critical care 2013 day 1

ISSUE 01

DELEGATES URGED TO TAKE ACTION TO BEAT THE SCOURGE OF SEPSIS

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very few seconds someone dies as a result of sepsis. Globally, 20 to 30 million patients are afflicted with sepsis each year and, every hour, approximately 2 000 people die from sepsis worldwide with over six million of these being neonatal deaths.

There has also been a dramatic increase in the number of sepsis related deaths in hospitals since 2008.

Speaking at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine, Konrad Reinhart, chairman of the Global Sepsis Alliance, called on medical professionals to support World Sepsis Day on September 13.

He provided shocking statistics. Sepsis is growing by 8.2 percent in developed countries with very little data from developing countries available. The mortality rate is unacceptably high, creating a massive health and economic burden and a need for providing effective practical guidelines and raising both professional and public awareness.

Drawing on a long list of research results from a number of different countries in Europe, America, Asia and Africa, he said that some figures suggested that around 220 out of 100 000 inhabitants are affected by sepsis each year. This is thought to escalate to as much as 327 out of 100 000 inhabitants in developing countries.

According to a study conducted by the United Sates Centres for Disease Control, American hospitals dealt with 123 590 patients with sepsis, at an annual cost of approximately $14.6 billion.

One of Reinhart’s key concerns was that research into sepsis is under-funded and undervalued.

By SHIRLEY LE GUIN He pointed out that, in the US where 377 out of 100 000 inhabitants were affected by cancer, $91 million was invested in research as against just $2,277 when it came to sepsis.

“Money and what you do with it makes a difference,” he said.

Nevertheless, he said a great deal could be learnt from how cancer and cardiology had been handled. When it came to cardiology, there had been huge advances since the 1960s, bringing down the death rate through the introduction of new diagnostic procedures and increasing public awareness.

According to Reinhart, in the run up to the formulation of the World Sepsis Declaration and the launch of World Sepsis Day, the goal had been to get commitment from 1 000 healthcare facilities.

So far, 93 countries around the world had pledged support and the Global Sepsis Alliance had hosted 200 events in 40 countries. The organization had also reached 550 publications with an estimated readership of 80 million.

Turning to his audience at the conference, Reinhart emphasised that all concerned with stemming the tide of sepsis infection worldwide needed to sign the Global Sepsis Declaration, encourage their health care facilities and hospitals to support it, start quality improvement initiatives for sepsis prevention and management, organise meetings and events on World Sepsis Day and create inter-disciplinary and transsectoral coalitions to fight sepsis.

Delegates were entertained by traditional dancers and a play and puppet show performed by conference organisers at the opening ceremony

DECIDING WHO GETS THE ICU BED IS NO EASY TASK FOR HOSPITALS H

ospitals in most countries struggle with the dilemma of a shortage of ICU beds and are faced with the ethical question of how to allocate the scarce resource fairly.

This was the issue raised by Charles Sprung, law and ethics director of the Institute of Medicine and director of the General Intensive Care Unit at the Hadassah Medical Organisation in Israel at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine. The conference is currently underway in Durban.

Charles Sprung, law and ethics director of the Institute of Medicine and director of the General Intensive Care Unit at the Hadassah Medical Organisation

By LYSE COMINS Sprung was speaking on triage in critical care and the integration of ethics and evidence regarding which patients should be admitted to ICU. “Many times we don’t always get what we want in terms of all the patients taken into the ICU,” Sprung said. “There are many factors we can use in selecting patients to admit them to the ICU.” Sprung said most people are admitted to ICU on the basis of ‘first come first served’. However, he added that the majority of intensivists used the clear medical benefit to the patient as espoused by the Society of Critical Care Medicine.

“But the question is what is benefit and how do we define benefit?

Is it overall survival? The asthmatic perhaps has a 98 or close to 100 percent expectation of survival if he is admitted.

“Or is it a difference in survival?”

He added that an 80-year-old patient may have only an overall 80 percent chance of survival if admitted to ICU compared to a 40 percent chance of survival if admitted to a ward.

