that the intensive care
setting must be separate from the concept of “expensive”
intensive care; instead, it must be thought in terms of
“appropriate” intensive care, thus strictly related to the
site of intervention. In this perspective, the introduction
of the routine use of a simple and standardised score,
such as Modified Early Warning System (MEWS) pro-
posed by Subbe and co-workers [3,4], represents an ex-
ample of intensification of standard of care without any
significant impact on economic resources. This simple
but important process can be realised thanks both to the
existing ICU reality and the favourable and constructive
collaboration between Eritrean and Italian physicians.
The goal of the project was to introduce a triage sys-
tem in the emergency room, and treatment protocols in
the operating theatre and in the Intensive Care Unit, ac-
cording to international guidelines.
The project included many activities:
 Italian staff performed clinical assistance on Orotta
patients;
 Teaching support to Eritrean staff was organised with
frontal classes twice a week, as well as simulation
courses. Moreover, on-the-job training activities were
performed during the daily working hours of the
nurses and doctors, with skills and knowledge assess-
ed by Italian tutors;
 Supply of medical equipment, such as a blood gas
analyser, an ultrasound machine, a ventilator machine,
sedation drugs, and thrombolytic drugs.
At the end of the project, Eritrean personnel were
thought to be able to manage critical medical or surgical
scenarios and to transfer skills to nurse and medical stu-
dents.
Italian staff permanence was 18 months. The entire
project cost of 1,050,000 euros was paid by the Tuscan
Region, and was used for human resources (insurance,
salaries, travel, and lodging expenses), medical equip-
ment, and shipping charges. After Italian departure, col-
laboration continued for 3 years more, offering 1 month
attendance periods to the Eritrean staff in the Careggi
Hospital ICU, to share the experience of intensive care
with proper clinical assessment, treatment protocols, and
bedside procedures on critical patients. Information about
Orotta ICU activities after Italian departure was collected
by Eritrean staff.
2. Setting and Methods
The co-operation project was aimed at performing clini-
cal assistance and training to the local staff to improve
the standard of care in the local Emergency Department.
The effective duration of the project was 3 years (2005-
2007), including 6 months for needs analysis and plan-
ning of intervention. The Italian staff was composed of
two physicians and two nurses per period (usually two
months each), working in the emergency room, the ICU,
and the operating theatre. Orotta Hospital in Asmara was
selected in the Eritrean Health Sheet as the referral hos-
pital to treat medical and surgical emergencies, because
critical patients could not receive proper care in periph-
eral health centres.
Orotta Hospital was built with a contribution from the
Chinese government in 2003. It includes 300 beds, with
surgical and medical wards, and an outpatient department
for medication, laboratory examination, and diagnostic
procedures. A central laboratory with blood units and a
radiology department are available, with an ultrasound
device, and a CT-scan. Only traditional X-rays are avai-
lable bedside.
The Emergency Department includes 4 operating
rooms, the emergency room, and 9 ICU beds, all sup-
plied with centralised oxygen. Surgical activity in the
Orotta is well organised, with numerous scheduled inter-
ventions, 3 surgeons, some medical students, and many
anaesthesia nurses. A recovery room is available to care
for patients after surgery, before returning to the ward.
The ICU is equipped with 3 multi-parametric monitors
and 2 ventilators. The ICU staff is composed of 4 nurses,
8 nurse assistants, and one doctor in the morning with
internist competencies. Consultants on call are available
to treat obstetric, paediatric, neurosurgical, and urologi-
cal patients. Another doctor is in charge of the emer-
gency room during the day, working with 6 nurses and 6
nurse assistants. One of the nurses is responsible for the
triage system, and the emergency room is equipped with
a defibrillator, a multi parametric monitor, and some ad-
vanced airway devices.
During the night shift, only one physician was on duty
at the hospital, and he decided whether to admit patients
to the medicine or surgical ward, to the ICU, or to dis-
charge them.
