Pediatric Intensive Care in South Africa: An Account of Making Optimum Use of Limited Resources at the Red Cross War Memorial Children’s Hospital* Andrew C. Argent, MBBCh, MMed, MD, FCPaeds(SA)1,2; Johann Ahrens, MBChB, FCPaeds(SA), Cert Crit Care (SA)1,2; Brenda M. Morrow, PhD1,2; Louis G. Reynolds, MBChB, FCPaeds(SA)1,2,3; Mark Hatherill, MBChB, FCPaeds(SA), PhD1,2,4; Shamiel Salie, MBChB, FCPaeds(SA), Cert Crit Care (SA)1,2; Solomon R. Benatar, MBBCh, PhD5
Objective: To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources. Setting: Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa. Design: Retrospective description of policy development and implementation Patients: All patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children’s Hospital. Interventions: Development and application of admission policy. *See also p. 82. 1 Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. 2 Division of Paediatric Critical Care and Children’s Heart Disease, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa. 3 Education Development Unit, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. 4 Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa. 5 Bioethics Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. Listen to the Critical Care podcasts for an indepth interview on this article. Visit www.sccm.org/iCriticalCare or search “SCCM” at iTunes. Dr. Argent is employed by the Red Cross War Memorial Children's Hospital, received grant support from Wellcome Trust, and received payment as an invited guest speaker for various congresses. Dr. Morrow received grant support from the Medical Research Council of Southern Africa (career development award) and received support for travel from Congress organizers as an invited speaker. Dr. Reynolds is employed by the University of Cape Town and participates in People's Health Movement meetings. His institution received royalties from Pearson's publishers. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2013 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000029
Pediatric Critical Care Medicine
Measurements and Main Results: In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain “buy-in” from all potential stakeholders in the process and also to implement such policies under conditions of high stress. Conclusion: Development and implementation of explicit policies for utilization of PICU resources provide a “reasonable” process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services. (Pediatr Crit Care Med 2014; 15:7–14) Key Words: critical care; developing country; elective surgery; emergency care; ethics; pediatrics; resource allocation
I
CUs have become an integral part of medical practice since the 1950s. The ability to extend life with modern medical techniques and the unwillingness of both physicians and the public to “give up” have been associated with escalation of expenditure on health. In poorer countries, many children simply do not have access to ICUs, whereas in some “developed” nations, a concern is that perhaps some children are being kept alive at great cost (sometimes when there is only minimal potential for them to have normal lives) (1). This www.pccmjournal.org
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raises the question of whether ICUs are being used optimally or even whether ICUs are relevant where child mortality from mainly preventable causes is high and resources for healthcare are limited (2, 3).
BACKGROUND Since its opening in 1956, the Red Cross War Memorial Children’s Hospital (RCWMCH) has made significant contributions to the development of pediatrics in South Africa (4). This 300-bed children’s hospital provides services in all pediatric and pediatric surgical subspecialties. The hospital is possibly unique, in that despite being in a “middle-income” country, intensive care for children has been available for over 50 years. Pediatric intensive care (PIC) for children with tetanus was initiated at this hospital in 1957, shortly after the hospital was opened (5). Intensive care for cardiothoracic surgery (6) and then for pediatric surgery (4) and finally neonatal surgery (7) soon followed. Despite being situated in a country with high under-five mortality (8), it is able to offer sophisticated services such as pediatric cardiothoracic surgery and transplantation. In 1999, a decision was made to create a single 26-bed multidisciplinary ICU for children by combining all the above ICUs at the hospital. Many factors contributed to that decision, not least the withdrawal of resources from academic institutions to provide improved primary care and more equitable care generally throughout the country, and a shortage of nursing staff skilled in the care of critically ill children. Although the 26 beds were sufficient to provide PIC during the first 2–3 years of operation, increasing stress arose over succeeding years as the number of operational beds was progressively reduced to 18 (or on occasion 16) in 2007. This reduction was forced by budgetary cuts and dwindling numbers of intensive care nurses. Similar forces led to a reduction in PICU beds at other Western Cape hospitals. The reduction in PICU facilities coincided with a surge in the population of the Western Cape Province (an increase of 33% from 1996 to 2007) (9) and an increase in the number of newborn deliveries in the obstetric services of this Province. In addition, a 2007 survey of critical care services throughout South Africa (10) suggested that children did not have an equitable share of intensive care resources.
MAKING DECISIONS REGARDING WHO SHOULD BE ADMITTED TO THE PICU Policy Development As the result of the escalating demand on the ICU at the RCWMCH, the process of decision making regarding bed allocation became more challenging. The response to this was to focus on systems to even out requests for elective intensive care beds over the week and thus decrease surges from elective demands; endeavor to optimize care in the PICU to reduce length of stay (including introduction of “bundles” of specific groups of interventions to reduce nosocomial infections); and 8
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to develop and establish an explicit general policy for admission to the PICU. The aims were to: 1 . provide consistent criteria for admission; 2. reduce the pressure on PICU staff by facilitating clear decisions for admission; 3. avoid burnout (particularly of nursing staff); and 4. ensure that postoperative PICU admission for patients requiring elective surgery could be reasonably guaranteed to avoid having to cancel such planned events. The policy was developed by the PICU team, who met fortnightly over a period of approximately 2 months with all sections of the hospital clinicians (pediatricians from within the hospital and from referring hospitals, surgeons, cardiothoracic surgeons, physicians from some referring hospitals, and with hospital and nursing management). These meetings were directed at identifying problems in the policy, gaining consensus, and facilitating general acceptance of the final documents and policy. Principles for Admission General indications for admission to the PICU were based on international guidelines for PICU admission (11, 12). The specifically stated principles in the development of the policy were as follows: 1 . The best interests of the child. 2. Provision of equitable access. 3. Optimization of the overall benefit that could result from use of the PICU resources. 4. Optimization of assessment mechanisms for the child. 5. Avoidance of burnout of existing staff. 6. Paying particular attention to the needs of children who require major elective surgery. Specifically, a. Very few pediatric surgical interventions are truly elective, and delays could result in elective surgery becoming emergency surgery, or to complications that lead to more complicated surgery. b. Delayed elective surgery could lead to unnecessarily prolonged hospital stays, increase the risk of nosocomial infection, or compromise access to hospital beds by other children. c. Cancellation of elective surgery could cause ineffective utilization of theater resources, particularly personnel. This would prevent the few skilled pediatric surgeons and anesthetists in the country from working optimally, thus wasting an important and scarce national resource and potentially resulting in these doctors leaving to practice elsewhere. Loss of such skills could have potentially deleterious effects on healthcare in the longer term. d. Delay of elective surgery is disruptive to families and children. Process to Establish the Content of the Policy General principles for the process of bed allocation were drawn up (Table 1), and a series of specific criteria were established for patients who would be refused admission to the PICU (Table 2): 1. The Royal College of Pediatrics and Child Health (RCPCH) (13) has provided specific recommendations for situations January 2014 • Volume 15 • Number 1
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Table 1.