Sprung said in a study at five Israeli hospitals, experts had evaluated all patients meeting inclusion criteria on the day of admission and again 30 days later. “There was a benefit of higher survival of ICU patients compared to those meeting ICU criteria who were admitted to the ward,” Sprung said.

A study in 11 ICUs in seven European Union countries explored the impact of ICU treatment on elderly patients over an 18-month period.

“The accepted patients had a lower mortality than those that were rejected and there was a survival advantage for those being admitted to the ICU as a critically ill patient,” Sprung said.

While older patients had a higher mortality rate in the ICU compared to younger patients, Sprung said, the study found a significant difference in survival for older patients who were admitted to ICU compared to those denied treatment in the same age group.

“It would appear that the benefit of the ICU is greater in the elderly patient,” Sprung said.

CULTURAL RESPONSES TO DEATH S

outh Africa needs to develop policies and training on how to deal with death in ICU. This was the message from Petra Brysiewicz, Professor of Nursing at the University of KwaZulu-Natal to delegates at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine in Durban.

Recent studies have revealed the cultural complexities and shortfalls of interactions between doctors, nurses and the family of the dying patient.

Brysiewicz said African ICU health professionals were at the epicenter of the health worker skills shortage with 23 percent of the global health burden and three percent of the staff.

Brysiewicz, who has researched the interactions of medical staff and families at health care facilities in the province over the past ten years, highlighted some of the complexities and challenges that she found.

“In SA working in the ICU you might often have the doctor, the nurse, the family and the patient all coming from completely different cultural groups which makes it an interesting situation to work in,” she said.

“It adds another dimension to managing these patients and their families.”

Brysiewicz said during her research she had asked staff how they dealt with the culturally diverse needs of patients.

“They speak about the need to

By LYSE COMINS have religious tolerance and respect.

One person who was interviewed said ‘family members often come back after the person has died to collect the spirit because they believe the spirit of that person is still there so we allow them to do that’.”

“Usually this involves bringing in the branch of a tree so you can imagine what it means in a sterile ICU environment when you are welcoming family members to come in with a dirty tree branch to wave it around.”

Brysiewicz said different cultural groups required different psychosocial support.

“Some cultures and people, for example, like touch, other people don’t. For some people its about eye contact for other’s not, so it becomes very difficult to keep up to date and to know what to do.”

Brysiewicz said there were also potential areas of conflict in carrying out rituals and practices in the ICU when families wanted to perform rituals that staff felt were not in the patient’s best interests. The rituals included the need to light matches to burn things in the ICU, which posed a hazard in the oxygen rich environment.

She added that there was also conflict between doctors and nurses in terms of providing information to patients, with some nurses feeling that doctors give false hope to families by telling them what they want to hear.

Professor Petra Brysiewicz

Some nurses found doctors to be “cold” and others “good and prepared to go the extra mile”.

Brysiewicz said families were often subservient and afraid to talk to staff or ask questions.

“Families in KZN see healthcare professionals as cold and unapproachable and say they are really not sure if they are caring,” Brysiewicz said.

Brysiewicz said there was a need for staff training to improve communication with families and for a collaborative multi-discliplinary team approach to develop policies and protocols to provide guidance and support when dealing with death.

AS TECHNOLOGY ADVANCES, DON’T FORGET THE HUMAN FACTOR T

he term ‘the more things change, the more they stay the same’ could have been the over-arching theme of the Max Weill Lecture, delivered by Jean-Louis Vincent, Professor and Head of Department at the Intensive Care faculty at the University of Brussels, Belgium at at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine.

“We have made much progress in our field, we now have sophisticated computers to help us at the bedside, we now have so many machines that the difficulty is to see the patient!”

But, he stressed, the human factor still remains the most important.

In his highly-entertaining, illustrated talk, Dr Vincent spoke about how technology has allowed critical care support, like machines and diagnostic equipment, to become smaller, more portable, more efficient and more personal.

At the same time the human element, the personal touch, remains the single most important factor in critical care.

