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 triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources


Authors' affiliations

G M Joynt, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong

D P Gopalan, Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa

A A Argent, Department of Paediatrics and Child Health, University of Cape Town, South Africa

S Chetty, Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa

R Wise, Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Edendale Hospital, Pietermaritzburg, South Africa

V K W Lai, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong

E Hodgson, Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Inkosi Albert Luthuli Central Hospital, Durban, South Africa

A Lee, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong

I Joubert, Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa

S Mokgokong, Department of Neurosurgery, University of Pretoria, South Africa

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

G A Richards, Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

C Menezes, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa;Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

R L Mathivha, Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

B Espen, Centre for Health Professions Education, Stellenbosch University, Cape Town, South Africa

B Levy, Netcare Rosebank Hospital, Johannesburg, South Africa

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

F Paruk, Department of Critical Care, University of Pretoria, South Africa

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Cite this article

Southern African Journal of Critical Care 2019;35(1b):36-52. DOI:10.7196/SAJCC.2019.v35i1b.383

Article History

Date submitted: 2019-08-15
Date published: 2019-08-15

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