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Pediatric Intensive Care in South Africa

An Account of Making Optimum Use of Limited Resources at the Red Cross War Memorial Children’s Hospital*

Argent, Andrew C. MBBCh, MMed, MD, FCPaeds(SA)1,2; Ahrens, Johann MBChB, FCPaeds(SA), Cert Crit Care (SA)1,2; Morrow, Brenda M. PhD1,2; Reynolds, Louis G. MBChB, FCPaeds(SA)1,2,3; Hatherill, Mark MBChB, FCPaeds(SA), PhD1,2,4; Salie, Shamiel MBChB, FCPaeds(SA), Cert Crit Care (SA)1,2; Benatar, Solomon R. MBBCh, PhD5

Pediatric Critical Care Medicine: January 2014 - Volume 15 - Issue 1 - p 7–14
doi: 10.1097/PCC.0000000000000029
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Objective: To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources.

Setting: Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa.

Design: Retrospective description of policy development and implementation

Patients: All patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children’s Hospital.

Interventions: Development and application of admission policy.

Measurements and Main Results: In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain “buy-in” from all potential stakeholders in the process and also to implement such policies under conditions of high stress.

Conclusion: Development and implementation of explicit policies for utilization of PICU resources provide a “reasonable” process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services.

1Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa.

2Division of Paediatric Critical Care and Children’s Heart Disease, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa.

3Education Development Unit, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.

4Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.

5Bioethics Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.

* See also p. 82.

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Dr. Argent is employed by the Red Cross War Memorial Children's Hospital, received grant support from Wellcome Trust, and received payment as an invited guest speaker for various congresses. Dr. Morrow received grant support from the Medical Research Council of Southern Africa (career development award) and received support for travel from Congress organizers as an invited speaker. Dr. Reynolds is employed by the University of Cape Town and participates in People's Health Movement meetings. His institution received royalties from Pearson's publishers. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: andrew.argent@uct.ac.za

©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies