Background & Definitions of Critical Illness and Critical Care
Background Definitions of critical illness and critical care Background There are significant global differences in the availability and structure of critical care services. Due to different definitions of critical care beds and differences in the quality of statistics available, it is difficult to directly compare the availability of critical care resources between countries. Availa
Definitions of critical illness and critical care
Background
There are significant global differences in the availability and structure of critical care services. Due to different definitions of critical care beds and differences in the quality of statistics available, it is difficult to directly compare the availability of critical care resources between countries. Available data suggests that the number of intensive care unit (ICU) beds per 100 hospital beds varies from 9.0 in the United States of America (USA), to 4.4 in Belgium, 4.1 in Germany, 3.5 in Columbia, 0.9 in New Zealand and 0.2 in Zambia (1). The number of ICU beds per 100 000 population in turn varies from 24.6 in Germany to 21.9 in Belgium, 20.0 in the USA, 8.0 in Australia, 4.8 in New Zealand, 3.5 in the United Kingdom and 1.6 in Sri Lanka (1). Data from South Africa is limited and is complicated by the coexistence of the public and private healthcare systems. An audit conducted in 2008-2009 determined that there were 4 719 ICU and high care beds in South Africa, of which 1186 were in the public sector and 3 533 in the private sector (2). The ICU/high care bed to hospital bed ratio varied from 1.7 per 100 in the public sector to 8.9 per 100 in the private sector (3). The total ICU/high care bed to population ratio for South Africa is thus in the range of 8.9 to 9.57 per 100 000 (depending on methodology), however the ratio for public sector ICU beds is 2.4 to 3.8 per 100 000 (1, 2). There are significant regional differences in ICU/high care bed availability in South Africa, with the ICU/high care bed to population ratio being as low as 0.7 per 100 000 in Limpopo, and as high as 5.0 per 100 000 in the Western Cape (2).
Global differences in critical care bed availability and utilisation are undoubtedly influenced by differences in financial resource availability. The appropriate number of critical care beds for a given population should, however, also vary depending on the burden of critical illness in the population (1). Other factors, such as differences in healthcare structure, philosophy and ethics also play a role. As an example, 47.1% of in-hospital deaths in the USA occur in ICU versus only 10.1% in the UK (4). This suggests significant social differences in concepts of appropriate use of critical care resources and end-of-life care. These local differences need to be considered when determining appropriate critical care bed numbers and utilisation.
The provision of critical care is costly. Critical care outcomes appear to be influenced by a country’s gross national income, with ICU mortality being higher in upper-middle income countries when compared to high income countries, despite similar illness severity scores (5). This suggests that resource limitations need to be considered in determining appropriate critical care norms and goals of critical care. The aim of this guideline is to promote the appropriate development of in-hospital critical care services in South Africa. These services should provide high-quality multidisciplinary care that is appropriate to the specific financial, ethical, and social circumstances of South Africa.
Definitions of critical illness and critical care
A critically ill patient is one that has, or is at high risk of developing, acute life-threatening organ dysfunction. Such patients require constant, intensive monitoring and comprehensive care including multiple modalities of vital physiologic organ support to sustain life during a period of life-threatening organ system insufficiency, intensive resuscitation, and appropriate end-of-life care.
Critical care is a specialised multidisciplinary field that is dedicated to the care of the critically ill patient. Critical care is not limited to a specific geographic location in a hospital. Critical care is a continuum of care that includes prehospital management, in-hospital management in non-ICU settings, management in the ICU, and management of the recovery phase of critical illness.
An intensive care unit is a clearly defined geographic area in a hospital, dedicated to the management of critically ill patients. It is characterised by the presence of a multidisciplinary team with specific expertise in the management of critically ill patients, and by the presence of advanced monitoring and organ support equipment and may require specific infrastructure. The level of monitoring and medical care offered in an ICU is greater than that which can be provided safely in a general hospital ward.
Critical Care Society of Southern Africa Guidelines for the Provision of Critical Care Services in South Africa - Critical Care Society of Southern Africa - Version 1: July 2022