As simple evaluating tool for early identification of
medical patients who need intensive care, the MEWS
score was introduced in Orotta Hospital. The MEWS is a
tool for bedside evaluation based on five physiological
parameters: systolic blood pressure, pulse rate, respira-
tory rate, urinary output, body temperature, and neuro-
logical status (Table 1). A total score of 4 or more was
considered as a ward alert. A MEWS score was retro-
spectively collected in all ICU patients, because all five
parameters were registered on ICU admission clinical
papers. The MEWS score was also taught during frontal
lessons, in order to train nurses to call for the doctor on
uty when a patient began to worsen, in a timely manner. d

Challenges of Improving Intensive Care Medicine in Eritrea: Impact of an Italian Cooperative Project
of Educational and Clinical Support
317
Table 1. The modified early warning score (MEWS).
Systolic blood pressure
(mmHg) <70 71 - 80 81 - 100 101 - 199 ≥200
Heart rate per min <40 41 - 50 51 - 100 101 - 110 111 - 129 ≥130
Respiratory rate per min <9 9 - 14 15 - 20 21 - 29 ≥30
Temperature (˚C) <35 35.1 - 38.4 ≥38.5
Neurological status Alert Reacting to voiceReacting to pain Unresponsive
Scores 3 2 1 0 1 2 3
To monitor the Orotta ICU activity and to improve co-
operation effectiveness, a retrospective survey of 36
months (from 6 months before Italian stay to 12 months
after Italian stay) was done, including the following data:
age, sex, admission cause, length of stay, and mortality in
ICU. No seriousness of illness score was used, due to the
lack of laboratory data.
GraphPad Prism 5 (GraphPad Software Inc., San
Diego, CA) was used for statistical analysis. Continuous
variables were analysed with Kruskal-Wallis test, where-
as categorical data were examined using Chi-square test
and Fisher's exact text (95% confidence interval). P val-
ues were considered significant if less than 0.05.
3. Results
During the 36 months of data collection, a total of 1169
patients were admitted in ICU. Table 2 summarizes
demographic and clinical characteristics of patients of the
3 periods of data collection. During the Italian stay, ad-
mission diagnosis was represented mostly by medical
disease (85%), with only 8% of patients coming from the
operating theatre, and 7% represented by trauma patients.
Regarding medical patients, cardiovascular problems are
widespread: 21% acute coronary syndrome, 9% deep
venous thrombosis, 8% rheumatic heart failure. Other
medical admissions are represented by respiratory prob-
lems (15% pneumonia), and HIV and tuberculosis infec-
tions are frequent comorbidities.
During the Italian stay, ICU admission resulted to be
higher than during the other periods. Intra-ICU mortality
rate resulted comparable before, during, and after Italian
presence. Due to data missing, the 28-days mortality
could not be used as an outcome parameter, even if a
decreasing trend was observed by the operator during the
Italian stay and the later period. During the same two
periods, MEWS scoring resulted comparable, and the
mean ICU length of stay higher, than the retrospective
control (Table 2).
Data collection from the Orotta ICU is still going on,
and we report data about ICU mortality and length of
stay related to the three following years (Table 3). No
Table 2. Baseline and outcome data of patients retrospec-
tively collected (Jan 2005-June 2006), during the Italian ex-
perience and MEWS introduction (July 2006-Dec 2007),
and after Italian experience (Jan 2008-Dec 2008).
January 2005
June 2006
July 2006
December
2007
January 2008
December
2008
N patients 294 515 349
Age, years (mean)48.4 48.8 45.2
Female sex (%) 46% (135) 45% (232) 47% (169)
Admission (%)
Medical 87% (256) 86% (443) 83% (299)
Surgical 7% (21) 7% (36) 9% (32)
Trauma 6% (18) 7% (36) 5% (18)
MEWS (mean) 4.5 5.4 5.1
ICU LOS, days
(mean) 6.5 8.3** 7.9**
ICU mortality, %
(N) 33% (97) 35% (180) 28% (101)
**P<0.001.
Table 3. Data collection of Orotta ICU data of activities
during 3 years following project interr uption.
