A pilot study to determine the profile of recovery room nurses in Johannesburg hospitals

Background: Apart from anecdotal evidence, very little is known of the recovery room nurses in South Africa.Method: An exploratory, prospective, descriptive pilot study was carried out in the recovery rooms of six Johannesburg hospitals, three academic and three private hospitals, one from each of the major private hospital groups. An appointment was scheduled and data were collected from either the theatre nursing manager, sister in charge of the recovery room or the nursing manager. The data collected reflected a brief profile of the selected recovery rooms and the demographic and education profile of nurses working there in August 2011.Results: Nurse:patient ratios were difficult to determine. Agency staff was used by one recovery room. The other recovery rooms used their permanent staff to work overtime. All the hospitals used anaesthetic nurses to double up when necessary. Only one of the recovery rooms had a supernumerary anaesthetist available during the day. A total of 49 nurses were working in the six recovery rooms during August 2011. The majority, 95.9% (n = 47), of the recovery room nurses were females and 4.1% (n = 2) were males. The average age of the recovery nurses was 44 years (25–63 years), with a median of 41 years. The experience of the recovery room nurses ranged from one month to 35 years with an average of 8.6 years. The majority of nurses, 57.1% (n = 28), were professional nurses, and 42.9% (n = 21) were enrolled nurses. Of the 28 professional nurses, 32.0% (n = 9) had no postgraduate training. The remaining 19 nurses had the following postgraduate qualifications: management and operating room technique 17.9% (n = 5), critical care 14.3% (n = 4), and education 10.7% (n = 3). The six-month anaesthetic nurse qualification, that is not an official South African Nursing Council-endorsed postgraduate qualification, was held by 35.7% (n = 10) of the professional nurses and 4.8% (n = 1) of the enrolled nurses. All the recovery rooms had an in-service education programme.Conclusion: There is a need to determine the profile of recovery room nurses in South Africa and to establish an appropriately trained and competent recovery room nursing workforce.Keywords: recovery room nurse, educational profile, demographic profil

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 – 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

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 – 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 – 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

Bacterial contamination of re-usable laryngoscope blades during the course of daily anaesthetic practice

Background and objectives. Hospital-acquired infections (HAIs) are largely preventable through risk analysis and modification of practice.Anaesthetic practice plays a limited role in the prevention of HAIs, although laryngoscope use and decontamination is an area of concern.We aimed to assess the level of microbial contamination of re-usable laryngoscope blades at a public hospital in South Africa.Setting. The theatre complex of a secondary-level public hospital in Johannesburg.Methods. Blades from two different theatres were sampled twice daily, using a standardised technique, over a 2-week period. Samples werequantitatively assessed for microbial contamination, and stratified by area on blade, theatre and time using Fisher’s exact test.Results. A contamination rate of 57.3% (63/110) was found, with high-level contamination accounting for 22.2% of these. Commoncommensals were the most frequently isolated micro-organisms (79.1%), but important hospital pathogens such as Enterobacter species and Acinetobacter baumannii were isolated from blades with high-level contamination. No significant difference in the level of microbial contamination by area on blade, theatre or time was found (p<0.05).Conclusions. A combination of sub-optimal decontamination and improper handling of laryngoscopes after decontamination results in significant microbial contamination of re-usable laryngoscope blades. There is an urgent need to review protocols and policies surrounding the use of these blades

Endotracheal Tube Cuff Pressures in Adult Patients Undergoing General Anaesthesia in Two Johannesburg Academic Hospitals

Background: Endotracheal tube (ETT) cuff pressure commonly exceeds the recommended range of 20–30 cm H₂O during anaesthesia. A set volume of air will not deliver the same cuff pressure in each patient and the pressure exerted by the ETT cuff can lead to complications, with either over- or under-inflated cuffs. These can include a sore throat and cough, aspiration, volume loss during positive pressure ventilation, nerve palsies, tracheomalacia and tracheal stenosis. No objective means of ETT cuff pressure monitoring is available in the operating theatres of Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Chris Hani Baragwanath Academic Hospital (CHBAH). The ETT cuff pressure of patients undergoing general anaesthesia is therefore unknown.Method: ETT cuff pressure of 96 adult patients undergoing general anaesthesia without nitrous oxide at CMJAH and CHBAH was measured by one researcher. A RUSCH Endotest™ manometer was used to measure ETT cuff pressure in size 7.0 – 8.5 mm ETTs. The cuff inflation technique that was used by the anaesthetist was also documented.Results: The mean ETT cuff pressure recorded was 47.5 cm H₂O (range 10–120 cm H₂O). ETT cuff pressures exceeded 30 cm H₂O in 64.58% of patients. Only 18.75% of patients had ETT cuff pressures within the recommended range of 20–30 cm H₂O. There was no statistically significant difference between the ETT cuff pressures measured at the two hospitals. Minimal occlusive volume was the most frequent technique used to inflate the ETT cuff (37.5%); this was followed by inflating the ETT cuff with a predetermined volume of air in 31.25% of cases and palpation of the pilot balloon (27.08%). There was no statistically significant difference between the ETT cuff pressure measured and the inflation technique used by the anaesthetist.Conclusion: ETT cuff pressures of the majority of patients undergoing general anaesthesia at two academic hospitals were higher than the recommended range. ETT cuff pressure should routinely be measured using a manometer.Keywords: Adults, Endotracheal Tube Cuff Pressures, General Anaesthesia, Manomete

Anaesthetists’ knowledge of surgical antibiotic prophylaxis: a prospective descriptive study

Background: Surgical site infection (SSI) is the second most common hospital-acquired infection and results in increased morbidity and mortality and a longer hospital stay. Surgical antibiotic prophylaxis (SAP) is one component of broader strategies to reduce rates of SSI. Adherence to SAP guidelines is largely sub-optimal globally, with knowledge of appropriate SAP being an important factor that affects this. The study’s objective was to describe awareness amongst anaesthetists at university-affiliated hospitals of available SAP guidelines and to describe their knowledge on the subject. Comparisons between senior and junior anaesthetists were to be made.Methodology: A prospective descriptive study design using a self-administered questionnaire was employed. The study population was the anaesthetists in a university-affiliated Department of Anaesthesiology in Johannesburg, South Africa.Results: The analysis included 135 completed questionnaires from the department’s anaesthetists. A total of 15.6% of participants followed a specific guideline in their practice, 28% for senior anaesthetists vs. 4.2% for junior anaesthetists. The overall mean score for knowledge was 56.2%, 59.3% for senior anaesthetists vs. 53.6% for junior anaesthetists, which was statistically significant (p-value < 0.001). Overall knowledge was found to be poor and, specifically, knowledge regarding indication for prophylaxis, antibiotic re-dosing interval and duration of prophylaxis was poor.Conclusion: The anaesthetists had poor knowledge regarding SAP. While the difference in knowledge between senior and junior anaesthetists was statistically significant, is it likely that this difference would not be substantial enough to have a clinical impact. The authors recommend interventions to improve the knowledge of the anaesthetists regarding SAP as well as the development of local SAP guidelines.Keywords: anaesthetist, antibiotics, knowledge, perioperative, surgical prophylaxis, surgical site infectio