Southern African Journal of Critical Care

Deep medicine … Navigating the intersection of technology, cognition and ethics in the digital age of medicine

P.D. Gopalan — 2024-02-02

The digital expansion in medicine and healthcare has been immense and extremely valuable. The biggest concern in the face of this inevitable growth is how we manage to keep contact with our patients and preserve the human touch so essential in healing. Digital healthcare should not be about technology replacing clinicians. Instead, it should be about augmenting and supplementing healthcare providers to improve the ways in which we deliver personalised healthcare. It is vital that we focus on how we can revitalise the patient- clinician relationship in this digital age.

Groote Schuur Hospital neurosurgical intensive care unit: A 2-year review of admission characteristics

S. Rashid — 2024-02-02

Background: At Groote Schuur Hospital (GSH), the neurosurgical intensive care unit (NsICU) is a 6-bed unit headed by a specialist neurosurgeon with extensive experience in neurocritical care, working in close collaboration with intensivists from the Division of Critical Care. There is currently no detailed analysis of the demographics, diagnosis and management of patients admitted to the NsICU at GSH.

Objectives: To provide a detailed descriptive analysis of the demographics, diagnosis and management of patients admitted to the NsICU at GSH from 1 January 2020 to 31 December 2021.

Methods: A retrospective descriptive analysis was done of patients who received treatment in the NsICU from 1 January 2020 to 31 December 2021.

Results: A total of 685 patients were admitted to the unit over a 2-year period, with a male preponderance (68.2%). The average age was 42.5 (standard deviation (SD) 17.2) years. The most common neurosurgical diagnoses were traumatic brain injuries (39.6%), brain tumours (22.6%) and aneurysmal subarachnoid haemorrhages (9.9%). Emergency admissions comprised 76.6% of the total and 86.7% of patients were admitted postoperatively. Three hundred and seventy-two patients (54.3%) required mechanical ventilation, 132 (19.3%) required both an intracranial pressure (ICP) monitor and brain tissue oxygenation monitor, 86 (12.5%) needed placement of an external ventricular drain, 50 (7.3%) needed placement of a tracheostomy tube and 16 (2.3%) needed placement of an ICP monitor only. The average duration of stay was 5.5 (1.3) days and NsICU mortality over 2 years was 11.1%.

Conclusion: The NsICU at GSH manages predominantly male trauma patients and a significant number of admitted patients require specialised invasive intracranial monitoring.

Core competencies in critical care for general medical practitioners in South Africa: A Delphi study

S.D. Maasdorp — 2024-02-02

Background: Despite a high burden of disease that requires critical care services, there are a limited number of intensivists in South Africa (SA). Medical practitioners at district and regional public sector hospitals frequently manage critically ill patients in the absence of intensivists, despite these medical practitioners having had minimal exposure to critical care during their undergraduate training.

Objectives: To identify core competencies in critical care for medical practitioners who provide critical care services at public sector hospitals in SA where intensivists are not available to direct patient management.

Methods: A preliminary list of core competencies in critical care was compiled. Thereafter, 13 national and international experts were requested to achieve consensus on a final list of core competencies that are required for critical care by medical practitioners, using a modified Delphi process.

Results: A final list of 153 core competencies in critical care was identified.

Conclusion: The core competencies identified by this study could assist in developing training programmes for medical practitioners to improve the quality of critical care services provided at district and regional hospitals in SA.

Patient perceptions of ICU physiotherapy: ‘Your body needs to go somewhere to be recharged … ’

