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

Abstract

GUIDELINE /SAJCCBackground. 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.

Admission triage tool for adult intensive care unit admission in Hong Kong during the COVID-19 outbreak

“…The use of predicted incremental benefit for decision making has been previously endorsed by expert consensus groups when triage is required, both under outbreak and non-outbreak conditions. 1,2,14 The CFS, which has nine variables, was chosen as the appropriate general health performance metric, as it meets local practice requirements: familiarity, ease of use, and having been validated as a predictor of short-and medium-term ICU outcomes. [23][24][25][26] The well-established ASA score was chosen for modification to guide assessment of comorbidities, as its descriptions are clear, concise, and logically presented (ASA 2019).…”

COVID-19 in South Africa: outbreak despite interventions

“…The order of magnitude of these numbers is consistent with earlier reports 15 . However, the factually available ICU beds have likely declined during the past decade necessitating rationing and triage (prioritisation) decisions that have been frequently necessary in South Africa even in times before COVID-19, particularly in the publicly funded health sector 14 , 16 . Moreover ICU capacity in the private sector is not readily and generally accessible.…”

Barriers to the Use of Neurologic Criteria to Declare Death in Africa

“…12 Low capacity to care for critically ill patients and resource limitations prompted the development of consensus statements on rationing techniques and regular review of the principles of beneficence and justice. 16,17 However, there is often ambiguity about how to manage the conflicting interests of a patient and their family due to the financial burden associated with treatment. 12 Of course, resource limitations are frequently taken into consideration when making decisions about provision of end-of-life care.…”