Contextual Critical Care
Multidisciplinary team Outreach Non-ICU critical care Rehabilitation Critical care and society Communication with family/surrogate decision makers Data collection Research Audit Multidisciplinary team Critically ill patients should be cared for by a multidisciplinary team including medical practitioners, nursing staff, dieticians, microbiologists, pharmacists, physiotherapists, psychologists, soc
Communication with family/surrogate decision makers
Multidisciplinary team
Critically ill patients should be cared for by a multidisciplinary team including medical practitioners, nursing staff, dieticians, microbiologists, pharmacists, physiotherapists, psychologists, social workers, occupational therapists and speech therapists. Each patient should have a clearly designated primary physician whose responsibility it is to coordinate the multidisciplinary team. In level 2 ICUs, the primary physician should be the ICU physician. In level 3 ICUs, the primary physician must be the intensivist. Where an intensivist is the primary physician, the need for other consulting physicians needs to be justified in order to limit over-servicing of patients.
Outreach
Level 2 and level 3 ICUs should have a clear ICU outreach plan. This outreach plan will differ depending on the structure of the healthcare system in which the ICU functions. In a tiered healthcare system where the ICU functions as a referral centre, the outreach should provide support for referring level 1 and 2 ICUs. Outreach may also take the form of “in-reach” where programmes are conducted in the same healthcare facility as the ICU. These may include initiatives aimed at, inter alia, improving patient stabilisation prior to ICU and transfer to ICU or improving post-ICU care. The programmes may also include training programmes in the ICU for non-ICU staff.
Non-ICU critical care
Given the lack of critical care beds in South Africa, it is a reality that critically ill patients are managed in non-critical care beds. This may include patients that are deemed “too well” for ICU but require intensive monitoring or lesser degrees of organ support, patients who require ICU but are waiting for an ICU bed, and patients where ICU admission is deemed non-beneficial due to the severity of their acute or chronic medical conditions. Furthermore, even in well-resourced environments, there is a growing appreciation that it is no longer feasible or desirable to limit critical care practices to one geographically distinct location in a hospital. The nature and duration of “critical care” provided in these non-ICU areas needs to be decided upon by all relevant stakeholders. Similarly, provision of equipment and training needs to be decided upon by the relevant stakeholders, as must the level of involvement/oversight by ICU staff. Creating and capacitating non-ICU critical care practices is a potential outreach project.
Rehabilitation
Many critically ill patients require rehabilitation after surviving critical illness. Adequate rehabilitation facilities and programmes are essential to allow patients to experience the full benefit of the lifesaving therapies provided in ICU. These should be fully funded by healthcare providers. In the absence of adequate rehabilitation services, it may be appropriate to limit access to critical care services for patients with conditions that are likely to have a poor functional prognosis without rehabilitation.
Critical care and society
Critical care practitioners should be cognisant of the needs and wishes of society. Critical care services should be managed with this in mind and should actively seek to balance the ethical principles of beneficence, non-maleficence, social justice and autonomy. Hospitals with critical care services should have functioning ethics committees. These should include members of the community. The critical care services should be actively represented on these committees.
Communication with family/surrogate decision makers
Open and compassionate communication with the patient and/or their surrogate (as appropriate) is encouraged. A family/surrogate liaison should be determined for all patients with diminished capacity. This liaison will default to the surrogate decision-maker as laid out in the National Health Act (Act 6 of 2003) unless the surrogate decision-maker specifically allocates this responsibility to another individual.
The patient should be provided with daily updates on their condition. If the patient has diminished capacity, the liaison should be allowed the opportunity to receive daily updates on the patient’s condition. Informed consent for procedures/therapy should be obtained by the responsible physician (or their designated representative) from the patient, or from the legally appropriate surrogate decision maker if the patient lacks capacity to provide informed consent. In the event of conflict between the patient (or their surrogate decision-maker) and the treating physician, the patient/surrogate should be offered the option of obtaining a second opinion. This second opinion should be from a medical practitioner with appropriate training and expertise in the relevant field and should be obtained within 48 hours.
Each ICU should have an information leaflet available to family members/surrogates.
An open visitation policy is ideal but may not be feasible in all settings. Each ICU should have a minimum of two one-hour visiting times per day. A maximum of two visitors should be allowed in the ICU per patient at any time. A maximum of six visitors should be allowed for any specific visiting time. These visiting times and numbers should only be reduced under exceptional circumstances.
Data collection
All critical care services need to have data collection policies. While adhering to Protection of Personal Information Act (Act 4 of 2013) and relevant local and national administrative and ethical requirements critical care services should actively seek to routinely collect relevant clinical and laboratory data for all patients. This will allow for locally relevant audit and research that will guide and improve patient care.
Research
Locally relevant critical care research is crucial to improving critical care in South Africa. All level 2 and 3 ICUs should have active research programmes. Collaborative research is highly encouraged.
Audit
All ICUs should conduct frequent audits (at least quarterly). Suggested areas amenable to audit include, but are not limited to, glycaemic control, thromboprophylaxis, antimicrobial prescribing, healthcare-associated infections, and nutritional support. Regular clinical record audits should also be conducted to ensure good record keeping. Audit should be followed by appropriate analysis and implementation plans and ongoing audit of the effect of any interventions.
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