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n Southern African Journal of Critical Care - From ICU to outreach : a South African experience
Introduction. The lack of critical care resources in South Africa can result in critically ill patients being nursed in the wards. Ward staff often lack the knowledge and skills to care for these patients adequately. Studies done internationally have revealed that ward patients often receive sub-optimal care before admission to the intensive care unit, with possible causes being cited as institutional failure, lack of knowledge, failure to appreciate urgency, and failure to seek advice. Furthermore, patients prematurely discharged from the ICU to the wards have an increased mortality rate. Internationally the critical care community is responding to these findings by taking steps to become proactive rather than reactive. This shift has led to the development of various approaches to assist in the recognition and early treatment of the deteriorating patient in the general wards. One such approach, introduced in the UK in 2000, is the Critical Care Outreach Programme instituted by the Department of Health as part of the Modernisation Programme. Reports in the literature suggest that this programme has positively impacted on emergency ICU admissions, ICU readmission rates, in-hospital mortality, and an improved level of knowledge and skills among ward nurses. An adapted form of this programme has been introduced in an urban public hospital in KwaZulu-Natal.
Method. A Critical Care Outreach Nurse was appointed at the target hospital to introduce the programme. The adapted form of the programme was introduced in two phases. Phase 1 consisted of following up of patients discharged from the ICU to the wards, and phase 2 incorporated the introduction of the Modified Early Warning Scoring System (MEWS) and referral algorithm to the surgical wards in the hospital. Owing to staff constraints the main focus of the programme was empowerment through knowledge. In this way a training programme was developed and implemented.
Results. Compliance with the scoring system was initially problematic but improved with the introduction of new forms. Night staff appears to be less compliant than day staff in the majority of wards. Respiration, the most sensitive indicator of critical illness, is recorded at 20 breaths/min in 77% of cases. Although the calculation of MEWS scores has improved it is still done inaccurately in 9% of cases. Scoring urine output is also problematic. Poor communication and lack of resources when managing acutely ill patients may potentially impact on the success of the scoring system. The nursing staff have generally responded positively to the MEWS, but there still appears to be a lack of awareness among medical staff.
Conclusion. Introduction of MEWS into the general wards in South Africa is potentially achievable but requires ongoing evaluation. The introduction of MEWS and Outreach may create a unique opportunity to improve the quality of care rendered to the patient in the general wards by relationship building and the sharing of ICU knowledge and skill through education and training.
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