2009 2010 2011
Number of ICU patients 283 326 299
ICU mortality (%) 36.7% 39.8% 42.8%
ICU LOS, days (mean) 6.8 4.4 6.2
information is available about severity of illness of ICU
admitted patients. In the year 2009 part of the ICU staff
was moved to a new dialysis unit, renewing about 2/3 of
the nurses trained before.
4. Discussion
The use of MEWS as a critical illness indicator permitted

Challenges of Improving Intensive Care Medicine in Eritrea: Impact of an Italian Cooperative Project
of Educational and Clinical Support
318
us to identify a low risk group (MEWS < 5) and a high
risk group (MEWS > 5), typically with severe organ dys-
function. The usefulness of such a scoring system is its
capability to quickly detect patients that need more ac-
curate assessment and targeted intensive care treatment.
The use of scoring systems to assess severity of illness of
admitted patients is a common practice in all developed
countries. The impact of such analysis could be stronger
in limited resource countries, where the burden of expen-
sive critical care is relevant both to the hospital and to the
patient. These scoring systems include physiological and
laboratory indicators which usually are not available in
African settings, thus, comparing the quality of care in
different countries, or care before and after intervention,
becomes a difficult task, given the difficulty in standard-
ising severity of illness [5]. As in many other Track and
Trigger warning systems, the introduction of MEWS was
aimed at quickly recognising patients with potential or
established critical illnesses, and to assure appropriate
care by skilled staff in a proper setting (ICU). In the
Orotta ICU, MEWS was introduced as a clinical assess-
ment method, easily usable by the nursing staff. No trig-
ger threshold was established, but parameters detected in
the MEWS were part of alarm criteria, according to
which, those who performed the clinical assessment
would call for the doctor in charge. In the period after the
Italian stay, although the number of patients decreased,
clinical assessment of ICU admitted patients resulted
similar (Table 2). After Italian departure, unfortunately
no MEWS assessment was done. We don’t know if the
ICU mortality increase observed from 2008 to 2011
could be related to more critical patients or, more proba-
bly, to the change of staff.
Patients observed in the Orotta emergency department
during our experience had mostly cardiovascular and
respiratory diseases (in essence medical patients). Con-
cerning cardiovascular disease, we observed a high inci-
dence of acute coronary syndromes and heart failure. The
first is epidemiological compared to occidental data, and
may reflect improvement in lifestyle in the capital city.
Heart failure was often observed in young patients pre-
senting cardiac valve disease from rheumatic aetiology,
living in rural areas with difficult access to health ser-
vices. Respiratory diseases, as in many African countries,
reflect tuberculosis or HIV prevalence. The increase in
ICU admission during the Italian stay may be related to
the strong working relationship between the emergency
room and the ICU, and the efficacy of the triage pro-
gramme performed in the emergency room.
Our results are limited by the lack of a follow-up pro-
gram aimed at monitoring the long term maintenance of
improvement obtained: this can be easily attributed to
limited resources both in the local area and in the inter-
national program. A strong limitation to this data collec-
tion is the missing data regarding 28-days survival after
ICU discharge. The major problem was that we had sur-
vival information only if patients were still in the hospital.
In many cases, no information about patients discharged
to home were available, neither if they were dead nor
alive.
5. Conclusion
As reported by attendant Eritrean people in the Italian
ICU, the Orotta staff introduced some bed-side proce-
dures in daily practice (ultrasound scan, tracheotomy,
antimicrobial policy, patient positioning) [6,7], thus im-
proving the quality of care in the hospital. Nevertheless,
adequate effectiveness indicators are necessary to prop-
erly conduct a co-operation project, and time to teach
“how to train” new staff must be prolonged over the
years with the local presence of trainers and a response
system assessment.
6. Acknowledgements
This project was supported by institutional funds (Tuscan
Region and Careggi Teaching Hospital). The authors
have reported that no significant conflicts of interest exist
with any companies/organizations whose products or
services may be discussed in this article.
A special thanks to the Sanitarians of Orotta Hospital.
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