The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa
DOI:
https://doi.org/10.7196/SAMJ.2022.v112i11.16452Keywords:
Peadiatric surgury, critical care, Health careAbstract
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.
References
Naidoo K, Singh J, Lalloo U. A critical analysis of ICU/HC beds in South Africa: 2008 - 2009. S Afr Med J 2013;103(10):751-753. https://doi.org/10.7196%2Fsamj.6415
Rhodes A, Moreno RP. Intensive care provision: A global problem. Rev Bras Ter Intensiva 2012;24(4):322-325. https://doi.org/10.1590/S0103-507X2012000400005
Vukoja M, Riviello E, Gavrilovic S, et al. A survey on critical care resources and practices in low- and middle-income countries. Glob Heart 2014;9(3):337-342.e331-335. https://doi.org/10.1016/j. gheart.2014.08.002
Siaw-Frimpong M, Touray S, Sefa N. Capacity of intensive care units in Ghana. J Crit Care 2021;61:76- 81. https://doi.org/10.1016/j.jcrc.2020.10.009
Horak RV, Griffin JF, Brown AM, et al. Growth and changing characteristics of pediatric intensive care 2001 - 2016. Crit Care Med 2019;47(8):1135-1142. https://doi.org/10.1097%2Fccm.0000000000003863 6. Bamford LJ, McKerrow NH, Barron P, Aung Y. Child mortality in South Africa: Fewer deaths, but better data are needed. S Afr Med J 2018;108(3 Suppl 1):S25-S32. https://doi.org/10.7196/samj.2017.
v108i3b.12779
United Nations Children’s Fund. Countdown 2015: Maternal, newborn and child survival. New York: World Health Organization, 2015. http://countdown2030.org/documents/2015Report/Countdown_ to_2015_final_report.pdf (accessed 22 January 2022).
McKerrow N, Mulaudzi M. 2nd triennial report of the committee on morbidity and mortality in children under 5 years (COMMIC). South Africa: National Department of Health, 2014. http://www. kznhealth.gov.za/mcwh/2nd-CoMMiC-Triennial-Report-2014.pdf (accessed 21 July 2016).
Gebhardt S. Saving Babies 2014 - 2016: Triennial report on perinatal mortality in South Africa. Pretoria: National Department of Health, 2018. https://www.westerncape.gov.za/assets/departments/ health/napemmco_triennial_report_2014-2016_saving_babies.pdf (accessed 10 December 2021).
Stephen C. Saving Children 2012 - 2013: An eighth survey of child healthcare in South Africa. Pretoria: Tshepesa Press, MRC, CDC, 2016. https://www.up.ac.za/media/shared/717/Child%20PIP/Saving%20 children%20reports/saving-children-2012-2013.zp207156.pdf (accessed 15 June 2016).
Lehohla P. Census 2011: Census in brief. Pretoria: Statistics South Africa, 2012. http://www.statssa.gov. za/census/census_2011/census_products/Census_2011_Census_in_brief.pdf (accessed 13 June 2016). 12. ScribanteJ,BhagwanjeeS.NationalauditofcriticalcareresourcesinSouthAfrica–researchmethodology. S Afr Med J 2007;97(12 Pt 3):1308-1310. https://www.ncbi.nlm.nih.gov/pubmed/18265910 (accessed 14
June 2016).
Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP. The variability of critical care
bed numbers in Europe. Intensive Care Med 2012;38(10):1647-1653. https://doi.org/10.1007/s00134-
-2627-8
Muttalib F, González-Dambrauskas S, Lee JH, et al. Pediatric emergency and critical care resources and infrastructure in resource-limited settings: A multicountry survey. Crit Care Med 2021;49(4):671-681. https://doi.org/10.1097/ccm.0000000000004769
Murthy S, Leligdowicz A, Adhikari NK. Intensive care unit capacity in low-income countries: A systematic review. PLoS One 2015;10(1):e0116949. https://doi.org/10.1371/journal.pone.0116949
Department of Health, KwaZulu-Natal. Referral system: Levels of health care. KwaZulu-Natal
Department of Health Corporate Communication, 2014 (updated 4 January 2022). https://www.
kznhealth.gov.za/Referral-system.htm. (accessed 8 January 2022).
World Health Organization. Guideline: assessing and managing children at primary health-care
facilities to prevent overweight and obesity in the context of the double burden of malnutrition. Updates for the Integrated Management of Childhood Illness (IMCI). Geneva: WHO, 2017. https:// www.who.int/publications/i/item/9789241550123 (accessed 10 December 2021).
