Research in practice

Caring for critically ill patients is challenging in resource-limited settings, where the burden of disease and mortality from potentially treatable illnesses is higher than in resource-rich areas. Barriers to delivering quality critical care in these settings include lack of epidemiologic data and context-specific evidence for medical decision-making, deficiencies in health systems organization and resources, and institutional obstacles to implementation of life-saving interventions. Potential solutions include the development of common definitions for intensive care unit (ICU), intensivist, and intensive care to create a universal ICU organization framework; development of educational programs for capacity building of health care professionals working in resource-limited settings; global prioritization of epidemiologic and clinical research in resource-limited settings to conduct timely and ethical studies in response to emerging threats; adaptation of international guidelines to promote implementation of evidence-based care; and strengthening of health systems that integrates these interventions. This manuscript reviews the field of global critical care, barriers to safe high-quality care, and potential solutions to existing challenges. We also suggest a roadmap for improving the treatment of critically ill patients in resource-limited settings.

https://www.annalsofglobalhealth.org/articles/10.5334/aogh.2413/galley/2535/download/

Global Critical Care: Moving Forward in Resource-Limited Settings

Objective Critical illness affects health systems globally, but low- and middle-income countries (LMICs) bear a disproportionate burden. Due to a paucity of data, the capacity to care for critically ill patients in LMICs is largely unknown. Haiti has the lowest health indices in the Western Hemisphere. In this study, we report results of the first known nationwide survey of critical care capacity in Haiti. Design Nationwide, cross-sectional survey of Haitian hospitals in 2017-2018. Setting Haiti. Subjects All Haitian health facilities with at least six hospital beds. Interventions Electronic- and paper-based survey. Results Of 51 health facilities identified, 39 (76.5%) from all ten Haitian administrative departments completed the survey, reporting 124 reported ICU beds nationally. Of facilities without an ICU, 20 (83.3%) care for critically ill patients in the emergency department. There is capacity to ventilate 62 patients nationally within ICUs and six patients outside of the ICU. One-third of facilities with ICUs report formal critical care training for their physicians. Only five facilities met criteria for a Level 1 ICU as defined by the World Federation of Societies of Intensive and Critical Care Medicine. Self-identified barriers to providing more effective critical care services include lack of physical space for critically ill patients, lack of equipment, and few formally trained physicians and nurses. Conclusions Despite a high demand for critical care services in Haiti, current capacity remains insufficient to meet need. A significant amount of critical care in Haiti is provided outside of the ICU, highlighting the important overlap between emergency and critical care medicine in LMICs. Many ICUs in Haiti lack basic components for critical care delivery. Streamlining critical care services through protocol development, education, and training may improve important clinical outcomes.

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Critical care capacity in Haiti: A nationwide cross-sectional survey.

BACKGROUND: SARS-CoV-2 infection may be associated with a prothrombotic state, predisposing patients for a progressive disease course. We investigated whether rivaroxaban, a direct oral anticoagulant factor Xa inhibitor would reduce COVID-19 progression. METHODS: Adults (N=497) symptomatic with mild COVID-19 and at high-risk for COVID-19 progression based on age, body mass index, or comorbidity were randomized 1:1 to either daily oral rivaroxaban 10 mg (N=246) or placebo-equivalent (N=251) for 21 days and followed to Day 35. Primary endpoints were safety and progression to moderate or severe disease, per the Gates MRI scale. Absolute difference in progression risk was assessed using a stratified Miettinen and Nurminen method. RESULTS: The study was terminated after 497 of target 600 participants were enrolled due to a pre-specified interim analysis of the first 200 participants which crossed the futility boundary for the primary efficacy endpoint in the Intent to Treat population. Enrollees were 85% aged < 65 years old, 60% female, 27% Hispanic, Black or other minorities and 69% with ≥2 comorbidities. Rivaroxaban was well-tolerated. Disease progression rates were 46/222 (20.7%) in rivaroxaban vs. 44/222 (19.8%) in placebo groups, with a risk difference of -1.0, 95% CI, -6.4 to 8.4; P = 0.78. CONCLUSIONS: Our study did not demonstrate an impact of rivaroxaban on disease progression in high-risk adults with mild COVID-19. There remains a critical public health gap in identifying scalable effective therapies for high-risk people in the outpatient setting to prevent COVID-19 progression.

Randomized study of rivaroxaban vs. placebo on disease progression and symptoms resolution in high-risk adults with mild COVID-19.

Background Providing optimal care to critically ill patients poses challenges in resource-poor settings because of the lack of equipment, inadequately trained personnel and limited infrastructure. Objectives This study explored challenges experienced by health care professionals working in resource-poor intensive care units. Method A qualitative, explorative, descriptive design was used. The population comprised nurses and doctors working in an intensive care unit of one hospital in the Limpopo province of South Africa. A purposive sample was selected and 17 semi-structured interviews were conducted. Data were analysed using Tesch's method. Ethical considerations were adhered to. Results Participants experienced challenges related to provision of suboptimal patient care, the challenge of non-adherence to protocols and/or instructions and the challenge of practising beyond the scope of practice. Conclusion Lack of resources resulted in providing suboptimal intensive patient care. Patients were prone to infections and their safety might be compromised.

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Challenges experienced by health care professionals working in resource-poor intensive care settings in the Limpopo province of South Africa.

