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Correspondence: Role of clinical laboratories in reporting results of transgender individuals on hormonal therapy by Phiri-Ramongane and Khine
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The Critical Care Society of Southern Africa Consensus Guideline on ICU triage and rationing (ConICTri)
Get PDFBackground. 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
High-frequency oscillatory ventilation in a tertiary paediatric intensive care unit in an academic hospital in Johannesburg, South Africa
Get PDFBackground. High-frequency oscillatory ventilation (HFOV) remains an option for the management of critically ill children when conventional mechanical ventilation fails. However, its use is not widespread, and there is wide variability reported with respect to how it is used.
Objectives. To describe the frequency, indications, settings and outcomes of HFOV use among paediatric patients with a primary respiratory disorder admitted to a tertiary paediatric intensive care unit (PICU).
Methods. The study was a 2-year, single-centre, retrospective chart review.
Results. Thirty-four (32.7%) patients were managed with HFOV in the PICU during the study period. Thirty-three of the 34 patients had paediatric acute respiratory distress syndrome. Indications for HFOV were inadequate oxygenation in 17 patients (50%), and refractory respiratory acidosis in 15 patients (44.1%) (2 patients did not fit into either category). Approaches to the setting of HFOV varied considerably, particularly with respect to initial pressure around the airways. HFOV was effective at improving both oxygenation, with a median (interquartile range (IQR)) decrease in oxygenation index of 6.34 (5.0 - 9.5), and ventilation with a the median decrease in PaCO2 of 67.6 (46.2 - 105.7) mmHg after 24 hours. Overall mortality was 29.4% in the HFOV group, which is consistent with other studies.
Conclusion. HFOV remains an effective rescue ventilatory strategy, which resulted in rapid and sustained improvement in gas exchange in patients with severe hypoxaemia and/or severe respiratory acidosis, particularly in the absence of extracorporeal support. However, the variability in practice and the adverse effects described highlight the need for future high-quality randomised controlled trials to allow for development of meaningful guidelines to optimise HFOV use
Variation in timing of decisions to withdraw life-sustaining treatment in adult ICU patients from three centres in different geographies: Do clinical factors explain the difference?
Get PDFBackground. Decisions to withdraw life-sustaining treatment (WLST) are common in intensive care units (ICUs). Clinical and non-clinical factors are important, although the extent to which each plays a part is uncertain.
Objectives. To determine whether the timing of decisions to WLST varies between ICUs in a single centre in three countries and whether differences in timing are explained by differences in clinical decision-making.
Methods. The study involved a convenience sample of three adult ICUs – one in each of the UK, USA and South Africa (SA). Data were prospectively collected on patients whose life-sustaining treatment was withdrawn over three months. The timing of decisions was collected, as were patients’ premorbid functional status and illness severity 24 hours prior to decision to WLST. Multivariate analysis was used to identify factors associated with decisions to WLST. Clinicians participated in interviews involving hypothetical case studies devoid of non-clinical factors.
Results. Deaths following WLST accounted for 23% of all deaths during the study period at the USA site v. 37% (UK site) and 70% (SA site) (p<0.0010 across the three sites). Length of stay (LOS) prior to WLST decision varied between sites. Controlling for performance status, age, and illness severity, study site predicted LOS prior to decision (p<0.0010). In the hypothetical cases, LOS prior to WLST was higher for USA clinicians (p<0.017).
Conclusion. There is variation in the proportion of ICU patients in whom WLST occurs and the timing of these decisions between sites; differences in clinical decision-making may explain the variation observed, although clinical and non-clinical factors are inextricably linked
Critical care research in the resource-limited setting: Leveraging the power of the database
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Intensive-care management of snakebite victims in rural sub-Saharan Africa: An experience from Uganda
Get PDFBackground. Antivenom is rarely available for the management of snakebites in rural sub-Saharan Africa(sSA).
Objective. To report clinical management and outcomes of 174 snakebite victims treated with basic intensive-care interventions in a rural sSA hospital.
Methods. This cohort study was designed as a retrospective analysis of a database of patients admitted to the intensive care unit (ICU) of St. Mary’s Hospital Lacor in Gulu, Uganda (January 2006 - November 2017). No exclusion criteria were applied.
Results. Of the 174 patients admitted to the ICU for snakebite envenomation, 60 (36.5%) developed respiratory failure requiring mechanical ventilation (16.7% mortality). Results suggest that neurotoxic envenomation was likely the most common cause of respiratory failure among patients requiring mechanical ventilation. Antivenom (at probably inadequate doses) was administered to 22 of the 174 patients (12.6%). The median (and associated interquartile range) length of ICU stay was 3 (2 - 5) days, with an overall mortality rate of 8%. Of the total number of patients, 67 (38.5%) were younger than 18 years.
Conclusion. Results suggest that basic intensive care, including mechanical ventilation, is a feasible management option for snakebite victims presenting with respiratory failure in a rural sSA hospital, resulting in a low mortality rate, even without adequate antivenom being available. International strategies which include preventive measures as well as the strengthening of context-adapted treatment of critically ill patients at different levels of referral pathways, in order to reduce deaths and disability associated with snakebites in sSA are needed. Provision of efficient antivenoms should be integrated in clinical care of snakebite victims in peripheral healthcare facilities. Snakebite management protocols and preventive measures need to consider specific requirements of children
Guideline recommendations for antimicrobial stewardship education for clinical nursing practice in hospitals: A scoping review
Get PDFBackground: Antimicrobial stewardship (AMS) is a proactive healthcare intervention to improve patient outcomes by optimising antimicrobial use. Although nursing involvement is a recognised necessity, bedside nurses may not yet possess competencies to fulfil this role.
