SAJCC Vol 33, No 2 (2017)

SAJCC SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE

November 2017 Vol. 33 No. 2 • Antimicrobial usage in Trinidad, West Indies • Role of the ICU nurse in antimicrobial stewardship • Nurses᾽ knowledge about and attitudes toward organ donation in SA • Care practices of emergency nurses in SA • Abstracts of the CCSSA 2017 Congress

THE OFFICIAL JOURNAL OF THE CRITICAL CARE SOCIETY OF SOUTHERN AFRICA

SAJCC SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE

The Official Journal of the Critical Care Society of Southern Africa November 2017 Vol. 33 No. 2

CONTENTS EDITORIAL

EDITOR W L Michell FFA (Crit Care) University of Cape Town

DEPUTY EDITOR B Morrow BSc (Physio), PhD University of Cape Town

NURSING SCIENCE EDITOR P Brysiewicz RN, PhD University of KwaZulu-Natal

ASSOCIATE EDITORS A Argent FCPaeds (Cert Crit Care), MD University of Cape Town

P D Gopalan FCA (Crit Care) University of KwaZulu-Natal

L Hill RD, PhD CriticalPoint Critical Care Nutrition Consultancy

I A Joubert FCA (Crit Care) University of Cape Town

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Antibiotic stewardship – it starts with you!

M Miller

R Mathiva FCPaeds (Crit Care)

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Organ donation in South Africa – a call to action D Thomson

University of the Witwatersrand

ARTICLES

F Paruk FCOG (SA) (Cert Crit Care), PhD

University of the Witwatersrand

M Mer FCP (Pulm) (Cert Crit Care) S Mokgokong MMed (Neurosurg), DSc University of Pretoria

Spectrum of microbial growth and antimicrobial usage in an intensive care unit of a tertiary-care hospital in Trinidad, West Indies S Bidaisee, S Hariharan, D Chen

University of Pretoria

Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa J Rout, P Brysiewicz

University of the Witwatersrand

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Nurses’ knowledge about and attitudes toward organ donation in state and private hospitals in Johannesburg, South Africa K Crymble, H R Etheredge, J Fabian, P Gaylard

PUBLISHED BY Health and Medical Publishing Group (HMPG), a subsidiary of the South African Medical Association

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Patient- and family-centred care practices of emergency nurses in emergency departments in the Durban area, KwaZulu-Natal, South Africa J P B Almaze, J de Beer

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Abstracts of scientific presentations at the 2017 Annual National Conference of the Critical Care Society of Southern Africa

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ABSTRACTS

LIST OF REVIEWERS, 2017

H Perrie RN, MSc University of the Witwatersrand

G Richards FCP(SA), PhD J Scribante RN, MSc University of the Witwatersrand

HMPG CEO AND PUBLISHER Hannah Kikaya CONSULTING EDITOR J P de V van Niekerk EXECUTIVE EDITOR Bridget Farham MANAGING EDITORS Naadia van der Bergh Claudia Naidu

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All letters and articles for publication must be submitted online at www.sajcc.org.za. Tel: 021 532 1281.

E-mail: publishing@hmpg.co.za Critical Care Society of Southern Africa Contact details: Alison Shaw (Royal House), CCSSA Secretariat, Tel: (031) 831 6416, Email: secretariat@criticalcare.org.za, Website: www.criticalcare.org.za The views and opinions expressed in the SA Journal of Critical Care are those of the authors and do not necessarily reflect the views of the editors of the journal or the Critical Care Society of Southern Africa.

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

EDITORIAL

Antibiotic stewardship – it starts with you!

‘The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin resistant organism.’

Sir Alexander Fleming, 1945 This edition of the SAJCC contains two publications on issues surrounding the effects of inappropriate use of antibiotics, but also the benefits of having an antibiotic stewardship programme in an intensive care unit (ICU).

The first paper by Bidaisee et al.[1] describes the patterns of resistance seen in a tertiary hospital ICU where there is a distinct lack of any antimicrobial stewardship initiatives and rational prescribing of antibiotics. This study revealed a high level of resistance among the pathogens seen in hospital acquired infections and a high mortality, which may be attributable to a number of factors. Studies have shown that mortality is significantly higher in patients infected with resistant organisms when compared with more susceptible organisms of the same species.[2] The reasons for this may be multiple, but factors include underlying comorbidities, inappropriate initial therapy, suboptimal dosing of antibiotics in critical illness and selection of resistance by inappropriate use of antibiotics.[3] Antibiotic stewardship is a strategy to preserve the life-saving power of antibiotics. Unfortunately, we have reached the end of the ‘golden age’ of antibiotics where we are faced with pan-drug resistance and no new antibiotics on the horizon for the foreseeable future.[4] Antibiotic stewardship is a multidisciplinary initiative aimed at optimal use of antibiotics focusing on timing, dose, duration and de-escalation of antimicrobial therapy. The programme involves role players from all disciplines, including clinical pharmacists, nursing, infection control, microbiology and the clinicians involved in the care of the patient. A recent study has shown a reduction in the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection.[5] The systematic review and meta-analysis showed that antibiotic stewardship programmes (ABS) were more effective when implemented along with infection control measures, especially hand hygiene interventions, than when implemented on there own. This was the first evidence to promote the implementation of an antibiotic stewardship programme by stakeholders and policymakers to reduce the burden of infections from antibiotic-resistant bacteria.

The second publication by Rout and Brysiewicz[6] in this edition of the SAJCC, describes the integral role that the ICU nurse practitioner plays as part of the antibiotic stewardship team. This qualitative research found the ICU nurse to be an essential cog in the wheel that ensures the success of an antibiotic stewardship programme.

Undoubtedly, any antibiotic stewardship programme is reliant on multidisciplinary input to ensure its success. This was shown in a study looking at the role of a clinical pharmacist in driving antibiotic stewardship in a group of private hospitals across South Africa (SA).[7] This study was particularly relevant to the South African setting where infectious diseases specialists are not available at every hospital. The results from this implementation study showed that antibiotic stewardship initiatives can be driven by any member of the team provided the programme is sustainable and is supported by policymakers and stakeholders.

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Daily defined doses per 1 000 patient days (DDDs/1 000 pt days) is the metric used for most ABS programmes to track and benchmark institutions in terms of success or failure of an ABS. This is easy to monitor and can identify problem areas early. The introduction of a dedicated antibiotic prescription chart and antibiotic stewardship ward rounds can reduce antibiotic consumption and pharmacy cost, particularly in resource limited environments.[8] However, the acid test should be whether resistance patterns change as a result of ABS, since the ultimate goal of any ABS programme is to preserve the lifesustaining power of antibiotics. The Empiric Coverage Index is a novel index proposed to evaluate the local impact of antibiotic resistance on empirical coverage.[9] So, the burning question that needs an answer is: What are the barriers to implementation of an ABS programme in your institution?

This question was the focus of an Australian study that revealed interesting results after in-depth interviews were conducted with both doctors and nurses. Firstly, clinical ownership of the patient’s condition is perceived to be challenged by ABS processes. Traditional hierarchies and etiquette are in conflict with ABS processes. Nurses are perceived to lack the knowledge and training to fulfill their role in ABS processes. Lastly, ABS teams challenge interspeciality and interprofessional relationships and this undermines optimal use of antibiotics.[10] Thus, the success of any ABS programme will require some behaviour change among clinicians to ensure its sustainability.

Finally, the issue of governance of antibiotic prescription has been spearheaded by the World Health Organization on a global level. In 2016, for only the fourth time in history, a health topic took centre-stage at a United Nations (UN) General Assembly high-level meeting, with a focused day-long meeting on antibiotic resistance. The involvement of the UN underlines the significance of this threat to public health and progress towards the 2030 Sustainable Development Goals.[11] At the local government level in SA, the Department of Health has thrown its support behind a National Strategic Framework tackling antimicrobial resistance. This ministerial advisory committee, led by the Director General for Health, has recently published guidelines on the implementation of the antimicrobial strategy in SA, the so-called ‘One Health Approach’. Apart from outlining the ABS processes, this document calls for an integrative effort from multiple disciplines, including government sectors and partners working locally, nationally, and globally to attain optimal health for people, animals, and the environment.[12] With veterinary medicine and agriculture coming on board to support the fight against antibiotic resistance, it begs the question to healthcare workers: Why aren’t you?

Malcolm Miller Department of Anaesthesia and Perioperative Medicine, Division of Critical Care, Groote Schuur Hospital, University of Cape Town, South Africa S Afr J Crit Care 2017;33(2):34-35. DOI:10.7196/ SAJCC.2017.v33i2.351

EDITORIAL

1. Bidaisee S, Harihara S, Chen D. Spectrum of microbial growth and antimicrobial usage in an intensive care unit of a tertiary care hospital in Trinidad, West Indies. S Afr J Crit Care 2017;33(2):39-44. https//doi.org/10.7196/SAJCC.2017.v33i2.284 2. Xu L, Sun X, Ma X. Systematic review and meta-analysis of mortality of patients infected with carbapenem-resistant Klebsiella pneumoniae. Ann Clin Microbiol Antimicrob 2017;16(1):18. https://doi.org/10.1186/s12941-017-0191-3 3. Barbier F, Lisboa T, Nseir S. Understanding why resistant bacteria are associated with higher mortality in ICU patients. Intensive Care Med 2016;42(12):2066-2069. https://doi.org/10.1007/ s00134-015-4138-x 4. Gould K. Antibiotics: From prehistory to the present day. J Antimicrob Chemother 2016;71(3):572575. https://doi.org/10.1093/jac/dkv484 5. Rout J, Brysiewicz P. Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa. S Afr J Crit Care 2017;33(2):46-50. https//doi. org/10.7196/SAJCC.2017.v33i2.331 6. Baur D, Gladstone BP, Burkert F, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: A systematic review and meta-analysis. Lancet Infect Dis 2017;17(9):990-1001. https://doi. org/10.1016/s1473-3099(17)30325-0

7. Brink AJ, Messina AP, Feldman C, et al. Antimicrobial stewardship across 47 South African hospitals: An implementation study. Lancet Infect Dis 2016;16(9):1017-1025. https://doi. org/10.1016/s1473-3099(16)30012-3 8. Boyles TH, Whitelaw A, Bamford C, et al. Antibiotic stewardship ward rounds and a dedicated prescription chart reduce antibiotic consumption and pharmacy costs without affecting inpatient mortality or re-admission rates. PLoS One 2013;8(12):e79747. https://doi.org/10.1371/journal. pone.0079747 9. Hughes JS, Hurford A, Finley RL, Patrick DM, Wu J, Morris AM. How to measure the impacts of antibiotic resistance and antibiotic development on empiric therapy: New composite indices. BMJ 2016;6(12):e012040. https://doi.org/10.1136/bmjopen-2016-012040 10. Broom J, Broom A, Kirby E, Gibson AF, Post JJ. How do hospital respiratory clinicians perceive antimicrobial stewardship (AMS)? A qualitative study highlighting barriers to AMS in respiratory medicine. J Hosp Infect 2017;96(4):316-322. https://doi.org/10.1016/j.jhin.2017.05.001 11. Jasovsky D, Littmann J, Zorzet A, Cars O. Antimicrobial resistance – a threat to the world's sustainable development. Ups J Med Sci 2016;121(3):159-164. https://doi.org/10.1016/j.jhin.2017.05.001 12. National Department of Health. Guidelines on implementation of the antimicrobial strategy in South Africa: One Health approach and governance. Pretoria: NDoH, 2017.

CRITICAL CARE SOCIETY OF SOUTHERN AFRICA

T

he Critical Care Society of Southern Africa (CCSSA) is a not-for-profit organisation dedicated to improving the care of patients with life-threatening illness or injury.

It does so through supporting its members in research and educational initiatives and related interventions.

Its members include doctors, nurses and allied healthcare professionals, e.g. physiotherapists, dieticians and technologists, who work in the field of Critical Care Medicine.

Dedicated to quality care for the critically ill.

Alison Shaw - Royal House CCSSA secretariat

Mobile: +27 (0)82 553 8201 Fax: +27 (0)86 617 9423 Email: secretariat@criticalcare.org.za www.criticalcare.org.za

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

EDITORIAL

Organ donation in South Africa – a call to action In this issue of the SAJCC, Crymble et al.[1] correctly point out that there is a desperate need for organ donors in South Africa (SA). Their article highlights the integral role of nurses in the organ donation process,[2] and elegantly shows that nurses would welcome a greater role, while at the same time noting that expanded education efforts are desperately needed.

Despite our place in history for performing the first heart transplant,[3] SA organ donation rates do not compare well with other countries. Our deceased donor rate is <3 per million population. Spain is the world leader in deceased organ donation, with a rate approaching 40 per million population and Brazil achieves a rate of 14 per million population.[4] Many people see living-related donation as the way forward, yet living-related donation is only an option for certain organ transplants.

The majority of patients in need of an organ do not have a suitable living donor. Living donation also exposes donors to a degree of risk which deceased donors by definition do not have, since they are always certified legally dead through a rigorous testing process. Under SA law, certification of brain death is required to be performed by two doctors, of whom one is required to have >5 years of experience and both should be completely independent of the transplant team.[5] The reasons for SA’s low deceased donation rate are multiple. The lack of awareness and knowledge among both the public and medical professionals about brain death and organ donation needs to be addressed.[6] Free, open-access online educational resources, such as the University of Cape Town’s course ‘Organ Donation: From Death to Life’, have been developed to improve training and awareness about brain death and organ donation.[7] The SA government’s healthcare policy, which is rightly focused on primary healthcare interventions as a cost-effective strategy to improve the health of the population,[8] should not neglect transplantation.

Although it is not prioritised as a major health need, transplantation activity is a reflection of the whole healthcare system. One can only be assessed as a potential organ donor when all treatment options have been exhausted and the clinical team has left no stone unturned. The family can only be approached for consent for donation when they have been adequately counselled about the clinical situation. If this is not done well, consent will not be given and without consent there can be no organ donation. As such, organ donation rates can and should be used as a measurable healthcare outcome.

In SA, the consent rate for deceased organ donation at Groote Schuur Hospital for 2017 was 18% at the time of publication of this editorial, in other words 82% of families opt not to support organ donation. Even in countries where consent is presumed, the family is always counselled.

Spain has a 16% refusal rate based on family objections. It is important to note that signing onto the organ donor registry in SA (which only 200 000 of 53 million people have done) does not constitute consent and the family will always be approached to provide this. Evidence supports that consent for organ donation should be obtained by specially trained individuals, where available, and not the treating clinical team, with the request for consent made at an appropriate moment.[9] Presumed consent is often touted as the reason for Spain being so successful. However, it was only 10 years after the law was put in place that a national body was formed with oversight of organ donation, after which the system improved. Together with adequate access to beds in the intensive care unit (ICU), the availability of transplant coordinators in each ICU, and continual quality assurance and education activities,

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the Spanish model for transplantation is now a role model for other countries wanting to improve organ donation rates.[10] Cultural reasons are often blamed for low donation rates, yet there is no society, religion or culture that does not champion helping our fellow man. ‘Ubuntu’ is a word that embodies all that organ donation represents. There is a perception that religions such as Judaism and Islam are opposed to organ donation; however, religious scholars of both these religions have come out in support of organ donation.[11,12] Culture is not static and evolves over time; therefore it is essential that we as healthcare professionals engage with our SA communities to allow organ donation to become the norm. The most effective slogan is ‘If you needed an organ, would you accept one?’.[13] None of the major cultures or religions forbid receiving an organ.

Brain death is a relatively rare event. Mechanical ventilation must have been instituted and the condition progressed to one where recovery is impossible. Only 1% of all deaths are able to be considered for possible organ donation.[14] For this reason, every opportunity for organ donation needs to be explored when appropriate – this does not always happen.

A UK review of potential organ donors in 2011/2012 showed that 26% of patients who were potentially brain dead as per their hospital notes never proceeded to formal brain death testing, and of those that were certified, 7% of families were not approached for consent.[15] There is no mandated requirement for discussion of a potential donor with a transplant team in SA, nor is there any system in place to audit the standard of our end-of-life care discussions to ensure that all families are given the opportunity to support organ donation. Crymble et al.[1] have illustrated a possible intervention to improve our organ donation system by empowering nurses, who deal intimately with the family during the dying process and beyond, with a role in the referral of patients for organ donation.

Such efforts need to be made on a national level across both public and private healthcare institutions. Pioneering efforts in SA in HIV-toHIV transplantation,[16] donation after circulatory death, and splitting donor livers[17] are all still limited by a lack of deceased organ donors.

Ultimately, organ donation always comes down to a treating clinical team discussing a potential donor with the transplant team and a family deciding to support organ donation.

David Thomson Critical Care Specialist and Transplant Surgeon, Department of Critical Care and Transplant Unit, Groote Schuur Hospital, University of Cape Town, South Africa S Afr J Crit Care 2017;33(2):36-37. DOI:10.7196/SAJCC.2017.v33i2.352

1. Crymble K, Etheredge HR, Fabian J, Gaylard P. Nurses’ knowledge about and attitude towards organ donation in state and private hospitals in Johannesburg, South Africa – 2015 to 2016. S Afr J Crit Care 2017;33(2):52-57. https://doi.org/10.7196/SAJCC.2017.v33i2.322 2. Domínguez‐Gil B, Delmonico FL, Shaheen FA, et al. The critical pathway for deceased donation: Reportable uniformity in the approach to deceased donation. Transplant Int 2011;24(4):373-378. https://doi.org/10.1111/j.1432-2277.2011.01243.x 3. Barnard CN. Human cardiac transplant: An interim report of a successful operation performed at Groote Schuur Hospital, Cape Town. S Afr Med J 1967;41(48):1271-1274.

4. Irodat. International Registry in Organ Donation and Transplantation 2015 http://www.irodat. org/img/database/pdf/NEWSLETTER2016_SecondEdition.pdf (accessed 15 September 2017).

EDITORIAL

5. McQuoid-Mason D. Human tissue and organ transplant provisions: Chapter 8 of the National Health Act and its regulations,in effect from March 2012 – what doctors must know. S Afr Med J 2012;102(9):730-732. https://doi.org/10.7196/samj.6047 6. Sobnach S, Wiese KR, Tselanyane ME, Borkum M, Kahn D, Segobin R. Medical students' knowledge about brain death: A South African contribution. Transplant Proc 2016;48(6):19041906. https://doi.org/10.1016/j.transproceed.2016.04.010 7. University of Cape Town. Organ Donation: From death to life 2017. https://www.coursera.org/ learn/organ-donation (accessed 15 September 2017).

8. Mayosi BM, Benatar SR. Health and health care in South Africa – 20 years after Mandela. N Engl J Med 2014;371(14):1344-1353. https://doi.org/10.1056/nejmsr1405012 9. Hulme W, Allen J, Manara AR, Murphy PG, Gardiner D, Poppitt E. Factors influencing the family consent rate for organ donation in the UK. Anaesthesia 2016;71(9):1053-1063. https://doi. org/10.1111/anae.13535 10. Rodríguez-Arias D, Wright L, Paredes D. Success factors and ethical challenges of the Spanish model of organ donation. Lancet 2010;376(9746):1109-1112. https://doi.org/10.1016/s01406736(10)61342-6

11. Lavee J, Ashkenazi T, Stoler A, Cohen J, Beyar R. Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law. Am J Transplant 2013;13(3):780-785. https://doi.org/10.1111/ajt.12001 12. Robson NZMH, Razack AH, Dublin N. Organ transplants: Ethical, social, and religious issues in a multicultural society. Asia Pacific J Pub Health 2010;22(3):271-278. https://doi. org/10.1177/1010539509357446 13. Team BI. Applying behavioural insights to organ donation: Preliminary results from a randomised controlled trial. London: Cabinet Office; 2013.

14. DonateLife. Australian Donation and Transplantation Activity Report 2016 - 2017 http://www. donatelife.gov.au/sites/default/files/Australian Donation and Transplantation Activity Report 2016.pdf (accessed 15 September 2017).

15. NHS. Potential Donor Audit 2011 – 2012. https://nhsbtdbe.blob.core.windows.net/umbracoassets-corp/3180/pda_report_1112.pdf (accessed 15 September 2017).

16. Muller E, Barday Z, Mendelson M, Kahn D. HIV-positive-to-HIV-positive kidney transplantation – results at 3 to 5 years. N Eng J Med 2015;372(7):613-620. https://doi.org/10.1056/nejmoa1408896 17. Loveland J, Britz R, Joseph C, et al. Paediatric liver transplantation in Johannesburg revisited: 59 transplants and challenges met. S Afr Med J 2014;104(11):799-802. https://doi.org/10.7196/samj.8627

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Spectrum of microbial growth and antimicrobial usage in an intensive-care unit of a tertiary-care hospital in Trinidad, West Indies S Bidaisee, MBBS, DM; S Hariharan, MBBS, MD, PhD, FCCM; D Chen, MBBS, FRCA, MBA Anaesthesia and Intensive Care Unit, Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago Corresponding author: S Hariharan (uwi.hariharan@gmail.com)

Background. Intensive-care units (ICUs) are a source of multidrug-resistant organisms, owing to the indiscriminate usage of broad-spectrum antimicrobial drugs. In such settings, one must be aware of the spectrum of microbes and pattern of antibiotic usage.

