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.
CONCLUSIONS: 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.
