The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa

Abstract

Background. Paediatric intensive care, a valuable resource that improves the outcomes of critically ill children, is often scarce.
 Objective. To evaluate the need for paediatric intensive care beds and compare the outcomes of admitted and non-admitted deserving cases.
 Methods. A prospective evaluation of all bed requests, in terms of need for intensive care and outcomes of those admitted and not admitted to a paediatric intensive care unit (PICU), was performed between July 2017 and June 2018. Factors for refusal and for poor outcomes were evaluated.
 Results. Of the 811 bed requests, 32.6% (n=264, p<0.001) were denied access. Of the 231 deserving cases who were denied access, 85.7% (n=198) were due to unavailability of a PICU bed. Patients not admitted to PICU had a twofold increased risk of dying compared with those admitted (34.4% v. 15.5% respectively, p<0.001), even though the patient characteristics of both groups were similar (age, gender and nutritional status). In those admitted, risk factors for mortality were requiring transfusion of blood and platelets (56.0%, p<0.001), requiring two or more inotropes (52.5%, p<0.001), instability on admission (41.3%, p<0.001), prior cardiac arrest (32.0%, p=0.021), severe acute malnutrition (26.9%, p=0.043), fungal infection (22.2%, p=0.004) and emergency admission (18.0%, p<0.001). In those not admitted, prior cardiac arrest (100%, p<0.001) and emergency referral (42.3%, p<0.001) were associated with adverse outcomes.
 Conclusion. The need for PICU beds exceeds availability, with a consequent twofold increase in mortality among cases not admitted to PICU. Paediatric critical care services have increased at appropriate sites of need following completion of this study.

Pediatric Acute Respiratory Distress Syndrome in South African PICUs: A Multisite Point-Prevalence Study

“…Study sites were selected on a convenience basis, which introduces the potential for selection bias and is thus a limitation of the study. The majority of data were contributed by PICUs in the two main provinces (Gauteng and Western Cape), in alignment with the disparity of PICU bed availability in the country; whereas the province with the third highest proportion of intensive care beds (KwaZulu-Natal) was under-represented in this study (18), with the 14-bedded PICU Inkosi Albert Luthuli Central Hospital (19) not volunteering to participate. The included study sites represent the majority (> 60%) of the currently available not-for-profit, dedicated PICU beds in the country.…”

“…Despite this, Southern Africa has extremely scarce and unequally distributed pediatric and adult intensive care resources serving a large population (17, 18). The need for PICU beds in one South African province (KwaZulu-Natal) was estimated to be 23.7 per 100,000 children, with actual PICU bed availability of only 0.73 of 100,000 children (19). The notably higher pARDS prevalence documented in the small Greys Hospital site (Fig.…”