General Principles of Process
Children will be considered for admission in terms of the chronological order in which that request is made Preference will not be given to children from the Red Cross War Memorial Children’s Hospital. In fact, where possible, preference will be given to children who are referred from other areas (where they have very limited access to alternative intensive care) Preference will be given to children who have conditions that are amenable to therapy, with good outcomes, and preferably with relatively short PICU stays No child will be refused admission to the PICU without a decision by the ICU consultant on call at the time No registrar will be asked (or in fact allowed) to make a final decision about the appropriateness or otherwise of PICU admission of a child. This MUST be a consultant decision Data will be collected on every child referred to the PICU (or booked for admission following elective surgery), and where at all possible follow-up data will be collected on these children
in which it may be appropriate to limit provision of lifesustaining therapy, although the RCPCH framework for practice explicitly excludes considerations of resource allocation. As these were difficult to apply directly to children being considered for PICU admission, these criteria were modified as laid out in Table 2. 2. Children deemed “too well” to benefit from PICU admission were excluded. 3. It was made explicit to the Western Cape Department of Health that implementation of this policy would not free up enough PICU beds to meet the needs of children in the Western Cape and that those needs still required specific attention. 4 . It was stated as likely that implications of the policy would include the following: a. Involvement of PICU consultants in decision making if there was doubt about whether a child fitted the criteria, but no direct involvement if these criteria were unequivocally met. b. Limited data collection on children who were refused admission on the basis of these criteria (this would become the role of the current medical team and not the responsibility of the ICU). c. The possibility of limiting advances in therapy as the chances of developing effective therapies for children with poor predicted outcomes would be decreased. d. More children dying in the wards and in the emergency areas of the hospital, with resources then required to deal with this situation. It was agreed that it would be inappropriate to attempt interventions such as ventilation in the wards (except possibly as a short-term intervention while awaiting PICU admission) as this had the potential to compromise the care of other children. e. The presence of sicker children in the ward would have a negative impact on the quality of care that could be provided in those areas. These criteria were extensively discussed and agreed to by clinicians in the hospital. After agreement, the document outlining these issues was drawn up and submitted through hospital administration to the Provincial health authorities for approval. Once approval for the process had been established, the policy was disseminated to the clinicians at the hospital and was initiated. Pediatric Critical Care Medicine
Implementation The guidelines were implemented during 2003. The presence of guidelines facilitated decision making around difficult (or potentially contentious) patients, and senior PICU staff were generally positive about the change, feeling that they were relieved of the pressure of making difficult decisions under impossible conditions. Although the guidelines were widely disseminated initially, it was difficult to maintain awareness because of turnover of junior- and middle-grade staff in the hospital. It was also difficult to maintain consistency in application of the guidelines. Individual doctors were aware of variations in their personal application of criteria, and there were different interpretations of the guidelines. Decisions were inevitably affected by factors other than clear logic. Pressures on staff hindered continuous data collection regarding patient outcomes, but it was possible to collect data over limited periods to sample outcomes. There are limited data available regarding the pattern of patient referrals. Pediatric emergencies were the reason for 53–60% of admissions from 2007 to 2011, all other admissions being surgical (elective/emergency/trauma related). Over the period 2009 to 2012, 46 to 79 patients per annum had surgery cancelled because no PICU beds were available, while 32–41% of admissions from 2007 to 2011 were elective. A concern that arose during the process regarded favoring patients awaiting elective cardiac surgery for admission to the ICU over HIV-infected patients. Initially, antiretroviral drugs (ARVs) were not available to patients, but with increasing availability, there was a perception that the prognosis for HIVinfected patients would improve and that PICU admission policies should be altered accordingly. Initially, a study of HIVinfected patients (14) showed that availability of ARVs had not made a significant difference to the prognosis of patients admitted to the PICU with severe infection. Subsequently, significant changes in programs to interrupt mother-to-child transmission of HIV, as well as implementation of effective antiretroviral therapy for children, dramatically improved the survival of children exposed to HIV perinatally and those with established HIV infections. As a result of this development, admission policies were reviewed. Subsequently, there has been some relief for the PICU as additional allocation of staff has made it possible to increase bed numbers to 20 patients on a consistent basis, www.pccmjournal.org
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Table 2.
Specific Exclusion Criteria
Category
Futile care
Specific Exclusions
Comments
A child who has been declared brain dead
The permanent vegetative state was not addressed in the admission criteria as this was more likely to be encountered as a problem following stay in the PICU
A child who has had a cardiac arrest and has not reestablished a normal respiratory pattern, or who has fixed dilated pupils
< 5% of children in this category survive the PICU admission with an acceptable neurological outcome
The child who has suffered a head injury such that there is no chance of recovery from that injury Children with underlying lethal conditions
Children with burns > 60% body surface area, where the surgical team are not able to guarantee that debridement and appropriate cover will happen within 24–48 hr of admission
Based on data that if children are not debrided and grafted early on in the course of their burn management, they suffer a prolonged course with considerable pain, anxiety, and recurrent infection. The death rate in these children is also unacceptably high
Children with chronic renal failure where there is no commitment to long-term dialysis Children with severe and lethal chromosomal abnormalities (e.g., Edward syndrome or thanatophoric dwarfism) Children with malignancies that are not responding to therapy Children with inoperable cardiac lesions Children with currently poor outcomes
Children with established HIV infection. “Children with established HIV infection whose lives are in danger from AIDS-related diseases will not normally be considered for admission. A child who is successfully established on ARV, and where the reason for admission does not relate to the underlying disease and/or its therapy will be considered for admission.”
