Pediatric intensive care in South Africa: an account of making optimum use of limited resources at the Red Cross War Memorial Children's Hospital*

Abstract

Objective: To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources.

Setting: Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa.

Design: Retrospective description of policy development and implementation

Patients: All patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children's Hospital.

Interventions: Development and application of admission policy.

Measurements and main results: In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain "buy-in" from all potential stakeholders in the process and also to implement such policies under conditions of high stress.

Conclusion: Development and implementation of explicit policies for utilization of PICU resources provide a "reasonable" process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services.