Juan Scribante

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.

Antibiotic prescription practices and their relationship to outcome in South Africa: Findings of the prevalence of infection in South African intensive care units (PISA) study

BACKGROUND The emergence of multidrug-resistant, extensively resistant and pan-resistant pathogens and the widespread inappropriate use of antibiotics is a global catastrophe receiving increasing attention by health care authorities. The antibiotic prescription practices in public and private intensive care units (ICUs) in South Africa are unknown. OBJECTIVE To document antibiotic prescription practices in public and private ICUs in South Africa and to determine their relationship to patient outcomes. METHODS A national database of public and private ICUs in South Africa was prospectively studied using a proportional probability sampling technique. RESULTS Two hundred and forty-eight patients were recruited. Therapeutic antibiotics were initiated in 182 (73.5%), and 54.9% received an inappropriate antibiotic initially. De-escalation was practised in 33.3% and 19.7% of the public and private sector patients, respectively. Antibiotic duration was inappropriate in most cases. An appropriate choice of antibiotic was associated with an 11% mortality, while an inappropriate choice was associated with a 27% mortality (p=0.01). The mortality associated with appropriate or inappropriate duration of antibiotics was 17.6% and 20.6%, respectively (p=0.42). CONCLUSION Inappropriate antibiotic prescription practices in ICUs in the public and private sectors in South Africa are common and are also associated with poor patient outcomes.

ICU nurse allocation in a cardiothoracic ICU: How many hands do we need?

Aim. To determine the nurse/patient ratios required to render safe, competent ICU nursing. Method. A patient classification system (CritScore) was used to compile an objective 3-month patient profile. The number (of full-time and agency staff) and the professional profiles of nursing staff allocated to the unit during this period were documented. Results. The majority of the patients were class 3 patients. While there was concordance between the total number of nurses present in relation to the number predicted by CritScore, the number of ICU-trained nurses was consistently below that ascertained by CritScore. This unit was staffed on average with more than 50% nonpermanent staff who were employed on a temporary basis via agencies. Conclusion. The number of nursing hands allocated is important, but even more so is the quality, or competence, of these hands. Nursing care without an acceptable level of competence in a critical care unit may be considered as a potentially harmful intrusion for the patient. Southern African Journal of Critical Care Vol. 23 (2) 2007: pp. 66-69

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.

A survey of oral care practices in South African intensive care units

Objectives. The aim of this study was to describe current oral care interventions for ventilated patients in South African ICUs. The objectives of the study were to determine the knowledge, attitudes and beliefs, and training of ICU nurses who render oral care; the type and frequency of oral care delivered to ventilated patients; hospital support and supplies available; and the availability of oral care protocols in the ICU.

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.

2006 profile of postgraduate critical care nursing research in South Africa

Critical care nursing research contributes to the advancement of critical care knowledge and promotes better patient care and the adoption of best or better practices, 3 all of which address important challenges currently faced by critical care nursing in South Africa. Every year a significant number of critical care nursing research studies are undertaken at a postgraduate level in South Africa. However, there is no generally available profile of this research and it is generally not known if and where it is published and/or presented. Given the current challenges to critical care, it is important that the profile of critical care nursing research, the extent to which this research is communicated to the critical care community, and the communication channels used are determined.

National audit of critical care resources. How long before we act

The estimated annual expenditure on health care is vastly different in the USA (16% of GDP) compared with developing countries (approximately 3% of GDP).1 South Africa is unique in sub-Saharan Africa, where expenditure on health is relatively high and is estimated to be between 8% and 10%.1 Despite this, there are serious limitations to many aspects of health care delivery based on multiple factors in South Africa. It may be argued that it will take decades before we outlive the injustices imposed on our society by apartheid. In attempting to offer reasonable and responsible guidance to policy makers and politicians, clinicians and allied health care workers have an obligation to base decisions on objective evidence. Southern African Journal of Critical Care Vol. 24 (1) 2008: pp. 4-6

Microbial contamination and labelling of self-prepared, multi-dose phenylephrine solutions used at a teaching hospital

Background: Common practice at Chris Hani Baragwanath Academic Hospital (CHBAH) is to use boluses from a self-prepared, multi-dose phenylephrine solution to treat spinal anaesthesia-induced hypotension in patients undergoing a Caesarean section. The aims of this study were to determine if there was microbial contamination of the solutions and to evaluate whether healthcare workers adhered to appropriate labelling and aspiration practices. Methods: A sample was collected and the labelling data were documented from the solutions found in the two obstetric theatres at CHBAH over a three-month period. The samples were sent to a laboratory for microbial investigation. Results: Microbial contamination was identified in 6.4% of samples collected. The name of the solution was indicated on 100% of the containers and the concentration of the solution was on 96.4%. The date the solution was prepared was indicated on 74.6% of containers and the time the solution was prepared was on 57.3%. Only 8.2% of healthcare workers who prepared the solution confirmed it by placing a signature on the container. Labelling data were written directly on 100% of the containers and a spike-device was used in 64.5% of the containers. Conclusions: This study demonstrated microbial contamination of the solution and may indicate an infection hazard. Healthcare workers also did not adhere to appropriate labelling and aspiration practices. This is important for all patients from a patient safety perspective and the need to improve quality of care.

Burnout among anaesthetists in South Africa

Background: Studies have been done to determine the level of burnout in anaesthesiology internationally, but not in South Africa. Method: The Maslach Burnout Inventory-Human Services Survey was used to assess the level of burnout. The primary objectives were to estimate the level of burnout among doctors working in the Department of Anaesthesiology at the University of the Witwatersrand (Wits doctors) and to estimate the level of burnout among private anaesthetist attending an anaesthetic symposium (Private doctors). Results: High levels of burnout were identified in 21.0% of Wits doctors. Higher burnout scores were noted in female doctors (p = 0.49), less years of anaesthetic experience (p = 0.37), doctors of younger age (p = 0.07), registrars (p = 0.22) and writing examinations within three months of completing the survey (p = 0.15), but none where statistically significant. High levels of burnout were identified in 8.1% of Private doctors Conclusion: High levels of burnout were identified, especially, among anaesthetists working in the academic hospitals affiliated to Wits.