Critical care, third newsletter

ISSUE 03

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Durban declaration: a call to action for critical care

he Durban Declaration, a unique outline for the future of Critical Care provision around the world, was issued today by the organisers of the 11th Congress of the World Federation of Societies of Intensive and Critical Care medicine, currently underway in Durban.

“We recognise that access to critical care is a basic human right,” said Dr Sats Bhagwanjee, co-Chair of the Congress.

“This Declaration can be seen as a founding statement for the discipline of critical care worldwide. It outlines what we believe are the key factors that must be considered when we look at providing critical care for all.”

The Durban Declaration provides very specific objectives for all people accessing critical care, from the patients and their broader community to the health care providers, funders and governments.

“We recognise that different countries have different resources, but we also believe that the access to critical care must be the same, no matter where you are. If there is only one ICU bed available, it must be of equal quality to an ICU bed anywhere in the world,” Dr Bhagwanjee explained.

The 10 Key Tenets in the Durban Declaration are expanded upon in a 10-point plan which the signatories hope will be the basis of change in the provision of critical care around the world.

The Durban Declaration is endorsed by the Presidents of the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM); the World Federation of Paediatric Intensive and Critical Care Societies (WFPICCS); the World Federation of Critical Care Nurses (WFCCN); the Critical Care Society of South Africa (CCSSA) and the Chairpersons of the Global Sepsis Alliance and InFact.

The declaration is summerised below and is available in full at http://goo.gl/rUyykl

The 10-point plan 1. It is a basic human right for all people to have access to nationally available Critical Care services. Access to Critical Care is a basic human right. Consequently, all

By LYNNE SMIT countries must provide critical care services.

Access to Critical Care services must be facilitated for all people within a country.

Whilst it is clear that low-income countries may not have the ability to invest the same resources as high-income countries, the quality of care provided in both should always be equivalent.

2. Critical Care must be an established specialty throughout the world.

For the delivery of effective services, Critical Care must be an established specialty.

The co-ordination of the discipline into a specialty requires the definition of the scope of practice of a multi-disciplinary team.

3. Patients, their families and their communities must be empowered to make informed Critical Care choices.

A key goal must be to empower patients, their families and communities pre-emptively such that they are adequately informed to make choices and to be advocates for the well being of the individual, at the same time serving the interests of the broader communities from which they come.

4. The Critical Care needs of the most vulnerable populations must be properly identified.

At-risk populations, such as people at extremes of age and those lacking mental capacity, represent a group that require particular attention by virtue of their vulnerability.

5. All basic ethical principles must be applied to ensure rational decision-making in Critical Care.

Ensuring respect for patient autonomy is fundamental to ethical Critical Care practice.

Beneficence and non-maleficence further drive caregivers to ensure care is appropriate and without harm. Since Critical Care is a limited resource, the social justice principle as a competing interest must be recognized.

6.Appropriately trained and supported health care personnel are fundamental to effective Critical Care practice.

Recruiting, training and retaining skilled personnel must occur in the context of

creating effective Critical Care by a cohesive team. It is crucial to provide adequate support and care for healthcare workers involved in Critical Care, as it is a very highrisk environment for the personnel.

7. Adequate infrastructure must be provided to ensure safe and effective Critical Care services within the broader health care system Whilst economic resources of countries vary, the healthcare system must provide vital infrastructure that is well defined, and ensure the availability of essential equipment, drugs and disposables for the provision of Critical Care specific to each environment.

8. A culture of learning must be fostered within the Critical Care domain.

Continuing medical education is essential for existing personnel. Training programs must aim to develop all healthcare providers in a nurturing environment that will foster a culture of learning.

9. All stakeholders must be committed to the development of strategies necessary to implement Critical Care services appropriate to the needs of each community.

Patients and families, healthcare providers, policy makers and funders as major stakeholders, must share the commitment and implementation strategies to develop Critical Care services appropriate to the needs of each community. Key opinion leaders have the responsibility of leading all facets of the Critical Care agenda in achieving the goal of providing Critical Care for all.

10. Effective, clinically relevant, collaborative Critical Care research programmes need to be developed and existing programmes expanded.

The vast global differences in disease patterns, human capacity and infrastructure demand that effective and innovative research programs be created that will direct caregivers to provide the best possible care based on evidence derived from suitably designed clinical research projects.

bed baths ‘a micro-organisim fest’

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raditional bed baths in ICU provide a micro-organism fest and nurses’ hands can become lethal weapons when it comes to spreading bacteria in a hospital environment.

