Core competencies in critical care for general medical practitioners in South Africa

Abstract

To prevent death or disability, critically ill patients require timeous life-sustaining interventions by competent healthcare providers. These patients often require management within an intensive care unit (ICU), although the initial resuscitation and stabilisation may happen outside of an ICU setting. Currently, there is a global shortage of intensivists or intensive care specialists. The majority of intensivists are employed at tertiary hospitals in major cities. At district and regional hospitals in South Africa, which are generally located outside major cities, critical care services are often provided by medical practitioners who are not intensivists. The problem is that the undergraduate medical curriculum does not provide dedicated critical care training and, therefore, there is uncertainty regarding the competency of non-intensivist medical practitioners to provide critical care services.

In order to address the problem stated, three research questions are addressed in this thesis: 𝘪. 𝘞𝘩𝘢𝘵 𝘪𝘴 𝘵𝘩𝘦 𝘤𝘶𝘳𝘳𝘦𝘯𝘵 𝘴𝘵𝘢𝘵𝘦 𝘰𝘧 𝘤𝘳𝘪𝘵𝘪𝘤𝘢𝘭 𝘤𝘢𝘳𝘦 𝘴𝘦𝘳𝘷𝘪𝘤𝘦 𝘱𝘳𝘰𝘷𝘪𝘴𝘪𝘰𝘯 𝘢𝘵 𝘥𝘪𝘴𝘵𝘳𝘪𝘤𝘵 𝘢𝘯𝘥 𝘳𝘦𝘨𝘪𝘰𝘯𝘢𝘭 𝘱𝘶𝘣𝘭𝘪𝘤 𝘴𝘦𝘤𝘵𝘰𝘳 𝘩𝘰𝘴𝘱𝘪𝘵𝘢𝘭𝘴 𝘪𝘯 𝘵𝘩𝘦 𝘍𝘳𝘦𝘦 𝘚𝘵𝘢𝘵𝘦 𝘱𝘳𝘰𝘷𝘪𝘯𝘤𝘦 𝘰𝘧 𝘚𝘰𝘶𝘵𝘩 𝘈𝘧𝘳𝘪𝘤𝘢? 𝘪𝘪. 𝘞𝘩𝘢𝘵 𝘪𝘴 𝘵𝘩𝘦 𝘬𝘯𝘰𝘸𝘭𝘦𝘥𝘨𝘦, 𝘢𝘵𝘵𝘪𝘵𝘶𝘥𝘦𝘴 𝘢𝘯𝘥 𝘱𝘳𝘢𝘤𝘵𝘪𝘤𝘦𝘴 𝘰𝘧 𝘮𝘦𝘥𝘪𝘤𝘢𝘭 𝘥𝘰𝘤𝘵𝘰𝘳𝘴 𝘸𝘩𝘰 𝘱𝘳𝘰𝘷𝘪𝘥𝘦 𝘤𝘳𝘪𝘵𝘪𝘤𝘢𝘭 𝘤𝘢𝘳𝘦 𝘢𝘵 𝘥𝘪𝘴𝘵𝘳𝘪𝘤𝘵 𝘢𝘯𝘥 𝘳𝘦𝘨𝘪𝘰𝘯𝘢𝘭 𝘱𝘶𝘣𝘭𝘪𝘤 𝘴𝘦𝘤𝘵𝘰𝘳 𝘩𝘰𝘴𝘱𝘪𝘵𝘢𝘭𝘴 𝘪𝘯 𝘵𝘩𝘦 𝘍𝘳𝘦𝘦 𝘚𝘵𝘢𝘵𝘦 𝘱𝘳𝘰𝘷𝘪𝘯𝘤𝘦 𝘰𝘧 𝘚𝘰𝘶𝘵𝘩 𝘈𝘧𝘳𝘪𝘤𝘢? 𝘪𝘪𝘪. 𝘞𝘩𝘢𝘵 𝘢𝘳𝘦 𝘵𝘩𝘦 𝘤𝘰𝘳𝘦 𝘤𝘰𝘮𝘱𝘦𝘵𝘦𝘯𝘤𝘪𝘦𝘴 𝘦𝘹𝘱𝘦𝘤𝘵𝘦𝘥 𝘰𝘧 𝘨𝘦𝘯𝘦𝘳𝘢𝘭 𝘮𝘦𝘥𝘪𝘤𝘢𝘭 𝘱𝘳𝘢𝘤𝘵𝘪𝘵𝘪𝘰𝘯𝘦𝘳𝘴 𝘸𝘩𝘰 𝘱𝘳𝘰𝘷𝘪𝘥𝘦 𝘤𝘳𝘪𝘵𝘪𝘤𝘢𝘭 𝘤𝘢𝘳𝘦 𝘢𝘵 𝘢 𝘯𝘰𝘯𝘴𝘱𝘦𝘤𝘪𝘢𝘭𝘪𝘴𝘵 𝘭𝘦𝘷𝘦𝘭 𝘰𝘧 𝘩𝘦𝘢𝘭𝘵𝘩𝘤𝘢𝘳𝘦 𝘪𝘯 𝘚𝘰𝘶𝘵𝘩 𝘈𝘧𝘳𝘪𝘤𝘢?

The aim of the study was to identify deficiencies in the competency of general medical practitioners who provide critical care services to patients at the district and regional levels of healthcare in South Africa, and the overall goal was to establish which core competencies are required of general medical practitioners if they are to provide critical care to patients in South Africa. The study was conducted in three phases, with each phase addressing one of the research questions. During phase 1, the objective was to gain deeper insight into the current state of critical care service provision in the public healthcare sector, specifically at district and regional hospitals in the Free State province of South Africa. The objective was achieved by means of a literature review and questionnaire survey among designated personnel at public sector hospitals who were knowledgeable about critical care service delivery in their respective hospitals in the Free State province and who were able to provide the required information. The findings are reported in the first draft manuscript (Title: A survey of critical care resources at district and regional public sector hospitals in the Free State province of South Africa), which describes a critical shortage of available ICU beds at regional hospitals, and reports that none of the ICUs had intensivists available.

During phase 2 of the study, the objective was to determine the knowledge, attitudes and practices of medical doctors who provide care to critically ill patients at district and regional public hospitals in the Free State province of South Africa. A survey was conducted among medical practitioners and the results indicate that medical practitioners had a severe deficiency in critical care knowledge and were of the opinion that their undergraduate medical training had not prepared them adequately to manage critically ill patients. The majority responded that additional training is required. These findings are reported in the second draft manuscript (Title: A survey of the knowledge, attitudes and practices pertaining critical care medicine among medical practitioners at district and regional hospitals in South Africa).

During phase 3 of the study, the objective was to establish core competencies expected of medical practitioners working in critical care settings or providing critical care services. A list of suggested core competencies was compiled, after which a Delphi study among international and national experts in the field of critical care medicine was conducted. The results of the Delphi study provide consensus recommendations on core competencies in critical care medicine and are reported in the third draft manuscript (Title: Core competencies in critical care for general medical practitioners in South Africa: A Delphi study).

The thesis concludes with recommendations with regard to a curriculum for a postgraduate diploma in critical care training programme, intended for medical practitioners already employed at hospitals where critically ill patients are managed. The training programme was compiled based on the findings of the three phases of the study. Such a training programme is suggested as a feasible solution to improve the critical care competencies of medical practitioners and, thereby, mitigate the challenges posed by the shortage of intensivists at district and regional hospitals in South Africa.