Based on data that despite the availability of ARV only approximately 20% of children with HIV infection who were admitted to the PICU were known to be alive and on ARV 6 mo later. These data have not changed since the availability of antiretroviral therapy
Children with kwashiorkor
Based on a virtual 100% mortality in the ICU for these patients
Children who have been in hospital wards for > 5 d and are deteriorating despite appropriate therapy
Based on an extremely high mortality rate in this group of patients. The failure to respond to therapy suggests that they have underlying conditions that are not amenable to conventional therapy
Children with severe adenoviral pneumonia who have not responded to appropriate therapy in the wards
Based on data showing that children with severe adenoviral infection requiring ventilation have a high mortality and very high morbidity from chronic lung disease
Children with diagnosed severe metabolic disorders (e.g., maple syrup urine disease) for which established treatment programs in the hospital and community are not established
Based on the fact that these children have a very poor likelihood of reasonable outcome
Children with acute hepatic failure, unless there is a reasonable likelihood that an acute transplant will be offered within the first 24–48 hr of PICU admission Children with complications of meningitis requiring ventilation (i.e., the requirement for ventilation is related to CNS disease rather than pneumonia) Children with cardiomyopathy unresponsive to therapy, and where transplantation is not being considered
This does not apply to the time of acute, first presentation. It is very difficult to prognosticate at that stage. This comment applies to children who have previously been treated, and where there has been time to make an appropriate assessment of likely prognosis
ARV = antiretroviral drugs.
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Table 3.
Review of Process: Ethical Principles and Extent to Which They Were Met
Duty to provide care
The process was an attempt to provide care to as many children as possible, within the resources available. In South African law, the principle has been established that the healthcare services cannot provide all services to all people (Soobramoney case [31])
Equity
No particular groups were excluded. In fact, attempts were made to improve access to care for children from outside the major teaching hospitals
Trust
The process improved trust between different departments in the hospital because it addressed the concerns of all regarding access to the PICU. We were not able to assess the impact of the policy on trust between families of patients and medical and nursing staff. Neither were we able to assess the impact of the policy on trust between different professionals in the hospital
Transparency
The process was open to comment and was made public to clinicians and managers within the health system. It was not transparent to the general public or to specific groups of people who were potentially (or actually) affected by the process. Where possible the rationale behind specific exclusions was provided in the documentation
Consistency
Implementation of a specific policy improved overall consistency, but individual consultants were aware of some variability in their implementation of the policy
Inclusiveness
The process was focused primarily on health professionals, and there was not adequate involvement of other stakeholders
Responsiveness
There were mechanisms within the system to respond to changes in circumstances, and there were mechanisms established to appeal against specific decisions
Accountability
The clinicians whose patients were affected by the process had every opportunity to appeal against decisions. In reality, this happened very rarely. Managers and administrators were given details of the implications of the resources available and the attempts to use those resources appropriately
and additional PICU beds have been opened in the city of Cape Town. However, the current bed occupancy of the PICU is consistently greater than 97%, and the average waiting time for a patient who has been assessed as requiring intensive care is approximately 5 hours (A. Argent, unpublished data, 2013). Despite considerable efforts, by 2012, the hospital had not been able to increase the number of cardiac operations performed but has been able to sustain a constant level despite increased demand for ICU admission from multiple areas. Table 4.
There had been pressure to “ring-fence” beds for cardiac surgery, but review of bed utilization suggested that this would not help as the number of “cardiac” patients already achieving access to the unit frequently exceeded the number of beds that would be ring-fenced. There are ongoing attempts to address this issue. Over the last 5 years, one additional response to poor access to intensive care beds has been the implementation of technologies such as continuous positive airway pressure (CPAP) in ward areas outside the PICU.
Contextual Information: The Relationship Between Patient Load and Staffing 2001
2005
2010
26
20
22
Admissions
1,380
1,129
1,265
Mortality (%)
11.01
10.34
8.93
3
4
4
Patient data Maximum beds available during the year
Staffing Specialist intensivists Registrars and medical officers
6 (out of hours calls supplemented by registrars who had previously worked in the PICU)
Fellows (subspecialist trainees in pediatric critical care)
Pediatric Critical Care Medicine
1
6 (out of hours calls 6 (out of hours calls supplemented by registrars who supplemented by registrars had previously worked who had previously worked in the PICU) in the PICU) 2
3
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Table 5.
Admissions, Deaths, and Mortality Data Pediatric Index of Mortality 2 Risk (Average)
Standardized Mortality Ratio
Year
Admissions
Deaths
Mortality (%)
2006
1,074
114
10.6
0.138
0.76
2007
1,067
131
12.2
0.1388
0.88
2008
1,330
139
10.4
0.129
0.81
2009
1,141
141
12.4
0.131
0.74
2010
1,265
115
9.0
0.132
0.68
DISCUSSION We have described the development and implementation of a process directed at optimizing the utilization of a scarce resource (see contextual detail in Table 4) in a developing country in response to a period of increasing pressure. An assessment of compliance with ethical principles of this process is shown in Table 3. Mortality in the PICU remained unchanged or decreased during implementation of this process (Tables 4 and 5), and there was an overall decrease in mortality in the hospital (A. Westwood, unpublished data, 2012), suggesting that this policy did not increase deaths in other parts of the system. Decisions have to be made at multiple levels as to how healthcare resources should best be allocated (15), and decisions regarding the availability of intensive care services have to be made by health systems. Decisions have to be made as to how those resources can be optimally used taking into account many factors including the level of intensive care that should be offered; the quality of “acceptable” ICU care (or the level of risk of errors that can be accepted); the value provided to the patient, his/her family by the PICU admission; the value provided to the medical community and the wider society by PICU; and how allocation of resources can be performed in a way that is equitable and practical. Our experience relates to the challenge of making decisions about individual patients while being mindful of the allocation of resources within pediatric services in a particular geographical region. Physicians are required to “act in the patient’s best interests.” The exact nature of the patient’s best interests where limitation of care for children is involved is controversial (16). The implications of limitation of care may be profound for the patient involved and his/her family (17, 18). In the United Kingdom, the Nuffield Council on bioethics argued that “healthcare professionals caring for babies in neonatal ICUs should continue to do the best possible for the ‘patient in front of them.’ They should be aware of, but not driven by, the resource implications of their decisions” (18). Although this principle should apply universally, it is inevitable that the ability to do so will be influenced by the context in which medicine is practiced. In the RCWMCH PICU, there is a greater tension than in the United Kingdom between focusing only on the individual child and considering how best to use a limited resource (19). Triage processes for critically ill patients in disaster situations have recently been reviewed by White et al (20). Much of the literature relating to triage for intensive care relates to 12
