Sats Bhagwanjee

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.

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.

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.

Resuscitation and anaesthesia for penetrating trauma.

Purpose of review The worldwide burden of trauma is increasing, but is unequal between nations. Trauma targets the young and productive in society and imposes a major burden on the health infrastructure. This review provides a distillation of practice in a busy urban trauma centre dealing with large volumes of penetrating trauma. Recent findings The anaesthetist holds a pivotal role in the management of penetrating injury; the requirements of prompt airway control, early delivery to theatre and control of a physiologically brittle patient can be challenging. Recognition that attempts at definitive surgery in exsanguinating patients may do more harm than good has made surgery a tool of resuscitation rather than an end in itself. Summary Depending on where they practice, clinicians are more or less likely to encounter patients with gunshot wounds. However, adherence to basic principles and attention to the details of temperature control, invasive haemodynamic monitoring, blood product therapy and effective communication should translate to improved outcomes for patients after penetrating trauma.

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