Speaking at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine, American ambassador for the World Federation of Critical Care Nurses, Kathleen Vollman, said that many traditional nursing practices that had been around since “the days of Florence Nightingale and the Crimean war” needed to be completely revised in order to protect patients from harm and to ensure better interventional patient hygiene.

She said that most patients were at risk from harmful multi drug resistant organisms. As the skin was the “first line of defence” and single largest barrier to infection, failing to take care of it put patients at risk. In addition, because bathing was usually the only time in a 24 hour period that the entire skin was looked

By SHIRLEY LE GEURN at, it acted as a potential early warning system.

Vollman said that there were large variations in how bathing was actually done from institution to institution and from country to country. In addition, techniques and equipment – including the use of soap and water and rough wash cloths – were doing a significant amount of harm. She also said that conventional tap water was proven to harbour a large amount of bacteria in hospital ICUs. She added that a great deal of research was being done into the use of no rinse pH balanced formulations that preserved the acid mantle of the skin. Use of an alkaline based soap provided the perfect opportunity for encouraging bacteria, she warned.

She said it was also necessary to reassess how bathing was actually carried out. Latest studies were pointing towards

Kathleen Vollman

basinless bathing and the use of pre-packed cloths containing two percent chlorhexidine which are approved by the American Federal Drug Administration for surgical preparation and other health authorities around the world for general bathing. She said a myriad of studies which compared traditional soap and water bathing using non medicated cloths, medicated cloths and the use of chlorhexidine cloths had showed that the use of chlorhexidine cloths reduced the transmission of bacteria and fungal infections significantly and also brought down bloodstream infections.

Overall, she recommended that patients were bathed daily, that use of reusable basins and the use of conventional washcloths be avoided and that baths were carried out at times convenient to the patients and not determined by organisational preferences or unit norms.

She said that an Australian study, backed up by other literature, suggested that at least 40 percent of patient baths were carried out between midnight and 6 am.

She questioned this, adding that timing of bathing needed to take into consideration conventional sleep patterns and the need to maintain energy reserves.

Steroids: controversial but beneficial

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ervyn Mer, President of the Critical Care Society of Southern Africa, addressed the issue of steroid use in critical care. He made the point that steriod use is extremely controversial, but the benefits of appropriate application could not be denied.

“The controversy about steroids goes back to the 1940s, and about ten years ago we would have said that steroids are out,” he said.

“But recent studies, case by case, are showing that appropriate steroids, carefully used, have benefits that far outweigh the risks. So - is there really any choice?”

In his presentation, Mer showed the different syndromes, conditions and diseases that respond to steroids and those that don’t.

For instance, automotive spinal cord injury, Acute Respiratory Distress Syndrome, pneumonia, septic shock, tuberculosis and meningitis were some of the examples where appropriate applications of steroids decreased

By NIKI MOORE mortality by up to 50%. The only area, according to studies, where steroids have proved detrimental, has been in the case of head injury and brain trauma.

There are a few caveats with steroid use, according to Mer: they must be used appropriately and where patients are not responding within one hour to other treatments; low doses are usually more effective than high doses, the treatment must taper off slowly, and the patient must be watched extremely closely.

“There is a trend in every single one of these studies that the use of steroids have benefits that outweigh the risks. Never under-estimate them. Don’t be blinded by the controversy, use them appropriately. They are integral, inexpensive, readily available and in many cases, life-saving,” Mer concluded.

Mervyn Mer

Breakthroughs in paediatric critical care but ‘shameful deficiency’ in pain relief

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aediatric critical care has seen huge advances worldwide, but in spite of this, a child in a low-income country today is 18 times more likely to die before the age of five than a child in a developing country.

This was the message from Dr Tex Kissoon, vice president of Medical Affairs at the British Columbia Children’s Hospital in Vancouver Canada, who was speaking at the 11th Annual Congress of the World Federation of Societies of Intensive and Critical Care Medicine, currently underway in Durban.

“Before I begin to talk about advances in paediatric critical care,” he began, “I would need to define an ‘advance’. Can advances be judged by better outcomes, better integration, sustainability, or the justification of critical care for children? And for whom has it been an advance - the child, the family, the population, the medical fraternity, or the policy makers?”

In his overview, Dr Kissoon identified six areas in which advances could be measured across both resource-rich and resource-poor countries. These are: effectiveness of critical care, its safety, its efficiency, whether it is patient-centred or not, its timeliness, and the equity of advances across all demographic and socioeconomic groups.

In terms of effectiveness, over the last ten years infant and child mortality has decreased significantly around the world, from almost 10 million deaths annually to less than nine million.