Objective. To determine the national distribution of intensive care unit (ICU)/high care (HC) beds and the implications for ICU bed availability in the envisaged national health insurance (NHI) scheme. Methods. A descriptive, non-interventional, observational study design was used. A desk-top audit of all public and private sector ICUs, including ICU/HC beds, in South Africa was undertaken for the period 2008 - 2009. For this study, both categories were analysed and referred to as ICU beds, as they reflect the critical care component of the health service in South Africa. Results. In 2008 - 2009, there were 4 719 ICU beds in the private and public sectors in South Africa, with 75% (3 533) in the former and 25% (1 186) in the latter. The majority of ICU beds in the two sectors were located in three provinces: Gauteng (49%), KwaZulu-Natal (14%) and Western Cape (15%), representing 78% of ICU beds (3 703/4 719) and catering for 54% of the country’s population. Eastern Cape had fewer than 300 beds, North West and Mpumalanga had fewer than 150 beds, and Limpopo and Northern Cape had 66 and 47 beds respectively. With the proposed NHI scheme, the number of ICU beds available would be 4 719, which would translate into a bed:population ratio of approximately 1:10 000. However, there are large variations across the provinces, which makes the availability of this level of care in some provinces non-existent. Conclusion. While increasing the number of ICU beds in the public sector will open critical care services to more users, the NHI scheme would not solve the huge discrepancies of access to ICUs, and availability of critical care staff, across the provinces.

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A critical analysis of ICU/HC beds in South Africa: 2008-2009

The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.

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Prioritising 'already-scarce' intensive care unit resources in the midst of COVID-19: a call for regional triage committees in South Africa.

Background: Emergency centres in South Africa are among the busiest in the world and serve as entry points for hospital care for most of the population. The South African Triage Scale (SATS) is a validated tool introduced nationally in 2006 and intended to increase the efficiency of emergency centres through a process of prioritisation of the severely ill patient. The objective of this study was to evaluate the use of the SATS in a busy urban district hospital in Durban, South Africa.Methods: A chart review of triaged patients was performed. The hospital uses a one-page SATS sheet and manages both medical and surgical patients. The triage history, physiological parameters, application of discriminator lists, final triage code and outcome was audited and compared with findings from the patients’ clinical records.Results: The mean triage early warning score was 1.50 (95% CI 1–2) and average time to treatment was 59 min (95% CI 51–67). Essential bedside investigations were missing on some very ill patients, ...

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An evaluation of the use of the South African Triage Scale in an urban district hospital in Durban, South Africa

In resource-constrained settings and in the context of HIV-infected patients requiring intensive care, value-laden decisions by critical care specialists are often made in the absence of explicit policies and guidelines. These are often based on individual practitioners’ knowledge and experience, which may be subject to bias. We reviewed published information on legislation and practices related to intensive care unit (ICU) admission in India, Brazil and South Africa, to assess access to critical care services in the context of HIV. Each of these countries has legal instruments in place to provide their citizens with health services, but they differ in their provision of ICU care for HIV-infected persons. In Brazil, some ICUs have no admission criteria, and this decision vests solely on the ‘availability, and the knowledge and the experience’ of the most experienced ICU specialist at the institution. India has few regulatory mechanisms to ensure ICU care for critically ill patients including HIV-infected persons. SA has made concerted efforts towards non-discriminatory criteria for ICU admissions and, despite the shortage of ICU beds, HIVinfected patients have relatively greater access to this level of care than in other developing countries in Africa, such as Botswana. Policymakers and clinicians should devise explicit policy frameworks to govern ICU admissions in the context of HIV status.

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HIV/AIDS and admission to intensive care units: A comparison of India, Brazil and South Africa.

Background. Maturing of the burgeoning HIV epidemic in South Africa has resulted in an increased demand for intensive care. Objectives. To investigate the influence of ethical dilemmas facing South African intensivists on decisions about access to intensive care for patients with HIV infection in resource-limited settings. Methods. A cross-sectional, descriptive, quantitative, analytical, anonymous attitudes-and-perception questionnaire survey of 90 intensivists. The main outcome measure was the rating of factors influencing decisions on admission to intensive care and responses to 5 hypothetical clinical scenarios. Results. The number of intensivists who considered the prognosis of the acute disease and of the underlying disease to be most important was 87.9% (n=74). Most (71.6%; n=63) intensivists cited availability of an intensive care unit (ICU) bed as influencing the decision to admit. Intensivists comprising 26.8% (n=22) of the total group rated as probably important or least important the ‘resources available’; ‘bed used to the prejudice of another patient’ was stated by 16.4% (n=14); and ‘policy of the intensive care unit’ by 17% (n=14). Nearly two-thirds (65.9%; n=58) would respect an informed refusal of treatment. A similar number would comply with a written ‘Do not resuscitate’ (DNR) order. In patients with no real chance of recovering a meaningful life, 81.6% (n=71) of intensivists would withhold sophisticated therapy (e.g. not start mechanical ventilation or dialysis etc.) and 75.9% (n=63) would withdraw sophisticated therapy (e.g. discontinue mechanical ventilation, dialysis etc.). Conclusions. A combination of factors was identified as influencing the decision to admit patients to intensive care. Prognosis and disease status were identified as the main factors influencing admission. Patients with HIV/AIDS were not discriminated against in admission to intensive care.

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Kantharuben Naidoo

Papers

A critical analysis of ICU/HC beds in South Africa: 2008-2009

Prioritising 'already-scarce' intensive care unit resources in the midst of COVID-19: a call for regional triage committees in South Africa.

An evaluation of the use of the South African Triage Scale in an urban district hospital in Durban, South Africa

HIV/AIDS and admission to intensive care units: A comparison of India, Brazil and South Africa.

Survey of ethical dilemmas facing intensivists in South Africa in the admission of patients with HIV infection requiring intensive care