Dr Vincent drew laughter from the 2000-strong audience when he showed a picture of a stethoscope, asking if -

By NIKI MOORE with all our state-of-the-art technology - we would ever use the stethoscope again? The answer, he said, is ‘of course’, as health professionals ‘you like to have it around your neck, but will you need it future?’ It is a symbol of our profession, he said, which means it would remain.

As a theme, Prof Vincent adopted the acronym PITCH, with its various meanings that could refer to music or sport. The P in pitch stood for Pathophysiology; the I for Investigation; the T is Teamwork, the C is communication; the H is Humanity.

When medical professionals were surveyed about what attracted them to critical care, people responded that they most liked the intellectual stimulation.

Critical care at the bedside rendered immediate effects.

Within minutes of treatment, it was possible to see the response in the patient.

However, the second item, the I for Investigation, urged professionals not simply to apply protocols but to do further investigation into the different factors affecting the patients.

Anita Graham from Johannesburg said she came to the conference to gain an international perspective on critical care practices.

The T in PITCH stood for Teamwork, and Prof Vincent declared that he would rather have a good nurse than good technology.

He stressed that there should be better collaboration between disciplines in the ICU. For example, physiotherapists were badly needed in critical care, as mobility of patients was extremely beneficial.

The C in PITCH stood for Communication: patients need to be told what is going on. There was a debate about whether patients could be left alone at night and over weekends, and the Professor made the point that nowadays, with telemedicine and video technology, communication was easier than ever.

“Rounds are important for communication,” he said, “to talk to the nurses, talk to the patient and are good for training of young doctors, even though it is possible nowadays for the doctor to do the rounds at home.”

The final letter in PITCH stands for Humanity. “How do you measure TLC?” asked Prof Vincent. “It is something that you can feel. There are no limits to humanity. Doctors and nurses should be proud of belonging to a team.”

Letty Setle from Johannesburg said she is at the critical care conference to gain more knowledge on critical care.

CRITICAL CARE NURSES encouraged TO COLLABORATE and COMMUNICATE C

ommunication and collaboration were dominant themes in the round table discussion which covered a worldwide perspective on critical care nursing (CCN).

Leanne Aitken, from Australia, said over the past five to 10 years, a strong body of work had focused on two critical issues – patient handover and identification and treatment of deteriorating patients. She said because communication failure on both verbal and non-verbal levels compromised patient safety during handover, a lot of work had been done on transferring patients from ambulances to emergency departments to other areas in hospitals.

An advance in bedside handover, she said, was the implementation of electronic based handover tools to encourage people to be more thorough.

When it came to treatment of the deteriorating patient, she said breakthroughs included a system of rapid response calls that could be handled by both staff and family. She said systems had been put in place to identify and treat problems ahead of a need to move a patient to an ICU. This included critical care nurses assessing patients while they were still in general wards.

Adriano Friganovic, president of the Croatian Critical Care Nurses Association, outlined a number of challenges faced by Croatian healthcare professionals. These include nursing registration, putting in place a scope of practice, guidelines and protocols and creating bundles of care. He said that 2003 had been a big year as a formal nursing Act had been put in place and a Nursing Council set up as a regulating body. However, CCN had had to break away in order to ensure development on a national and international level.

Belle Rogado said that, in the Philippines, CCN followed an open model which included family involvement. She said a priority was the amendment of current legislation

By SHIRLEY LE GUIN governing the nursing profession which would address higher levels of competency and provide for areas of specialization. She said nursing had won a seat in congress which gave the profession a voice to lobby for change.

South Africa’s Petra Brysiewicz discussed empowerment of nurses in light of the country’s political history and cultural diversity. She said that there were often difficulties when nurses attempted to communicate with doctors and patient’s families. Nurses were being empowered to have greater confidence in themselves and transcend gender issues.

She said the ultimate aim was to promote inter disciplinary education which has been rare in South Africa so that all could work together and not in isolation.

According to Hong Kong’s Esther Wang, challenges include paving the way for nursing specialisation.

Legislation provided for general registration but not for registration for specialisations. She said this required amendment of legislation.

