Results from the first audit of an intensive care unit in Botswana

Abstract

The intensive care unit (ICU) is slowly establishing itself in low-middle income countries (LMIC), including in sub-Saharan Africa (sSA). Few studies have been published on ICU services in sSA. However, they reveal multiple challenges, especially in limited bed capacity, infrequent resources and medical personnel. [1-4] Recent articles highlight the paucity of LMICs ICU data and the need for more research. [5,6] Botswana is an upper middle-income country in southern Africa with a population of over 2 million people. Princess Marina Hospital (PMH) in Gaborone, the capital city, is currently the largest publicly funded and university teaching hospital in Botswana with a 24-hour emergency department (ED), 567 inpatient beds and the most complete range of specialty services. PMH ICU is an 8-bed ward managed by specialists 24 hours, 7 days a week, assessing patient eligibility for admission and managing clinical care. These specialists consist of anaesthetists and one intensivist with formal ICU postgraduate training, but are only onsite Monday to Friday during normal working hours. There are no ICU registrars or ICU training programmes in the country; hospital medical officers are infrequently available from the ED to provide clinical support to the ICU. PMH ICU nurse to patient ratio is 1:2 during day shifts and 1:3 during night shifts with no formal ICU or critical care nursing education programmes in the country. PMH ICU has 24-hour access to radiology (X-rays, ultrasound, computed tomography (CT) scan) and basic laboratory investigations. Dietitians, physiotherapists, psychologists, occupational therapists and social workers are available on referral bases, but no clinical pharmacist is available. At the time of this study there were no endorsed official local ICU admission or management guidelines. Botswana has not escaped the large southern African burden of HIV, with a recent UNAIDS estimate of 370 000 adults aged 15 and over living with HIV in Botswana, representing 18.2% of the total population. [7] Botswana was one of the first countries in sSA to initiate HIV interventions, including highly active antiretroviral treatment (HAART) with a local study showing significant improvements in HIV mortality since these initiatives. [8] A 2015 study of medical admissions to PMH revealed a continued high burden of HIV disease and opportunistic illnesses of tuberculosis (TB) and cryptococcal meningitis. [9] To date, no clinical ICU studies have been

An analysis of referrals to a level 3 intensive care unit in a resource-limited setting in South Africa

“…When comparing our patient cohort with another ICU in the same province, 36.2% of our patients had a qSOFA score ≥2 v. 60.6% in a study by Khan et al [10] This trend continued when looking at a study done in Botswana, where their mean APACHE II score was 25 v. 18 in our study. [14] However, when comparing the mean APACHE II score in our study group with high-income countries such as Japan and the USA, no difference was seen, with similar mean APACHE II scores of 18 noted across all three studies. [15 , 16] …”

“…This is in keeping with data from other ICUs in South Africa and other low-middle-income countries. [2 , 8 , 10 - 14] The spread of primary diagnoses illustrates the triple burden of non-communicable disease, communicable disease and trauma faced by South African ICUs. Although trauma comprised a large proportion of ICU admissions, this is lower than reported in another large South African ICU.…”

“…The impact of the HIV epidemic is apparent in this regard, with 24.0% of patients known to be HIV positive, which is in keeping with data from other centres in South Africa. [10 , 13 , 14] …”