Consensus statement

The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri)

G M Joynt, D P Gopalan, A A Argent, S Chetty, R Wise, V K W Lai, E Hodgson, A Lee, I Joubert, S Mokgokong, S Tshukutsoane, G A Richards, C Menezes, R L Mathivha, B Espen, B Levy, K Asante, F Paruk

Abstract


 

 Background. In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector. 

Purpose. The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care. 

Recommendations. In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years. 

Conclusion. In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate 


Authors' affiliations

G M Joynt, The Chinese University of Hong Kong

D P Gopalan, University of KwaZulu Natal

A A Argent, University of Cape Town

S Chetty, Stellenbosch University

R Wise, University of KwaZulu Natal

V K W Lai, The Chinese University of Hong Kong

E Hodgson, University of KwaZulu Natal

A Lee, The Chinese University of Hong Kong

I Joubert, University of Cape Town

S Mokgokong, University of Pretoria

S Tshukutsoane, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg

G A Richards, University of the Witwatersrand, Johannesburg

C Menezes, University of the Witwatersrand, Johannesburg

R L Mathivha, University of the Witwatersrand, Johannesburg

B Espen, Stellenbosch University

B Levy, Netcare Rosebank Hospital, Johannesburg, Gauteng

K Asante, African Organization for Research and Training in Cancer, Cape Town, South Africa

F Paruk, University of Pretoria

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Cite this article

South African Medical Journal 2019;109(8b):613-629. DOI:10.7196/SAMJ.2019.v109i8b.13947

Article History

Date submitted: 2019-08-22
Date published: 2019-08-22

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