Kathleen Vollman said latest trends in the United States focused on the bundling of care according to an ABCD model with A standing for spontaneous wakening trials, B spontaneous breathing trials and C and D choice of sedation and management of delirium. She said that an E and F had been added – exercise to minimise loss of muscle strength and feeding to ensure that patients had the right nutrition to speed up their recoveries.

Her message was for CCN to move away from the routine issues that had dominated over the past 30 years.

“Be courageous. We all are responsible for the safety of our patients and ourselves. We need to own the issues,” she said.

DOING MORE FOR LESS GETS STAMP OF APPROVAL FROM DEPUTY MINISTER W

elcoming delegates to the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine in Durban, the South African Deputy Minister of Health, Gwen Ramakgopa, confirmed the South African government’s commitment to supporitng the goals of the organisation.

“We will continue to invest in academic medicine and the revitalisation of health care overall,” she said. “The African continent is experiencing unprecedented economic growth, and is becoming more sophisticated in primary health care.

“We have seen a reduction in child mortality, and have significantly reduced the mother-to-child transmission of the HIV. We are closer to an AIDS-free generation sooner than we expected.”

In the Free State province, as an example, life expectancy has increased to 60 years from 53 years.

“But,” she warned, “increased longevity is increasing the cost of health care, in fact the rising financial aspect of health care has become our biggest concern.

We need to look at noncommunicable and lifestyle diseases as a matter of urgency, as it further increases the burden on our health care system.”

“Our theme, therefore,” she said, “is to do more with less. We need to look at more innovative and sustainable solution to limit the escalating costs of health care.

The goal of South Africa’s health care system is to achieve a long and healthy life for our citizens. We have put regulatory interventions in place to decrease the disease burden, and we are looking to expand universal health care coverage.”

“Africa has been at the forefront of developments in critical care, not only did we perform the first heart transplant, but we are pioneers in the use of high-frequency ventilation for premature babies, which is a cost-effective, non-intrusive intervention.”

“Preventative medicine will reduce the costs of health care, but less cost cannot translate into lower quality.

Our citizens have a constitutional right to access to health treatment.

Outreach programmes will improve the quality of care through education and training.”

By NIKI MOORE The Deputy Minister commented that it was ‘unlikely that we will have enough medical experts in our lifetime’, which is why the country needs to invest in improving the supply of doctors and other health professionals, especially in the field of critical care. The universities had doubled their intake of medical students in 2012, and the government was building new medical schools and investing in upgrading the existing ones.

The greatest challenge facing the South African government, said the Deputy Minister, was the inequitable distribution of health care.

Escalating health costs were putting people at risk of financial disaster if they should fall ill.

“People cannot shop around to choose to contract an affordable disease” she said. “Getting sick can be a financial disaster. Our government is committed to introduce affordable health care for everyone, but at the same time we need to diminish the impact of lifestyle diseases, which take resources away from critical illnesses.”

She made the point that people indulge in dangerous behaviour like smoking, drinking, eating badly, not

exercising, abusing drugs - and these were causing diseases which were preventable.

She appealed to the health professionals present to assist with eradicating lifestyle diseases.

“The practice of medicine is both an art and a science. It has high standards.

You are upholding the human rights of the vulnerable. You might face lawsuits. There has been a recent increase in malpractice lawsuits, and this is discouraging medical professionals from specialising. Our Ministry is planning a high-level summit to look at this phenomenon and develop a response.”

“We can rely on our experts present here today, to reflect on what else we can do to reduce the disease burden. It places strain on all aspects of critical care. As we move towards our Millennium Development Goals in 2015, we are hoping that this conference will move towards putting universal access to health on the global agenda.”

“We want you to join in the fight against non-communicable diseases, the developing world cannot afford the high burden of non-communicable diseases. We must take the lead in finding new solutions...

Especially doing more with less.”

Deputy Minister of Health, Gwen Ramokgopa meets some of the Critical care 2013 co-chairs.

Clockwise from top left are Juan Scribante, Brian Levy and Sats Bhagwanjee

This newsletter was produced by the team at HIPPO. www.hippocommunications.com