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the implications of that decision for particular patients. There is limited literature addressing triage as related to the need for sustaining and developing healthcare systems, while providing optimal care for individual patients (21–25). Although not perhaps fully understood at the time of development, the policy was an attempt to balance several different priorities. An underpinning concern was that overall healthcare services were not functioning optimally, and potentially increased investment in critical care services could have reduced funding for fundamental pediatric services with an unintentional effect of undermining the healthcare of children. The policy attempted to balance the needs of individual patients (both emergency and elective); the capacity of existing staff and resources to provide critical care services sustainably over a period of time; and the need to sustain small highly specialized surgical services within the healthcare system. Positive aspects of this process included an increased understanding of the pediatric healthcare services and increased transparency and consistency in the way in which policies were applied. In many ways, this process met the criteria of the accountability for reasonableness (25–27) process. In addition, senior staff felt that it was advantageous that difficult issues had been debated fully in principle prior to actual implementation of the decision regarding admission of an individual patient. This helped to reduce pressure and emotional load on the decision-making personnel. In retrospect, there are a number of issues that were problematic including failure to involve representatives of the communities potentially affected by the process; difficulty with definition of how particular priorities would be applied to complex patient situations (20); inability to consistently collect data on implementation of the protocols; and difficulty with ongoing communication with all affected clinical units. There was also underestimation of the complexity of decision making. For some patients, it was quite clear as to whether they would benefit from PICU admission. However, for many patients, there is complexity around PICU admission including limited information regarding their specific diagnosis and prognosis; limited information regarding the particular circumstances of that child and his/her family; interaction of several disease processes simultaneously; and limited capacity to predict the particular trajectory of an illness in an individual patient. There was also realization on the part of the clinical staff that it is difficult to be consistent in decision making. January 2014 • Volume 15 • Number 1
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The quality of patient care and reduction of risk to patients in ICUs is a topical issue following publication of documents such as “To Err is Human” (28). An issue that is rarely addressed in the literature is what level of risk is acceptable. In the context of our ICU, it may have been possible to reduce the risk of adverse events by reducing the number of patients admitted to the unit and insisting on higher staff-to-patient ratios. The price paid for reducing risk of adverse events in this way would have been a decrease in the number of patients who would have access to intensive care. In the context of disasters, the principle has been established that the standards of expected medical care will have to alter (29), and it is a challenge for both medical and legal practitioners to consider how standards of care should be adjusted to a particular context. The question of value added by intensive care admission is complex. A patient who survives an illness after ICU admission when he/she would not have survived without that admission has gained value from that admission. However, it could be argued that society gains more value from ICU admissions that are of short duration with low mortality than from admissions that are of long duration with potentially high mortality. As mentioned earlier, a specific problem in our context was the juxtaposition of a cardiac waiting list in excess of 200 patients with the need to admit HIV-infected children for PICU care. Data from the ICU database suggested that patients undergoing cardiac surgery had a mortality of less than 5% and a median length of ICU stay of less than 3 days. By contrast, HIV-infected patients (at that time) had a median duration of stay greater than 5 days, an ICU mortality of approximately 25%, a hospital mortality of 50%, and a 6-month mortality in excess of 70% (A. Argent, unpublished data, 2003). The PICU team felt that it was not unreasonable to limit access of HIV-infected patients to the PICU in order that more cardiac elective surgery could be completed. This view was not generally accepted and was opposed by the view that HIV-infected patients were generally people who had suffered considerable discrimination and that this was yet another manifestation of prejudice. Subsequently, the specifics of this situation have changed dramatically as noted above, and HIV infection is no longer a reason to limit PICU admission. The PICU is an environment where more resources are available to manage the end of life. The care offered to the family of those patients is also of significance and may be particularly important in South Africa where the life experience of many is that their lives have been regarded as of little value. It may be a significant and life-changing event for people with that life experience to observe and experience considerable care, expertise, and concern being expended around their child. Although the benefits to society of such a facility may be uncertain, they cannot be ignored. One of the underlying assumptions regarding policies for PICU admission is that clinicians are able to accurately assess the risks and benefits of PICU admission. If it is possible to admit patients with a low risk of dying to the PICU, then there are unlikely to be deaths related to refusal of admission. However, if the pressure on PICU beds is such that patients have a high risk of dying before they can be admitted, it is inevitable that Pediatric Critical Care Medicine
clinicians will make errors that result in “unnecessary deaths.” Previously, Joynt et al (30) have demonstrated that adult intensive care clinicians were far from perfect at predicting the outcomes of patients referred for admission. The principles have previously been established in South African law that healthcare workers are unlikely to be held accountable for adverse events if they were working in accordance with carefully established principles for allocation of scarce resources (31). One of the more controversial aspects of the policy was the decision to limit access to the PICU for patients who were “deteriorating on appropriate therapy” in general wards. Studies in other settings (30, 32, 33) have shown a similar pattern with patients more likely to benefit from early rather than delayed PICU admission. The process has focused at admission priorities, but there is also a need to focus on “long-stay” PICU. They consume significant PICU resources and in many cases still have poor outcomes (34). For such patients, policies for withdrawal of life support need to be reconsidered.
CONCLUSIONS Increasing pressure has been exerted on the ICU facility with the growing pediatric population of the Western Cape. Noticeable features have been increasing severity of illness at admission; increasing delays prior to admission; and an increasing need to provide ventilatory support such as CPAP or ventilation in wards for up to 1–2 days. Given persisting high levels of preventable deaths in childhood in South Africa, it is appropriate to question the relevance and role of PICUs. We believe it is arguable that such services should be retained, and should be accompanied by explicitly articulated and defendable policies for admission and for withholding and withdrawal of intensive care (while continuing to provide palliative care). Such explicit policies will enable the retention of a small but essential service, sustain the ability to train the next generation of pediatric intensivists and expand the service in the future for the less privileged members of our society if, once overall improvements have been achieved in child survival in our country, additional resources become available. The arguments we have articulated acknowledge that while hospitals and ICUs are not the only routes to improved health for children, they remain an essential component of a modern medical school in a context in which aspirations justifiably include, but extend beyond, the goal of improving living conditions and providing better primary healthcare.
