The Southern African journal of critical care : the official journal of the Critical Care Society最新文献

Background: In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector.

Purpose: The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources.

Recommendations: An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years.

Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.

Background: Intubated patients with a high tracheal tube cuff pressure (CP) are at risk of developing tracheal or subglottic stenosis. Recently an increasing number of patients have presented to our hospital with these complications.

Objectives: To determine the frequency of tracheal tube CP measurements and the range of CP and to explore nursing knowledge regarding CP monitoring.

Methods: Frequency of CP measurement was assessed using a prospective chart review, followed by an interventional component. In the final stage nurses completed a self-administered questionnaire.

Results: A total of 304 charts from 61 patients were reviewed. Patients' ages ranged from 1 to 71 years, with a male preponderance (1.5:1). The majority of charts (87%) did not reflect a documented CP measurement and only 12 charts showed at least one measurement per shift. Only 17% of recorded CPs were within the recommended range; 59% were too low. The questionnaire was completed by only 51% of the 75 respondents. Nursing experience ranged from 3 to 35 years and 92% of respondents were trained in critical care. Knowledge of current critical care CP monitoring guidelines was reported by 62% of the respondents (n=23/37). Only 53% (20/38) reported routinely measuring CP. Almost all respondents (94%) knew of at least one complication of abnormal CP.

Conclusion: Having a basic knowledge of CP measurement, having awareness of the complications of abnormal CP and the availability of national best practice guidelines did not translate into appropriate ICU practice. Research into effective implementation strategies to achieve best practice is needed.

Contributions of the study: Basic knowledge of cuff pressure measurement may not always result in best practice.Improvement in current practice requires research into effective implementation strategies.

Background: In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector.

Purpose: The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care.

Recommendations: In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years.

Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.

Background: Internationally, the declining number of organ donors does not meet the rising demand for life-saving solid organ transplant operations. Critical care professional nurses play an important role in the identification of organ donors. A deeper understanding is needed of the missed opportunities of identification and referral of potential organ donors to organ transplant co-ordinators in the critical care environment.

Objectives: To describe the knowledge and views of critical care professional nurses (CCPNs) in South Africa concerning the early identification and referral of organ donors, and to describe the short-term effect of implementing a PowerPoint training intervention on nurses' knowledge in this domain.

Methods: A mixed method, experimental, exploratory, descriptive study design was followed. Critical care professional nurses in seven intensive care units at five private hospitals completed a data collection instrument comprising 11 quantitative and three qualitative questions, before and after completing a PowerPoint training intervention. The post test was done directly after the training intervention due to the environment of nursing shift work.

Results: A total of 173 (79%) CCPNs participated, from a population of 218. The median (interquartile range) score for all participants increased from 60% (48 - 76) prior to the PowerPoint training intervention, to 96% (88 - 96) after the intervention (p<0.0001). Three main themes emerged from the qualitative questions: stress experienced by the CCPNs during the organ donor process (62%); inadequate collaboration between doctors and nurses (34%); and the need for a policy (9%) to guide the donor referral process.

Conclusion: CCPNs' knowledge regarding the early identification and referral of potential organ donors increased significantly following a targeted PowerPoint training intervention. The identified themes suggest that CCPNs require support in order to effectively communicate with the donor's family and medical staff.

Contributions of the study: The findings of this study will contribute to the increase in organ donor referrals. Increased education of critical care professional nurses and doctors on effective communication, and the early identification and referral of organ donors, will expectedly help to resolve the critical barriers in the organ donor process.

Summary: Acute coronary syndromes due to coronary artery vasospasm occur rarely and are difficult to diagnose in the acute setting. We present a patient with hypocalcaemia-induced coronary artery vasospasm, which resulted in an acute ST-elevation myocardial infarction. This was reversible upon administering intravenous calcium, with no long-term cardiac consequences for our patient.

Contributions of the study: Hypocalcaemia is a common clinical problem that is usually clinically quiescent, but in the acute setting can present with dramatic signs and symptomsHypocalcaemia resulting in an acute coronary syndrome is usually rapidly reversed by administering intravenous calcium.A hypocalcaemia-induced acute coronary syndrome is most likely a function of the myocardium being perfused primarily during diastole, with partial vasospasm limiting the diastolic flow during times of increased cardiac output or energy requirements.