National audit of critical care resources in South Africa – research methodology

This article provides an in-depth description of the methodology that was followed and the quality control measures that were implemented during the audit of national critical care resources in South Africa. South African Medical Journal Vol. 97 (12) 2007: pp. 1308-131

National audit of critical care resources in South Africa – transfer of critically ill patients

Objectives. To establish the efficacy of the current system of referral of critical care patients: (i) from public hospitals with no ICU or HCU facilities to hospitals with appropriate facilities; and (ii) from public and private sector hospitals with ICU or HCU facilities to hospitals with appropriate facilities. Design and setting. A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICUs and HCUs in South Africa was undertaken. Results. A 100% sample was obtained; 77% of public and 16% of private hospitals have no IC/HC units. Spread of hospitals was disproportionate across provinces. There was considerable variation (less than 1 hour - 6 hours) in time to collect between provinces and between public hospitals that have or do not have ICU/HCU facilities. In the private hospitals, the mean time to collect was less than an hour. In public hospitals without an ICU, the distance to an ICU was 100 km or less for approximately 50% of hospitals, and less than 10% of these hospitals were more than 300 km away. For hospitals with units (public and private), the distance to an appropriate hospital was 100 km or less for approximately 60% of units while for 10% of hospitals the distance was greater than 300 km. For public hospitals without units the majority of patients were transferred by non-ICU transport. In some instances both public and private hospitals transferred ICU patients from one ICU to another ICU in non-ICU transport. Conclusion. A combination of current resource constraints, the vast distances in some regions of the country and the historical disparities of health resource distribution represent a unique challenge which demands a novel approach to equitable health care appropriation. South African Medical Journal Vol. 97 (12) 2007: pp. 1323-132

National audit of critical care resources in South Africa – unit and bed distribution

Objective. To determine the national distribution of intensive care unit (ICU)/high care (HC) units and beds. Design and setting. A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICU and high care units in South Africa was undertaken. Results. A 100% sample was obtained; 23% of public and 84% of private hospitals have ICU/HC units. This translates to 1 783 public and 2 385 private beds. Only 18% of all beds were HC beds. The majority of units and beds (public and private) were located in three provinces: Gauteng, KwaZulu-Natal and the Western Cape. The Eastern Cape and Free State had less than 300 beds per province; the remaining four provinces had 100 or fewer beds per province. The public sector bed:population ratio in the Free State, Gauteng and Western Cape was less than 1:20 000. In the other provinces, the ratio ranged from 1:30 000 to 1:80 000.The majority of units are in level 3 hospitals. The ICU bed:total hospital bed ratio is 1.7% in the public sector compared with 8.9% in the private sector. The ratio is more when the comparison is made only in those hospitals that have ICU beds (3.9% v. 9.6% respectively). In the public and private sector 19.6% beds are dedicated to paediatric and neonatal patients with a similar disparity across all provinces. Most hospitals admit children to mixed medical surgical units. Of all ICU beds across all provinces 2.3% are commissioned but not being utilised. Conclusion. The most compelling conclusion from this study is the need for regionalisation of ICU services in SA. South African Medical Journal Vol. 97 (12) 2007: pp. 1311-131

National audit of critical care resources in South Africa – nursing profile

Objectives. (i) To determine the profile and number of nurses working in South African intensive care units (ICUs) and high care units (HCUs); (ii) to determine the number of beds in ICU and HCUs in South Africa; and (iii) to determine the ratio of nurses to ICU/HC beds. Design and setting. A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICU and HCUs in South Africa was undertaken. Results. A 100% was sample obtained; 74.8% of the ICU nursing managers were ICU-trained nurses with an average of 12.8 years of ICU experience. Only 25.6% of nurses working in ICU were ICU trained. The majority were registered nurses (49.2%), while 21.4% were semi-professional nurses. Private sector nurses represented 50.3% of all nurses. Some 42.8% of the professional nurses had 0 - 5 years of experience and 28.7% had 5 - 10 years. The groups 10 - 15 and 15 - 20 years represented 16.1% and 6.6% respectively. Only 5.7% nurses had 20 and more years' experience. In the units that used agency staff the ratio of permanent to agency nursing staff for the month of June 2003 was 64.5% versus 35.5%. In total there are 4 168 ICU and HC beds in South Africa that are serviced by 4 584 professional nurses. The nurse:bed ratio is 1.1 nurses per ICU/HC bed. Conclusions. This study demonstrates that ICU nursing in South Africa faces the challenge of an acute shortage of trained and experienced nurses. Our nurses are tired, often not healthy, and are plagued by discontent and low morale. South African Medical Journal Vol. 97 (12) 2007: pp. 1315-131

National audit of critical care resources in South Africa – open versus closed intensive and high care units

Objectives. To evaluate the distribution and functioning of South African intensive care units (ICUs) and high care units (HCUs), in particular the extent to which units were ‘closed units'. Design and setting. A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICUs and HCUs in South Africa was undertaken. Results. A 100% sample was obtained. A total of 396 acute care public and 256 private hospitals were identified; 23% of public hospitals had ICUs and/or HCUs compared with 84% of private hospitals. In the public hospitals there were 210 unitsand 238 units in the private hospitals. Only 7% of public units and less than 1% of private units were ‘ideal closed units'. A total number of 3 414 ICU and high care beds were identified; 71% of beds were in open units versus 29% in closed units. The distribution of ICU and ICU/high care beds comprised 64% in private sector and 36% (1 223) in public units. A total of 244 024 patients were admitted to all units in South Africa during 2002, of whom 63% were to private units and 37% to public sector units. Conclusion. In the face of already limited resources (financial and human) and given the emphasis on primary care medicine (with consequent limited capacity for further ICU development), it is crucial that existing facilities are maximally utilised. Like the USA we are not in a position to implement the Leapfrog recommendations and must modify our approach to dealing with South African realities. South African Medical Journal Vol. 97 (12) 2007: pp. 1319-132

Global burden of influenza as a cause of cardiopulmonary morbidity and mortality

Severe acute respiratory infections, including influenza, are a leading cause of cardiopulmonary morbidity and mortality worldwide. Until recently, the epidemiology of influenza was limited to resource-rich countries. Emerging epidemiological reports characterizing the 2009 H1N1 pandemic, however, suggest that influenza exerts an even greater toll in low-income, resource-constrained environments where it is the cause of 5% to 27% of all severe acute respiratory infections. The increased burden of disease in this setting is multifactorial and likely is the result of higher rates of comorbidities such as human immunodeficiency virus, decreased access to health care, including vaccinations and antiviral medications, and limited healthcare infrastructure, including oxygen therapy or critical care support. Improved global epidemiology of influenza is desperately needed to guide allocation of life-saving resources, including vaccines, antiviral medications, and direct the improvement of basic health care tomitigate the impact of influenza infection on the most vulnerable populations

Critical care resources in the Solomon Islands: a cross-sectional survey

<p>Abstract</p> <p>Background</p> <p>There are minimal data available on critical care case-mix, care processes and outcomes in lower and middle income countries (LMICs). The objectives of this paper were to gather data in the Solomon Islands in order to gain a better understanding of common presentations of critical illness, available hospital resources, and what resources would be helpful in improving the care of these patients in the future.</p> <p>Methods</p> <p>This study used a mixed methods approach, including a cross sectional survey of respondents' opinions regarding critical care needs, ethnographic information and qualitative data.</p> <p>Results</p> <p>The four most common conditions leading to critical illness in the Solomon Islands are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis. Complications of surgery and trauma less frequently result in critical illness. Respondents emphasised the need for basic critical care resources in LMICs, including equipment such as oximeters and oxygen concentrators; greater access to medications and blood products; laboratory services; staff education; and the need for at least one national critical care facility.</p> <p>Conclusions</p> <p>A large degree of critical illness in LMICs is likely due to inadequate resources for primary prevention and healthcare; however, for patients who fall through the net of prevention, there may be simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality. Emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment, to prevent critical care from unduly diverting resources away from other important parts of the health system.</p

United States Critical Illness and Injury Trials Group

The United States Critical Illness and Injury Trials (USCIIT) Group is an inclusive, grassroots “network of networks” with the dual missions of fostering investigator-initiated hypothesis testing and developing recommendations for strategic plans at a national level. The USCIIT Group’s transformational approach enlists multidisciplinary investigative teams across institutions, critical illness and injury professional organizations, federal agencies that fund clinical and translational research, and industry partners. The USCIIT Group is endorsed by all major critical illness and injury professional organizations spanning the specialties of anesthesiology, emergency medicine, internal medicine, neurology, nursing, pediatrics, pharmacy and nutrition, surgery and trauma, and respiratory and physical therapy. Recent successes provide the opportunity to significantly increase the dialogue necessary to advance clinical and translational research on behalf of our community. More than 200 investigators are now involved across > 30 academic and community hospitals. Collectively, USCIIT Group investigators have enrolled > 10,000 patients from academic and community hospitals in studies during the last 3 years. To keep our readership “ahead of the curve,” this article provides a vision for critical illness and injury research based on (1) programmatic organization of large-scale, multicentered collaborative studies and (2) annual strategic planning at a national scale across disciplines and stakeholders

Chest radiography practice in critically ill patients: a postal survey in the Netherlands

BACKGROUND: To ascertain current chest radiography practice in intensive care units (ICUs) in the Netherlands. METHODS: Postal survey: a questionnaire was sent to all ICUs with > 5 beds suitable for mechanical ventilation; pediatric ICUs were excluded. When an ICU performed daily-routine chest radiographs in any group of patients it was considered to be a "daily-routine chest radiography" ICU. RESULTS: From the number of ICUs responding, 63% practice a daily-routine strategy, in which chest radiographs are obtained on a daily basis without any specific reason. A daily-routine chest radiography strategy is practiced less frequently in university-affiliated ICUs (50%) as compared to other ICUs (68%), as well as in larger ICUs (> 20 beds, 50%) as compared to smaller ICUs (< 20 beds, 65%) (P > 0.05). Remarkably, physicians that practice a daily-routine strategy consider daily-routine radiographs helpful in guiding daily practice in less than 30% of all performed radiographs. Chest radiographs are considered essential for verification of the position of invasive devices (81%) and for diagnosing pneumothorax, pneumonia or acute respiratory distress syndrome (82%, 74% and 69%, respectively). On demand chest radiographs are obtained after introduction of thoracic drains, central venous lines and endotracheal tubes in 98%, 84% and 75% of responding ICUs, respectively. Chest films are also obtained in case of ventilatory deterioration (49% of responding ICUs), and after cardiopulmonary resuscitation (59%), tracheotomy (58%) and mini-tracheotomy (23%). CONCLUSION: There is notable lack of consensus on chest radiography practice in the Netherlands. This survey suggests that a large number of intensivists may doubt the value of daily-routine chest radiography, but still practice a daily-routine strategy