Essential Emergency and Critical Care (EECC) in Ethiopia: A Multicenter mixed-method assessment of Critical Illness Burden, Management, and Implementation Barriers

Background: Critical illness is a major contributor to morbidity and mortality in low-resource settings, yet data on its prevalence, location, management, and contextual barriers to care outside intensive care units remain limited in Ethiopia. This study aimed to determine the burden of critical illness, patient outcomes, Essential Emergency and Critical Care (EECC) provision, and barriers to implementation. Methods: This prospective mixed-methods multicenter study was conducted across 12 public hospitals in Ethiopia. A quantitative point prevalence survey assessed all adult inpatients ([≥]18 years) on a single census day per site using standardized vital sign criteria for critical illness. Patients were followed for 7-day in-hospital mortality, and hospital EECC resource availability was evaluated. A complementary qualitative component consisting of five key informant interviews and one focus group discussion was conducted with healthcare professionals to explore barriers to EECC implementation. Thematic analysis was used for qualitative data. Results: Of 1,077 hospitalized patients, 221 (20.5%) were critically ill. Most critically ill patients (62.0%) were managed in general wards. The 7-day in-hospital mortality was 14.0% among critically ill patients compared to 2.8% in non-critically ill patients. Only 1.8% of critically ill patients received all indicated EECC treatments. Median hospital EECC resource availability was 70.9% (IQR 41.4-79.1%), with no hospital fully equipped across all domains. Qualitative analysis identified seven major themes: challenges in early identification, resource constraints, knowledge gaps, attitudes toward EECC, organizational barriers, staff motivation issues, and delays in timely care delivery. Independent predictors of mortality included male sex, hypertension, cancer, HIV/AIDS, other comorbidities, and presence of critical illness. Conclusion: This critical illness outcome study in Ethiopia demonstrates that one in five hospitalized patients is critically ill, predominantly managed in general wards, with high short-term mortality and profound gaps in basic EECC delivery. Qualitative findings highlight multiple interconnected barriers to effective EECC implementation. Strengthening decentralized EECC through training, resource provision, ward-level protocols, and addressing systemic barriers is urgently needed to improve outcomes in resource-limited settings. Keywords: Essential Emergency Critical Care (EECC), Critical illness, Point prevalence, Mortality, Ethiopia.