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20. White DB, Katz MH, Luce JM, et al: Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med 2009; 150:132–138 21. Miljeteig I, Johansson KA, Sayeed SA, et al: End-of-life decisions as bedside rationing. An ethical analysis of life support restrictions in an Indian neonatal unit. J Med Ethics 2010; 36:473–478 22. Maluka SO: Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania. Glob Health Action 2011; 4:7829 23. Kapiriri L, Martin DK: Bedside rationing by health practitioners: A case study in a Ugandan hospital. Med Decis Making 2007; 27:44–52 24. Kapiriri L, Martin DK: A strategy to improve priority setting in developing countries. Health Care Anal 2007; 15:159–167 25. Kapiriri L, Martin DK: Priority setting in developing countries health care institutions: The case of a Ugandan hospital. BMC Health Serv Res 2006; 6:127 26. Martin DK, Giacomini M, Singer PA: Fairness, accountability for reasonableness, and the views of priority setting decision-makers. Health Policy 2002; 61:279–290 27. Maluka S, Kamuzora P, San Sebastián M, et al: Improving district level health planning and priority setting in Tanzania through implementing accountability for reasonableness framework: Perceptions of stakeholders. BMC Health Serv Res 2010; 10:322 28. Kohn LT, Corrigan J, Donaldson MS: To Err Is Human: Building a Safer Health System. Washington, DC, National Academy Press, 2000 29. Hanfling D, Hick JL, Cantrill SV: Understanding the role for crisis standards of care. Ann Emerg Med 2012; 60:669–670; author reply 670–671 30. Joynt GM, Gomersall CD, Tan P, et al: Prospective evaluation of patients refused admission to an intensive care unit: Triage, futility and outcome. Intensive Care Med 2001; 27:1459–1465 31. South Africa Constitutional Court, 1997: Soobramoney v Minister of Health (Kwazulu-Natal): (CCT32/97) [1997] ZACC 17; 1998 (1) SA 765 (CC); 1997 (12) BCLR 1696 (27 November 1997). Available at: http://www.saflii.org/za/cases/ZACC/1997/17.html. Accessed November 25, 2013 32. Simchen E, Sprung CL, Galai N, et al: Survival of critically ill patients hospitalized in and out of intensive care. Crit Care Med 2007; 35:449–457 33. Simchen E, Sprung CL, Galai N, et al: Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med 2004; 32:1654–1661 34. Naghib S, van der Starre C, Gischler SJ, et al: Mortality in very longstay pediatric intensive care unit patients and incidence of withdrawal of treatment. Intensive Care Med 2010; 36:131–136
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Objective: To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources. Setting: Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa. Design: Retrospective description of policy development and implementation Patients: All patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children’s Hospital. Interventions: Development and application of admission policy. *See also p. 82. 1 Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. 2 Division of Paediatric Critical Care and Children’s Heart Disease, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa. 3 Education Development Unit, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. 4 Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa. 5 Bioethics Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. Listen to the Critical Care podcasts for an indepth interview on this article. Visit www.sccm.org/iCriticalCare or search “SCCM” at iTunes. Dr. Argent is employed by the Red Cross War Memorial Children's Hospital, received grant support from Wellcome Trust, and received payment as an invited guest speaker for various congresses. Dr. Morrow received grant support from the Medical Research Council of Southern Africa (career development award) and received support for travel from Congress organizers as an invited speaker. Dr. Reynolds is employed by the University of Cape Town and participates in People's Health Movement meetings. His institution received royalties from Pearson's publishers. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2013 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000029
Pediatric Critical Care Medicine
Measurements and Main Results: In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain “buy-in” from all potential stakeholders in the process and also to implement such policies under conditions of high stress. Conclusion: Development and implementation of explicit policies for utilization of PICU resources provide a “reasonable” process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services. (Pediatr Crit Care Med 2014; 15:7–14) Key Words: critical care; developing country; elective surgery; emergency care; ethics; pediatrics; resource allocation
I
CUs have become an integral part of medical practice since the 1950s. The ability to extend life with modern medical techniques and the unwillingness of both physicians and the public to “give up” have been associated with escalation of expenditure on health. In poorer countries, many children simply do not have access to ICUs, whereas in some “developed” nations, a concern is that perhaps some children are being kept alive at great cost (sometimes when there is only minimal potential for them to have normal lives) (1). This www.pccmjournal.org
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raises the question of whether ICUs are being used optimally or even whether ICUs are relevant where child mortality from mainly preventable causes is high and resources for healthcare are limited (2, 3).
BACKGROUND Since its opening in 1956, the Red Cross War Memorial Children’s Hospital (RCWMCH) has made significant contributions to the development of pediatrics in South Africa (4). This 300-bed children’s hospital provides services in all pediatric and pediatric surgical subspecialties. The hospital is possibly unique, in that despite being in a “middle-income” country, intensive care for children has been available for over 50 years. Pediatric intensive care (PIC) for children with tetanus was initiated at this hospital in 1957, shortly after the hospital was opened (5). Intensive care for cardiothoracic surgery (6) and then for pediatric surgery (4) and finally neonatal surgery (7) soon followed. Despite being situated in a country with high under-five mortality (8), it is able to offer sophisticated services such as pediatric cardiothoracic surgery and transplantation. In 1999, a decision was made to create a single 26-bed multidisciplinary ICU for children by combining all the above ICUs at the hospital. Many factors contributed to that decision, not least the withdrawal of resources from academic institutions to provide improved primary care and more equitable care generally throughout the country, and a shortage of nursing staff skilled in the care of critically ill children. Although the 26 beds were sufficient to provide PIC during the first 2–3 years of operation, increasing stress arose over succeeding years as the number of operational beds was progressively reduced to 18 (or on occasion 16) in 2007. This reduction was forced by budgetary cuts and dwindling numbers of intensive care nurses. Similar forces led to a reduction in PICU beds at other Western Cape hospitals. The reduction in PICU facilities coincided with a surge in the population of the Western Cape Province (an increase of 33% from 1996 to 2007) (9) and an increase in the number of newborn deliveries in the obstetric services of this Province. In addition, a 2007 survey of critical care services throughout South Africa (10) suggested that children did not have an equitable share of intensive care resources.
MAKING DECISIONS REGARDING WHO SHOULD BE ADMITTED TO THE PICU Policy Development As the result of the escalating demand on the ICU at the RCWMCH, the process of decision making regarding bed allocation became more challenging. The response to this was to focus on systems to even out requests for elective intensive care beds over the week and thus decrease surges from elective demands; endeavor to optimize care in the PICU to reduce length of stay (including introduction of “bundles” of specific groups of interventions to reduce nosocomial infections); and 8
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to develop and establish an explicit general policy for admission to the PICU. The aims were to: 1 . provide consistent criteria for admission; 2. reduce the pressure on PICU staff by facilitating clear decisions for admission; 3. avoid burnout (particularly of nursing staff); and 4. ensure that postoperative PICU admission for patients requiring elective surgery could be reasonably guaranteed to avoid having to cancel such planned events. The policy was developed by the PICU team, who met fortnightly over a period of approximately 2 months with all sections of the hospital clinicians (pediatricians from within the hospital and from referring hospitals, surgeons, cardiothoracic surgeons, physicians from some referring hospitals, and with hospital and nursing management). These meetings were directed at identifying problems in the policy, gaining consensus, and facilitating general acceptance of the final documents and policy. Principles for Admission General indications for admission to the PICU were based on international guidelines for PICU admission (11, 12). The specifically stated principles in the development of the policy were as follows: 1 . The best interests of the child. 2. Provision of equitable access. 3. Optimization of the overall benefit that could result from use of the PICU resources. 4. Optimization of assessment mechanisms for the child. 5. Avoidance of burnout of existing staff. 6. Paying particular attention to the needs of children who require major elective surgery. Specifically, a. Very few pediatric surgical interventions are truly elective, and delays could result in elective surgery becoming emergency surgery, or to complications that lead to more complicated surgery. b. Delayed elective surgery could lead to unnecessarily prolonged hospital stays, increase the risk of nosocomial infection, or compromise access to hospital beds by other children. c. Cancellation of elective surgery could cause ineffective utilization of theater resources, particularly personnel. This would prevent the few skilled pediatric surgeons and anesthetists in the country from working optimally, thus wasting an important and scarce national resource and potentially resulting in these doctors leaving to practice elsewhere. Loss of such skills could have potentially deleterious effects on healthcare in the longer term. d. Delay of elective surgery is disruptive to families and children. Process to Establish the Content of the Policy General principles for the process of bed allocation were drawn up (Table 1), and a series of specific criteria were established for patients who would be refused admission to the PICU (Table 2): 1. The Royal College of Pediatrics and Child Health (RCPCH) (13) has provided specific recommendations for situations January 2014 • Volume 15 • Number 1
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Table 1.