In Australia, infant mortality decreased from 15% to 5%, and the survival rate in PICU in the US increased by 22%.

The safety of paediatric critical care also had a number of breakthroughs. One of these was the introduction of checklists to assist health professionals in checking their procedures,

By NIKI MOORE higher standards for intravenous feeding, and - as a result of a highly-publicised case in the US where a schoolboy died from a minor scrape - a greater awareness of septic shock in children.

The efficiency of paediatric care was being shown quite clearly in developing countries such as Malawi, where official intervention resulted in fewer infant deaths through a greater training in paediatric critical care. For instance, invasive procedures were not recommended for malnourished children, long fasting was discouraged and nurses were trained to recognise the challenges in sepsis, especially with regard to burns and traffic accidents.

A change in the approach to the speed of treatment was also an advance, as several countries were recognising that the timeliness of treatment was vital. Children could be treated immediately at home, instead of being transported to the doctor’s office, there was better communication with families (especially in Pakistan and Vietnam, where this is a recognised field of innovation), and villagers were retrained in basic first aid to provide immediate care. Field workers were provided with low-cost antibiotics to give treatment on the spot But one area where there has been no progress, said Dr Kissoon, is in the prevention of needless pain.

“There is a shameful deficiency in this area,” he said. “Hospitals have a shortage of oral morphine. Published evidence is lacking and children are often left to suffer, especially in terminal illnesses, where preventatives can be made available.”

Another area where there had been no advance was in the equity between rich and poor

Dr Tex Kissoon

countries in child critical care.

“A child in a low-income country today is 18 times more likely to die before the age of five than in a developing country,” said Dr Kissoon. “In 1990, this figure was 14 times.” So even though total child and infant mortality had decreased, it had decreased more in richer populations than in poorer populations. Equity of child care, therefore, was a cause of concern.

Innovations in paediatric critical care included kinder and gentler ventilation protocols with a better approach to sedation and analgesics; better neuro-critical care; and SMS alerts to monitor pregnancies to reduce maternal and child deaths.

“In total,” said Kissoon,” there have been some advances in paediatric critical care, but in other areas there has not been much progress, and regrettably even some reverses.”

Dire shortage of burn centres in sa S

outh Africa has a shortage of specialist ICU burn centres with just two facilities in the country, despite the reality that burn injuries are common in Sub-Saharan Africa and often lead to devastating consequences.

Dr Dave Kloeck, paediatric ICU specialist with the Chris Hani Baragwanath Hospital revealed this at the 11th Congress of the World Federation of Societies of Intensive and Critical Care medicine, currently underway in Durban.

Kloeck, who offered delegates advice on child burn treatment, said the most recent statistics (2002) showed that more boys present with burn injuries than girls in South Africa with a prevalence of 2:1 and that burns were a significant cause of injury in children aged 1 to 6 years old.

Dr Dave Kloeck paediatric ICU specialist with the Chris Hani Baragwanath Hospital

By LYSE COMINS “Muslim children covered with nylon dresses can be at higher risk and the incidence can be the same for boys and girls,” Kloeck said.

Kloeck said the lack of infrastructure – there are only two ICU units at Chris Hani Baragwanath Hospital and at the Red Cross Children’s Hospital - and the use of traditional methods contributed to the unsatisfactory status of overall burn management, prevention and rehabilitation. For example, a study had revealed that 22 percent of epilepsy patients in Zimbabwe’s Semokwe district were inflicted with potions and “therapeutic burns” to treat seizures.

Kloeck urged delegates to focus on prevention and be examples of child safety as doctors in their communities.

“There is nothing more tragic than a preventable burn that leaves a child disfigured for life,” Kloeck said.

Kloeck said tissue damage was proportional to the temperature or strength of the burning agent and contact time, which was far less in children.

“In an infant you need water at 60 deg C, not quite boiling, and a contact time of one second to develop a full thickness burn and five seconds in an older child (two to eight years) and in adults it takes 20 seconds,” Kloeck said.

He said it was often not possible to remove the child from the burning source to prevent the third degree burn. Apart from the controversial “stop, drop and roll” theory, cooling was the most important aspect of dealing with burn wounds, Kloeck said.

“In first aid most important is the cooling of the wound using water that is 15 C (tap water), not

Ivan Hayes is from Ireland and said he was inspired to attend the conference because of the good programme and because Durban is like a fantastic location.

icy, for between 15 to 30 minutes,” Kloeck said.