F. Karachi — 2024-02-02

Background: Patient satisfaction is an essential concept to consider for the improvement of quality care in healthcare centres and hospitals and has been linked to increased patient compliance with treatment plans, better patient safety and improved clinical outcomes.
Objective: As part of a before-and-after clinical trial aimed to investigate the implementation of an evidence-based and -validated physiotherapy protocol within a surgical intensive care unit (ICU), we decided to include the patient perception of physiotherapy received in the intervention unit.
Method: A nested, exploratory, descriptive, qualitative study design was adopted. Purposively selected adult patients discharged from ICU during the implementation phase of the trial were interviewed.
Results: Eighteen patients (10 male) with a median age of 44 years and median ICU length of stay (LOS) of six days were included. Three themes and nine categories emerged: (i) linking therapy to clinical outcome (patient expectations and understanding; physiotherapy activities and the implication of mobilisation; physiotherapy benefits and progression); (ii) the importance of developing a trusting relationship (physiotherapy value; safety; continuity of care); and (iii) communication (satisfaction; interactions and patient perception and experience of physiotherapy).
Conclusion: While confirming barriers to early mobility, patients perceived participation in mobility activities as a marked jolt in their journey to recovery following a critical incident. Effective communication and preservation of trust between physiotherapist and patient are essential for understanding expectations and can facilitate improved outcomes. Clinicians can use the information when managing critically ill patients. Including patient-reported outcomes to measure physiotherapy interventions used in the ICU is feasible and can inform the development of such outcomes.

Outcomes of traumatic brain injury patients in an adult intensive care unit of a South African regional hospital, without on-site neurosurgical service: A retrospective quantitative study on the neurological improvement at discharge

A. Sallie — 2024-02-02

Background: Traumatic brain injury (TBI) is a major cause of mortality and disability. The South African (SA) province of Kwazulu-Natal faces challenges in providing appropriate care for TBI patients owing to limited resources and delayed access to healthcare services. We aimed to assess the outcomes of patients with TBI who were treated at a hospital without a neurosurgical unit (NSU).

Objectives: The primary objective was to compare the Glasgow Coma Scale (GCS) scores at admission and discharge from the intensive care unit (ICU) for patients with TBI receiving neuroprotection. Secondary objectives included analysing demographics and identifying predictive factors associated with GCS score improvement.

Methods: This retrospective study analysed data from the already established ICU Integrated Critical Care Electronic Database. Data on patient demographics, mechanisms of injury and GCS scores were collected and analysed.

Results: The analysis included 95 TBI patients, most of whom were young males. Interpersonal violence and transport-related trauma were the main causes of injury among patients. Approximately 63% of patients had a GCS score improvement >1 upon discharge from the ICU. Patients who received >12 hours of neuroprotection in the emergency department had significantly lower rates of improvement.

Conclusion: Sixty-three percent of TBI patients had improved GCS scores by >1 on discharge from the ICU, but outcomes varied. Delayed
ICU admission from the emergency department of >12 hours might contribute to worse outcomes. Timely neuroprotection, improved access to neurosurgical care and better understanding of the factors affecting outcomes are needed.

The utility of brain natriuretic peptide as a prognosticating marker in critical care patients

A. Naidoo — 2024-02-02

Background: Brain natriuretic peptide (BNP) is an established biomarker of morbidity and mortality in cardiac failure. Data also suggest potential prognostic utility in non-heart failure cohorts. The utility of BNP in predicting intensive care unit (ICU) outcomes has not been well evaluated in a mixed critical care population in the South African (SA) context.

Objective: To evaluate the ability of BNP to predict ICU mortality in a heterogeneous critical care population in SA.

Methods: This was a retrospective observational study of 100 patients admitted to a multidisciplinary, closed, intensivist-run ICU in a tertiary academic hospital serving KwaZulu-Natal Province (1 January 2020 - 31 July 2022). Initial BNP was evaluated as a predictor of ICU mortality using univariate and multivariable analyses.

Results: There was a statistically significant difference in BNP between survivors and non-survivors in the cohort of patients without heart failure. The median initial BNP in the non-heart failure cohort was 411 (interquartile range (IQR) 116 - 848) ng/L in non-survivors, and 150 (44 - 356) ng/L in survivors (p=0.028). The optimal cut-off for BNP was determined as 366 ng/L. A BNP ≥366 ng/L was an independent predictor of ICU outcome.

Conclusion: This study highlights the potential utility of BNP as a predictor of ICU mortality in a heterogeneous ICU population, with the greatest utility in patients without heart failure. Further studies are required to confirm this finding.