General Principles of Process
Children will be considered for admission in terms of the chronological order in which that request is made Preference will not be given to children from the Red Cross War Memorial Children’s Hospital. In fact, where possible, preference will be given to children who are referred from other areas (where they have very limited access to alternative intensive care) Preference will be given to children who have conditions that are amenable to therapy, with good outcomes, and preferably with relatively short PICU stays No child will be refused admission to the PICU without a decision by the ICU consultant on call at the time No registrar will be asked (or in fact allowed) to make a final decision about the appropriateness or otherwise of PICU admission of a child. This MUST be a consultant decision Data will be collected on every child referred to the PICU (or booked for admission following elective surgery), and where at all possible follow-up data will be collected on these children
in which it may be appropriate to limit provision of lifesustaining therapy, although the RCPCH framework for practice explicitly excludes considerations of resource allocation. As these were difficult to apply directly to children being considered for PICU admission, these criteria were modified as laid out in Table 2. 2. Children deemed “too well” to benefit from PICU admission were excluded. 3. It was made explicit to the Western Cape Department of Health that implementation of this policy would not free up enough PICU beds to meet the needs of children in the Western Cape and that those needs still required specific attention. 4 . It was stated as likely that implications of the policy would include the following: a. Involvement of PICU consultants in decision making if there was doubt about whether a child fitted the criteria, but no direct involvement if these criteria were unequivocally met. b. Limited data collection on children who were refused admission on the basis of these criteria (this would become the role of the current medical team and not the responsibility of the ICU). c. The possibility of limiting advances in therapy as the chances of developing effective therapies for children with poor predicted outcomes would be decreased. d. More children dying in the wards and in the emergency areas of the hospital, with resources then required to deal with this situation. It was agreed that it would be inappropriate to attempt interventions such as ventilation in the wards (except possibly as a short-term intervention while awaiting PICU admission) as this had the potential to compromise the care of other children. e. The presence of sicker children in the ward would have a negative impact on the quality of care that could be provided in those areas. These criteria were extensively discussed and agreed to by clinicians in the hospital. After agreement, the document outlining these issues was drawn up and submitted through hospital administration to the Provincial health authorities for approval. Once approval for the process had been established, the policy was disseminated to the clinicians at the hospital and was initiated. Pediatric Critical Care Medicine
Implementation The guidelines were implemented during 2003. The presence of guidelines facilitated decision making around difficult (or potentially contentious) patients, and senior PICU staff were generally positive about the change, feeling that they were relieved of the pressure of making difficult decisions under impossible conditions. Although the guidelines were widely disseminated initially, it was difficult to maintain awareness because of turnover of junior- and middle-grade staff in the hospital. It was also difficult to maintain consistency in application of the guidelines. Individual doctors were aware of variations in their personal application of criteria, and there were different interpretations of the guidelines. Decisions were inevitably affected by factors other than clear logic. Pressures on staff hindered continuous data collection regarding patient outcomes, but it was possible to collect data over limited periods to sample outcomes. There are limited data available regarding the pattern of patient referrals. Pediatric emergencies were the reason for 53–60% of admissions from 2007 to 2011, all other admissions being surgical (elective/emergency/trauma related). Over the period 2009 to 2012, 46 to 79 patients per annum had surgery cancelled because no PICU beds were available, while 32–41% of admissions from 2007 to 2011 were elective. A concern that arose during the process regarded favoring patients awaiting elective cardiac surgery for admission to the ICU over HIV-infected patients. Initially, antiretroviral drugs (ARVs) were not available to patients, but with increasing availability, there was a perception that the prognosis for HIVinfected patients would improve and that PICU admission policies should be altered accordingly. Initially, a study of HIVinfected patients (14) showed that availability of ARVs had not made a significant difference to the prognosis of patients admitted to the PICU with severe infection. Subsequently, significant changes in programs to interrupt mother-to-child transmission of HIV, as well as implementation of effective antiretroviral therapy for children, dramatically improved the survival of children exposed to HIV perinatally and those with established HIV infections. As a result of this development, admission policies were reviewed. Subsequently, there has been some relief for the PICU as additional allocation of staff has made it possible to increase bed numbers to 20 patients on a consistent basis, www.pccmjournal.org
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Table 2.
Specific Exclusion Criteria
Category
Futile care
Specific Exclusions
Comments
A child who has been declared brain dead
The permanent vegetative state was not addressed in the admission criteria as this was more likely to be encountered as a problem following stay in the PICU
A child who has had a cardiac arrest and has not reestablished a normal respiratory pattern, or who has fixed dilated pupils
< 5% of children in this category survive the PICU admission with an acceptable neurological outcome
The child who has suffered a head injury such that there is no chance of recovery from that injury Children with underlying lethal conditions
Children with burns > 60% body surface area, where the surgical team are not able to guarantee that debridement and appropriate cover will happen within 24–48 hr of admission
Based on data that if children are not debrided and grafted early on in the course of their burn management, they suffer a prolonged course with considerable pain, anxiety, and recurrent infection. The death rate in these children is also unacceptably high
Children with chronic renal failure where there is no commitment to long-term dialysis Children with severe and lethal chromosomal abnormalities (e.g., Edward syndrome or thanatophoric dwarfism) Children with malignancies that are not responding to therapy Children with inoperable cardiac lesions Children with currently poor outcomes
Children with established HIV infection. “Children with established HIV infection whose lives are in danger from AIDS-related diseases will not normally be considered for admission. A child who is successfully established on ARV, and where the reason for admission does not relate to the underlying disease and/or its therapy will be considered for admission.”