Kloeck said icy water would constrict the blood vessels and worsen the injury. He said the next step would be to add a clean wrap or a burn shield, but warned that a burn shield may not be the ideal treatment after 24 hours or more had passed.

“Prevent hypothermia, cool the burn but don’t cool the core. We need to keep paediatric patients warm - they suffer from hypothermia a lot more quickly than adults.” He added that inhalation injury also needed to be excluded when assessing a patient.

“When in doubt admit over night and you can always reassess the next day and take photos and send them to a burn specialist for re-evaluation,” Kloeck said.

Kloeck summarised the objectives of the management of severe burns that need to be met as: • Prevention; • Stop the burning process; • Provide life support measures such as oxygen, fluids, food and surgery; • Give appropriate analgesia; • Promote wound healing; • Restoration of function by rehabilitation and construction; and • Support and reassurance of patients, relatives and staff.

Kloeck said there was also a 2,5 percent risk of toxic shock syndrome, which was the most common unexpected death in children with small burns, because they usually received low care.

“We need to be monitoring those kids to pick up the signs,” Kloeck said. He said children under two with just 10 percent of total body surface area burns were most at risk.

Mahlatse Malepe is a nurse at Johannesburg Hospital who came to Durban to get ideas about how to update their standards of critical care in her unit.

Akhtar Aziz Khan is a critical care doctor from Pakistan, who came to Durban to hear the latest trends and developments in the field.

Diane Blackstock is a nurse at Milpark hospital in Johannesburg. She came to the conference because she thinks it’s vital to keep up with trends and to network.

DoctORS APPEAL FOR LIFTING OF FLUID BAN S

outh African critical care experts have appealed to the Medicine Control Council to reconsider its ban on life saving new generation ICU starch drip fluids.

Speaking on the sidelines of the 11th Congress of the World Federation of Societies of Critical Care Medicine in Durban today Dr Ivan Joubert head of critical care at the University of Cape Town said experts had appealed via letters in medical journals for the MCC to remove the ban. The MCC had also issued a product recall in August.

Joubert, speaking on behalf of several local experts from across the country said the MCC had over-reacted to an EU Medicine’s Agency’s, Pharmacovigilance Risk Assessment Committee (PRAC) recommendation to suspend market authorisation of the widely used hydroxyethl starches.

It said the starch drips were more likely to cause death or kidney damage than saline solution alternatives.

The doctors, all associated with the SA Society of Aneasthesiologists and the SA Society of Critical Care raised their concern in letters published in the SA Medical Journal and the SA Journal of Anaesthesia and Analgesia recently.

Hydroxyethyl starch drips are a new generation of colloid drugs used to improve blood volume in dehydrated patients, those who have lost a lot of blood, or who have experienced a sharp drop in blood pressure. The drugs are also used in ICU to treat patients with bacterial blood infections, those who are undergoing surgery and for trauma and burn victims.

Joubert said the benefit of colloids was that they were more like blood than the alternative, crystalloid solutions, and had the ability to remain in the intravascular space (the space inside the blood vessels) to provide a better and more lasting expansion of blood volumes.

Joubert said the meta-analysis that the EU regulator had used to inform its recommendation was “flawed” because it had drawn data from studies on the older forms of the drugs and cases where it was not indicated. He said research on the use of hydroxyethyl starches spanned 40 years.

“They are removing them based on pools of data from studies which includes a wealth of information from the old starches which is crazy.

Unfortunately, they have used different starches and different indications for therapy,” Joubert said.

By LYSE COMINS “The MCC made the decision and they haven’t listened to the expertise in the country. As clinicians we have really grave concerns in that the most recent advanced available therapy has been taken away from us and the alternatives that we have are all older drugs. We have evidence that those older fluids are not better,” Joubert said.

“There are a number of experts in the field in the country from all centres who have appealed that the MCC reconsider the decision,” Joubert said.

Joubert said consequences for patients were that doctors now had to use less effective resuscitation solutions in ICUs, which could lead to a greater risk of complications.

He said hydroxyethyl colloids resulted in the more rapid resuscitation, or stabilization of patients, which reduced complications and saved lives.

“There has been no response from the MCC, our hands are tied,” Joubert said.

Immediate past professor and head of the Department of Anaesthesia at UCT, Michael James, said his SA study called Fluids in Resuscitation of Severe Trauma (The First Study) had shown the distinct advantage of hydroxyethyl colloids over crystalloids in penetrating trauma – gun shot and stab wounds – which are the greatest trauma injuries in the country.