Objectives. To evaluate the spectrum, susceptibility and resistance patterns of microbes found in ICU patients in a tertiary-care teaching hospital in Trinidad, and to quantify antimicrobial usage.

Methods. All adult patients (â&#x2030;Ľ15 years of age) admitted to the ICU for â&#x2030;Ľ48 h who developed nosocomial infections conforming to the Centers for Disease Control and Prevention criteria were included. Demographic data and clinical data, including specimens sent, isolates grown, antimicrobial sensitivity and resistance patterns, the usage of antimicrobials and patient outcomes, were recorded. Variables such as age, admission white blood cell count, duration of first antibiotic used, length of ICU stay, length of hospital stay, organ support and total comorbidities were analysed. Antimicrobial usage was quantified as the defined daily dosage per 1 000 patient-days.

Results. A total of 153 patients with 287 microbiological specimens were studied. The mean patient age was 48.4 years, and the mean ICU length of stay was 7.9 days. The most common admitting diagnoses were sepsis and multiple trauma. Staphylococcus aureus was the most common isolate from blood and central venous lines, and Pseudomonas aeruginosa from tracheal aspirates and wound swabs. Non-survivors had significantly higher age, leucocyte count and organ support requirements, and shorter lengths of stay. Cefuroxime was the most-used antimicrobial in the unit.

Conclusion. The usage pattern of antimicrobials did not correlate with susceptibility in most instances. There is a need to improve antimicrobial usage by implementing antimicrobial-stewardship programmes to establish an antimicrobial protocol and guidelines for usage in the ICU. S Afr J Crit Care 2017;33(1):39-44. DOI:10.7196/SAJCC.2017.v33i2.284

Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality in patients admitted to hospitals, and can lead to the spread of multidrug-resistant pathogens.[1] HAIs, by definition, may be either local and/or systemic, and result from the presence of an infectious agent or its toxin after 48 hours or more following a hospital admission, where the incubation period for the infection does not occur prior to hospital admission.[2] Over the years, patterns of microbial growth have seen many shifts, with emerging strains of potential drugresistant species, including methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas spp., Acinetobacter spp., Stenotrophomonas maltophilia and extended-spectrum beta-lactamase (ESBL)-producing Gram-negative organisms.[3] Inappropriate antimicrobial use and poor prescription practices have contributed to the development of multidrug-resistant organisms, rendering treatment of HAIs very difficult.[4] In addition, failure to comply with infection-control measures has a negative impact on hospital infection rates. Overcrowding and understaffing of wards also contribute to HAIs in the developing world. In low- and middleincome countries, the major factors contributing to serious nosocomial infections include lack of infrastructure, inconsistent surveillance, deficiency in trained personnel and infection-control programmes, and poverty-related factors.[5] Intensive-care patients are often the most susceptible to HAIs, due to the acute disease process, the presence of comorbidities, invasive devices,

exposure to various procedures and general immunocompromised status.[6] Therefore microbial surveillance and knowledge of resistance patterns to antimicrobials is critically important in any ICU setting.

A recent review showed that the implementation of continuous surveillance measures had a positive impact in controlling nosocomial infections.[7] Although surveillance programmes may be relatively expensive to implement, they are indeed cost-effective when compared to the expenditure of treating sepsis and the morbidity associated with it. Surveillance studies also play a vital part in the optimal management of infections in the intensive-care setting. Many developed countries have well-established surveillance teams and programmes that have accounted for lower infection rates when compared with less-developed countries.[8] In the USA, the Centers for Disease Control and Prevention (CDC) launched a subset division called the National Nosocomial Infections Surveillance System in 2004, and publish yearly benchmarks for the surveillance measures.[9] Such surveillance, along with intervention with prevention strategies, can decrease infection rates, morbidity and mortality, increasing patient safety.

The International Nosocomial Infection Control Consortium is an international collaborative body founded 10 years ago to promote infection control in the hospitals of countries with limited resources.[10] Thus far, it has been successful in increasing compliance rates for prevention strategies and has reduced the rates of HAI.[11] Trinidad and Tobago, unfortunately, has not been part of any such international programme.

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ARTICLE

Trinidad is one half of the twin island-nation of Trinidad and Tobago, with a population of approximately 1.3 million. The study hospital has 323 beds and the Intensive Care Unit (ICU) is a 10-bed mixed surgical and medical ICU. Admissions to the ICU are either directly from the emergency departments, the operating theatres, the High Dependency Unit or the general wards. The ICU team consists of an anaesthesia consultant, a registrar and two house officers. Although the aim is to have a nurse-to-patient ratio of 1:1, sometimes it happens to be 1:2. Four beds are in isolation rooms at the back of the ICU, and are designated for barrier nursing. An infection prevention and control officer visits the ICU on a daily basis.

these samples are placed in a Bactec 9240 (BD, USA) machine set at 35°C, where they are rotated. Once CO2 is detected by the machines, the bottles are removed and set for Gram stain and plating. The samples are plated on different media (blood, chocolate agar, MacConkey agar, anaerobic agar). Each medium is set at specific temperatures and left for 5 days to observe for growth, but they are monitored on a 24-hour basis.

Catheter tips (e.g. central venous catheter (CVC) tips) are rubbed onto the plates and streaked. Any wet material present on the catheter is also Gram stained. Urine samples obtained are either catheter or midstream samples, and either they are placed in a calibrated loop, or the appropriate quantity of urine is placed on a cystine lactose electrolyte deficient (CLED) plate to observe for growth. Tracheal aspirates are obtained from suctioning of a patient’s trachea with inline suction traps.

In the laboratory, they are plated on blood, or MacConkey or chocolate agar. The isolates are then tested for antimicrobial susceptibility using disks which have been incubated overnight, and the minimum inhibitory concentration is estimated in accordance with the standards of the Clinical and Laboratory Standards Institute.

Description of the study

Data analysis

Design and methods Study setting

Approval for this retrospective observational study was obtained from the Ethics Committee of the Faculty of Medical Sciences, University of the West Indies, with a waiver of individual informed patient consent.

Approval was also given by the medical chief of staff and the head microbiologist at the hospital.

All adult patients (≥15 years of age) admitted to the ICU between January 2008 and June 2010 for ≥48 h who developed nosocomial infections meeting the CDC criteria were included. Paediatric patients (i.e. <15 years) and patients admitted for <24 h were excluded.

Data collection

The demographic data on patient age and gender were collected. The clinical data collected included the following: • admission diagnosis • comorbidities • body temperature on admission • leukocyte count on admission • culture sites/specimens sent • isolates grown from specimens • sensitivity profiles and resistance patterns for each isolate • antimicrobial agent(s) used in each patient throughout the stay, including the dosage and duration of use • length of stay in ICU and hospital • types of organ support provided in the ICU – mechanical ventilation for the respiratory system, renal-replacement therapy for acute kidney injury, haemodynamic support (pharmacological/intra-aortic balloon pump, etc.) for the cardiovascular system.

• patient outcome – death or discharge from ICU.

Data were entered into Excel spreadsheets and Statistical Package for Social Sciences (SPSS) version 12 (IBM, USA) was used for statistical analyses. Statistical significance was fixed at p<0.05. Descriptive analyses were used for demographic data, and independent t-tests were used to compare the variables such as age, admission white blood cell count (WBC), duration of first antibiotic used, length of ICU stay, length of hospital stay, organ support and total comorbidities between patients who died in the ICU and those who survived.

Antimicrobial usage was represented as defined daily dosage (DDD) per 1 000 patient-days (using the following formula: DDD = DDD for specific agent (ATC/DDD Code) × 1 000 Total number of patient-days

Results

A total of 153 patients were included in the study, 79 (51.6%) of whom were female. The most common admitting diagnoses were multiple trauma and neurological disorders, and the most common comorbidities were diabetes mellitus, hypertension and ischaemic heart disease. Fig. 1 depicts the distribution of the diagnoses on admission to ICU. 35 30 No. of patients

Against this background, this study aimed to look at the microbial growth patterns, susceptibility profiles, resistance patterns and antimicrobial usage in the ICU at Eric Williams Medical Sciences Complex, a major tertiary-care teaching health facility in Trinidad.

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Fig. 1. Distribution of diagnoses on admission. (CNS = central nervous system; 70 CVS = cardiovascular system.)

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In this hospital, during the study period, the ICU did not have a surveillance policy. Specimens were taken from patients based on clinical requirements as ordered by the intensivists. In addition, the microbiology laboratory did not have an international policy manual to follow. The testing was done based on guidelines proposed by the consultant microbiologist, which were based on those recommended by the American Society for Microbiology. The study samples were processed as follows: As per hospital general procedure, blood-culture samples taken on wards are placed in either aerobic or anaerobic bottles. In the laboratory,

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The age of patients ranged from 16 to 90 years. The mean (standard deviation (SD)) age of patients was 48.4 (18.7) years (range 16 - 90) and the mean (SD) WBC on admission was 12.9 (5.9) (range 4.2 - 40.9). The mean (SD) length of ICU stay was 7.9 (5.9) (range 2 - 33) days, while the mean (SD) overall length of hospital stay was 15.3 (9.7) (range 2 - 65) days.

The comparison between patients who survived their ICU stay and those who died is shown in Table 1. The length of ICU stay and duration of first antibiotic use did not show a statistically significant difference between the two groups. With respect to age, the survivors were younger than those who died (p=0.01). The non-survivors had a higher WBC count on admission when compared with those who survived (p=0.02). As expected, the patients who had a higher number of comorbidities and required more organ support had a higher mortality (p<0.001).

Of all the patients, only two did not require organ support, and were admitted for close monitoring of vital signs. The majority (62.7%) of patients received support for one organ in the form of mechanical ventilation and 33.3% received support for two organs. The most common (96.7%) organ system supported was the respiratory system.

Of these, 3 patients (1.9%) required non-invasive positive-pressure ventilation, while the remainder required invasive ventilation. Inotropic support was required in 52 patients (33.9%), while 3 patients (1.9%) needed renal replacement therapy (RRT). While 107 patients (69.9%) were discharged from the ICU, 46 (30.1%) died.

In total, 88 patients had at least one isolate in one of the specimens sent to the microbiology laboratory, meaning that the prevalence rate of nosocomial infections in this ICU was 57.5%. The total number of specimen samples sent for microbiological analysis during the study was 282. The various specimens included blood, tracheal aspirates, urine, CVC tips, wound swabs, urinary catheter tips and pleural fluid. Wound

swabs had the highest prevalence of microbial growth (95%), followed by tracheal aspirates (78%). Blood was the most common sample site to be cultured, accounting for 105 specimens (36.6%).

The isolates grown from the different specimens are shown in Table 2.

In general, Pseudomonas aeruginosa and Enterobacter spp. were reported in all the various sites and specimens sampled for microbiological analyses, while Staphylococcus aureus was reported in all except urine.

P. aeruginosa was predominantly sensitive to gentamicin (63.1%), as well as to ciprofloxacin (60.1%). It showed 37% sensitivity to piperacillin/ tazobactam. Sensitivity to imipenem was 32% while meropenem was at 13%. It was least sensitive to ceftazidime (8%). Fig. 2 shows the individual sensitivity and resistance pattern of this organism. Fig. 3 shows the sensitivity profile for Klebsiella, and of particular note is that 5% of these isolates were resistant to meropenem.

Fig. 4 shows the sensitivity-resistance pattern of S aureus. A total of 42% of these isolates were sensitive to oxacillin, amoxicillin/lavulanic acid and gentamicin.

S. epidermidis showed highest sensitivity to gentamicin, followed by levofloxacin. Sensitivity to cefuroxime was 19%, while that for cefotaxime was 3%. Resistance to gentamicin was at 19%, while that for piperacillin/tazobactam and imipenem was 6% each.

Enterobacter spp. showed 75% sensitivity to gentamicin. Sensitivity to ciprofloxacin was at 60% and piperacillin/tazobactam at 50%. Sensitivity to cefotaxime and ceftazidime were at 5% each. Resistance was highest for ciprofloxacin and lowest for gentamicin at 5%.

S. haemolyticus showed no resistance to the cephalosporins, gentamicin or vancomycin.

Methicillin-resistant S. aureus was sensitive to linezolid (71%), tigecycline (57%) and rifampin (43%). There was no vancomycinresistant specimen in this study.

Table 1. Comparison of patient variables between survivors and non-survivors Variable Age (years) Admission leukocyte count (×103/μL) Hospital length of stay (days) Organ support (n) Total comorbidities (n) Duration of first antibiotic (days)

Overall, mean (SD) 48.4 (18.7) 13.0 (5.9) 15.3 (9.7) 1.3 (0.5) 1.57 (0.8) 6.9 (3.9)

Survivors, mean (SD) 45.7 (18.3) 12.3 (4.9) 16.9 (9.8) 1.2 (0.5) 1.48 (0.8) 6.9 (3.6)

Non-survivors, mean (SD) 54.7 (18.4) 14.6 (7.4) 11.8 (8.7) 1.7 (0.6) 1.78 (0.8) 6.8 (4.6)

p-value* 0.01 0.02 0.002 <0.001 0.04 0.855

*Statistical significance by independent t-test.

Table 2. Isolates from various specimens Organisms identified Total isolates Sterile (no bacterial growth) Pseudomonas aeruginosa Staphylococcus aureus S. haemolyticus S. epidermidis Enterobacter spp.

Klebsiella MRSA Candida spp.

Other

Blood (N=105) 51 54 (51.6) 4 (7.8) 7 (13.7) 8 (15.6) 23 (45.1) 4 (7.8) 5 (9.8) -

Tracheal aspirate (N=94) 73 21 (22.3) 24 (32.8) 4 (5.5) 1 (1.3) 1 (1.3) 11 (15.1) 13 (16.7) 5 (6.8) 1 (1.3) 13 (17.8)†

Urine (N=43) 13 30 (69.8) 1 (7.7) 2 (15.4) 1 (7.7) 2 (15.4) 2 (15.4) 4 (30.8) -

CVC (N=20) 14 6 (30.0) 2 (14.3) 1 (7.1) 8 (57.1)* 1 (7.1) 1 (7.1) 1 (7.1)‡

Wound swabs (N=20) 19 1 (5.0) 8 (42.1) 2 (10.5) 1 (5.2) 2 (10.5) 3 (15.8) 3 (15.8)§

CVC = central venous catheter; MRSA = methicillin-resistant Staphylococcus aureus. *One isolate was MRSA. † S. maltophilia, S. pneumoniae, S. viridans, Moroxella, Acinetobacter. ‡ Serratia. § Serratia, Citrobacter, Acinetobacter.

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Fig. 4. Sensitivity-resistance patterns for Staphylococcus aureus.

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Table 3. Antimicrobial usage as DDD per 1 000 patient-days

%

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Fig. 3. Sensitivity-resistance patterns for Klebsiella.

Antimicrobial Cefuroxime Piperacillin/tazobactam Meropenem Ceftriaxone Metronidazole Levofloxacin Azithromycin Gentamicin Cefotaxime Vancomycin Augmentin Erythromycin Imipenem

ATC/DDD code J01DCO2 J01CR05 J01DHO2 J01DD04 J01XD01 J01MA12 J01FA10 J01GB03 J01DDO1 J01XA01 J01CR02 J01FA01 J01DH51

DDD 483.66 433.67 418.06 305.55 261.44 170.75 101.67 98.66 46.29 40.52 24.65 22.70 19.61

DDD = defined daily dosage; ATC = anatomical therapeutic chemical.

SAJCC November 2017, Vol. 33, No. 2 Sensitivity Resistance

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Acinetobacter showed high sensitivity to piperacillin/tazobactam, ceftazidime, imipenem and tobramycin, gentamicin and levofloxacin; 50 however, only 20% each of the isolates showed sensitivity to meropenem 45 and ceftazidime.

S. maltophilia was isolated in two blood specimens. On both 40 occasions it was sensitive to gentamicin (100%), but only once to 35 and levofloxacin (50% each). There was 100% resistance to amikacin tobramycin.

30 The antimicrobial usage during the study period is depicted in Table 3 as the 25 DDD per 1 000 patient-days, along with the respective anatomical therapeutic chemical (ATC) classification and DDD code. The most 20 common antibiotic prescribed in this study group was cefuroxime.

Piperacillin/tazobactam, meropenem and ceftriaxone were the second, 15 third and fourth most commonly used antimicrobials, respectively.

10 Antibiotic usage ranged from one agent to a maximum of four agents per patient throughout ICU stay, and the ranges of duration of antibiotic 5 use are shown in Table 4. Monotherapy was used in 51 patients (33.1%), 0 patients (37.3%) were given two antibiotics. Three antibiotics while 57

Table 4. Comparison of antibiotic usage Category 1st antibiotic (n=153) 2nd antibiotic (n=96) 3rd antibiotic (n=32) 4th antibiotic (n=8)

Duration, range (days) 1 - 21 1 - 39 1 - 14 2 - 10

Mean (SD), (days) 6.92 (3.9) 7.5 (5.1) 5.6 (3.0) 5.13 (2.4)

SD = standard deviation.

were used in 37 patients (24.7%), while 8 patients (5.2%) received the maximum of 4 antibiotics.

All patients admitted to the ICU received antibiotics, irrespective of their infective status. Since the antimicrobial choice was made by the clinicians (including the parent units as well as the intensivists) devoid of a standard protocol, it was difficult to quantitate the inappropriate use of antimicrobials. There were no correlations between the culture and

ARTICLE

sensitivity reports and the usage of antimicrobials in individual patients, and there was no evidence of de-escalation of antimicrobials in any patient during the study period.

Discussion

Surveillance of microbes and their resistance patterns is invaluable in infection control and prevention in hospital medicine. Data regarding microbial spectrum and antimicrobial usage in different settings also help to compare these factors in developed and developing countries.

The present study was able to achieve these objectives.

The demographics of the patients in the present study were similar to those in a study from the neighbouring island Barbados.[12] There was a significant relationship between increased WBC and mortality in this study. WBC has been shown to be a clinical marker of inflammation and infection, and is considered an independent predictor of all-cause mortality in a previous report.[13] Increased length of ICU stay is generally associated with increased infection rates, contributing to higher mortality risk and increased cost of illness.[14,15] This study did not, however, show a significant difference in this regard. Overall, the length of ICU stay of patients in the present study was comparable to that of previous reports originating from Barbados and China.[12,16] Blood was the most frequently sent specimen for bacteriological culture in the present study. This differs from the Barbados study, where tracheal aspirates were the most common specimens.[12] Unlike in the Barbados research, in the present study not all patients were routinely sampled for microbiological cultures on admission, and many patients did not have such investigations during their whole ICU stay, unless signs of respiratory infection were evident, such as a change in the nature of tracheal secretions or radiological evidence suggestive of chest infection.

The majority of the tracheal aspirates yielded Gram-negative bacilli.

P. aeruginosa was one of the most common organisms, as was found by a study from the USA that reported Pseudomonas and Klebsiella as the most common organisms.[17] A report from Serbia also found Gram-negative organisms such as Pseudomonas and Acinetobacter to be the most common organisms in hospital-acquired pneumonias.[18] Studies from ICUs in Egypt and India found Klebsiella to be the most common organisms associated with ventilator-associated pneumonia (VAP).[19,20] The ICU where the present study was conducted does not formally adhere to any â&#x20AC;&#x2DC;ventilator care bundleâ&#x20AC;&#x2122;, and VAP rates might have been underestimated. However, endotracheal-tube colonisation

by Pseudomonas is a well-established phenomenon; a recent study investigating the microbiome of endotracheal tubes showed that the presence of Pseudomonas in the endotracheal tube showed a strong correlation with the poor prognosis of ICU patients.[21] A small percentage of patients also grew MRSA from their tracheal aspirates. Although it has been previously reported, the prevalence of MRSA in hospital-acquired pneumonia is still low.[22] S. maltophilia was grown in two specimens. This opportunistic pathogen primarily infects immunocompromised patients, is often multidrug resistant and is considered to be an independent risk factor for mortality.[23] In this study, both patients who had this infection died despite the organismâ&#x20AC;&#x2122;s susceptibility to quinolones and aminoglycosides.

The laboratory did not test the susceptibility of this organism for trimethoprim-sulfamethoxazole owing to lack of disks, and hence the susceptibility to this drug could not be ascertained.

Candida spp. and Gram-negative bacilli were the most prominently grown organism from the urine specimens, comparable with previous reports from different regions of the world.[16,24]

S. epidermidis was grown from more than 50% of the blood specimens.

This was the most common organism grown from CVC tips as well. It is often regarded as a commensal, unless its growth is associated with infective signs. The high rates may be due to contamination as a result of poor aseptic techniques when obtaining the samples.