Jeena PM, Adhikari M. Provision of critical care services to HIV-infected children in an era of advanced intensive care and availability of combined antiretroviral therapy. Paediatr Int Child Health 2017;37(3):166-171. https://doi.org/10.1080/20469047.2016.1254892
Hendricks CL, McKerrow NH, Hendricks RJ. Factors present on admission associated with increased mortality in children admitted to a paediatric intensive care unit (PICU). S Afr J Child Health 2016;10(1):57-62. https://doi.org/10.7196/SAJCH.2016.v10i1.1048
Solomon LJ, Naidoo KD, Appel I, et al. Pediatric index of mortality 3 – an evaluation of function among ICUs in South Africa. Pediatr Crit Care Med 2021;22(9):813-821. https://doi.org/10.1097/ pcc.0000000000002693
Cowburn C, Hatherill M, Eley B, et al. Short-term mortality and implementation of antiretroviral treatment for critically ill HIV-infected children in a developing country. Arch Dis Child 2007;92(3):234-241. https://doi.org/10.1136/adc.2005.074856
Argent AC, Ahrens J, Morrow BM, et al. Pediatric intensive care in South Africa: An account of making optimum use of limited resources at the Red Cross War Memorial Children’s Hospital. Pediatr Crit Care Med 2014;15(1):7-14. https://doi.org/10.1097/PCC.0000000000000029
Punchak M, Hall K, Seni A, et al. Epidemiology of disease and mortality from a PICU in Mozambique. Pediatr Crit Care Med 2018;19(11):e603-e610. https://doi.org/10.1097/pcc.0000000000001705
Bagri NK, Jose B, Shah SK, Bhutia TD, Kabra SK, Lodha R. Impact of malnutrition on the outcome of critically ill children. Indian J Pediatr 2015;82(7):601-605. https://doi.org/10.1007/s12098-015- 1738-y
Ross PA, Newth CJ, Leung D, Wetzel RC, Khemani RG. Obesity and mortality risk in critically ill children. Pediatrics 2016;137(3):e20152035. https://doi.org/10.1542/peds.2015-2035
Straney L, Clements A, Parslow RC, et al. Paediatric index of mortality 3: An updated model for predicting mortality in pediatric intensive care. Pediatr Crit Care Med 2013;14(7):673-681. https://doi. org/10.1097/PCC.0b013e31829760cf
Straney LD, Schlapbach LJ, Yong G, et al. Trends in PICU admission and survival rates in children in Australia and New Zealand following cardiac arrest. Pediatr Crit Care Med 2015;16(7):613-620. https://doi.org/10.1097/pcc.0000000000000425
Royal C, McKerrow NH. A retrospective review of the transfer of critically ill children to tertiary care in KwaZulu-Natal Province, South Africa. S Afr J Child Health 2015;9(4):112-118. https://doi. org/10.7196/SAJCH.2015.v9i4.913
Gregory CJ, Nasrollahzadeh F, Dharmar M, Parsapour K, Marcin JP. Comparison of critically ill and injured children transferred from referring hospitals versus in-house admissions. Pediatrics 2008;121(4):e906-911. https://doi.org/10.1542/peds.2007-2089
Mat Bah MN, Syed Mohamed SA, Abdullah N, Alias EY. Unplanned PICU readmission in a middle- income country: Who is at risk and what is the outcome? Pediatr Crit Care Med 2020;21(11):e959-e966. https://doi.org/10.1097/pcc.0000000000002406
Radebe PBS, Jeena PM. Red blood cell concentrate transfusion strategies utilised at a tertiary- level paediatric intensive care unit: A descriptive study on impact and cost. S Afr J Child Health 2018;12(4):164-169. https://doi.org/10.7196/SAJCH.2018.v12i4.1517
Kruger I, Gie RP, Harvey J, Kruger M. Outcome of children admitted to a general high care unit in a regional hospital in the Western Cape, South Africa. S Afr J Child Health 2016;10(3):156-160. https:// doi.org/10.7196/SAJCH.2016.v10i3.981
Hlophe ST, Govender NP, Masekela R. Invasive fungal infections among critically ill children: Epidemiology, risk factors and outcomes. Afr J Thorac Crit Care Med 2018;24(1):11-14. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC8432925/pdf/AJTCCM-24-1-172.pdf (accessed 12 January 2021).
Hatherill M, Waggie Z, Reynolds L, Argent A. Transport of critically ill children in a resource-limited setting. Intensive Care Med 2003;29(9):1547-1554. https://doi.org/10.1007/s00134-003-1888-7
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