Based on data that despite the availability of ARV only approximately 20% of children with HIV infection who were admitted to the PICU were known to be alive and on ARV 6 mo later. These data have not changed since the availability of antiretroviral therapy
Children with kwashiorkor
Based on a virtual 100% mortality in the ICU for these patients
Children who have been in hospital wards for > 5 d and are deteriorating despite appropriate therapy
Based on an extremely high mortality rate in this group of patients. The failure to respond to therapy suggests that they have underlying conditions that are not amenable to conventional therapy
Children with severe adenoviral pneumonia who have not responded to appropriate therapy in the wards
Based on data showing that children with severe adenoviral infection requiring ventilation have a high mortality and very high morbidity from chronic lung disease
Children with diagnosed severe metabolic disorders (e.g., maple syrup urine disease) for which established treatment programs in the hospital and community are not established
Based on the fact that these children have a very poor likelihood of reasonable outcome
Children with acute hepatic failure, unless there is a reasonable likelihood that an acute transplant will be offered within the first 24–48 hr of PICU admission Children with complications of meningitis requiring ventilation (i.e., the requirement for ventilation is related to CNS disease rather than pneumonia) Children with cardiomyopathy unresponsive to therapy, and where transplantation is not being considered
This does not apply to the time of acute, first presentation. It is very difficult to prognosticate at that stage. This comment applies to children who have previously been treated, and where there has been time to make an appropriate assessment of likely prognosis
ARV = antiretroviral drugs.
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Table 3.
Review of Process: Ethical Principles and Extent to Which They Were Met
Duty to provide care
The process was an attempt to provide care to as many children as possible, within the resources available. In South African law, the principle has been established that the healthcare services cannot provide all services to all people (Soobramoney case [31])
Equity
No particular groups were excluded. In fact, attempts were made to improve access to care for children from outside the major teaching hospitals
Trust
The process improved trust between different departments in the hospital because it addressed the concerns of all regarding access to the PICU. We were not able to assess the impact of the policy on trust between families of patients and medical and nursing staff. Neither were we able to assess the impact of the policy on trust between different professionals in the hospital
Transparency
The process was open to comment and was made public to clinicians and managers within the health system. It was not transparent to the general public or to specific groups of people who were potentially (or actually) affected by the process. Where possible the rationale behind specific exclusions was provided in the documentation
Consistency
Implementation of a specific policy improved overall consistency, but individual consultants were aware of some variability in their implementation of the policy
Inclusiveness
The process was focused primarily on health professionals, and there was not adequate involvement of other stakeholders
Responsiveness
There were mechanisms within the system to respond to changes in circumstances, and there were mechanisms established to appeal against specific decisions
Accountability
The clinicians whose patients were affected by the process had every opportunity to appeal against decisions. In reality, this happened very rarely. Managers and administrators were given details of the implications of the resources available and the attempts to use those resources appropriately
and additional PICU beds have been opened in the city of Cape Town. However, the current bed occupancy of the PICU is consistently greater than 97%, and the average waiting time for a patient who has been assessed as requiring intensive care is approximately 5 hours (A. Argent, unpublished data, 2013). Despite considerable efforts, by 2012, the hospital had not been able to increase the number of cardiac operations performed but has been able to sustain a constant level despite increased demand for ICU admission from multiple areas. Table 4.
There had been pressure to “ring-fence” beds for cardiac surgery, but review of bed utilization suggested that this would not help as the number of “cardiac” patients already achieving access to the unit frequently exceeded the number of beds that would be ring-fenced. There are ongoing attempts to address this issue. Over the last 5 years, one additional response to poor access to intensive care beds has been the implementation of technologies such as continuous positive airway pressure (CPAP) in ward areas outside the PICU.
Contextual Information: The Relationship Between Patient Load and Staffing 2001
2005
2010
26
20
22
Admissions
1,380
1,129
1,265
Mortality (%)
11.01
10.34
8.93
3
4
4
Patient data Maximum beds available during the year
Staffing Specialist intensivists Registrars and medical officers
6 (out of hours calls supplemented by registrars who had previously worked in the PICU)
Fellows (subspecialist trainees in pediatric critical care)
Pediatric Critical Care Medicine
1
6 (out of hours calls 6 (out of hours calls supplemented by registrars who supplemented by registrars had previously worked who had previously worked in the PICU) in the PICU) 2
3
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Table 5.