Wound swabs from burns and surgical wounds cultured P. aeruginosa and MRSA as the most common organisms. In comparison, the most common isolates for wound swabs were Enterobacteriacae, P. aeruginosa and S. aureus in Barbados.[12] In the present study, P. aeruginosa showed high sensitivity to quinolones and aminoglycosides. Acinetobacter commonly demonstrates multi-antimicrobial-resistance patterns. In the present study, it showed high sensitivity to quinolones, aminoglycosides and imipenem.

Enterobacteriaceae showed high susceptibility to aminoglycosides and penicillins. However, resistance rates were highest for cephalosporins.

Enterobacteriaceae are well known to be resistant to third-generation cephalosporins.[25] The most common antimicrobial used overall in the ICU in this study was cefuroxime, followed by piperacillin/tazobactam and meropenem.

Imipenem use was significantly lower than meropenem.

Cefuroxime is often used for surgical prophylaxis, and is continued on the general wards as well. This was shown in a previous study in the same hospital, which revealed a high frequency of prescriptions for cephalosporins on the adult and paediatric medical and surgical wards.[26] In Barbados, the most commonly used antibiotic in their ICU was cefazolin, and this remained consistent during the 3-year period of the study.[12] A study in Brazil also showed similar antimicrobialusage patterns, with high cephalosporin prescription.[27] Such high cephalosporin usage may simply be explained by the fact that there is greater familiarity with the drug, and represents choice based on physician preference rather than being evidence based.

The fact that sensitivity to piperacillin/tazobactam is generally higher than sensitivity to cephalosporins may point towards an inappropriate use of cephalosporins in the study hospital. This is not a problem unique to this hospital; it has also been demonstrated in a tertiary hospital in Port of Spain, the capital city of Trinidad, where there was inappropriate third-generation cephalosporin use in medical, surgical, gynaecological and orthopaedic wards.[28] In our situation, such inappropriate antimicrobial use might also be explained by the absence of an antimicrobial protocol. Also, there is a lack of culture-directed antimicrobial usage, which has implications for the poor de-escalation practices. This results in prolonged, indiscriminate use of broad-spectrum antimicrobials. In addition, this hospital does not have a clinical microbiologist or pharmacist assigned to the ICU to help to guide prescription practices.

The present study had some limitations, the major one being the retrospective design. Missing samples and documentation are commonly encountered in chart reviews, which may impact the findings. In addition, there were some pitfalls unique to the setting, in the guidelines for obtaining samples. For example, tracheal aspirates were the only form of specimens for respiratory infections. Given their low specificity to differentiate colonisation from infection in this sample, bronchoalveolar lavage (BAL) specimens might have been much more informative; however, the ICU did not have a protocol of collecting BAL specimens. This could possibly have led to some overtreatment. Shortage of testing disks for many drugs was also another limitation.

Nevertheless, the present study was able to report the spectrum of microbial growth in the ICU of a tertiary hospital in Trinidad and

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Tobago. It also showed that the overall usage of antimicrobial agents was inappropriate in most instances. This clearly points to a need for improved regular surveillance, the institution of a multidisciplinary team to guide usage and also a need to establish an antimicrobial protocol and guidelines for this ICU.

Conclusion

Routine microbial surveillance, implementation of an antimicrobial protocol, developing guidelines to regulate the use of antimicrobials and input from infectious-disease specialists are necessary in every ICU setting to contain the development of multidrug-resistant organisms.

Acknowledgements. We acknowledge the contributions made by the staff at the Medical Records Department and the Microbiology Unit at Eric Williams Medical Sciences Complex for their assistance in data collection.

Author contributions. All authors contributed equally.

Funding. None.

Conflicts of interest. None.

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10. Rosenthal VD, Maki DG, Graves N. The International Nosocomial Infection Control Consortium: Goals and objectives, description of surveillance methods and operational activities. Am J Infect Control 2008;36(9):1-12. https://doi.org/10.1016/j.ajic.2008.06.003

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11. Rosenthal VD. Device associated nosocomial infection in limited resource countries: Findings of the International Nosocomial Infection Control Consortium. Am J Infect Control 2008;36(10):712. https://doi.org/10.1016/j.ajic.2008.10.009 12. Hariharan S, Nanduri SB, Moseley HSL, et al. Spectrum of microbes and antimicrobial resistance in a surgical intensive care unit, Barbados. Am J Infect Control 2003;31(5):280-287.

13. Tamakoshi K, Toyoshima H, Yatsuya H, et al. White blood cell count and risk of all-cause and cardiovascular mortality in nationwide sample of Japanese – results from the NIPPON DATA90.

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14. Chen YY, Chou YC, Chou P. Impact of nosocomial infection on cost of illness and length of stay in intensive care units. Infect Control Hosp Epidemiol 2005;26(3):281-287. https://doi. org/10.1086/502540 15. Jeganathan N, Yau S, Ahuja N, et al. The characteristics and impact of source of infection on sepsisrelated ICU outcomes. J Crit Care 2017;41:170-176. https://doi.org/10.1016/j.jcrc.2017.05.019 16. Ding JG, Sun QF, Li KC, et al. Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007. BMC Infect Dis 2009;9:115. https://doi. org/10.1186/1471-2443-9-115 17. Sader HS, Castanheira M, Flamm RK. Antimicrobial activity of ceftazidime-avibactam against Gram-negative bacteria isolated from patients hospitalized with pneumonia in US medical centers, 2011 to 2015. Antimicrob Agents Chemother 2017;61(4):e02083-16. https://doi. org/10.1128/AAC.02083-16 18. Djordjevic ZM, Folic MM, Jankovic SM. Distribution and antibiotic susceptibility of pathogens isolated from adults with hospital-acquired and ventilator-associated pneumonia in intensive care unit. J Infect Public Health 2017;S1876-0341(17)30028-X (e-pub. ahead of print). https://doi. org/10.1016/j.jiph.2016.11.016 19. Azzab MM, El-Sokkary RH, Tawfeek MM, Gebriel MG. Multidrug-resistant bacteria among patients with ventilator associated pneumonia in an emergency intensive care unit, Egypt. East Mediterr Health J 2017;22(12):894-903.

20. Bhadade R, Harde M, deSouza R, More A, Bharmal R. Emerging trends of nosocomial pneumonia in intensive care unit of a tertiary care public teaching hospital in Western India. Ann Afr Med 2017;16(3):107-113. https://doi.org/10.4103/aam.aam_7_17 21. Hotterbeekx A, Xavier BB, Bielen K, et al. The endotracheal tube microbiome associated with Pseudomonas aeruginosa or Staphylococcus epidermidis. Sci Rep 2016;6:36507. https://doi. org/10.1038/srep36507 22. Lollar DI, Rodil M, Herbert B, Burlew CC, Pieracci FM. Empiric methicillin resistant Staphylococcus aureus coverage in the early ventilator associated pneumonia window: If and when.

Surg Infect (Larchmt) 2016;17(2):187-190. https://doi.org/10.1089/sur.2014.159 23. Nseir S, Di Pompeo C, Brisson H, et al. Intensive care unit-acquired Stenotrophomonas maltophilia: Incidence, risk factors, and outcome Crit Care 2006;10:R143. http://doi.org/ 10.1186/ cc5063 24. Aubron C, Suzuki S, Glassford NJ, Garcia-Alvarez M, Howden BP, Bellomo R. The epidemiology of bacteriuria and candiduria in critically ill patients. Epidemiol Infect 2015;143(3):653-662. https://doi.org/10.1017/S0950268814000934 25. Oliveira MC, Oliveira CR, Gonçalves KV, Santos MS, Tardelli AC, Nobre VA Jr. Enterobacteriaceae resistant to third generation cephalosporins upon hospital admission: Risk factors and clinical outcomes. Braz J Infect Dis 2015;19(3):239-245. https://doi.org/10.1016/j. bjid.2015.01.006 26. Hariharan S, Pillai G, McIntosh D, et al. Prescribing patterns and utilization of antimicrobial drugs in a tertiary care teaching hospital of a Caribbean developing country. Fundam Clin Pharmacol 2009;23(5):609-615. https://doi.org/10.1111/j.1472-8206.2009.00713.x 27. Dos Santos EF, Lauria-Pires L. Patterns of antibacterials use in intensive care units. Rev Bras Ter Intensiva 2010;22(2):144-152. https://doi.org/10.1590/S0103-507X2010000200008 28. Pinto Pereira LM, Phillips M, Ramlal H, et al. Third generation cephalosporin use in a tertiary hospital in Port of Spain, Trinidad: Need for an antibiotic policy. BMC Infect Dis 2004;4:59. https://doi.org/10.1186/1471-2334-4-59

Accepted 28 August 2017.

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Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa J Rout, RN, MN; P Brysiewicz, PhD School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: J Rout (joanrout@worldonline.co.za)

Background. Care of the critically ill patient has become increasingly challenging, with a rising incidence of resistant pathogens resulting in the ineffectiveness of many antibiotics. Severe infection is associated with prolonged intensive care unit (ICU) length of stay, and increased morbidity, mortality, and healthcare costs. Antimicrobial stewardship (AMS) aims to prevent resistance and protect patients and the wider community by promoting correct antimicrobial use. The current AMS literature has failed to describe the role of the ICU nurse in this important initiative.

Objective. To explore the perceptions of AMS team members regarding the role of the ICU nurse in the AMS team.

Methods. Using a qualitative research approach, purposive sampling was used to identify participants in an ICU. Semi-structured interviews were conducted with 15 participants, including ICU shift-leader nurses, nursing management, surgeons, anaesthetists, physicians, microbiologists and pharmacists. Data were analysed and categorised using content analysis. The study was conducted in a general ICU in the private healthcare sector in KwaZulu-Natal, South Africa.

Results. Participants representing various disciplines of the AMS team felt that the role of the ICU nurse within the team was an important part of the AMS programme. Four categories that emerged from the data are discussed: organisational, advocacy, clinical and collaborative roles.

Conclusion. The role of the ICU nurse was found to be essential to the success of AMS in the ICU. These findings provide implications for practice, which, if recognised and supported by all healthcare stakeholders from ICU and hospital management, could improve AMS in this acute care area.

S Afr J Crit Care 2017;33(2):46-50. DOI:10.7196/SAJCC.2017.v33i2.331

Globally, antimicrobial resistance has become one of the most important issues facing critical care. Resistance to antibiotics is escalating owing to overuse of antibiotics in the community and in hospitals, with increasing use of broad-spectrum antibiotics and delayed de-escalation practices.[1] Decreasing availability of antimicrobial therapy to treat complicated infections is attributed to the growing ineffectiveness of these medications due to increasing resistance, and the move of the pharmaceutical industry away from research and development of these products.[2] Therefore, it is becoming more difficult to manage infections in the very ill patient, resulting in prolonged intensive care unit (ICU) stay and increased mortality.[3] Antimicrobial stewardship (AMS) has developed as a proactive healthcare initiative to reduce antibiotic-selective pressure by promoting appropriate use of antimicrobial therapy and effective infection control.

This is especially important in an ICU, which has the highest proportion of patients vulnerable to infection and uses the most antibiotics in the hospital setting.[4] Research into the prevalence of infection in private and public ICUs in South Africa (SA) found that, in the private ICU sector, an inappropriate antibiotic was prescribed in 60.8% of patients, duration of administering an antibiotic was inappropriate in 81.7% of patients, and de-escalation was used in only 19.7% of patients. The authors attributed these figures to poor prescribing practices in this sector.[5] Infection control has become a large part of nursing responsibilities in the ICU arena, but the nurse does not yet have clear responsibilities regarding antimicrobial therapy, and it appears that the role and skills required of the nurse in AMS have not been adequately explored.[6,7]

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Objective

The purpose of this qualitative study was to explore AMS team membersâ&#x20AC;&#x2122; perceptions of the role of the ICU nurse within the AMS team.

Methods

A qualitative research approach was chosen, as it allows in-depth examination of a subject and is open to the multiple realities of multidisciplinary participants.[8]

Setting

This study was conducted in the general adult 20-bed ICU/high-care unit in a 200-bed private hospital in KwaZulu-Natal, SA, where a new AMS programme was being implemented by nursing management.

Participants

After institutional ethical review and gate-keeper permission, purposive sampling identified 9 nursing and 8 non-nursing members of the ICU team most likely able to answer the research question; they were invited to participate.[8] Inclusion criteria for nursing participants were as follows: nurses registered with the SA Nursing Council; those involved in setting up the AMS programme; or ICU shift leaders conducting daily AMS rounds. Specialised ICU training was not a criterion. Non-nursing participants were from the disciplines of medicine, surgery, anaesthesiology, pharmacy and microbiology and were included if they prescribed antibiotics/antifungals to patients, dispensed this treatment or were consulted regarding laboratory findings in the ICU.

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Data collection process

After informed consent by participants and assurance of anonymity and confidentiality, data were collected during 3 weeks in August 2014.

Semi-structured interviews were held in a private room in the hospital and were chosen to allow flexibility in the interview process. Core questions were used as a basis to facilitate discussion of the topic.

These predetermined open-ended questions provided an initial focus of attention for both the researcher (JR) and the participants, and issues raised by the participants in the interviews allowed the researcher to explore a wide range of topics, further developing these in subsequent interviews. Participants were encouraged to talk frankly and were assured that no responses were viewed as being incorrect. A verbatim, typed transcript of the recorded interview was given to each participant to check for accuracy and to make additional comments if necessary.

Data analysis

Interview transcripts were subjected to content analysis to identify categories from the data, guided by the purpose of the study. A process of interpretation was carried out by familiarisation with the text, examining each participant’s contribution and paraphrasing and condensing the content of the text (Table 1) to determine codes and categories.[9]

Rigour

Academic rigour was to be met by the required qualitative criteria of trustworthiness, credibility, transferability, dependability and confirmability.[10] Credibility was assured by researcher familiarity with the culture of the study setting as an ICU nurse, request for participant honesty, review of transcript analysis by a more experienced researcher and returning transcript analysis to participants following initial analysis to validate the findings. Transferability was assured by providing a detailed context for the study and a comprehensive description of phenomena being studied. For dependability, a detailed methodology was described by the researchers. Confirmability was assured by record keeping and the use of multidisciplinary participant viewpoints to provide a coherent, deeper perspective.

Ethical approval

After approval by the Ethics Committee of the University of KwaZuluNatal (ref. no. BE281/14) and hospital management, participants were invited to take part in the study. Information was given to the participants prior to written consent, which emphasised the right

to decline participation in or withdraw from the study at any stage.

Permission was obtained to record the interviews. Participants were invited to choose pseudonyms to ensure anonymity and confidentiality.

Results

Fifteen participants from six different disciplines agreed to take part: 8 nurses and 7 non-nurses. Two potential participants declined to participate in the study – 1 nursing and 1 non-nursing. Two nursingmanagement participants described their experiences of starting the AMS programme. Six ICU nurse shift leaders discussed how they conducted daily AMS rounds and communicated with other members of the ICU team. Two surgeons, 2 physicians and 1 anaesthetist shared their perceptions of working with nurses during the daily routine of ward rounds and treatment changes. A microbiologist and pharmacist discussed their experiences of working with both nurses and prescribers.

Four categories emerged from the content analysis, i.e. organisational, advocacy, clinical and collaborative roles.

Organisational role

Nursing participants explained that the AMS programme in the ICU was a nursing initiative designed to monitor antibiotic/antifungal use in the unit. There was minimal knowledge or experience of how to set up or run this initiative. Of the 15 participants who took part in the study, only 2 of them – 1 nursing and 1 non-nursing – had previously been part of an AMS programme and only the non-nursing participant had gained experience in SA: ‘Initially there was absolutely no awareness of antibiotic stewardship among the registered nurses that started. And I think that this was maybe because they were all from different hospitals and maybe they didn't really know about … and it was also a new thing, I think … and so we had to explain to them what we're doing and get their buy in into it.’ (Nursing participant) Nursing participants described how daily shift-leader rounds were performed each morning in the ICU to monitor Best Care … Always!

(BCA) bundle compliance, documentation of antibiotic treatment, tracking of laboratory results, antibiograms and any changes in doctors’ instructions. BCA is an SA national campaign to reduce healthcareassociated infections and introduce AMS to the SA setting. Documentation of laboratory results, invasive ‘line days’ and duration of antimicrobial therapy was routinely carried out by the floor nurse allocated to care for

Table 1. Example of content analysis coding and categorisation Meaning units ‘Initially there was absolutely no awareness of antibiotic stewardship among the registered nurses.’ ‘… we had to explain to them what we’re doing and get their buy in into it.’

Condensations No awareness of antibiotic stewardship Explain to get buy-in Alerting doctors

‘Because the doctors can miss the results if we don’t draw it to their attention.

And that includes antibiotic days.’ ‘… and the other thing is washing hands. That is very, very important, to prevent Need for diligent cross infection between patients.’ practice ‘… we try to have a weekly meeting … It doesn’t always happen, but during that meeting we do a case discussion, so we will talk about that patient, the clinical picture of the patient, together with the laboratory results, what antibiotic the patient is on … .’

Discussing the condition of ICU patients

Codes Educating

Category Organisational role

Setting up

Organisational role

Responsibility

Advocacy role

Infection prevention and control Communication

Clinical role

Collaborative role

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a specific patient during a 12-hour shift. Nursing participants viewed the monitoring of line days as an important daily task and invasive lines were removed when no longer indicated. Participants explained: ‘What I expect of them is to do the daily rounds, preferably in the morning after the doctor rounds. Just what we normally do is we check your patient’s infection markers … if it was done that day. You write all your results in and then you also write the antibiotic. The name, the dose, the strength and how often it gets given … I want them to monitor all that.’ (Nursing participant) ‘Very important, they usually help me … with keeping the book. They will tell me how long the lines have been in. They will alert me on …

“Listen this CVP’s been in for two weeks and the wound site looks red … .” In other words, they would make sure I don’t overlook the things, especially with long-admitted patients.’ (Non-nursing participant)

Advocacy role

Nursing and non-nursing participants felt strongly that patients should be given the correct antimicrobial treatment for an infection and that the ICU nurse had a responsibility to promote the interests of the patient: ‘Talking on behalf of the patient … Making the initiative to actually do something for them … you know … for the patient. So, we’re acting on behalf of the patient, telling the doctor. Look … this is what bug the patient’s got and this is what antibiotic can be given.’ (Nursing participant) ‘The best thing about the intensive care nurse is that she has all the information in that file at that point … she has the culture results … she sees the doctor every day. She would know when the dose is given, when it was not given … the duration.’ (Non-nursing participant) De-escalation was raised as a key aspect of correct antimicrobial management. Nursing participants felt that an important part of their role was to monitor the duration of antimicrobial therapy and alert specialists to ‘antibiotic days’ to contribute to the de-escalation process.

Non-nursing participants agreed: ‘Because the doctors can miss the results if we don't draw it to their attention. And that includes antibiotic days. Because you will see patients on day 8, day 9, day 14, and that’s when we say to the doctor … “This antibiotic we’ve been doing it for 14 days” … and “Oh, maybe we need to look at stopping it, maybe we need to look at changing it” … .’ (Nursing participant) ‘So, the nurses’ function is to make sure that the correct antibiotic has been given and it has been correctly given. They can also monitor that this patient has been on it for 7 days and this patient has not improved and they can discuss with the doctor.’ (Non-nursing participant)

Clinical role

Nursing and non-nursing participants agreed that the nurses’ ongoing monitoring of the critically ill patient was essential to identify early signs of infection: ‘We monitor the patient’s temperature and specific bloods like the PCT, the white cells and the CRP and also what antibiotic and how many days they’ve been on that antibiotic … what dosage and what duration … .’ (Nursing participant) ‘Very important role … I mean the intensive care nurse is there, you know, all the time. They are monitoring the trends … they can pick up the little subtle things that happen in change of condition. We’re there twice a day for a short period of time. The ICU nurse is vital in the care of the patient … it’s a massive responsibility.’ (Non-nursing participant)

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Nursing and non-nursing participants agreed that infection control should be properly managed in the ICU to minimise healthcare-associated infections, cross-infection and environmental resistance: ‘… and the other thing is washing hands. That is very, very important, to prevent cross infection between patients.’ (Nursing participant) ‘Still universal precautions are very important … and they are the ones doing it. Fortunately, they work with one patient only, but I can imagine if you quickly have to do something for the patient next door, you actually need to unscrub, unglove, wash and go to the next one.

And that is important because that is how antibiotic resistance spreads as well.’ (Non-nursing participant)

Collaborative role

Nursing participants described daily ward rounds during which doctors reviewed antimicrobial treatment at the bedside of their patient and gave instructions to the floor nurse allocated to care for that patient for the day. The role of the ICU nurse in communicating information to doctors was identified by non-nursing participants as an important part of stewardship: ‘So, for communication they are important, for source control they are important, for making sure the actual antibiotic is given they are important … because, let’s be honest, they do the actual work.’ (Nonnursing participant) Nursing participants reported a hierarchical nursing structure in the ICU, with the floor nurse working closely with the shift nurse throughout the day. Frequent communication took place with regard to the condition of patients, infective markers and the need for antimicrobial therapy. Shift leaders would then discuss developments with the ICU unit manager who was in regular contact with the infection control co-ordinator: ‘The floor nurse, who is looking after the patient … she’s got to make sure that the records on her charts are up-to-date and that the lab records are in good nick in the file. So, it starts from the floor nurse.

