Implementing the Leapfrog standard in a developing country

Introduction

The Leapfrog standard of ICU physician staffing is regarded as the gold standard. It is suggested that hospital leaders should focus on how to implement intensivist staffing [1]. Internationally, especially in developing countries, the 'how to' poses a tremendous challenge. The Critical Care Society of Southern Africa identified the need to objectively quantify existing ICU resources in South Africa (SA) with a view to making recommendations for the future. From this audit we discuss the challenges of implementing the Leapfrog standard of ICU physician staffing in a developing country.

Methods

Approval to conduct a national audit was obtained from appropriate authorities and was undertaken in 2004 and 2005 in all public and private hospitals in SA.

Results

A 100% sample was obtained. At the time there were 448 units in SA, of which 7% of ICUs in the public sector and 1% in the private sector were closed units. There were a total of 4,168 ICU and HC beds, with 30 intensivists and 4,584 nurses (25% ICU trained) working in the ICU [2–4].

Conclusions

SA ICU services face challenges and the results show the difficulty of implementing the Leapfrog standard. A strategy to deal with these challenges must be reality based and contextually appropriate. We propose short-term, medium-term and long-term recommendations that consider fiscal pressure and competing healthcare imperatives [5]. Short term: Regionalisation and integration of ICU services, development of guidelines and protocols to guide practice. Introduction of continuous professional development programs and a structured outreach program for medical and nursing staff. Active recruitment and training of personnel. Medium term: Development of telemedicine and a two-tiered ICU program. The first tier to comprise nurses and doctors with intermediate skills and experience. The second tier to comprise intensivists and fully trained ICU nurses. Both tiers to have a clear scope of practice, training and incentive schemes. A significant percentage of ICU beds are not in use due to various factors, these beds to be recommissioned. Long term: A strategy to convert open units to closed units over a period of time. New ICUs to be established as closed units. An up-to-date national ICU database to be maintained to direct future planning.