Objectives: To identify recommendations for AMS education for the bedside nurse in key global AMS guidelines.
Methods: Scoping review methodology was used to systematically search published and ‘grey’ literature in PubMed, EBSCOhost, Google Scholar, government websites and websites of professional societies and organisations. Search dates were from 1990 to 2020. Inclusion criteria were English language AMS guidelines for hospitals.
Results: Literature searches retrieved 1 824 articles, with 43 meeting the review inclusion criteria. Reference was made to AMS nursing education in 23 (53.4%) of the articles. Educational opportunities for nurses were recommended: inclusion of AMS concepts/content into undergraduate and postgraduate nursing curricula (n=12; 27.9%), in-hospital training (n=14; 32.5%) and continuing professional development (n=6; 13.9%).
Recommendations for nursing education were as follows: role of AMS in preventing antimicrobial resistance (n=7; 16.2%), infection prevention and control (n=3; 6.9%), diagnostics in AMS (n=5; 11.6%), pharmacology (n=11; 25.5%) and collaboration (n=2; 4.6%). Identified nursing educational gaps were: nurses not recognising their role within AMS (n=5; 11.6%), inadequate nursing resources and expertise for dosing, pharmacokinetic/pharmacodynamic strategies and managing possible drug incompatibilities with extended/prolonged infusions (n=3; 6.9%), and inappropriate nurse disposal of antibiotic waste (n=1; 2.3%).
Conclusions: Although recommendations for nursing education were found in many key AMS guidelines, few guidelines provided detailed descriptions of the nursing competencies that were required for this role
Hypertension and associated factors among patients attending HIV clinic at Korle-Bu Teaching Hospital
Get PDFObjectives: This study determined the prevalence of hypertension and its associated factors among patients attending the HIV clinic at the Korle-Bu Teaching Hospital (KBTH).Design: A hospital-based cross-sectional study was conducted at KBTH. The prevalence of hypertension was estimated among study participants, and socio-demographic, lifestyle, anthropometric, metabolic and HIV/ART-related factors associated with hypertension were determined by logistic regression modelling.Setting: Study participants were recruited from the HIV clinic at the KBTH.Participants: A total of 311 Persons Living with HIV were recruited as study participantsInterventions: Simple random sampling technique was used to recruit study participants. A questionnaire adapted from the WHO STEPwise approach to chronic disease risk-factor surveillance was used to collect study participants' data.Results: The prevalence of hypertension was 36.7%, and the factors associated with hypertension were increasing age, positive family history of hypertension, minimal exercising, current BMI ≥25.0 kg/m2, total cholesterol level ≥5.17 mmol/L, exposure to anti-retroviral therapy (ART) and increasing duration of ART exposure.Conclusions: This study shows a high prevalence of hypertension among patients attending the HIV clinic at KBTH, associated with exposure to ART and increasing duration of this exposure. Blood pressure monitoring should move from routine to a more purposeful screening of patients for hypertension. Patients with the identified risk factors should be encouraged to have regular blood pressure measurements at home and not only when they visit the HIV clinic
Leadership in health and medical education: lessons from a symposium on health sector development in Ghana
Get PDFThe Ghana College of Physicians and Surgeons (GCPS) has established an annual leadership symposium celebrating innovative leadership in the health sector. The 2022 symposium under the theme “Health Sector Development in Ghana; The Power of Good Leadership” was held in honour of Professor Samuel Ofosu-Amaah (the laureate), an Emeritus Professor of Public Health at the University of Ghana, about his leadership legacy. This article reflects on the leadership challenges in the health sector, the lessons learnt from the symposium, and the way forward.Leadership challenges identified in the health sector included the need for mentorship and coaching, the importance of teamwork and networking for delivering high-quality healthcare, and the role of leadership and governance in the health system. Key lessons from the symposium focused on skills in leading an event organisation, effective collaboration and teamwork, and learning from recognising prominent leaders’ contributions to the health sector while these leaders are still alive. Key lessons from the personal and professional life of the laureate included a focus on giving back to the community, building mentorship of health leaders, being a catalyst of change, leadership and governance in public health institutions and publication of research findings.Suggestions were made to name the School of Public Health of the University of Ghana after Professor Ofosu-Amaah, to include a leadership and management module in all training modules at the GCPS and to establish a health leadership “Observatory” to focus on research on how leadership influences relevant health sector policy issues
Birds of an extensive papyrus swamp in Uganda and their conservation
No full textThe delta of the Nile as it enters Lake Albert is part of a Ramsar site and supports 35 km2 of papyrus swamp through which run channels of the river. For 12 months in 2017-2018, we made monthly bird counts, each of ten minutes, at 20 points along swamp edges. Overall, 143 species were recorded, of which 13 were particularly common in the papyrus, and a similar number along the channels. Of seven papyrus-restricted species observed, three are globally red-listed notably papyrus gonolek and shoebill. Most species are resident, but white-winged terns and several hirundine species were seasonally common. Our baseline counts should be repeated in future years as well as recording potential threats—climate change, oil and gas operations and other human activities. Most, but not all, of the Ramsar site is within Murchison Falls National Park, which is well-protected; if possible, the protection should be extended to the whole sit