Then it goes to the team leader on the floor. She does a round … on all the patients and she updates, you know, picks up … any problems … if there’s a problem with the patient. And then it goes to the manager of the unit.’ (Nursing participant) Nursing participants described contact with microbiologists during the weekly telecommunication AMS meetings: ‘… we try to have a weekly meeting … It doesn’t always happen, but during that meeting we do a case discussion, so we will talk about that patient, the clinical picture of the patient, together with the laboratory results, what antibiotic the patient is on … what other therapies involved with the patient. And we talk about infection control practices as well, like isolation of the patient and hand washing and so forth … .’ (Nursing participant)

Discussion

Findings showed that participants representing various disciplines of the AMS team felt that the role of the ICU nurse in the team was an essential part of the AMS programme. The value of the ICU nurse has been identified as: organising shift-leader AMS rounds and diligent record keeping for data surveillance; advocating for antimicrobial treatment that is in the best interests of the patient; administering antimicrobial therapy correctly, preventing healthcare-associated infections; and ongoing clinical monitoring of the ill patient for signs of infection and documenting; and communicating these findings to other members of the AMS team.

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Organisational role

At the time of the study, the AMS programme in the ICU had been in progress for 2 years. Nursing management started this soon after the study hospital had opened in response to a growing awareness of the need to manage ICU environments optimally, and provide safe care for patients.[4] Small community hospitals use antimicrobial therapy more frequently than large academic medical centres and are less likely to have AMS programmes in the acute-care setting.[11] The early detection of pathogens, appropriate use of antibiotics and reduction of healthcare-associated infections are essential in the care of the critically ill patient, and all ICUs should have AMS programmes that aim to ensure prompt, effective treatment.[12] All the nursing participants felt that it was an important qualitycontrol initiative, although this type of intervention was new to them.

Only two participants had previous experience of AMS. Nursing participants viewed the organisational role of the ICU nurse as setting up the AMS programme in the ICU according to the Centers for Disease Control and Prevention (CDC) guidelines, daily monitoring of patient records during shift-leader rounds to ensure BCA bundle compliance, documenting of antibiotic/antifungal treatment, tracking of laboratory results and antibiograms, and noting any changes in doctors’ instructions. Audits, compliance and feedback are important in an AMS programme,[13] and documentation from the shift-leaders’ rounds was also used for the collection of data by the hospital’s infection prevention and control nurse for long-term analysis of nursing care, antimicrobial usage, and resistance profiles in the ICU. Non-nursing participants identified management of laboratory results as the main organisational aspect of the nurse’s role in AMS.

Advocacy role

There is a growing awareness among health professionals of the enormity of the challenges that face healthcare in the 21st century. Nurses should be an important part of AMS, and monitoring of antibiotic/ antifungal use should be done by hospital pharmacists, microbiologists, doctors and nurses. Nursing and non-nursing participants felt strongly that patients should be administered the correct antimicrobial treatment for an infection and that they had a responsibility to promote the interests of the patient by reminding specialists of ‘antibiotic days’ to facilitate de-escalation. All participants interviewed showed a good understanding of AMS and that the objective is to promote the appropriate use of antimicrobial therapy, with the correct choice of antibiotic/ antifungal, the correct dose and the prompt use of antibiograms to direct de-escalation.[14]

Clinical role

An important part of AMS is to minimise bacterial resistance by implementing effective infection control practices[1] and monitoring infections, infective markers and invasive lines. Nursing and nonnursing participants perceived the ICU nurse’s clinical responsibilities as the monitoring of changes in the condition of the ill patient to identify early signs of infection, specimen collection, correct administration of antibiotics/antifungals, and adherence to infection control protocols by all ICU staff and visitors to minimise healthcare-associated infections, cross-infection, and environmental resistance. Stewardship monitoring was added to daily ICU shift rounds in this ICU, and BCA bundles were introduced to ensure evidence-based patient care.[6] AMS is promoted as the fifth pillar, or bundle, of the BCA campaign in SA.[15]

Collaborative role

Intercepting a verbal or written prescription, discussing it with the doctor and confirming that it is the correct drug based on microbiology results

contribute to patient safety.[16] Nursing and non-nursing participants thought that nurses working in an ICU in the private healthcare sector in SA have a very important role to play, as they are at the patients’ bedside 24 hours a day, whereas medical specialists are not able to be present in the ICU at all times. Nursing and non-nursing participants identified the collaborative role of the ICU nurse in AMS as conducting shiftleader stewardship rounds, participating in doctors’ bedside rounds and communicating telephonically with doctors. Microbiologists from a private laboratory were instrumental in providing guidance and support for the AMS programme and individually to doctors, and participated actively in the weekly telecommunication AMS meetings. The contact with microbiologists allowed very important analysis of patient care and of the treatment plan, and facilitated surveillance-data collection by the infection control nursing co-ordinator.[17]

Study limitations

The study findings are contextual, specific to the study hospital and have limited generalisability owing to non-random selection in a single ICU.

Conclusion

The nurse had a strong organisational role in this nurse-driven AMS programme, which was set up as a quality-improvement initiative in a new ‘clean’ hospital, with the aim of adhering to international AMS guidelines by promoting these principles among all stakeholders, and careful record keeping to assist with antimicrobial monitoring and pathogen surveillance. There was awareness of the advocacy role of the nurse in reminding prescribers of the duration of antimicrobial therapy, and alerting them to antibiograms. The clinical role of the nurse in monitoring infection and infection control was emphasised in this ICU. Nurse interaction with other members of the AMS team was seen as vital to effective communication.

Recommendations

A sound understanding of the principles and objectives of AMS is vital for ICU nurses to advocate for the process of de-escalation of antimicrobial therapy. ICU nurses should actively participate in AMS, according to World Health Organization and CDC guidelines. ICU nurses are advised to follow infection control bundle recommendations, such as those of the BCA initiative. Diligent monitoring of the critically ill patient is needed to identify early signs of infection, and ICU nurses should be able to effectively communicate changes in the patient’s condition to the relevant member of the healthcare team.

Acknowledgements. We wish to acknowledge Dr J de Beer for her assistance in conceptualising the study.

Author contributions. JR: collected the data; JR and PB: analysed the data, drafted the manuscript and approved it for submission.

Funding. None.

Conflicts of interest. None.

1. Mendelson M, Whitelaw A, Nicol M, et al. Wake up, South Africa! The antibiotic ‘horse’ has bolted. S Afr Med J 2012;102(7):607-608. https://doi.org/10.7196/SAMJ.5759 2. Gould I, Bal A. New antibiotic agents in the pipeline and how they can help overcome microbial resistance. Virulence 2013;4(2):185-191. https://doi.org/10.4161/viru.22507 3. Deege M, Paterson D. Reducing the development of antibiotic resistance in critical care units.

Curr Pharm Biotechnol 2011;12(12):2062-2069. https://doi.org/10.2174/138920111798808301 4. Kaki R, Elligsen M, Walker S, et al. Impact of antimicrobial stewardship in critical care: A systematic review. J Antimicrob Chemother 2011;66(6):1223-1230. https://doi.org/10.1093/jac/dkr137 5. Paruk F, Richards G, Scribante J, et al. Antibiotic prescription practices and their relationship to outcome in South African intensive care units: Findings of the Prevalence of Infection in South African Intensive Care Units (PISA) study. S Afr Med J 2012;102(7):613-616. https://doi.org/10.7196/SAMJ.5833

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6. Ziady L. Antibiotic stewardship: A nut without a definite shell to crack. Prof Nurs Today 2012;16(5):12-14.

7. Edwards R, Drumright L, Kiernan M, et al. Covering more territory to fight resistance: Considering nurses’ role in antimicrobial stewardship. J Infect Prevent 2011;12(1):6-19. https://doi. org/10.1177/1757177410389627 8. Erlingsson C, Brysiewicz P. Orientation among multiple truths: An introduction to qualitative research. Afr J Emerg Med 2013;3(2):92-99. https://doi.org/10.1016/j.afjem.2012.04.005 9. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs 2008;62(1):107-115. https:// doi.org/10.1111/j.1365-2648.2007.04569.x 10. Guba E. Criteria for assessing the trustworthiness of naturalistic inquiries. Educ Commun Technol 1981;29(2):75-91.

11. Storey D, Patel P, Nguyen A, et al. Implementation of an antimicrobial stewardship program on the medical-surgical service of a 100-bed community hospital. Antimicrob Resist Infect Control 2012;1(32):1-8. https://doi.org/10.1186/2047-2994-1-32 12. Kollef M, Micek S. Antimicrobial stewardship programs: Mandatory for all ICUs. Crit Care 2012;16(179):1-2. https://doi.org/10.1186/cc11853

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13. Du Toit B. The role of the infection control practitioner in antimicrobial stewardship. Mediclinic Nursing 2012:26-27.

14. Chunnilall D, Peer A, Naidoo I, et al. An evaluation of antibiotic prescribing patterns in adult intensive care units in a private hospital in KwaZulu-Natal. S Afr J Infect Dis 2015;30(1):17-22. https://doi.org/10.1080/23120053.2015.1103956 15. Kantor G, van den Bergh D, Brink A. Best Care, Always! S Afr J Epidemiol Infect 2011;26(1):3-5. https://doi.org/10.1080/10158782.2011.11441411 16. Dickson G, Flynn L. Nurses’ clinical reasoning: Processes and practices of medication safety. Qual Health Res 2012;22(1):3-16. https://doi.org/10.1111/j.1475-6773 17. Charani E, Cooke J, Alison A. Antibiotic stewardship programmes – what’s missing? J Antimicrob Chemother 2010;65(11):2275-2277. https://doi.org/10.1093/jac/dkq357

Accepted 28 August 2017.

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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Nurses’ knowledge about and attitudes toward organ donation in state and private hospitals in Johannesburg, South Africa K Crymble,1 Dip Nurs; H R Etheredge,1 PhD; J Fabian,1,2 MD; P Gaylard,3 PhD Wits Donald Gordon Medical Centre, Johannesburg, South Africa Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Data Management and Statistical Analysis (DMSA), Johannesburg, South Africa 1 2

Corresponding author: H R Etheredge (harriet.etheredge@mediclinic.co.za)

Background. Nurses are intricately involved in organ donation; however, the referral of donors appears to be declining in Johannesburg, South Africa (SA). This may be due to barriers in the referral process.

Objectives. The objectives of this study were to explore nurses’ knowledge of the organ donation process and to explore personal beliefs and attitudes around organ donation.

Methods. A quantitative, self-administered questionnaire was completed by nurses in Johannesburg, SA. Results. A total of 273 nurses participated, of whom most were female and <50 years old. The majority of participants (64.2%) reported positive attitudes, and 63.2% stated that their personal beliefs about organ donation did not influence the advice they gave to patients. However, only 36.8% felt confident referring potential donors and 35.8% felt that referral was within their scope of practice. Most participants (84.5%) felt that it was the doctor’s responsibility to refer donors, but 80.3% noted that they would refer donors themselves if there was a mandatory referral protocol. Only 61% of nurses were aware that there was access to a transplant procurement coordinator through their hospitals; however, there was uncertainty regarding the role of the coordinator.

Conclusion. There is an urgent need to clarify the role of nurses in the process of organ donor referral in SA. Although nurses felt positive about organ donation, they expressed uncertainties about referring potential donors. However, if a clear protocol for referral was introduced, the majority of nurses noted that they would willingly follow it. We advocate for the development and implementation of a nationally endorsed protocol for donor referral and for the training of nurses in organ donation in SA. S Afr J Crit Care 2017;33(2):52-57. DOI:10.7196/SAJCC.2017.v33i2.322

As is the case in the rest of the world, the supply of donor organs in South Africa (SA) falls far short of the need for organs. The need to increase solid organ donor rates has spurred a number of innovative transplant programmes such as splitting livers from deceased donors, living donor liver transplants from adult donors to paediatric recipients,[1] and HIVpositive donor to HIV-positive recipient kidney transplants.[2] Such initiatives have generally been driven by motivated academic transplant teams at the hospital level, while there has been little corresponding change in transplant legislation or protocol at the national level, even though protocols for organ donor referral have been incorporated into best practice guidelines internationally.[3] There have been significant advances in transplantation in SA with regard to surgical technique and immunosuppression therapy that have allowed this specialised field of medicine to evolve with outcomes that are internationally comparable in many centres;[4] however, this is not supported by a solid regulatory framework that involves good governance procedures, national guidelines and protocols for clinical practice. Previous research in SA suggests that this results in confusion about professional roles, challenging inter-professional interactions and loss of potential donors owing to ambiguities in the referral process.[5] This environment of regulatory uncertainty means that organ donation is viewed differently by different health professionals. Attitudes and opinions depend on the nature of their work, the sector in which

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they work and the extent to which it is encouraged in their place of work. Transplant procurement coordinators, who are tasked with ensuring organ procurement for all health sectors, are continually faced with the challenge of working in a cross-sector protocol vacuum where organ donation is often a source of uncertainty and moral distress.[5] As a transplant procurement coordinator who has been in the field for 18 years, the principal investigator (PI) of this study had anecdotally experienced substantial challenges to organ donor referral in the Johannesburg health sector. These challenges were particularly related to facilitating the buy-in of nurses to refer potential organ donors in both sectors. The rationale for this study was to further investigate these factors through a formal empirical research project so that evidencebased recommendations for change can be made.

The main aim of this study was to explore knowledge about and attitudes toward organ donation among nurses in Johannesburg, SA. The specific objectives were to explore nurses’ knowledge of the organ donation process and their attitudes toward organ donation.

Methods Sampling

Sampling was undertaken across state and private sector intensive care units (ICUs), casualty and high-care departments, as well as two transplant units in Johannesburg (one state and the other private).

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In total, 7 sites were sampled, including 3 state sites (Chris Hani Baragwanath Academic Hospital, Helen Joseph Hospital, Charlotte Maxeke Johannesburg Academic Hospital) and 4 private sites (Wits Donald Gordon Medical Centre, Sandton Mediclinic, Life Wilgeheuwel Hospital and Life Flora Clinic). Participants were considered eligible to participate if they were qualified nurses, >18 years of age and felt comfortable answering an English questionnaire.

The sampling strategy was specifically designed to obtain a fully representative sample of the two healthcare sectors in SA; the ratio of state to private sector nurses was 2:1. The purpose of this sampling strategy was two-fold: firstly, to account for the fact that the state sector services the healthcare needs of approximately two-thirds of South Africans, and hence it was important that this demographic was reflected in the sampling; secondly, this sampling ratio allowed for measuring knowledge, attitudes and perceptions of organ donation in the state sector in Johannesburg, where donor referrals are observed to be low in comparison with the SA private sector.

Data collection

Data were collected between July 2015 and March 2016, using a quantitative, structured, self-administered which was carefully designed, piloted and pre-tested prior to sampling. The questionnaire was anonymous and no identifying information was collected. Participation in the study was voluntary, and the study was fully explained to all potential participants by the PI before questionnaires were handed out.

Administration of the questionnaires took place during nurses’ working hours to ensure that both day and night shift nurses were included.

Sample size

Based on worst-case (for sample size) estimates of 50% (for any given question response), a 6% precision and the 95% confidence level, a sample size of 267 was required.[6] In total, 396 questionnaires were handed out.

Data analysis

Data were collected and managed using REDCap (Vanderbilt University, USA) electronic data capture tools hosted at the Faculty of Health Sciences, University of the Witwatersrand.[6] A knowledge score was derived from the six knowledge questions by calculating the sum of correct responses from these questions, thus creating a score with a possible range of 0 - 6. A Contactability Indicator was derived from Q10 - 11. It was assumed that the transplant coordinator was contactable by the respondent if either Q10 (‘Please write down the name and the telephone number of the coordinator you refer potential donors to. If you don’t know, please leave the space empty.’) was answered correctly or Q11 (Do you have access to the telephone number for the on-call transplant coordinator if you need it?) was answered affirmatively.

The χ2 test was used to assess the relationship between pairs of categorical variables. Fisher’s exact test was used for 2 × 2 tables or where the requirements for the χ2 test could not be met. The relationship between knowledge score and categorical variables was assessed by the t-test (or analysis of variance >2 categories). Where the data did not meet the assumptions of these tests, a non-parametric alternative, the Wilcoxon rank sum test (or the Kruskal-Wallis test for >2 categories) was used. Data analysis was carried out using SAS version 9.4 (SAS, USA). The 5% significance level was used.

This research was approved by the Human Research Ethics Committee of the University of the Witwatersrand (ref. no. M150334). As this was

a self-administered questionnaire, consent was implied by nurses choosing to participate. Permission to undertake the study was obtained from the chief executive officers of all participating sites as well as the nursing unit managers of the various sections.

Results

The overall response rate for completion of the questionnaire was 68.6% (273/396) and there was no difference in the response between the state and private sectors with rates of 67.7% (182/269) and 71.7% (91/127), respectively (p=0.42).

Most of the participants were female, ≤50 years old and were registered nurses. Of the registered nurses, 40.1% had formal ICU training. Of the total sample, 177 participants (70.5%) did not have any formal ICU training; however, more than half of the respondents (56.5%) had >1 year of experience working in an ICU. The sample appears to represent a broad sociocultural diversity, evidenced by the range of home languages spoken by participants. There were approximately equal proportions of isiZulu speakers across both sectors and a relatively higher proportion of Setswana and English speakers in the state and private sectors, respectively. Sample demographics are detailed in Table 1.

Perceptions, opinions and personal beliefs about organ donation

Two-thirds of participants expressed a willingness to donate their own organs after death (172/268; 64.2%). English home-language nurses were more willing to donate compared with those of other language groups (p=0.015). When asked to consider their personal choice regarding deceased organ donation, 51.1% of nurses felt that the most important person to make this decision should be themselves, while alive, rather than their next-of-kin. The response rate to this question was lower than for other questions (221/273; 19.0% did not respond). This suggested that participants may not have considered organ donation previously or found it difficult to answer the question.

Respondents were predominantly of the Christian faith (172/249; 69.1%), with African traditional religions being the second most commonly practised religion in the sample (41/249; 16.5%). Christian participants were more highly qualified (p=0.0026) and were more inclined to donate their organs after death (p=0.028), compared with those of an African traditional religious faith.

Irrespective of their employment sector, age and qualification, approximately two-thirds of nurses (168/266; 63.2%) felt that their personal beliefs did not influence advice given to patients and families regarding organ donation. However, when asked about how the staff in their unit felt about organ donation, only 36.8% (98/266) of participants felt positive about referring patients as potential organ donors. Older nurses (>50 years) were more positive than their younger colleagues (p=0.1017) (Fig. 1).

Referral for organ donation and scope of practice

The majority of the participants 223/264 (84.4%) felt it was the responsibility of the attending doctor to refer potential organ donors to the transplant procurement coordinator. However, older nurses (>50 years), those with formal ICU training and English home-language speakers favoured nurse-based referrals when compared with their younger, less-qualified colleagues.

When asked whether they would follow a clear protocol – approved by their hospital and the Department of Health (DoH) – that supports organ donor referral, most nurses (216/269; 80.3%) said they would

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Table 1. Participant demographics

Unit* ICU Casualty High care Ward Other Qualification † RN ICU-trained RN EN NA SN CW ICU experience of non-ICU-trained RN‡ (n=177) <3 months 3 - 6 months 6 - 12 months 1 - 5 years >5 years Age (years) 20 - 30 31 - 40 41 - 50 51 - 60 61 - 70 Gender ¶ Female Male Home language║ isiZulu English Setswana Sepedi Sesotho isiXhosa Tsonga Afrikaans Venda Siswati Ndebele

Overall, n (%) 273 (100)

Sector State, Private, n (%) n (%) 182 (66.7) 91 (33.3)

121 (44.3) 51 (18.7) 24 (8.8) 20 (7.3) 33 (12.1)

75 (46.9) 47 (29.4) 18 (11.3) 20 (12.5) ND

46 (50.4) 4 (7.1) 6 (10.7) 0 (0.0) ND

112 (41.0) 75 (27.5) 42 (15.4) 16 (5.9) 6 (2.2) 1 (0.4)

73 (42.4) 53 (30.8) 31 (18.0) 15 (8.7) ND ND

39 (49.4) 22 (27.8) 11 (13.9) 7 (8.9) ND ND

40 (22.6) 8 (4.5) 19 (10.7) 51 (28.8) 36 (20.3)

26 (25.2) 21 (20.4)

14 (27.5) 6 (11.8)

0.56

34 (33.0) 22 (21.4)

17 (33.3) 14 (27.5)

38 9 (13.9) 113 (41.4) 68 (24.9) 38 (13.9) 5 (1.8)

28 (15.9) 70 (39.8) 46 (26.1) 32 (18.2)

10 (11.6) 43 (50.0) 22 (25.6) 11 (12.8%)

0.37

229 (83.9) 32 (11.7)

150 (85.2) 26 (14.8)

79 (92.9) 6 (7.1)

0.075

61 (22.3) 35 (12.8) 35 (12.8) 29 (10.6) 22 (8.1) 20 (7.3) 16 (5.9) 14 (5.1) 10 (3.7) 7 (2.6) 4 (1.5)

43 (48.3) 13 (14.6) 33 (37.1)

18 (42.9) 22 (52.4) 2 (4.8)

<0.0001

p-value for intergroup test

<0.0001

0.73

RN = registered nurse; ICU = intensive care unit; EN = enrolled nurse; NA = nurse assistant; SN = student nurse; CW = care worker; ND = not determined. *24 (8.8) not answered. † 21 (7.7) not answered. ‡ 23 (13.0) not answered. § 11 (4.0) not answered. ¶ 12 (4.3) not answered. ║ 20 (7.3) not answered.

abide by a protocol. This agreement was uniform across both sectors, regardless of qualification, age or home language.