Admissions, Deaths, and Mortality Data Pediatric Index of Mortality 2 Risk (Average)
Standardized Mortality Ratio
Year
Admissions
Deaths
Mortality (%)
2006
1,074
114
10.6
0.138
0.76
2007
1,067
131
12.2
0.1388
0.88
2008
1,330
139
10.4
0.129
0.81
2009
1,141
141
12.4
0.131
0.74
2010
1,265
115
9.0
0.132
0.68
DISCUSSION We have described the development and implementation of a process directed at optimizing the utilization of a scarce resource (see contextual detail in Table 4) in a developing country in response to a period of increasing pressure. An assessment of compliance with ethical principles of this process is shown in Table 3. Mortality in the PICU remained unchanged or decreased during implementation of this process (Tables 4 and 5), and there was an overall decrease in mortality in the hospital (A. Westwood, unpublished data, 2012), suggesting that this policy did not increase deaths in other parts of the system. Decisions have to be made at multiple levels as to how healthcare resources should best be allocated (15), and decisions regarding the availability of intensive care services have to be made by health systems. Decisions have to be made as to how those resources can be optimally used taking into account many factors including the level of intensive care that should be offered; the quality of “acceptable” ICU care (or the level of risk of errors that can be accepted); the value provided to the patient, his/her family by the PICU admission; the value provided to the medical community and the wider society by PICU; and how allocation of resources can be performed in a way that is equitable and practical. Our experience relates to the challenge of making decisions about individual patients while being mindful of the allocation of resources within pediatric services in a particular geographical region. Physicians are required to “act in the patient’s best interests.” The exact nature of the patient’s best interests where limitation of care for children is involved is controversial (16). The implications of limitation of care may be profound for the patient involved and his/her family (17, 18). In the United Kingdom, the Nuffield Council on bioethics argued that “healthcare professionals caring for babies in neonatal ICUs should continue to do the best possible for the ‘patient in front of them.’ They should be aware of, but not driven by, the resource implications of their decisions” (18). Although this principle should apply universally, it is inevitable that the ability to do so will be influenced by the context in which medicine is practiced. In the RCWMCH PICU, there is a greater tension than in the United Kingdom between focusing only on the individual child and considering how best to use a limited resource (19). Triage processes for critically ill patients in disaster situations have recently been reviewed by White et al (20). Much of the literature relating to triage for intensive care relates to 12
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the implications of that decision for particular patients. There is limited literature addressing triage as related to the need for sustaining and developing healthcare systems, while providing optimal care for individual patients (21–25). Although not perhaps fully understood at the time of development, the policy was an attempt to balance several different priorities. An underpinning concern was that overall healthcare services were not functioning optimally, and potentially increased investment in critical care services could have reduced funding for fundamental pediatric services with an unintentional effect of undermining the healthcare of children. The policy attempted to balance the needs of individual patients (both emergency and elective); the capacity of existing staff and resources to provide critical care services sustainably over a period of time; and the need to sustain small highly specialized surgical services within the healthcare system. Positive aspects of this process included an increased understanding of the pediatric healthcare services and increased transparency and consistency in the way in which policies were applied. In many ways, this process met the criteria of the accountability for reasonableness (25–27) process. In addition, senior staff felt that it was advantageous that difficult issues had been debated fully in principle prior to actual implementation of the decision regarding admission of an individual patient. This helped to reduce pressure and emotional load on the decision-making personnel. In retrospect, there are a number of issues that were problematic including failure to involve representatives of the communities potentially affected by the process; difficulty with definition of how particular priorities would be applied to complex patient situations (20); inability to consistently collect data on implementation of the protocols; and difficulty with ongoing communication with all affected clinical units. There was also underestimation of the complexity of decision making. For some patients, it was quite clear as to whether they would benefit from PICU admission. However, for many patients, there is complexity around PICU admission including limited information regarding their specific diagnosis and prognosis; limited information regarding the particular circumstances of that child and his/her family; interaction of several disease processes simultaneously; and limited capacity to predict the particular trajectory of an illness in an individual patient. There was also realization on the part of the clinical staff that it is difficult to be consistent in decision making. January 2014 • Volume 15 • Number 1
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The quality of patient care and reduction of risk to patients in ICUs is a topical issue following publication of documents such as “To Err is Human” (28). An issue that is rarely addressed in the literature is what level of risk is acceptable. In the context of our ICU, it may have been possible to reduce the risk of adverse events by reducing the number of patients admitted to the unit and insisting on higher staff-to-patient ratios. The price paid for reducing risk of adverse events in this way would have been a decrease in the number of patients who would have access to intensive care. In the context of disasters, the principle has been established that the standards of expected medical care will have to alter (29), and it is a challenge for both medical and legal practitioners to consider how standards of care should be adjusted to a particular context. The question of value added by intensive care admission is complex. A patient who survives an illness after ICU admission when he/she would not have survived without that admission has gained value from that admission. However, it could be argued that society gains more value from ICU admissions that are of short duration with low mortality than from admissions that are of long duration with potentially high mortality. As mentioned earlier, a specific problem in our context was the juxtaposition of a cardiac waiting list in excess of 200 patients with the need to admit HIV-infected children for PICU care. Data from the ICU database suggested that patients undergoing cardiac surgery had a mortality of less than 5% and a median length of ICU stay of less than 3 days. By contrast, HIV-infected patients (at that time) had a median duration of stay greater than 5 days, an ICU mortality of approximately 25%, a hospital mortality of 50%, and a 6-month mortality in excess of 70% (A. Argent, unpublished data, 2003). The PICU team felt that it was not unreasonable to limit access of HIV-infected patients to the PICU in order that more cardiac elective surgery could be completed. This view was not generally accepted and was opposed by the view that HIV-infected patients were generally people who had suffered considerable discrimination and that this was yet another manifestation of prejudice. Subsequently, the specifics of this situation have changed dramatically as noted above, and HIV infection is no longer a reason to limit PICU admission. The PICU is an environment where more resources are available to manage the end of life. The care offered to the family of those patients is also of significance and may be particularly important in South Africa where the life experience of many is that their lives have been regarded as of little value. It may be a significant and life-changing event for people with that life experience to observe and experience considerable care, expertise, and concern being expended around their child. Although the benefits to society of such a facility may be uncertain, they cannot be ignored. One of the underlying assumptions regarding policies for PICU admission is that clinicians are able to accurately assess the risks and benefits of PICU admission. If it is possible to admit patients with a low risk of dying to the PICU, then there are unlikely to be deaths related to refusal of admission. However, if the pressure on PICU beds is such that patients have a high risk of dying before they can be admitted, it is inevitable that Pediatric Critical Care Medicine
clinicians will make errors that result in “unnecessary deaths.” Previously, Joynt et al (30) have demonstrated that adult intensive care clinicians were far from perfect at predicting the outcomes of patients referred for admission. The principles have previously been established in South African law that healthcare workers are unlikely to be held accountable for adverse events if they were working in accordance with carefully established principles for allocation of scarce resources (31). One of the more controversial aspects of the policy was the decision to limit access to the PICU for patients who were “deteriorating on appropriate therapy” in general wards. Studies in other settings (30, 32, 33) have shown a similar pattern with patients more likely to benefit from early rather than delayed PICU admission. The process has focused at admission priorities, but there is also a need to focus on “long-stay” PICU. They consume significant PICU resources and in many cases still have poor outcomes (34). For such patients, policies for withdrawal of life support need to be reconsidered.
CONCLUSIONS Increasing pressure has been exerted on the ICU facility with the growing pediatric population of the Western Cape. Noticeable features have been increasing severity of illness at admission; increasing delays prior to admission; and an increasing need to provide ventilatory support such as CPAP or ventilation in wards for up to 1–2 days. Given persisting high levels of preventable deaths in childhood in South Africa, it is appropriate to question the relevance and role of PICUs. We believe it is arguable that such services should be retained, and should be accompanied by explicitly articulated and defendable policies for admission and for withholding and withdrawal of intensive care (while continuing to provide palliative care). Such explicit policies will enable the retention of a small but essential service, sustain the ability to train the next generation of pediatric intensivists and expand the service in the future for the less privileged members of our society if, once overall improvements have been achieved in child survival in our country, additional resources become available. The arguments we have articulated acknowledge that while hospitals and ICUs are not the only routes to improved health for children, they remain an essential component of a modern medical school in a context in which aspirations justifiably include, but extend beyond, the goal of improving living conditions and providing better primary healthcare.
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January 2014 • Volume 15 • Number 1
