Limited Resources=Difficult Decisions

Carrie Vaughan, for HealthLeaders Media, February 6, 2009

I had the pleasure of hearing L. Rudo Mathivha, MD, a critical care physician at the Chris Hani Baragwanath Hospital in Johannesburg, South Africa, speak this week at the Society of Critical Care Medicine's national conference in Nashville, TN. Mathivha discussed the challenge of providing critical care with scarce resources, and she detailed some of the difficult choices leaders at her hospital are forced to make as they prioritize cases.

Chris Hani Baragwanath Hospital has approximately 3,000 beds and sits on roughly 173 acres, but it only has 18 multidisciplinary ICU beds, eight trauma beds, and an eight-bed high dependency ICU unit, according to Mathivha. Yes, you read that correctly. The world's largest hospital (according to Wikipedia) has less than 40 critical-care beds. And when it comes to staffing the critical-care unit, the hospital has no respiratory therapists, no nutritionists, and no clergy to help counsel family members. It has physicians, nurses, and technologists. That's it. You can't just order an MRI for a patient, either; you have to fill out a written document detailing why your patient needs that MRI and then hope it's approved.

The region is a mix of villages with no running water and cities with high-rise office buildings. As a result, patients seeking treatment at CHBH have a mix of first-and third-world pathologies. Working in an environment with some of these challenges is hard to fathom for U.S. providers, but Mathivha and her people deal with them every day. For obvious reasons, prioritizing which patients will be admitted to the ICU is essential. "We don't want to waste resources," said Mathivha. "We want to bring an active person back to society." So what are some of the factors that they consider when admitting patients to the ICU?

  • Age. If an 82-year-old patient and a 43-year-old patient both need critical care, the bed will go to the younger patient, said Mathivha. The thinking is the older patient has lived a full life and the younger patient may be the sole bread winner for a family of four. The average age of a person in the ICU is 38 years old. They are also 65% male, Mathivha added.
  • Terminal illness. If the patient has a terminal illness, they will not be admitted to the unit.
  • Fatal injuries. If the patient's injuries are almost certainly fatal and surgery offers little hope, they will not be transferred to the ICU to die there instead. "A positive outcome is expected," she said.
  • Reversal of disease process or condition. The ICU will admit borderline cases or patients who are unstable after surgery, but patients should continue to improve. Patients will be reevaluated if they stop making progress.
  • Staffing. If they don't have enough staff members to care for the patient, they will not admit them to the unit.

Her message was that the leaders of the critical-care unit "try to set priorities that fit in with their resources." CHBH will continue to function that way until they have unlimited resources—which will never happen, Mathivha added, pointing out that we don't have unlimited resources in the United States, either.

No kidding. That's something of which hospital CEOs have become even more acutely aware in recent months. Fortunately, we don't have a system where patients are routinely turned away for treatment. Granted they may have to wait long hours, but at least they can get in the door.

Still, limited resources mean that healthcare CEOs are forced to make some heart-wrenching decisions like cutting a money-losing service line. More and more hospitals have already had to cut services like obstetrics, pediatrics, rehabilitation, or long-term care because they could no longer afford to provide those services to the community.

I recently spoke with Martin Gavin, president and CEO of Hartford, CT-based Connecticut Children's Medical Center, for a story that will run in the March issue of HealthLeaders magazine on the importance of healthcare providers looking past their own interests and partnering with other healthcare organizations to provide care in a manner that is best for the community. "In looking out toward the future of healthcare delivery, you really have to think in terms of not just a sense of optimism but what do you have to give up," Gavin says. "What sacrifices have to be made to serve the community you are dealing in?"

So do you really need to have the newest MRI machine or da Vinci surgical system? Or can you partner with another hospital to bring some of those services to your community?

Carrie Vaughan is leadership editor with HealthLeaders magazine. She can be reached at
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