In contrast, only 35.8% (97/271) of nurses felt that referring potential organ donors to a transplant coordinator was within their scope of practice and the remainder disagreed or were unsure, in equal proportions. Nurses who were older (>50 years) (p=0.0005) and English home-language speakers felt more confident that they could refer potential donors compared with other groups (p<0.0001). Further, more qualified nurses felt significantly more confident that they could refer

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potential donors (p<0.0001) (Fig. 2). This ranged from 50.7% for ICUtrained registered nurses to only 13.6% for student nurses.

Access to transplant services and perceptions of the role of transplant procurement coordinators

Most nurses (61.0%) were aware that there was access to a procurement coordinator through their hospital, but more nurses in the private sector (70.3%) were aware of this compared with those in the state sector (56.3%; p=0.0058). Across both sectors, younger, less-qualified

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Respondents in each groupgroup (%) (%) Respondents in each

nurses were least aware of this aspect. Of the respondents, 69.6% felt that they would be able to contact a procurement coordinator if required, but only the older and more qualified nurses knew whom to contact. Most participants indicated that the main roles of the procurement coordinator included obtaining consent from donor families, facilitating end-

of-life discussions, reminding staff about the potential for organ donation, teaching the community about organ donation and tracing the family of a potential donor for consent (Fig. 3). Participants felt that the procurement coordinator should visit their units weekly. A noticeable difference was that more nurses in the state sector felt that coordinators should

100

Disagree

90 100 80 90 70 80 60 70 50 60 40 50 30 40 20 30 10 20 0 10

Neutral Disagree Agree Neutral Agree

0

20 - 30

31 - 40

41 - 50

51 - 70

20 - 30

31Age - 40 category (years) 41 - 50

51 - 70

Respondents in each groupgroup (%) (%) Respondents in each

Fig. 1. Attitudes of staff members in the sampled units to organ donation.

100

Unsure

100 90

No Unsure Yes No

90 80

Yes

80 70 70 60 60 50 50 40 40 30 30 20 20 10 100 ICU-trained RN

RN

EN

SN/NA

ICU-trained RN

RN Qualification EN

SN/NA

Qualification

Fig. 2. Organ donation referrals and nursing scope of practice. (ICU = intensive care unit; RN = registered nurse; EN = enrolled nurse; SN = student nurse; NA = nurse assistant.)

Respondents (%)

0

20

40

Knowledge-based questions about organ procurement in South Africa

The mean (standard deviation) knowledge score was 3.6 (1.3) (range 0 - 6). Knowledge regarding the supply of organs, access to transplants and legal rights was fair, whereas knowledge related to the allocation of organs and the use of organs from children and the elderly was poor (Fig. 4). The scores achieved by nurses in the state sector was lower compared with those in the private sector; ICU-trained nurses scored higher than enrolled nurses, and those who were willing to donate their organs after death scored higher than those who were unwilling to donate.

Discussion

Age category (years)

0

be involved with educating communities regarding prevention of end-stage kidney disease.

60

80

100

This is the first quantitative study across the state and private sectors in SA showing that nurses expressed favorable attitudes to deceased organ donation; our findings indicated that the nursesâ&#x20AC;&#x2122; personal beliefs did not influence the donor referral process. Despite this, referral numbers in Johannesburg have been static for the past 5 years (K Crymble, Transplant Unit, Wits Donald Gordon Medical Centre, personal communication, July 2017). Our findings add to other SA studies which dispel perceptions that low referral rates are a function of personal opinions or beliefs that do not favour organ donation.[5,7] Rather, our findings suggest that lack of a structured protocol is an endemic obstacle to deceased organ donor referral for nurses. Considering the finding that most nurses would willingly follow a structured referral protocol, this study presents good evidence for addressing low referral rates through the implementation of a protocol. Internationally, similar changes in legislation and guidelines have resulted in a significant increase in donor referrals.[7]

Scope of practice and professional roles: Nurses and transplant procurement coordinators

Do consent with families who are making an end-of-life decision Remind staff about organ donation Teach the community about organ donation Trace the family of a potential donor for consent Do rounds and identify potential organ donors

Our results reveal a lack of clarity regarding the roles of nurses and transplant procurement coordinators in organ donation in Johannesburg. Although nurses do have a formal scope of practice, it is vague and interpreting the role of the nurse in organ donation is challenging.

Provide support for staff who are identifying potential donors Do community outreach to prevent end-stage organ disease Do end-of-life discussions and break bad news to families Take over the nursing management of a brain-dead donor Pop-in, be social and have tea and cake with the staff

Fig. 3. Perceived role of the transplant coordinator.

Respondents who answered correctly (%)

0

20

40

60

80

100

SAJCC November 2017, Vol. 33, No. 2 Are there enough organs in SA to transplant to everyone who needs them?

Can anyone get a transplant, no matter how much/little money they have?

Who has the legal right to make the OD decision for you?

Should organs donated by adults over 55 years of age only be transplanted to patients >55 years?

55

Teach the community about organ donation Trace the family of a potential donor for consent Do rounds and identify potential organ donors Provide support for staff who are identifying potential donors Do community outreach to prevent end-stage organ disease Do end-of-life discussions and break bad news to families Take over the nursing management of a brain-dead donor

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Pop-in, be social and have tea and cake with the staff

Respondents who answered correctly (%)

0

20

40

60

80

100

Are there enough organs in SA to transplant to everyone who needs them?

Can anyone get a transplant, no matter how much/little money they have?

Who has the legal right to make the OD decision for you?

Should organs donated by adults over 55 years of age only be transplanted to patients >55 years?

Are children's organs only donated to children?

Are organs allocated on regional/national basis?

Fig. 4. Knowledge questions. (OD = organ donation.)

Table 2. Formal organ donation training for nurses and nursing students in Johannesburg* Qualification Organ donation training Bachelor of Nursing (Undergraduate) One 45-minute session in the 4th year Diploma in Nursing Not covered ICU specialist training through the One 45-minute session University of the Witwatersrand Netcare and Mediclinic nursing One 3 - 6-hour session on transplant programmes ICU = intensive care unit. *A Hayward, personal communication, November 2016.

Nursing scope of practice is legally defined within a set of parameters in SA; however, the specific roles required of nurses are not condensed into an exhaustive list because it is not feasible to accommodate every aspect of nursing management in a single document. This is particularly relevant with highly specialised and technology-intensive biomedicine which can be unpredictable in the role it requires of nurses.[8] Previous SA and international research has found that the psychological and professional challenges facing nurses and doctors present major barriers to referral of potential organ donors.[5,10,11] Owing to these challenges, formal donor referral guidelines that specify the role of nurses are warranted as a matter of urgency. The results of this study could be used to strongly advocate for, and inform, a protocol for mandatory donor referral that is nationally endorsed and supported by the DoH, the South African Nursing Council, the South African Transplant Society and all hospital groups.

Our results show that the role of the procurement coordinator is seen as varied and that nurses did not agree on exactly what their role was. While a procurement coordinatorâ&#x20AC;&#x2122;s duties would include securing consent from the organ donorâ&#x20AC;&#x2122;s family, bedside donor care, family support, referral for transplantation and educating healthcare staff, there was a misperception that the role of the coordinator was to educate the public about disease prevention. This may be due to variations in the job description of transplant procurement coordinators across sectors and provinces, and in Johannesburg undertaking public

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education is not the primary responsibility of the procurement coordinator. Rather, it is the responsibility of donor education foundations, primarily the Organ Donor Foundation of SA. Confusion about the role of the coordinator is also evident in results suggesting that many of the research participants did not know how to contact the transplant procurement coordinator when there was a potential donor.

This finding suggests that a more robust system for such communication is needed.

The roles and responsibilities for transplant procurement coordinators are defined in their employment contracts, and these vary widely across sectors and institutions, and may therefore differ depending on their employer and the region in which they are employed.

Transplant coordinators play one of the most important roles in the organ donation process, so this ambiguity is a concern. It likely exacerbates doubts that nursing staff may experience about their role when liaising with transplant coordinators when there is a donor. International and SA research have shown that this type of uncertainty can hinder organ donation in a highly pressurised clinical environment where organisational routine and structured interaction are essential for its success.[5,12] Our study revealed that the lack of knowledge about organ donation and uncertainty about policies and roles in organ donation may also be explained by a lack of formal organ donation education for nurses in the Johannesburg region.

However, nurses in the private sector scored higher on the knowledge component of the questionnaire compared with those in the

state sector. Because the private sector is more active when it comes to transplantation in Johannesburg, exposure to transplant on a regular basis, in practice, may also influence nursesâ&#x20AC;&#x2122; knowledge. In terms of national curricula, there is no formal obligation to teach organ donation and each educational institution chooses whether to include it at their discretion, with the approval of the nursing council. Table 2 summarises the paucity of formal organ donation education and training for nurses in Johannesburg.

The lack of formal organ donation education for nurses translates to a gap in patient management that should otherwise be standard practice. Furthermore, nurses have limited exposure to the practical aspects of organ donation, because transplantation is a lengthy and expensive procedure that takes place at a limited number of centres.

Study limitations and strengths

The limitations of this study were that it was conducted across Johannesburg and may not be generalisable to other regions in SA. Nurses who may not have felt sufficiently proficient in English could have self-excluded. A validated questionnaire was not used; however, there are no relevant, published, validated survey tools available for use in the SA setting.

The first advantage of this research is that the questionnaire, which has now been used in a large study, can be made available to other researchers. Secondly, the results of this quantitative study reflect the views of nurses across both private and state sectors in the correct ratio.

Conclusion

Our study found that there was a distinct lack of transplant protocol to guide nurses practising in Johannesburg, SA. Furthermore, there are misconceptions regarding the roles and responsibilities of nurses in the referral process. This creates an environment of uncertainty and insecurity for nurses who work in hospital units that may refer donors.

Even when nurses reported positive attitudes, it appeared that the lack of protocol and defined guidelines prevented them from referring donors, probably because of the fear of retribution if a referral was perceived to be outside of their scope of practice. Future research should include a national extension of this study to other regions in SA. The study presents evidence for the need for a nationally endorsed protocol that could guide nurses in donor referral. This

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is especially important given that nurses in Johannesburg said they would willingly adhere to such a protocol. It would be important for this protocol to emphasise teamwork and to clarify the role of doctors, as nurses need to be aware of how they might navigate relationships with doctors in the event that doctors themselves are unwilling to refer a potential donor. Regarding nursing education and training, it appears that substantial curriculum change is needed, and while it would have to be balanced with other priorities, some organ donation education at the undergraduate level could be helpful. At the level where nurses specialise by undertaking ICU training, organ donation education may be particularly beneficial, as these nurses could refer donors or care for recipients. While it is clear from the study that the coordinators do provide in-service training, this does not appear to be standardised and relatively few nurses access it because it is often confined to larger urban centres. A recognised nursing speciality training for transplant coordinators in SA, with a formal curriculum, should also be considered.

Acknowledgements. The authors would like to thank Heather Maher for database design and support and Victoria Masilo for her assistance with data capture. We are also very grateful to the Johannesburg nursing staff who participated in this study, with special thanks to the team of nurses in ward 565 at Charlotte Maxeke Johannesburg Academic Hospital who supported this project whole. We would like to pay tribute to every organ donor in SA, and to thank their families – without you there would not be life for others. We would also like to acknowledge all procurement coordinators countrywide for their commitment to ensuring compassionate care for all.

We would like to thank Astellas Pharma (Pty) Ltd, SA and Wits Donald Gordon Medical Centre for financial support and we would particularly like to acknowledge to Astellas Pharma (Pty) Ltd, SA for their continued support of nurse-driven research in organ donation and transplant.

This paper is dedicated to the memory of Belinda Karen Rossi Britz (1966 - 2016).

Author contributions. KC: research design, ethics approval, data collection, data interpretation, feedback on drafts for submission. HRE: research design, ethics approval, data interpretation, paper drafting for submission (first and all subsequent drafts). JF: research design, ethics approval, data interpretation, substantial input on drafts for submission. PG: study design, piloted the study questionnaire, statistical analysis, feedback on drafts for submission.

Funding. This research was funded by an unrestricted educational grant from Astellas Pharma Pty (Ltd.) South Africa in conjunction with funding from Wits Donald Gordon Medical Centre.

Conflicts of interest. None.

1. Loveland J, Britz R, Joseph C, et al. Paediatric liver transplantation in Johannesburg revisited: 59 transplants and challenges met. S Afr Med J 2014;104(11):799-802.

2. Muller E, Barday Z, Mendwelson M, Kahn D. HIV-positive-to-HIV-positive kidney transplantation – results at 3 to 5 Years. N Engl J Med 2015;372(7):613-620. https://doi.org/10.1056/nejmoa1408896 3. Donor Identification and Referral Strategy Group. Timely identification and referral of potential organ donors. Watford: NHS Blood and Transplant, 2014. www.odt.nhs.uk/pdf/timelyidentification-and-referral-potential-donors.pdf (accessed 11 July 2017).

4. Fabian J, Maher H, Bentley A, et al. Favourable outcomes for the first 10 years of kidney and pancreas transplantation at Wits Donald Gordon Medical Centre, Johannesburg, South Africa. S Afr Med J 2016;106(2):172-176. https://doi.org/10.7196/samj.2016.v106i2.10190 5. Etheredge HR, Penn C, Watermeyer J. Interprofessional communication in organ transplantation in Gauteng Province, South Africa. S Afr Med J 2017;107(7):615-620. https://doi.org/10.7196/ SAMJ.2017.v107i7.12355 https://doi.org/10.7196/SAMJ.2017.v107i7.12355 6. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377-381. https://doi.org/10.1016/j. jbi.2008.08.010 7. Miranda B, Fernandez-Lucas M, De Felipe C, Naya M, Gonzalez-Posada J, Matesanz R. Organ donation in Spain. Nephrol Dial Transplant 1999;14:15-21.

8. N Geyer. Scope of nurses’ practice. Prof Nurs Today 2016;20(1):51-52.

9. Wang Y-J, Lin C-Y. The experience of perioperative nurses involved in organ procurement. J Nurs Res 2009;17(4):278-285. https://doi.org/10.1097/jnr.0b013e3181c0038d 10. Greenhalgh T, Voisey C, Robb N. Interpreted consultations as ‘business as usual’? An analysis of organisational routines in general practices. Sociol Health Ill 2007;29(6):931-954. https://doi. org/10.1111/j.1467-9566.2007.01047.x 11. Becker MC. Organizational routines: A review of the literature. Ind Corp Change 2004;13(4):643678. https://doi.org/10.1093/icc/dth026 12. Naude A, Nel E, Uys H. Organ donation: Attitude and knowledge of nurses in South Africa. J Renal Care 2002;28(1):44-48. https://doi.org/10.1111/j.1755-6686.2002.tb00198.x

Accepted 28 August 2017.

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Patient- and family-centred care practices of emergency nurses in emergency departments in the Durban area, KwaZulu-Natal, South Africa J P B Almaze, CCN; J de Beer, PhD School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: J de Beer (beerje@ngha.med.sa)

Background. Admission of a loved one to an emergency/critical care unit can result in role conflict, high levels of stress, interruption of normal routines and potential changes in relationships among family members (FMs). Other potential stressors that FMs can be exposed to are deterioration in the condition of the patient, an uncertain outcome for the patient, pain and suffering experienced by the patient, the unfamiliar environment, and the large amount of high-tech equipment. An approach to support FMs during this crisis period is patient- and family-centred care (PFCC).

Objectives. To describe PFCC practices of emergency nurses in emergency departments (EDs) in KwaZulu-Natal (KZN) Province, South Africa.

Methods. A descriptive survey was done among 44 emergency nurses (enrolled and registered nurses) from four EDs in the Durban area of KZN. The Self-Assessment Inventory Tool was used and adapted for a resource-constrained setting.

Results. The majority of emergency nurses (84%) acknowledged the importance of family participation in patient care, 87% reported that FMs were provided with information in a timely manner, and 77% indicated that they had the necessary skills to provide care to FMs. Conclusions. The study showed that the majority of emergency nurses in EDs in the Durban area of KZN provided PFCC. The findings demonstrate that although PFCC is a challenge, nurses in EDs acknowledge the importance of this model of care.

S Afr J Crit Care 2017;33(2):59-65. DOI:10.7196/SAJCC.2017.v33i2.317

Patient- and family-centred care (PFCC) is an approach to the planning, delivery and evaluation of healthcare that focuses on a mutually beneficial partnership between patients, families and heathcare professionals.[1] An integral part of this approach is being responsive to the needs, values and cultural needs of the patient and family members (FMs).[2] Further to this, a PFCC approach in critical care in the emergency department (ED) recognises the needs of both the patient and FMs. This approach is central to delivering effective care, including prompt assessment of FMs’ needs, that not only reduces FMs’ stress and anxiety but also enhances the patient’s satisfaction with care.[3] FMs often find it a traumatic experience when a loved one is admitted to a critical care unit. They are not usually psychologically prepared for this event, as most of these admissions are emergencies.[4] Admission of a loved one can result in role conflict, high levels of stress, interruption of normal routines and potential changes in relationships among FMs.[5] Other potential stressors that FMs can be exposed to are deterioration in the condition of the patient, an uncertain outcome for the patient, pain and suffering experienced by the patient, the unfamiliar environment and the large amount of high-tech equipment that the patient is connected to. This can lead to emotional reactions in FMs such as shock, anger, fear, anxiety, guilt, frustration and depression.[6] The primary goal of critical care is to help patients recover from acute threats to their health. However, despite this societal expectation, the mortality rate among patients in EDs is higher than in most other healthcare settings. As many as one in five patients in EDs do not survive.[7] This is very apparent in the South African (SA) context, where the mortality rate of trauma patients is six times and that of patients with road traffic injuries double the global rate.[8] In addition, SA is a violent

country, and injuries account for 12 - 15% of all deaths, as opposed to the global figure of 3.2%. Most penetrating injuries, for example, are due to interpersonal violence, and these are typical of patients presenting to EDs. The average age of victims of violence is 33.6 years, and they account for 30% of the patient load and 53% of deaths.[9] Motor vehicle accidents result in ~11 deaths per million kilometres travelled, which is ~10 times higher than the rate in developed countries. Management of patients receiving critical care in SA is also complicated by an increasing prevalence of infectious diseases such as HIV/AIDS and tuberculosis.[10] In addition to these challenges, there is inadequate distribution of emergency services, especially in rural and periurban areas with poor infrastructure, resulting in poor communication systems and poor access by emergency services. This often results in the ideal of the ‘golden hour’ not being possible.[11] There are also staff shortages as a result of emigration to other countries, and staff who remain behind often experience threats of violence. EDs are often staffed with junior and sessional doctors, and in rural areas with part-time general medical practitioners. This means that nurses have to function without the necessary training, potentially leading to burnout, which is reflected in unemotional involvement in work and development of a cynical attitude towards patients and their FMs.[11] Despite these challenges, healthcare organisations have a responsibility to care for the physical and emotional health of severely stressed FMs. Healthcare practitioners have the responsibility to create a sympathetic environment for FMs of patients admitted to EDs, by showing awareness of their feelings, thoughts and needs and implementing interventions to reduce stress levels.[12] FMs need to support the patient, and in some cases to speak for patients who are unable to communicate

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themselves. [13] Support of the patient and FMs in the ED can be achieved through a PFCC approach.[14] Since the seminal work of Molter (1979),[15] the needs of FMs have been studied extensively, with the quantitative evidence[16-18] being supplemented to a lesser extent by qualitative studies.[19,20] Although implementing PFCC has been shown to increase staff satisfaction, decrease costs and improve patient outcomes internationally,[21] little attention has been paid to this field in the SA context, and most studies have been done in the paediatric setting.

