Bosnia-Herzegovina

Local context: Building modern critical care after conflict

Bosnia-Herzegovina's healthcare system has faced significant challenges since the international armed conflicts of the 1990s. Hospitals across the country have had to build or rebuild clinical infrastructure while managing limited resources and fragmented care systems.

At the University Clinical Center of the Republic Srpska (UCCRS) in Banja Luka, clinicians began working toward a different model of care. Under the leadership of Pedja Kovacevic, M.D., Ph.D., the hospital established the country's first dedicated medical intensive care unit (ICU). UCCRS's goal was to introduce structured, evidence-based critical care while adapting to the realities of a resource-limited environment. The transformation relied heavily on international collaboration.

The challenges: Development, economic instability and infrastructure

War, economic instability and infrastructure challenges have contributed to major gaps in ICU development. Obstacles include:

  • Limited ICU capacity and infrastructure. The country has few intensive care beds and insufficient and outdated monitoring and life-support equipment.
  • Scarcity of critical care training. An absence of formal critical care training programs resulted in a shortage of physicians and nurses who are specifically trained in intensive care medicine.
  • Lack of standardized ICU protocols and multidisciplinary care models. While clinicians are committed to delivering high-quality care, differences in training and access to current evidence often lead to variability in practice.
  • Professional isolation. Healthcare professionals have limited access to continuing medical education and little exposure to international evidence-based critical care practices and networks.
  • Insufficient research opportunities. Academic collaboration and research capacity in critical care are underdeveloped, limiting the ability to generate local evidence or adopt new clinical practices.
  • Resource constraints. Staffing, infrastructure and access to specialized training are limited. These constraints made it difficult to implement new practices quickly.

Our advisory approach: Knowledge sharing, checklist implementation and long-term growth

Mayo Clinic's CERTAIN: Global Critical Care and Emergency Medicine Program and our in-country partners recognized that improving critical care in resource-limited settings requires more than short-term training. We therefore focused on sharing high-value clinical knowledge, building sustainable educational structures and adapting to the local healthcare environment.

CERTAIN program leaders set up weekly, case-based tele-education sessions to connect the Banja Luka medical ICU team with international critical care experts. These sessions allowed clinicians to discuss real ICU cases and reinforce evidence-based practices.

We also introduced the structured Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) protocol. Using the CERTAIN checklist helped standardize ICU rounds and patient evaluation. Dr. Kovacevic notes that, "In the chain of development of critical care, the CERTAIN checklist was the key link in the first period of the growth process."

What changed: Stability, safety, satisfaction and growth

By combining mentorship with simple, structured clinical frameworks, the CERTAIN Program helped create a culture of continuous learning, enabling local teams to build long-term critical care capacity within their own healthcare system. This included:

  • Adoption of evidence-based clinical practices. The Banja Luka medical ICU team initiated practices such as:
    • Daily sedation interruption for patients relying on mechanical ventilation.
    • Spontaneous breathing trials for patients relying on mechanical ventilation.
    • Restrictive fluid and transfusion strategies for all patients in the ICU.
    • Routine device assessment for all patients in the ICU.
    • Prone positioning with neuromuscular blockade for patients with acute respiratory distress syndrome.
  • Growth of multidisciplinary teams. ICU teams expanded to include a variety of healthcare professionals, such as pharmacists and physical therapists, strengthening the breadth and depth of care.
  • Improved quality and safety. Healthcare teams introduced new quality and safety initiatives, including an ICU antibiogram, hand hygiene programs and broader access to point-of-care ultrasound.
  • Better resource utilization. Teams learned to use resources more efficiently by standardizing care pathways and optimizing use of medicines. They successfully replaced less-effective or more-expensive therapies with better alternatives.
  • Increased communication and confidence. Clinicians reported better communication within the ICU team and more confidence in applying evidence-based practices during patient care. This was confirmed with a staff satisfaction survey completed in 2016 and 2017 by all 10 participating doctors and nurses.

Impact

  • Clinical outcomes. ICU mortality dropped from 43% to 27%. Hospital mortality fell from 51% to 44%. The average ICU stay was reduced from 8.3 days to 3.6 days.
  • Cost savings. The CERTAIN Program intervention generated substantial financial benefits, with approximately $400,000 in cost savings over two years.
  • Workforce development. The program contributed to long-term workforce development, fostering a culture of continuous learning and strong multidisciplinary collaboration. "We started with seven or eight ICU doctors; today we have 21," says Dr. Kovacevic.

Reflecting on the results of this transition, Dr. Kovacevic emphasized: "As of today, we have the biggest medical ICU in West Balkan countries, and we are able to better serve patients and their families."

What we learned: Local partnership and capacity are key

In Bosnia-Herzegovina, we saw that successful implementation requires strong local partnership with leaders who deeply understand the country's culture, healthcare system and political structure. Moreover, sustainable improvement depends on building local capacity and critical mass.

Dr. Kovacevic highlighted: "If you don't have enough doctors and nurses everything will stop — you have to find enough doctors who want to deal with the process of changes." By strengthening education, teamwork and clinical leadership, the medical ICU in Banja Luka created a foundation for continued progress in critical care across the region.

What comes next: Steady improvement

The Bosnia-Herzegovina team continues to use what they learned during the CERTAIN Program. They are focused on steadily improving care metrics and continue to work with the CERTAIN Program team on ways to improve antibiotic stewardship.