“The incidence of kidney injury in the starch group in my study was zero compared to 17 percent in the saline group but that was because the patients needed volume resuscitation.”

“In peri-operative and trauma use there is absolutely zero evidence that these products are harmful. Those of us that wish to retain them realise that it is being badly used in intensive care and that these studies have certainly shown us that we should not be using colloids after the initial resuscitation. They have shown us a limited window on practice,” James said. James added that three countries had banned the use of colloids – Poland, Italy and the UK – but that Poland had yesterday announced it would continue to use the drugs.

James is among several local experts who have written to the EU’s PRAC objecting to its recommendation.

Innovative research and training programme for critical care launched A

CART – the Acute Care for Africa Research and Training Programme – is set to revolutionise the way that critical care is studied and performed throughout Africa according to Satish Bhagwanjee, director of the Critical Care Training Program in the Department of Anesthesiology at the University of Washington Medical Center in Seattle and co-chair of the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine.

Born out of Bhagwanjee’s passion for empowering medical professionals throughout Africa and enabling them to optimise the use of their very limited capacity and resources, ACART will comprise research and training programmes that will run in parallel. It will be based at the Nelson Mandela School of Medicine at the University of KwaZulu-Natal but will bring together medical professionals from across the African continent as well as from global centres of excellence such as America and Australia.

The starting point for the formation of ACART was the lack of data available on acute and critical illness from low and middle income countries. Without this data, there was a complete lack of evidence on which to base and formulate guidelines on how to practice critical care in these environments.

“In countries that have high resources or high income, there’s a large body of evidence to guide critical care practitioners to optimally provide care. These guidelines cannot be extrapolated to lower and middle income countries because the resources are not the same. Therefore, for us to appropriately describe what we should do and how we should do it, we need evidence,” he explained.

A good example, he said, was the Surviving Sepsis Guideline which embraced all the elements of effective practice based on evidence and consensus of opinion and allowed people to selectively apply evidence based suggestions within their own clinical environments.

By SHIRLEY LE GEURN “However, in low income countries, many of these guidelines cannot be applied because we don’t have the equipment, the nursing support or the skills needed,” he said. The end result is that people try to apply the guidelines in some situations, do what they feel they need to in others and continue doing what they have done for the past 20 years – all of which can be a problem.

Another problem concerns the allocation of resources. Bhagwanjee said it was impossible to recommend the allocation of resources without identifying a starting point – exactly what is happening and what resources are available at present and where.

He said that a few years ago, he had audited all of the ICUs in South Africa but that this was yet to be done in the rest of Africa.

The ACART research group wanted to complete this continent-wide audit by January 2014.

Background work that had already created a minimum information sheet would facilitate this early completion date, he said.

He said that one of the most compelling reasons for creating the ACART research group and project was the biggest challenge of all – a lack of human capacity. “There are very few qualified intensivists in South Africa. Even in the United States, there is a major deficit of intensivists and they are way behind where they should be. Comparatively, our problem is insurmountable while their problem is challenging. What you have to do is find other solutions. I cannot tell our Minister of Health to create 10 000 intensivists as it would be impossible. But I can create a training programme that will ensure that the care we provide for the acutely ill is maximised at the first point of contact. By doing that, you reduce the number of people who need to go into ICU and you improve the outcome for the patient,” he said.

When it came to the need for training,

Bhagwanjee said no preliminary research was necessary. “I don’t need to be told that we have a problem with training. I don’t need to do a study. Therefore, rather than be unrealistic and make demands that cannot be met, we decided to offer solutions that make sense.”

These training solutions come from group members who are able to provide a wide variety of different programmes. “We have now identified a small group that will sit down with these options, create a working document that describes the pros and cons of each and then select which we want to launch within the next month,” he said.

Research that will run concurrently will validate the implementation of certain training programmes and either demonstrate their efficacy or suggest why adjustments might be necessary.

Bhagwanjee assembled the ACART group over a four year period. The groundwork leading up to this week’s meeting that formally constituted the group looked at the configuration of the group, its structure and how it should operate. Again, just a month has been set aside for this to be circulated and rubber stamped by all participants.

He said that, when it came to research, the major consideration had been actually identifying the major research questions that needed to be considered. “We are going to use the network of 27 African countries that have indicated that they want to participate to answer two critical questions – what is your critical care capacity and what do you believe are the training requirements based on your environment?”

He said his overall intention, through ACART, was to empower every one of the participating critical care sites to become an independent functioning unit that conducted important research and training in its own right. “Until they develop the capacity to do that, they will need support. We are going to do that as a collaborative effort,” he said.

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