Objectives

To describe PFCC practices of emergency nurses in the EDs in the Durban area of KwaZulu-Natal (KZN) Province, SA, with a particular focus on: (i) the status of PFCC in the EDs in the Durban area; and (ii) challenges in providing PFCC in the EDs.

Methods Design

A descriptive, quantitative, non-experimental survey design was used.

Setting

The study was conducted in the EDs of four hospitals (two public and two private) in the Durban area. The public hospitals included one regional and one tertiary referral hospital. All four hospitals had level 1 emergency units, responsible for providing total care of injury from prevention to rehabilitation.

Study population

Enrolled and registered nurses in the EDs in the study hospitals, with at least 6 monthsâ&#x20AC;&#x2122; experience working in an ED, were eligible for inclusion. A convenient non-probability sampling method enabled the researcher to recruit emergency nurses who were available and willing to participate.

Data collection tool

The Self-Assessment Inventory Tool[22] was used. The tool was developed by the Emergency Medical Services for Children National Resource Center in Washington, DC, to help healthcare professionals and FMs to assess PFCC relating to paediatric care in EDs in the USA. Although this tool was developed for paediatric patient settings, it included adult patients in our study. The original tool is only available in English, and no documented research to date has shown any translation into other languages. The tool is organised into seven sections (vision, mission and philosophy of care; family participation in care; family support; information and decision-making; service co-ordination and continuity; personnel practices and training; and environment and design, evaluation/continuous quality improvement, and community partnerships).

The tool was adapted for the SA context, and certain items were excluded to make it relevant in a resource-constrained environment.

Some of the items on the tool were not relevant to the SA context, so only the sections on family participation in care, information and decision-making, and personnel practices were used in the study, as these sections directly related to its objectives.

Data collection process

The researcher was given 10 minutes at the beginning of each day and night shift handover to explain the purpose of the study to the nurses present. Questionnaires were left with nurses who verbally agreed

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to participate in the study. The completed questionnaires were then collected at the end of the shift.

Validity and reliability

Validity. A pilot test was conducted with five participants, who were asked to comment on the content of the tool in relation to the subject of the study to ensure that it was appropriate in terms of wording, layout and questions asked. Furthermore, the ED study sites cared for all age groups in the SA context, thereby providing a comprehensive description of PFCC in this context.

Reliability. The pilot test revealed a Cronbach alpha of 0.92, indicating a high reliability coefficient.

Statistical analysis

The data were analysed using the Statistical Programme for Social Science (SPSS), version 16 (IBM, USA). Descriptive statistics were used to describe the research phenomena. Tests included frequencies, percentages and Cronbach alpha >0.70 as acceptable.

Ethical considerations

Ethical approval was obtained from the Research and Ethics Committee of the University of KwaZulu-Natal (ref. no. FECHSC 05009).

Permission was also obtained from the KZN Department of Health (ref. no. HRKM088/09) and the management of all the hospitals.

Informed consent was obtained from the respondents, and they were assured that all participation was voluntary. Confidentiality, privacy and anonymity were maintained by ensuring that the questionnaires were anonymous. No names were indicated on the questionnaire. In addition, the completed questionnaires were kept in a locked office and any electronic data sets were kept on a computer that required access using a password.

Results

The total population of emergency nurses targeted for the study at the four hospitals was 60. Fifty-five nurses were given questionnaires, excluding the five nurses who were involved in the pilot test. Eleven nurses did not consent to participate in the study and were excluded.

Finally, 44 nurses from the four study sites, 18 (40.9%) from private and 26 (59.1%) from public hospitals, were included in the final analysis (Table 1), giving a response rate of 80.0%.

Demographic details of respondents

The largest proportion of respondents were aged 36 - 45 years (34.1%), and most respondents were female (86.4%) (Table 2). A diploma in nursing (88.6%) was the most common qualification, with most respondents having 16 - 20 yearsâ&#x20AC;&#x2122; experience in nursing. Most of the emergency nurses included in the study were registered nurses (70.5%).

The PFCC Self-Assessment Inventory Tool

The four categories, comprising 58 items, that were included in the questionnaire are shown in Tables 3 - 7. The overall reliability coefficient

Table 1. Sampling per hospital (N=44) n (%) Hospital 1

8 (18.2)

Hospital 2

10 (22.7)

Hospital 3

15 (34.1)

Hospital 4

11 (25.0)

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Table 2. Demographics of respondents (N=44)

of the items used in this study was 0.88, with all categories showing acceptable reliability of >0.70 (Table 3).[23]

n (%) Age (years) 20 - 25

3 (6.8)

26 - 35

14 (31.8)

36 - 45

15 (34.1)

46 - 55

7 (15.9)

56 - 65

5 (11.4)

Family participation in care (Table 4) All respondents (100%) agreed that FMs are important sources of information on the patient and the patient’s condition, with 52.3% of respondents indicating that policies and procedures in their unit were flexible during invasive procedures and 54.5% disagreeing that FMs should be allowed to be present during resuscitation. In addition, 75.0% of respondents agreed that FMs should be encouraged and supported to stay with the patient, while 59.1% indicated that FMs should be encouraged to provide support and assist with patient care.

Gender Male

6 (13.6)

Female

38 (86.4)

Qualifications Diploma

39 (88.6)

Bachelor’s degree

4 (9.1)

Master’s degree

1 (2.3)

Family support (Table 5) Of the respondents, 79.5% agreed that ED staff effectively promoted family/patient relationships, 68.2% agreed that staff supervision was provided for patients in the waiting area, and 70.4% both viewed interactions with FMs as an opportunity to support FMs, and viewed interactions with FMs as being respectful. In addition, 79.5% of respondents indicated that they were available to assist FMs when they first arrived in the ED, and 75.0% that they were available to help and support FMs as they waited for routine care and information; 72.7% reported that there was a procedure in their unit for initiating family support and providing frequent information updates during a crisis or life-threatening situation, and 54.5% that a specific individual was designated to co-ordinate the exchange with FMs.

Experience (years) 0-5

9 (20.5)

6 - 10

6 (13.6)

11 - 15

8 (18.2)

16 - 20

12 (27.3)

>20

8 (18.2)

Information missing

1 (2.3)

Current position held Staff nurse

13 (29.5)

Registered nurse

31 (70.5)

Table 3. Items and categories in the Self-Assessment Inventory Tool Item

Items, n

Mean (SD)

Cronbach alpha

Family participation in care

7

9.3 (2.0)

0.75

Family support

17

22.2 (4.7)

0.88

Information-sharing and decision-making

22

30.3 (6.2)

0.91

Personnel practices

12

16.0 (3.8)

0.88

Total

58

0.88

Information-sharing and decision-making (Table 6) Most respondents (56.8%) reported that bereavement information in their unit did not include hospital and community bereavement groups, and 52.8% that information on funeral services, planning a service and other resources was not provided; 84.1% of respondents indicated that FMs were provided with timely information in order to make decisions regarding the patient’s treatment, 90.9% that FMs’ choices about patient care were respected, and 72.7% that FMs were given information about follow-up care and were supported in obtaining information through educational materials.

Personnel practices (Table 7) Most respondents (65.9%) reported that orientation and/or in-service programming included discussions about PFCC principles. Only 59.1%

Table 4. Family participation in care (N=44) 1. Does ED staff recognise that FMs are important sources of information on the patient and the patient’s condition?

Yes, n (%)

No, n (%)

44 (100)

0

Cronbach alpha

2. Are policies/procedures flexible enough for a family to decide for themselves if and who stays with the patient during: Invasive procedures?

23 (52.3)

21 (47.7)

0.68

Critical care including resuscitation?

20 (45.5)

24 (54.5)

0.65

3. Are FMs encouraged and supported in staying with the patient?

33 (75.0)

11 (25.0)

0.74

4. Are FMs encouraged to provide support and to assist with care for the patient in the ED?

26 (59.1)

18 (40.9)

0.67

How to facilitate the patient’s coping during painful or stressful procedures?

37 (84.1)

7 (15.9)

0.78

The use of stress- or anxiety-reducing techniques?

39 (88.6)

5 (11.4)

0.78

5. Are FMs provided information/assistance on:

ED = emergency department; FMs = family members.

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Table 5. Family support (N=44) Yes, n (%)

No, n (%)

Cronbach alpha

1. Do ED staff, in the way they deliver services, effectively promote and support family/patient relationships?

35 (79.5)

9 (20.4)

0.88

2. Is staff supervision provided for the patient in the waiting area?

30 (68.2)

14 (31.8)

0.87

3. Do staff view interactions with FMs as opportunities to support FMs in the care and nurture of the patient?

31 (70.4)

13 (29.5)

0.87

4. Do staff interact respectfully with all FMs?

31 (70.4)

13 (29.5)

0.87

5. Are the following available to support patient and FMs in the ED: Translators/interpreters?

26 (59.1)

18 (40.9)

0.87

Sign language interpreters?

26 (59.1)

18 (40.9)

0.87

Social workers?

30 (68.2)

14 (31.8)

0.87

Spiritual advisors?

33 (75.0)

11 (25.0)

0.88

Mental health professionals?

34 (77.3)

10 (22.7)

0.87

Patient representatives?

34 (77.3)

10 (22.7)

0.87

6. Are staff members available to help and support FMs at the following times: When they first arrive in the ED?

35 (79.5)

9 (20.4)

0.89

As they wait for routine care and information?

33 (75.0)

11 (25.0)

0.88

7.

Is there a procedure for initiating family support during a crisis or lifethreatening situation?

32 (72.7)

12 (27.3)

0.87

8.

In trauma and other crises or life-threatening situations, are frequent information updates (every 5 - 10 minutes) provided to the family when they are outside the room as well as when they are present with the patient?

32 (72.7)

12 (27.3)

0.88

Is a specific individual designated to co-ordinate the exchange of information with the family?

24 (54.5)

20 (45.5)

0.87

Does this individual remain involved as a support person throughout the crisis or resuscitation?

25 (56.8)

19 (43.2)

0.88

FMs = family members.

of respondents reported that staff were trained in working with FMs and children in emergency situations, 68.2% agreed that the cultural and ethnic diversity of patients and FMs were met, 70.5% reported that they were encouraged to learn the languages of the main communities served by their hospital, and 72.7% reported that there were opportunities for staff to debrief and share feelings and concerns after critical incidents.

Discussion

Family participation in care

All the emergency nurses agreed that FMs are important sources of information on the patient and the patientâ&#x20AC;&#x2122;s condition. According to De Beer and Brysiewicz,[24] although there has been a movement in recent years to promote the patient as a partner in care, this is not always possible, as critically ill patients are often sedated and ventilated, and unable to make decisions for themselves. This results in FMs being involved in these partnerships. They are important sources of information and are able to make decisions on behalf of the patient when necessary.[25] Most emergency nurses agreed that policies and procedures during invasive procedures were flexible, but the majority reported that this was not the case during critical care interventions, including resuscitation. According to Goldberger et al.,[26] many institutions have adopted policies that allow family presence during resuscitation in the hope of addressing the needs of FMs. In addition, Jabre et al.[27] highlight the fact that FM presence during resuscitation confers psychological benefits for FMs regardless of the treatment outcome.

However, FM presence during resuscitation may also intimidate and

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cause increased emotional stress to medical staff.[28,29] In terms of practicalities, family presence during attempts at resuscitation can be implemented if environmental, staff and spatial conditions are met.

However, it should only be allowed if there is adequate staff to support the FMsâ&#x20AC;&#x2122; emotional and physical needs.[30] This study also revealed that 75% of emergency nurses encouraged and supported the general presence of FMs in the unit, and that FMs were encouraged to provide support and assist with the care of the patient. McKieran and McCarthy[31] noted that FMs expressed a strong desire to be closer to the patient in order to see first-hand how the patient was progressing.

Family support

This study showed that the majority of emergency nurses reported promoting family/patient relationships. Family/patient therapeutic relationships are central to many health-related disciplines, and in nursing, a therapeutic relationship is described as one that allows for the meeting of nursing needs to the mutual satisfaction of the nurse, patient and FMs.[32] According to Leininger,[33] such relationships are pertinent to the delivery of individualised and holistic nursing care, and it is the responsibility of the nurse to encourage the development of such relationships. Brunero et al.[34] state that engaging with patients is seen as a critical part of the therapeutic relationships between healthcare professionals, patients and FMs, with empathy and respect being reported as an integral part of this relationship.

Of the emergency nurses, 75% indicated that they were available to help and support FMs as they waited for routine care and information.

ARTICLE Table 6. Information-sharing and decision-making Yes, n (%)

No, n (%)

Cronbach alpha

1. Does bereavement information include hospital and community bereavement support groups?

19 (43.2)

25 (56.8)

0.91

2. Does bereavement information include information on funeral services, planning a service and available community resources?

21 (47.7)

23 (52.8)

0.90

3. Does bereavement information include telephone number of a contact person at the hospital if the family has questions after discharge?

25 (56.8)

19 (43.2)

0.90

4. Are families provided, in a timely manner, with the information they need to make decisions about the patient’s treatment?

37 (84.1)

6 (13.6)

0.91

5. Are families asked how they would like medical and other information provided to them?

31 (70.5)

11 (25.0)

0.91

6. Are family choices and decisions about the patient’s care respected and honoured by staff ?

40 (90.9)

3 (6.8)

0.92

7. Is there a process for resolving conflicts between families and providers?

35 (79.5)

9 (20.5)

0.91

8. Are families given information about follow-up care for their loved one, and pharmaceutical and other supplies or equipment they may need?

32 (72.7)

12 (27.3)

0.90

Educational material in the ED?

32 (72.7)

12 (27.3)

0.91

Access to translators?

29 (65.9)

15 (34.1)

0.88

The medical library?

21 (47.7)

23 (52.3)

0.81

The internet?

24 (54.5)

20 (45.5)

0.76

9. Does the ED support families in obtaining information through:

ED = emergency department.

Table 7. Personnel practices Yes, n (%)

No, n (%)

Cronbach alpha

1. Does orientation and/or in-service programming include discussion about family-centred principles?

29 (65.9)

15 (34.1)

0.77

2. Does orientation and/or in-service programming include discussion about cultural competence and overcoming language barriers?

28 (63.6)

16 (36.4)

0.88

3. Does orientation and/or in-service programming include discussion about sharing medical and other information with FMs?

27 (61.4)

17 (38.6)

0.76

4. Are staff trained in working with FMs and children with special needs/ disabilities in emergency situations?

26 (59.1)

18 (40.9)

0.84

5. Do staff and volunteers reflect the cultural and ethnic diversity of patients and FMs served by the hospital?

30 (68.2)

14 (31.8)

0.86

6. Are staff encouraged to learn the languages of the primary communities served?

31 (70.5)

13 (29.5)

0.69

7. Are FMs who have experienced emergency care involved in providing orientation and/or servicing for staff ?

27 (61.4)

17 (38.6)

0.75

8. Is there sufficient space for staff support, including a staff lounge accessible for frequent short breaks?

31 (70.5)

13 (29.5)

0.75

9. Is there a staff support group or other regularly occurring opportunities for peer support?

31 (70.5)

13 (29.5)

0.94

10. Are there opportunities for staff to debrief and share feelings and concerns after critical incidents?

32 (72.7)

12 (27.3)

0.71

11. Are there staff recognition and appreciation initiatives?

33 (75.0)

11 (25.0)

0.91

FMs = family members.

According to Washington,[35] the ‘golden hour of trauma’ does not only apply to the trauma or emergency patient, but also includes FMs. Most of the emergency nurses acknowledged the importance of regularly updating FMs with information about the patient’s condition while they are waiting in the ED, and reported that information was usually given by a designated individual who was allocated to co-ordinate the exchange of information. Cypress[6] reported that psychosocial support

of FMs was fulfilled through the sharing of information, and that providing information to FMs about the care of the patient lessened their anxiety. In addition to this, lack of information negatively affects emotion, with uncertainty about the outcome of the patient, fear and apprehension.[35,36] Providing accurate and timely information is respectful, and without this information FMs are left in a void that has the potential to affect them both physically and emotionally.[37]

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Information-sharing and decision-making

The majority of emergency nurses indicated that bereavement information was not available to FMs or the community at large. A study

by Brysiewicz and Uys[38] highlighted the fact that health professionals in the ED had difficulties in managing sudden death, and that guidelines would therefore help in the therapeutic management of the dying patient and the bereaved FMs. Although nurses provided support to the FMs while in the ED, 52% did not follow up on FMs following a patient’s death. Brysiewicz and Uys[38] stated that a follow-up call to FMs is beneficial and that a bereavement co-ordinator could be responsible for this. In the resource-constrained SA context, ED managers have taken on the bereavement co-ordinator role.

Most emergency nurses agreed that information should be provided to FMs. Accurate and complete information has been reported to be the most essential need of FMs during a sudden critical illness, for them to comprehend what is happening and to have realistic expectations. [39,40] Information in this study was shared by the majority of emergency nurses using written departmental resources. It is vitally important to provide comprehensible written information for FMs to refer to at a later stage, as they are often unable to take in information during a loved one’s sudden critical illness.[40] Most emergency nurses in this study reported that FMs were provided with information in a timely manner, in order to make decisions about the patient’s treatment. According to Shorofi et al.,[41] FMs need timely, honest and factual information. Quinton et al.[42] explain that they feel immobilised and helpless in their inability to control the outcome of the patient, and excluding them from decision-making creates further stress. They suggest that FMs should be included in the decision-making process, as this climate preserves the family as a unit.

Our study also revealed that information was provided to FMs both verbally and in writing, in various languages. However, a deficiency in grief and bereavement information was noted. According to Brysiewicz and Uys,[38] health professionals need to be provided with the necessary knowledge and skills in the management of the dead or dying patient.

Personnel practices

The majority of the items in this category indicated that most in-service and orientation programmes included some content regarding PFCC principles. According to Moghaddasian et al.,[43] one of the principles of the nursing process is that care should be holistic, and developing a care programme requires nurses to have a comprehensive training of FMs’ needs. According to Neuman’s[44] model focusing on a family approach, the nurse’s function is to help the family to achieve and maintain a steady state after a stressor, and nurses have a crucial role in assisting people develop coping strategies. This requires the nurse to be knowledgeable about family dynamics. Interacting with relatives is a challenging task that requires complex skills, and critical care nurses must be knowledgeable about the individual needs of both patients and FMs to be able to provide proper care and support for both. Some critical care nurses reported that gaining expertise and acquiring technical competence, knowledge and professional experience helped them to become more confident to provide PFCC. Ongoing learning and acquisition of knowledge is seen as vital in enhancing caring.[40] Some emergency nurses stated that learning from experience is essential, and this was also expressed by Brysiewicz and Bhengu,[12] who reported that lack of training led to critical care nurses using their own experiences in dealing with FMs. Most emergency nurses reported that staffing in their units reflected the cultural and ethnic diversity of the patients served by the hospital.

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As stated by Davidson et al.,[45] culture can have an impact on the nursing profession, because it is a pattern of shared values and beliefs, including language, styles of communication and practices. According to Leininger,[33] care and culture are inextricably intertwined. Healthcare professionals around the world are faced with the challenge of the need to learn about culturally appropriate healthcare. An appreciation of the influence of culture on health, illness and care is important if patients are to be managed effectively by nurses. Leininger[33] states that knowledge of meanings and practices of diverse cultures is vital to guide nursing decisions and actions in providing culturally congruent care. In order to overcome cultural barriers, the nurse should have knowledge of the FMs’ cultural beliefs; 64% of nurses in this study were aware of the cultural beliefs of the families, as opposed to 36% who reported that they were not culturally competent. In addition, most emergency nurses reported that they were encouraged to learn their patients’ primary language.

According to Bradby,[46] nurses may be skilled in interpreting patients’ needs, but the professional language that they use can be difficult for patients to understand, so they need to simplify complex terminology and avoid medical jargon. Not understanding the language of healthcare professionals could limit access to healthcare for patients and FMs, as it is difficult for them to communicate their needs and find out what services are available or what treatment they require. This situation is further compounded for patients and FMs who already feel anxious about the illness.[47]

Recommendations

We recommend that a family needs assessment be included as part of every patient’s assessment. In addition, evaluation of hospital policies and procedures for congruency with PFCC, especially in relation to family-witnessed resuscitation and invasive procedures, is needed to promote family participation in patient care. More formal education for staff regarding the needs of families is needed, particularly in view of SA’s diverse cultural context. Bereavement programmes to support staff in dealing with bereavement issues would be beneficial. Further research is warranted to improve PFCC in the SA critical and emergency care context.

Study limitations

A small sample size of only 44 emergency nurses makes it difficult to generalise the findings. The questionnaire was lengthy and could have been time consuming in the context of the ED, as the average time taken to complete the questionnaire was 15 minutes. Respondents completed the questionnaire indicating yes/no responses to questions.

The questionnaires did not include a section for comments, making it difficult for the researcher to identify strengths, weaknesses and ideas for possible changes.

