The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri)

Abstract

GUIDELINE /SAJCCBackground. 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.

The SAPS 3 score as a predictor of hospital mortality in a South African tertiary intensive care unit: A prospective cohort study.

“…The low number of O&G admissions (2.8%) is explained by the presence of a separate O&G high care; only cases requiring ventilation or dialysis are transferred to ICU. The relatively low percentage of elective admissions is a reflection of the fact that emergency admissions are often triaged over planned surgery in South Africa when there are not enough ICU beds available [11]. The elective cases who did not survive were largely complicated vascular and neurosurgical cases.…”

“…Other reasons for demise in hospital after ICU discharge may be due to premature discharge from ICU, medical care in wards and resource limitations. There is considerable pressure on ICU beds in SA [11] and this may prompt early discharge from ICU to accommodate patients who requires organ support.…”

“…Depending on the level of care, the ratio in high income countries tends to be between 2.5% and 10% [9,10]. This shortage of ICU beds has therefore resulted in the need for triage in South African public health care sector critical care units [11,12]. Objective data regarding ICU outcomes, which would include accurate case mix description with a modern severity score, is therefore essential for resource allocation and to inform local patient triage guidelines [8,13].…”

Outcomes of paediatric patients ventilated in a high-care area outside an intensive care unit

“…[2,10,12] Limited available current evidence reports that SA has critical care resource shortages in terms of both numbers of beds and trained staff, resulting in limitations in the number of ICU beds available. [3,13,14] Contributing to this problem is the discrepancy between the availability of resources in the public and private healthcare systems, with only 30% of doctors working in the public sector, which serves >80% of the country's population. [13] An audit of critical care resources carried out in 2004/05 showed that 84% of private hospitals but only 23% of public hospitals have ICUs or HCAs.…”

“…[3] This imbalance between demand and availability of resources in the public sector has resulted in the need for triaging of patients to prioritise ICU admission for patients who need intensive care the most. [14] International guidelines for ICU admissions in developed countries with more resources have fewer exclusionary criteria and are difficult to apply in our resource-limited setting. [15] A consensus statement to provide a framework to inform ICU admission, rationing and triage decision in an SA context was published recently.…”