The organisational response of a hospital critical care service to the COVID-19 pandemic: The Groote Schuur Hospital experience

Background. There are limited data about the coronavirus disease-19 (COVID-19)-related organisational responses and the challenges of expanding a critical care service in a resource-limited setting.Objectives. To describe the ICU organisational response to the pandemic and the main outcomes of the intensive care service of a large state teaching hospital in South Africa.Methods. Data were extracted from administrative records and a prospective patient database with ethical approval. An ICU expansion plan was developed, and resource constraints identified. A triage tool was distributed to referring wards and hospitals. Intensive care was reserved for patients who required invasive mechanical ventilation (IMV). The total number of ICU beds was increased from 25 to 54 at peak periods, with additional non-COVID ICU capacity required during the second wave. The availability of nursing staff was the main factor limiting expansion. A ward-based high flow nasal oxygen (HFNO) service reduced the need for ICU admission of patients who failed conventional oxygen therapy. A team was established to intubate and transfer patients requiring ICU admission but was only available for the first wave. Results. We admitted 461 COVID-19 patients to the ICU over a 13-month period from 5 April 2020 to 5 May 2021 spanning two waves of admissions. The median age was 50 years and duration of ICU stay was 9 days. More than a third of the patients (35%; n=161) survived to hospital discharge. Conclusions. Pre-planning, leadership, teamwork, flexibility and good communication were essential elements for an effective response. A shortage of nurses was the main constraint on ICU expansion. HFNO may have reduced the requirement for ICU admission, but patients intubated after failing HFNO had a poor prognosis.

Mechanisms of Oedema: the Minor Role of Hypoalbuminaemia

Objectives: Seriously ill patients often suffer from disorders of salt and water balance and present with clinical signs of either dehydration or oedema. The relationship of hypoalbuminaemia to oedema is complex and controversial and formed the central issue of this study. Design: Prospective study Setting: Medical wards of New Somerset Secondary Hospital; November 2004. Subjects: 50 patients admitted consecutively to the medical wards at New Somerset Hospital were evaluated. 26 males and 24 females participated. Outcome measures:. An attempt was made to correlate causes of salt and water imbalance with the clinical assessment of volume status; oedema formation; nutritional state and serum albumin levels. Results: Hypoalbuminaemia was not related to oedema in this study. From the 24 patients with serum albumin below 30 g/L; only 6 had oedema. These patients all had other abnormalities which could have resulted in the oedema: notably primary salt retention by failing kidneys; cor pulmonale and malignan- cy. None of the patients with serum albumin levels below 15 g/L had any signs of oedema. The combined insult of a chronic inflammatory disease and malnutrition had a marked effect on serum albumin levels. Conclusion: Significant hypoalbuminaemia was present in a substantial portion of the patients included in this study; yet oedema was detected infrequently and generally had an easily identifiable cause not related to low albumin levels. Most patients with hypoalbuminaemia presented with normal or positive water balance. This study supports the notion that hypoalbuminaemia is infrequently associated with oedema and plays a minor role in its formation

Prescribing Patterns of Antiretroviral Drugs in a Section of Private Health Care Sector of South

The general objective of this study was to investigate the prescribing patterns and cost of antiretroviral (ARV) drugs in the private health care sector in South Africa by using a medicine claims database. A quantitative; retrospective drug utilisation review was performed on data retrieved from 2001; 2002 and 2004 records. Antiretroviral drugs repre- sented 0.38 (n = 1 475 380) for 2001; 0.72 (n = 2 076 236) for 2002; and 1.68 (n = 2 595 254) for 2004 of all studied prescriptions. The total cost of the ARV drugs represen-ted 1.31 (R379 708 489) for 2001; 3.03 (R601 350 325) for 2002; and increased to 5.25 (R661 223 146) for 2004 of all drugs claimed. All ARV medicine items claimed during 2001 (n = 9 796) and 2002 (n = 35 271) were innovator products. Only 5.23 (n=5 329) of all the ARV medicine items (n = 101 938) claimed during 2004 were generic products. The average cost per ARV medicine item for 2004 increased from R317.93 (SD = R190.80) for the period January to April to R369.20 (SD = R219.50) for the period May to August; and decreased to R324.79 (SD = R212.48) for the period September to December and resulted in a cost saving of R41 044.35 for the period May to August versus September to December. Both the prevalence and cost of ARV drug therapy increased from 2001 to 2002. The prevalence increased from 2002 to 2004; but the cost decreased during 2004. The decrease in the cost of ARV drug therapy is probably a result of the implementation of the new pricing regulations in May 2004