Conclusions

This study highlights that some aspects of PFCC services are provided by emergency nurses in EDs in the Durban area of KZN. PFCC is a challenge, but to provide such care it needs to be kept in mind that caring is the essence of nursing. As much as the world is advancing in terms of medical technology, nurses should remember the importance of caring and communication with the patient and their FMs, which is essential for the nurse-patient-family therapeutic relationship.

Acknowledgements. We thank Prof. Petra Brysiewicz of the School of Nursing and Public Health at the University of KwaZulu-Natal for proposing the idea of using the Self-Assessment Inventory Tool in this study.

ARTICLE

Author contributions. JPA: student; JdeB: supervisor (manuscript preparation).

Funding. None.

Conflicts of interest. None.

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CCM.0000254067.14607.EB 46. Bradby H. Communication, interpretation and translation. In: Cully L, Dyson S, eds. Ethnicity and Nursing Practice. New York: Palgrave, 2001.

47. Jirwe M, Gerrish K, Emami A. Student nurses’ experience of communication in crosscultural care encounters. Scand J Caring Sci 2010;24(3):436-444. https://doi.org/10.1111/j.14716712.2009.00733.x

Accepted 5 September 2017.

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Getting to the Critical

of

ACCREDITED

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24-25 November Venue: Misty Hills Muldersdrift Estate 69 Drift Blvd, Muldersdrift

CRITICAL CARE SOCIETY OF SOUTHERN AFRICA EGOLI BRANCH

For more information Janice Candlish

T: + 27 11 894 1278 E: ccssa@velocityvision.co.za W: www.velocityvision.co.za

ABSTRACTS

Abstracts of scientific presentations at the 2017 Annual National Congress of the Critical Care Society of Southern Africa Opening the cubby-hole of curriculum development: Reflections on academics’ experiences M Matlakala* University of South Africa *matlamc@unisa.ac.za Background. As curriculum developers, academic lecturers are seldom included in the dialogues regarding curriculum development (CD).

In this study, CD was initiated to align new nursing and public health programmes to the Higher Education Qualification Sub Framework.

Objectives. The objective of the research was to explore the experiences of academic lecturers regarding CD. Methods. A qualitative and exploratory design was used, following interpretivism. The participants were lecturers involved in CD in a specific department at an open distance learning (ODL) university.

Ethical clearance was sought and obtained from the research ethics committees of the university and the department where the lecturers worked. Triangulation of roundtable group discussion with written narratives was done, followed by content analysis of data.

Results. The reflections on experiences revealed the challenges related to CD, which included programme classification typology, ‘red tape’ in organisational processes, and legislative and statutory body compliance.

Conclusion. The information obtained from this study provides a reflection on the pedagogic requirements for the development of new programmes, as well as staff development and support to achieve academic excellence and active citizenship in CD.

Early mobilisation practices of patients in intensive care units in Zimbabwean government hospitals: A cross-sectional study C Tadyanemhandu,* H van Aswegen, V Ntsiea University of the Witwatersrand *cathytadya@gmail.com Background. For the successful implementation of early mobilisation programmes in intensive care units (ICUs) as routine care, a description of regional variations may help to better contextualise the working environment and may aid analyses of relevant barriers.

Objectives. To evaluate the structure and organisational practices of Zimbabwean government hospital ICUs and to describe early mobilisation practices in these units.

Methods. A cross-sectional survey was conducted in all government hospitals in Zimbabwe. Data collected included hospital and ICU structure, patient demographic data and mobilisation activities performed in ICU during the previous 24 hours prior to the day of the survey.

Results. A total of 5 quaternary-level hospitals were surveyed, with each hospital having 1 adult ICU – 4 of the units were open-type ICUs. Only 1 ICU (20%) had a patient eligibility guideline for early mobilisation in place. Across the ICUs, 40 patients were surveyed. The mean (standard deviation) age was 33.9 (14.9) years and 24 (60%) patients were mechanically ventilated. The primary reasons for admission to the ICU included acute lung injury (n=12; 30%) and perinatal complications (n=10; 25%). Mobilisation activities performed in the 24 hours before completing the survey included turning the patient in the bed (n=39; 97.5%), sitting over the edge of bed (n=10; 25.0%), marching on the spot (n=3; 7.5%) and walking away from the bedside (n=2; 5.0%). The reasons listed for treatment being performed in the ICU bed included sedation (n=15; 37.5%) and unresponsiveness (n=16; 40.0%).

Conclusion. Out-of-bed mobilisation activities were infrequent and mostly influenced by patient unresponsiveness and sedation.

Factors associated with out-of-bed early mobilisation of intensive care unit patients in government hospitals in Zimbabwe C Tadyanemhandu,* H van Aswegen, V Ntsiea University of the Witwatersrand *cathytadya@gmail.com Background. Although the literature indicates that early mobilisation is safe and feasible in critically ill adult patients, not all intensive care units (ICUs) have adopted an early mobilisation programme as the standard practice for every ICU patient and it is not frequently practised.

Objectives. To determine the factors associated with out-of-bed mobilisation of patients admitted in government hospitals in Zimbabwe.

Methods. A cross-sectional survey was conducted in all government hospitals in Zimbabwe. Data collected included hospital and ICU structure, as well as mobilisation activities activities of ICU patients.

Results. A total of 5 ICUs were surveyed. Only 2 units (40.0%) reported that multidisciplinary rounds were conducted daily. A total of 7 physiotherapists were working in the five ICUs during the time of the survey. Five of the physiotherapists worked in 3 ICUs permanently, while the other 2 covered the 2 ICUs on a rotational basis. None of the ICUs had structured protocols in place for patient management. Out of the 40 surveyed patients, only 10 (25.0%) had out-of-bed mobilisation, with 29 (72.5%) of the patients having in-bed mobilisation activities. Level of mobilisation was found to be associated with the type of ICU (χ2 (1)=13.333; p=0.0003). Other factors that were found to be associated with out-of-bed mobilisation in these units included the following: availability of a resident physiotherapist (p=0.03); conduction of multidisciplinary ward rounds (p=0.01); and non-invasive type of ventilation (p=0.01) Conclusion. Successful implementation of early mobilisation is influenced by many factors that are not only patient-related.

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ABSTRACTS

Invasive fungal infections in the paediatric intensive care unit: Epidemiology, risk factors and outcome S Hlophe* Inkosi Albert Luthuli Central Hospital *sbehlophe@gmail.com Background. Fungal infections and colonisation are common in the paediatric intensive care unit (PICU). Systemic antifungal agents have been used successfully to prevent invasive fungal infection by Candida spp.

Objectives. To describe the epidemiology, predictors and outcomes of invasive fungal infection.

Methods. A retrospective cross-sectional study was conducted at the Inkosi Albert Luthuli Central Hospital PICU, between January 2015 and December 2016. Cases hadconfirmed invasive fungal infection with positive fungal blood cultures; or probable invasive fungal infection, with at least two of the following indicators: elevated serum (1-3)-β-D glucan levels, positive urine culture, or positive endotracheal aspirate culture. Controls were those with bacterial, negative or mixed cultures.

Results. Invasive fungal infection was detected in 19 of 1 029 patients, with a prevalence of 1.85 per 100 admissions. Predisposing risk factors identified were central venous catheters (84%), urinary catheters (100%), previous surgery (63%), total parenteral nutrition (63%), and previous broad-spectrum antibiotics (vancomycin) in 47%. The in-hospital mortality rate was 16.5% (170/1 029) and the case fatality ratio was 36.8% (n=7) v. 16.1% (163/1 010) in the controls. The average length of stay for cases was 20.5 days v. 8.3 days for controls. Conclusion.

Fungal infections contribute to increased mortality and morbidity. Risk factors identified in this study included catheter placements and the use of parenteral nutrition and broad-spectrum antibiotics.

The clinical utility of non-invasive pulse co-oximetry haemoglobin measurements in dark skinned critically ill patients.

S Murphy,* S Omar Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand *Susan.Murphy@wits.ac.za Background. Noninvasive devices which measure percutaneous haemaglobin (Hb) have been evaluated previously, predominantly in pale-skinned adults.

Objectives. To assess the clinical usefulness of a point-of-care device that measures haemoglobin non-invasively (SpHb) in critically ill participants with dark skin pigmentation.

Methods. A total of 149 adult and paediatric participants from a multidisciplinary intensive care unit had intermittent readings of noninvasive Hb measurements performed at 4-hour intervals. In total, 371 readings were performed. Concurrent blood samples were taken to assess Hb levels using a point-of-care blood gas analyser. Samples were analysed at the central laboratory. Bland-Altmann plots were constructed to assess the agreement between results from the 2 pointof-care devices and the reference standard (laboratory Hb).

Results. SpHb exhibited significant bias when compared with laboratory Hb, while blood gas Hb did not. The mean bias for SpHb was +1.64 (limits of agreement, LOA –1.03 - 4.31) compared with blood gas HB,

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which showed a bias of +0.26 ( LOA: –0.84 - 1.37). The magnitude of the bias for SpHb increased with increasing mean Hb levels. Of all the additional study variables assessed for their effects on bias, only the Apache II score in adult patients (p<0.0001) and mean arterial blood pressure (p=0.001) had an effect. Skin pigmentation did not have any effect on the magnitude of the bias.

Conclusion. Non-invasive Hb devices require further refinements to be clinically useful in dark-skinned critically ill patients with low Hb levels.

Low-molecular-weight heparin dosing in critically ill patients: Are we getting it right?

J Chausse,1* G Joynt,2 N Mojaki,1 M Karodia,3 J Vlok,4 S Mootilall,1 F Paruk1 Department of Critical Care, University of Pretoria, South Africa Department of Anesthesia and Intensive Care, Chinese University of Hong Kong, China 3 Lancet Laboratories 4 Independent Practice, South Africa *julianmchausse@yahoo.com 1 2

Background. In critically ill patients there is a suggestion that conventionally recommended doses of low-molecular-weight heparin (LMWH) prophylaxis may be inadequate, yet routine monitoring of anti-factor Xa (anti-Xa) levels is not considered to be standard of care.

Objectives. To ascertain if the current prophylaxis regimen for enoxaparin produces adequate plasma anti-Xa concentrations in patients and secondly, to determine whether there is a correlation between creatinine clearance or body mass index (BMI) and achieved anti-Xa concentrations.

Methods. A prospective descriptive pilot study of 45 adult patients admitted to the surgical intensive care and high care unit was conducted at Steve Biko Academic Hospital. Anti-Xa levels were evaluated pre and post enoxaparin administration on days 2 and 4 following enoxaparin initiation. Creatinine clearance was simultaneously measured on days 2 and 4, with the collection of a 24-hour urine sample.

Results. Forty-five participants aged 18 - 70 years were recruited.

The mean (standard deviation (SD)) APACHE 2 and SOFA Scores on admission were 11 (5) and 5 (3), respectively. Seven participants (16%) were receiving vasopressor therapy. The mean (SD) creatinine clearance was 150 (56) and 148 (62) mL/min on days 2 and 4, respectively. AntiXa levels were in the prophylactic range for only 10 (22%) and 18 (40%) participants on days 2 and 4, respectively. Only one participant demonstrated an adequate pre-dose anti-Xa level on day 4.

Conclusion. A large proportion of the participants exhibited subprophylactic anti-Xa levels. Anti-Xa level monitoring with dose adjustment is thus recommended for critically ill patients.

Pharmacokinetics and dosing simulations to evaluate cefazolin prophylaxis regimens for cardiopulmonary bypass surgery A Alli,1* C Roger,2 J Lipman,3 D Calleemalay,1 S Wallis,4 J Scribante,1 G Richards,1 J Roberts,3 F Paruk,5 1 2

University of the Witwatersrand, Johannesburg, South Africa Department of Anesthesiology, Critical Care Pain and Emergency Medicine, Nimes University Hospital, France

ABSTRACTS

Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia 4 Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia 5 Faculty of Health Sciences, Department of Critical Care, University of Pretoria, South Africa *halothane@gmail.com 3

Background. There is no consensus regarding what constitutes an appropriate antibiotic prophylaxis regimen in the scenario of cardiopulmonary bypass (CPB).

Objectives. To describe the effects of CPB on serum concentrations of cefazolin during a bolus dosing regimen.

Methods. Patients undergoing CPB for elective cardiac valve replacement in an academic hospital in Johannesburg, South Africa were eligible for inclusion. Institutional ethics committee approval was obtained. Intravenous cefazolin (2 g) was administered pre-incision and repeated at 4 hours. Serial blood and urine samples were analysed using validated chromatography. Population pharmacokinetic modelling and Monte-Carlo simulations were employed using Pmetrics to determine the attainment of therapeutic exposures of cefazolin (probability of target attainment) against organisms known to cause surgical site infections. Minimum inhibitory concentration (MIC) data of the organisms from the EUCAST database were used.

Results. From the 16 included patients, 195 total and 64 unbound concentrations of cefazolin were obtained. The mean (standard deviation) fraction excreted in urine and CPB extraction ratio of cefazolin was 39.6% (0.2) and 3.2% (2.1), respectively. A threecompartment linear population pharmacokinetic model best described the data. We observed that the standard dosing regimen was suboptimal for Staphylococcus aureus and Escherichia coli at a creatinine concentration ≤50 μmol/L, and for S. epidermidis at any dose and creatinine concentration.

Discussion: Cefazolin 2 g at 4-hourly intervals was not able to maintain concentrations above the MIC for relevant pathogens in patients undergoing cardiac surgery involving CPB with normal creatinine and albumin concentrations. The simulations showed that optimised dosing should increase the dose and/or dosing frequency.

Muscle strength and endurance as potential predictors of successful extubation in mechanically ventilated patients: A pilot study CR de Beer,* AJ van Rooijen, JP Pretorius, P Rheeder, F Paruk Departments of Physiotherapy, Critical Care and Internal Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa *crdebeer@gmail.com Background. Since the inception of mechanical ventilators, it has been acknowledged that successful weaning is not always predictable. No single test in isolation has demonstrated to accurately predict the extubation outcome. Earlier studies have shown an association between peripheral and respiratory muscle weakness. To our knowledge, no study has explored the association between muscle strength (deltoid, sternocleidomastoid and trapezius), endurance and the readiness for extubation.

Objectives. To ascertain whether muscle strength and endurance may be used as possible predictors of successful extubation in mechanically ventilated patients.

Methods. Thirty patients were recruited in a prospective study conducted at a tertiary academic hospital. Deltoid, sternocleidomastoid and trapezius muscle strength were evaluated with the Oxford grading scale. Respiratory muscle strength was adjudged with the maximum inspiratory and expiratory pressures. Muscle endurance was determined by subjecting the patients to ride the MOTOmed letto2 cycle ergometer for five minutes with the upper limbs. Ethical approval was obtained from the research ethics committee, University of Pretoria.

Results. Patients ventilated for >3 days with grade 3 muscle strength of deltoid and sternocleidomastoid muscles, respectively, had a 100% chance of successful extubation (p=0.038). Trapezius muscle strength (p=0.366) was not associated with successful extubation. Patients unable to ride the MOTOmed letto2 cycle ergometer actively with the upper limbs for 4.5 minutes and covering a distance of 0.5 km demonstrated a linear trend (p=0.006) to fail extubation.

Conclusion. Muscle strength and endurance may be useful tools to predict the success of extubation.

The development of a framework for the improvement of intensive care delivery: A systemic intervention J Scribante,1* T Andrew,2 A van Nieuwkerk,3 S Bhagwanjee3 Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa 2 Faculty of Engineering and the Built Environment, Durban University of Technology, Durban, South Africa 3 School of Governance, University of the Witwatersrand, Johannesburg, South Africa 4 Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, United States of America *juan.scribante@wits.ac.za 1

Background. Initiatives following the traditional reductionist approach to improve the complex delivery of intensive care has had limited success.

Objectives. To develop a systemic framework for the improvement of intensive care delivery.

Methods. Following approval from the Wits Human Research Ethics Committee, an understanding of intensive care delivery in South Africa was obtained by ‘making sense of the mess’ using a systems approach.

Systemic intervention served as the meta-methodology and methods and techniques from interactive planning, critical systems heuristics, soft-system methodology and viable system model were employed.

Making sense of the mess emphasised the complexity of intensive care delivery, both on a situational and cognitive level. It became clear that one methodology would not suffice, but that a pluralist methodological approach was required to guide improvement in intensive care delivery.

Based on this understanding, nine principles were formulated to guide the development of the framework. The same systems, methods and techniques used in the understanding phase were used to build a systemic framework.

Results. Embedded in the proposed framework are matters relating to systemicity, complexity, flexibility, empowerment and transformation of intensive care delivery. It allows for multiple perspectives, including that of marginalised stakeholders and the mitigating of multi-vested interests and power relationships.

Conclusion. The proposed framework is both flexible and adaptable to promote learning about the complex problems of intensive care delivery.

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ABSTRACTS

It aims to facilitate sustainable improvement of intensive care delivery and to ensure the just use of resources that fosters distributive justice.

A comparison of haemoglobin monitoring by two point-of-care devices with standardised laboratory-based measurement M Johnson,* JF Coetzee, AI Levin Anaesthesiology and Critical Care, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa *mariannejohnson@sun.ac.za Background. Point-of-care (POC) haemoglobin concentration [Hb] estimations guide acute decisions on red blood cell transfusion.

Objectives. We studied the accuracy of POC devices compared with laboratory [Hb] testing and how between-method [Hb] disagreements affected the decision to transfuse.

Methods. Institutional ethics approved a method comparison study of perioperative arterial blood sampling from 60 adult cardiothoracic surgical patients. Samples were handled as prescribed. [Hb] was measured by two IlexGEM Premier 3500 blood gas analysers (BGa and BGb) and the HemoCue Hb 201+ device (HCue) and our laboratory’s Siemens Advia 2120 flow cytometry system. A between-method [Hb] difference exceeding 10% (1 g/dL at [Hb] of 10 g/dL) would likely erroneously inform the transfusion decision. Furthermore, one red blood cell unit represents the smallest transfusion risk and will increase the [Hb] by approximately 1 g/dL. Results. The mean POC (HCue, BGa, BGb) [Hb] underestimated mean laboratory [Hb] by 0.79, 0.81 and 0.67 g/dL, respectively. The 95% confidence interval (CI) of the between-method difference revealed that, unlike the BGa (95% CI 0.45 - 1.15) and the BGb (95% CI 0.46 - 1.16), the HCue (95% CI 0.47 - 0.87) values did not breach the 1 g/dL predetermined limit. Bland-Altman analysis revealed similar between-method mean [Hb] differences. However, the HCue’s upper and lower limits of agreement (LOA) were narrower, without encroachment on those of the BGa and BGb. Also, the 95% CI of the HCue’s lower LOA was <1 g/dL; this device did not clinically overestimate lab [Hb].

Conclusion. The HCue was more accurate than the BG devices, with reduced potential for transfusion error.

Reliability of ultrasonic diaphragm thickness measurement in mechanically ventilated infants and children: A pilot study M Terhart,* SD Hanekom, AR Lupton-Smith, BM Morrow Stellenbosch University *maxineterhart@gmail.com Background. Diaphragmatic atrophy in mechanically ventilated infants and children could be due to ventilator-induced diaphragmatic dysfunction, which could lead to extubation failure. Ultrasound may be used to identify diaphragmatic atrophy reliably and could be beneficial for further research that would ultimately lead to clinical practice changes. There are currently no data reporting on the use of ultrasound to monitor diaphragm atrophy in the paediatric population.

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Objectives. To assess the inter- and intra-rater reliability of using ultrasound to measure diaphragm thickness in mechanicallyventilated infants and children.

Methods. Diaphragm thickness measures were compared between two individual researchers for inter-rater reliability and between multiple measures from a single researcher for intra-rater reliability.

Measures were compared using intraclass correlation coefficients and Bland-Altman plots.

Results. Results indicated excellent reliability between measures for both inter- and intra-rater reliability, with slightly better reliably for intra-rater than inter-rater reliability. Intraclass Correlation Coefficients for inter-rater reliability were between 0.77 and 0.98, and 0.94 for intra-rater reliability.

Conclusion. Ultrasound measures of diaphragm thickness can be used to reliably measure diaphragm thickness in mechanically-ventilated infants and children. This modality could therefore be used as a reliable outcome measure in clinical research studies, with the ultimate goal of identifying children at risk for extubation failure due to ventilatorinduced diaphragmatic atrophy.

Initial experience of extracorporeal membrane oxygenation service at a tertiary academic centre: Acase series of 7 patients D Thomson,* T Pennel, G Calligaro, M Miller, I Joubert Groote Schuur Hospital and University of Cape Town *thomson.david@gmail.com Background. Extracorporeal membrane oxygenation (ECMO) is a complicated, expensive therapy with a significant expected mortality.

Objectives. To review all patients undergoing ECMO treatment at our institution.

Methods. Patient notes, ELSO registry data and nurse training initiatives were reviewed from the initiation of our ECMO service.

Information relating to clinical condition, rescue interventions prior to ECMO initiation, details of each ECMO run and subsequent ICU and hospital stay was reviewed. All patients undergoing ECMO were individually consented for inclusion in the study.

Results. A series of 7 ECMO training workshops and twelve 1-hour refresher sessions were run over the study period. A total of 7 patients received ECMO during the period of 1 June 2016 to 1 August 2017. There were 3 veno-arterial (VA) ECMO patients and 4 veno-venous (VV) ECMO patients. All VA patients were post cardiotomy with inability to come off cardiopulmonary bypass.

There was 1 survivor in this group. All VV ECMO patients were successfully weaned from ECMO onto mechanical ventilation.

Two patients with alveolar proteinosis had ECMO for inability to tolerate single lung ventilation for whole lung lavage, one patient had Pneumocystis carinii pneumonia and another patient had H1N1 pneumonia with refractory hypoxaemia and protracted runs of 48 and 30 days, respectively.

Conclusion. ECMO has clinical utility for carefully selected patients and good results can be achieved in resource-constrained environments with low patient volume where there is adequate training. Our results are in accordance with published ELSO registry data with worse outcomes shown for VA ECMO when compared with VV ECMO.

ABSTRACTS

Renal transplantation from donors after circulatory arrest: The Initial Groote Schuur Hospital Experience D Thomson,* T du Toit, K Manning, E Muller, Z Barday Groote Schuur Hospital and the University of Cape Town *thomson.david@gmail.com Background. Critical shortages of deceased donor organs for transplantation have led to expansion of the donor pool through the use of extended criteria donors. One such extended criterion donor is a donor after circulatory death (DCD).

Objectives. The aim of this study was to review our experience with the use of DCDs by reporting on donor characteristics and kidney recipient outcomes.

Methods. Retrospective descriptive study of DCD referrals, donor characteristics and recipient outcome at Groote Schuur Hospital (from January 2007 to December 2016), utilising a donor referral and recipient registry.

Results. Compared with donor after brain death (DBD) referrals, DCD referrals were less likely to be eligible for kidney donation (33.0% v.

66.7%) and less likely to grant consent to donation (25.9% v. 33.4%).

Over the 10-year period, there were 146 DBD procurements and 13 DCD procurements. No DCD kidneys were discarded. The cause of death was more likely to be traumatic in the DCD cohort with a terminal creatinine of 120.9 mmol/L (v. 100.6 mmol/L in the DBD cohort). There was an increased incidence of delayed graft function in the DCD cohort but transplant outcomes were acceptable.

Conclusion. DCD is an effective method of increasing the donor pool and expanding the number of patients who are offered transplantation.

There is an increased incidence of delayed graft function but outcomes are acceptable.

Adverse event reporting system experienced by critical care nurses in KwaZulu-Natal, South Africa T Gqaleni,* BR Bhengu University of KwaZulu-Natal *gqalenit@ukzn.ac.za Background. Critically ill patients admitted to critical care units (CCUs) have life-threatening or potentially life-threatening problems. It is perceived that, irrespective of high percentages of occurrence of adverse events, the incidences remain under-reported. For those that are reported, little is done to prevent future recurrence as feedback may be lacking.

Objectives. This study explored the experiences of critical care nurses (CCNs) in relation to how the reported adverse events were analysed and handled in CCUs. Methods. The study was conducted in the CCUs of 5 purposively selected hospitals. A qualitative design was used to obtain data through in-depth interviews from a purposive sample of 5 unit managers working in the CCUs to provide insights into their experiences. This study was a part of a larger study using a mixed-method approach. The recorded qualitative data were analysed using Teschâ&#x20AC;&#x2122;s content analysis.

Results. The main categories of information that emerged during data analysis were: (i) the existence of adverse event reporting system; (ii)

occurrence of adverse events; (iii) promotion and barriers of an adverse event reporting; and (iv) handling of adverse events. The findings demonstrated that there were major gaps that affected the maximum utilisation of the reporting system.

Conclusion. Our study provides an understanding of how the adverse events reporting system is utilised and highlights barriers that affect reporting. To improve adverse event reporting, a non-punitive and non-confrontational system should be promoted.

The effects of a stress management intervention on stress levels of nurses practising in intensive care units: A quasi-experimental study M Haarde,1 S Schmollgruber,1* A Huiskamp,1 S Olorunju2 Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand, South Africa, 2 Medical Research Council of South Africa. *shelley.schmollgruber@wits.ac.za 1

Background. South African professional nurses working in the intensive care unit (ICU) experience many physical and psychosocial hazards and risks. Stress provoked by failure to meet work demands leads to illness, injury and psychological suffering. It is therefore necessary to address the aspects leading to stress and work burnout. This study was conducted in the adult ICUs of a public-sector hospital.

Objectives. The purpose of the study was to develop and pilot test a stress management intervention for nurses practising in ICUs. Methods. A quasi-experimental non-equivalent control group design was selected for this study. It comprised of pre-testing, development and implementation of the intervention and post-testing. Both groups of nurses were recruited from the same hospital by means of convenience sampling, and completed the Expanded Nurses Stress Scale (ENSS).

The intervention group participated in the educational intervention on stress management. The control group received no intervention.

Both groups completed the ENSS 4 weeks after the completion of the intervention. The quantitative data were analysed by means of descriptive summary statistics.

Results. There was clear evidence of significant differences (p=0.000) emerging in all nine subscale scores with respect to level of stress when considering the pre- and post-test scores. This indicates the stress management intervention had an effect on the stress levels of participating nurses. Evaluation of the stress management intervention workshop also revealed that an overwhelming number of nurse participants experienced all activities as meaningful, with contributory worth.

Conclusion. The study concluded that the stress management intervention had an effect on the stress levels of nurses practising in the ICUs at the selected study site.

Roles of specialist intensive care nurses in mechanical ventilation C Ladipo, S Schmollgruber* Department of Nursing Education, Faculty of Health Sciences, School of Therapeutics, University of the Witwatersrand, Johannesburg, South Africa *shelley.schmollgruber@wits.ac.za

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ABSTRACTS

Background. Ventilation management is fundamentally described as a collaborative effort between doctors and specialist nurses. However, this is based on the perceptions and opinions of nurse managers in these studies, and not the viewpoints of individual nurses themselves.

If nurses are to gain credibility in advanced practice they need to have a clear understanding of what is expected of them.

Objectives. The aim of this study was to describe the roles of specialist intensive care nurses in ventilation management.

Methods. A quantitative and cross-sectional survey design was utilised.

The data were collected using a validated questionnaire developed by Rose et al. in 2011.

Results. Of the 165 surveys distributed, 110 were returned (response rate 66.6%). Most nurses agreed that nurses and doctors collaborated in key ventilation decisions, but not when decisions to extubate and initial ventilation settings are made. Regarding independent titrations of ventilator settings, findings showed that the nurses reported a frequency of >50% of the time for titration of respiratory rate, tidal volume, decreasing pressure support, increasing pressure support, titration of inspiratory pressure and ventilation mode changes. Nurses with higher levels of autonomy, influence in decision-making and years of experience scores, frequently (>50% of the time) made independent changes to ventilation settings (p<0.05).

Conclusion. The study concludes that specialist intensive care nurses need to reevaluate their role in ventilation management and focus on key ventilation settings as nurses could strengthen their contribution in the collaboration of key ventilator settings.

The association between diaphragm contractile activity and maximal inspiratory pressure in the intensive care unit – a pilot study LE Brouwer,*1 A Lupton-Smith,1 C Koegelenberg,2 SD Hanekom1 Division of Physiotherapy, Faculty of Health Sciences, Stellenbosch University 2 Division of Pulmonology, Faculty of Health Sciences, Stellenbosch University *lindiegerber15@gmail.com 1

Background. Ventilator-induced diaphragmatic dysfunction causes a loss of the force-generating capacity of the diaphragm and may contribute to weaning failure. Maximal inspiratory pressure is often used to measure inspiratory muscle strength. We investigated whether there is an association between diaphragm contractile activity and maximal inspiratory pressure (MIP).

Objectives. To determine whether the change in the contractile activity of the diaphragm during the course of mechanical ventilation was associated with post-extubation inspiratory muscle strength.

Methods. Diaphragm thickness was measured daily with ultrasound in the zone of apposition using a 5 - 12 MHz ultrasound transducer.

Diaphragm thickness was measured at end-inspiration and endexpiration for three breaths. Diaphragm thickening fraction (DTF) was calculated as the percentage change between thickness at endinspiration and end-expiration, and represents the contractile activity of the diaphragm. MIP was measured within 24 hours of extubation.

Results. A total 27 participants (16.59% male) were studied. The DTF decreased by a median (interquartile range (IQR)) of 0.4% (–2.60 1.15) per day. The mean age (range) was 44 (19 - 80) years and the median (IQR) duration of ventilation was 4 (3 - 7) days. There was an insignificant negative correlation between the rate of change in

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DTF while intubated and MIP post-extubation (r=—0.317; p=0.108).

The first (r=0.17; p=0.39), last (r=—0.09; p=0.65) and post-extubation DTF (r=0.01; p=0.96) were not significantly correlated with MIP. Conclusion. Majority of participants showed a decline in DTFs during mechanical ventilation. Diaphragm contractile activity is not strongly correlated with volitional measures of inspiratory muscle strength.

Understanding the psychological contracts of intensive care unit nurses D Thomson,1* L Ronnie2 Groote Schuur Hospital and the University of Cape Town University of Cape Town Graduate School of Business, Green Point, Cape Town, South Africa *thomson.david@gmail.com 1 2

Background. Nurses, especially those in intensive care units (ICUs), are instrumental in managing the quality and efficiency of patient care and play a critical role within the South African (SA) public health system. Factors such as staff shortages and a lack of basic resources have the potential to impact negatively on their psychological contract and motivation levels.

Objectives. This paper examined the mutual obligations implicit in the psychological contract of ICU nurses and nursing management.

Psychological contract fulfilment and its effect on the motivation of these nurses was also explored.

Methods. Data were gathered through semi-structured interviews with 44 ICU nurses at a tertiary hospital in SA. Nine senior nursing staff were also interviewed to provide a management perspective. Fifteen nurses declined to participate in the study. Thematic analysis was used to identify the relevant elements of the psychological contract and to establish connections with motivational aspects.

Results. Provisional analysis showed that the psychological contracts of most ICU nurses are relational in nature. Nurses experience sincere enjoyment of their work and are emotionally connected to their patients and the hospital. The nurses thrive on the challenges of the ICU and appreciate ongoing professional development initiatives. These factors underpin the high motivation levels of most nurses despite some interpersonal issues between themselves and their management.

Conclusion. ICU nurses want visible unit management with appreciation demonstrated in both tangible and non-tangible ways.

A 1-year audit of central venous catheter colonisation in the Dr George Mukhari Academic Hospital Intensive Care Unit, Ga-Rankuwa, South Africa T Namanyane,1* M Motiang2 Department of Anaesthesiology, Sefako Makgatho Health Science University Department of Intensive Care, Sefako Makgatho Health Science University *mammie@telkomsa.net

1 2

Background. Central venous catheters (CVC) are used to access the vascular system for the delivery of medication, parenteral nutrition and haemodynamic monitoring in the intensive care unit (ICU).

CVC colonisation rates as high as 63% have been reported, and are considered a prerequisite for the development of catheter-related bloodstream infection.

ABSTRACTS

Objectives. To determine the incidence of catheter tip colonisation, the types of microorganisms, length of ICU stay in patients with positive cultures and their outcomes.

Methods. We conducted a retrospective study of all patients with positive catheter tip cultures from April 2015 to March 2016, as reported by the microbiology department.

Results. In total, 70 patients were reviewed. The mean (standard deviation (SD)) age of the patients was 40.46 (16.96) years. Of the total number of ICU admissions, 9.9% (n=70) had positive CVC tip cultures.

Coagulase-negative staphylococci (42.9%; n=30), Acinetobacter baumannii (20.0%; n=14), Klebsiella pneumoniae (10.0%; n=7), and Pseudomonas aeruginosa (4.3%; n=3) were the most commonly isolated organisms. The mean (SD) length of ICU stay was 19 (15.29) days (range 8 - 87). The mortality rate was 37.1% (n=26).

Conclusion. Coagulase-negative staphylococci were the most frequent microorganisms that colonised the CVCs in our unit. These results must be interpreted with caution with regard to the clinical context, especially given the relatively high mortality rate. A blood, wound and urine culture must always be performed to correlate the results. Guidelines for the prevention of intravascular catheter-related infections should always be implemented.

Acid load and urinary chloride excretion during metabolic acidosis in critically ill patients S Omar,1* R Mathivha,1 J George,2 M Maphayi,2 BT Wilding,1 T Ferreira3 University of Witwatersrand University of Witwatersrand, NHLS 3 Chris Hani Baragwanath Academic Hospital *shahedicu@gmail.com 1 2

Background. The administration of intravenous fluids is a common intervention in the intensive care unit. A high chloride content fluid may be associated with detrimental effects but the exact mechanism is unknown.

Objectives. To describe renal chloride handling in critically ill adult patients with metabolic acidosis.

Methods. A prospective experimental study was performed.

Routine bloods and additional urine samples were collected. Urine pH, electrolytes and osmolality were measured. A physicochemical approach was used to calculate total acid load (standard base deficit, SBDacid) and components. Urinary measurements were used to describe renal tubular acidosis (RTA) and its absence (no RTA). Finally, we assessed the independent predictors of urine chloride concentration (UCl).

Results. The median age was 44.5 years and the predicted mortality rate was 12.1% (n=22). The median lactate concentration was 4.5 mmol/L, while the median pH was 7.24. Chloride contributed 79.5% to the SBDacid. Six of the 22 cases could be defined as RTA or no RTA. The median UCl (mmol/L) was 75 (no RTA) v. 115 (RTA). The median pH was lower (7.21 v. 7.26) and the lactate concentration (mmol/L) was higher (9.0 v. 3.1) in the no RTA group. Spearman correlations showed significant correlations between UCl and lactate concentration (inverse), SBD unmeasured anions (inverse), estimated glomerular filtration rate (eGFR) and urinary sodium concentration (UNa). Applying these to a multiple regression model revealed that the independent predictors of UCl were lactate, eGFR and UNa.

Conclusion. UCl is reduced by elevations in lactate concentration and eGFR (increased unmeasured anions). Preferential excretion of other anions limiting chloride excretion may be adaptive rather than deleterious.

Sepsis and outcomes of admission to the paediatric intensive care unit at the Nelson Mandela Academic Hospital, Mthatha, South Africa N Sotobe-Mbana,1* B Makongwana,1 L Pepeta2 Walter Sisulu University Nelson Mandela Metropolitan University *mizpa00@gmail.com 1 2

Background. The paediatric burden of sepsis in developing countries is poorly documented.

Objective. To assess the contribution of sepsis to paediatric mortality in a paediatric intensive care unit (PICU) in a resource-poor tertiary hospital.

Methods. We conducted a retrospective review of records of paediatric patients (1 month to 13 years of age) admitted to the PICU at the Nelson Mandela Academic Hospital from January 2016 to December 2016. Patient demographics, sepsis prevalence, culture results, risk factors (including immunologic status and herbal medication use) and patient outcomes were analysed. The International Paediatric Sepsis Conference Group definition of sepsis was used.

Results. A total of 176 patients were included in the study. There were 85 (48%) females and 91 (52%) males; 122 (69%) patients were <1 year of age, 26 (15%) patients were aged 1 - 5 years, and 28 (16%) patients were >5 years of age. The sepsis prevalence was 57.14% (95% confidence interval 49.46 - 64.58), and the prevalence was higher in infants (63.11%). There was a high contamination rate with more Gram-positive than Gram-negative blood culture results. Extendedspectrum β-lactamase-producing (ESBL) Klebsiella pneumoniae and Acinetobacter baumannii were the most common Gram-negative isolates. The two most significant risk factors for sepsis were age <1 year and HIV infection. One hundred (56.8%) patients were discharged and 76 (43.2%) patients demised. Sepsis, length of stay <2 days and herbal medicine ingestion were the three significant predictors of mortality in the PICU. Conclusion. Sepsis prevalence was high in this setting and is associated with high mortality. Age <1 year and HIV infection are significant risk factors. ESBL K. pneumoniae and A. baumannii were commonly associated with sepsis in this cohort.

A bicarbonate-based physiologically balanced fluid in critically ill patients S Omar,1* LR Mathivha2 University of Witwatersrand Chris Hani Baragwanath Academic Hospital *shahedicu@gmail.com 1 2

Background. Most crystalloid solutions used in critically ill patients have a greater chloride (Cl—) concentration than plasma, which may be detrimental. Replacement with some bicarbonate (HCO3—) may reduce Cl–, but may have its own side-effects.

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ABSTRACTS Objectives. To determine if balanced fluid resulted in increased PaCO2 compared with the conventional fluid group.

Methods. A single-centre, open and randomised controlled trial was conducted in an academic adult intensive care unit (ICU), comparing balanced fluid (sodium (Na+) = 142 mmol/L; Cl—= 99 mmol/L) with conventional fluid (Na+ = 130 mmol/L; Cl— = 110 mmol/L).

Results. A total of 46 patients were allocated to the conventional fluid group and 40 to the balanced fluid group. At baseline, the two groups were well matched (p>0.05) for age, weight, gender, severity of illness and organ support. There were no significant differences in PaCO2 between the two fluid groups, overall or at D1, D5 or D7. The balanced fluid group showed a significant improvement in estimated glomerular filtration rate, between D0 and D5 (p=0.02), while the conventional fluid group exhibited a significant decline (p=0.00). There were no significant differences between the 2 groups with respect to fluid requirements, number of positive blood cultures, ICU renal replacement utilisation, ICU length of stay, ICU mortality and 28-day mortality.

Conclusion. The use of a physiologically balanced fluid containing 142 mmol/L of Na+, 99 mmol/L of Cl— and 49 mmol/L of HCO3— did not result in an increase in PaCO2 and appears to be safe in our population of critically ill patients. There appears to be a beneficial effect on renal function.

Patients’ experience of mechanical ventilation OB Adeyemi, S Schmollgruber* Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg *shelley.schmollgruber@wits.ac.za

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Background. Mechanical ventilation is a life-saving and frequentlyused treatment modality in a variety of medical diagnoses in the intensive care unit (ICU). Despite this, mechanical ventilation can be a distressing experience for the patient and may result in anxiety and discomfort.

Objectives. This study explored and described the experiences of patients on mechanical ventilation in the intensive care unit of a public-sector hospital in Johannesburg.

Methods. A qualitative, descriptive and explorative design was used, and 10 mechanically ventilated patients were recruited from the ICU. The data were collected using audio-taped in-depth interviews. The data was analysed using Clarke and Braun’s 2013 descriptive method.

Results. Physical experiences were described in terms of experiences of breathlessness, mouth dryness, pain and physical discomfort as a result of being placed on the ventilator. Emotional experiences were described as experiences of bothering, fear of the unknown, anxiety, feeling shocked and frightened at the moment of waking up from anaesthesia.

The administration of sedation to some of the participants affected their memory in recalling events that happened while in the ICU. Lack of sufficient information, short visiting hours and family presence also impact the emotional state of the participants. Amid these unpleasant experiences, most of the participants appreciated the caring attitude of the ICU nursing staff which gave them a sense of comfort and safety.

Conclusion. Physical and emotional experiences were the major challenges faced by patients on mechanical ventilation. Most of the participants’ experiences were described as unpleasant.

NOTES

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

REVIEWERS

List of reviewers, 2017 Peer review is the life blood of this Journal. The Editors are deeply grateful to the following experts who freely gave their time during 2017 to review articles submitted for publication.

Alison Lupton-Smith Andrew Argent Andrew Whitelaw Anna-Lena du Toit Anri Human Brenda Morrow Bronwen Espen Cathrine Tadyanemhandu Charmaine Cunningham Cheryl Carter David Thomson Dean Gopalan Debbie Baker Fathima Paruk Gladness Nethathe Heide Kunzmann Ivan Joubert Jacques Scherman Janet Bell Juan Scribante Kim de Vasconsellos

Konstantin Dimitriades Lance Michell Lauren Hill Lettie Prins Malcolm Miller Marianna van der Heever Maryke Spruyt Mervyn Mer Mike James Monique van Dijk Natascha Plani Norbert Welkowics Petra Brysiewicz Portia Jordan Rencia Gillespie Ricky Raine Robert Kleinloog Sam Ntuli Shelley Schmollgruber Susan Hanekom Yolanda Walsh

Contact details: Alison Shaw, CCSSA Secretariat, 5 Hayman Park, Sunbury Park, Douglas Saunders Drive, La Lucia Ridge, KwaZulu-Natal, 4051, South Africa Tel: (031) 831 6416, Critical Care Society of Southern Africa

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Email: secretariat@criticalcare.org.za, Website: www.criticalcare.org.za

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