Intermediate Care Unit at the St Francis Referral Hospital

St Francis Referral Hospital in Ifakara, Tanzania, serves as a referral centre for a rural population of ~1.5 million people. Its Emergency Department (ED) sees 88,000 patients a year, 10% of whom are in a serious condition. For further stabilisation of critically ill patients who have been successfully treated in the ED and for patients who have undergone surgery, an intermediate care unit is needed.

Therefore, an Intermediate Care Unit (IMC) will be established for about 1,000 patients per year. We aim to significantly reduce morbidity and mortality in critically ill patients who have been stabilised in the ED or have had surgery and require further intermediate care.

The primary objective is to train health care staff in intermediate care medicine and nursing. Secondary objectives are i) the organisation of clinical work at the IMC; ii) the collaboration between the IMC, the ED, the surgical theatre and specialised clinics; iii) the implementation of equipment; and iv) the conduct of research to identify indicators of success.

Measures

Training

Two one-week intensive courses are planned, as well as e-learning and hands-on training, in collaboration with the University Hospital of Basel, Switzerland. Training will cover trauma, stroke, sepsis, heart failure, cardiac arrhythmias, respiratory arrest, major obstetric and gynecologic problems, bleeding and other serious conditions, recognition and management of deteriorating conditions, blood transfusion, indication and use of vasoactive drugs, antibiotic stewardship, use of point-of-care ultrasound, advanced cardiac life support (ACLS), advanced trauma life support (ATLS), performance and interpretation of electrocardiograms (ECG), non-invasive ventilation, invasive procedures and physiotherapy.

Organisation

Organisational measures include a three-shift rota with nurses and at least one physician per shift staying at the IMC and being responsible for IMC patients, close collaboration between the IMC physicians and the specialist department teams, patient flow from the ED and theatres to the IMC and later to the wards, including the implementation of a communication system between these units, a rapid diagnosis and treament of stroke patients presenting within 4.5 hours of the onset of symptoms, and the patient relatives' visits.

Implementation of Equipment

Several pieces of equipment will be introduced, including patient monitors, ventilators for non-invasive ventilation, an ultrasound machine, an ECG machine and a defibrillator, the Abbott iSTAT point of care laboratory system and a suction machine. All equipment is protected by stabilisers.

Sustainability

Patients at the IMC will be charged a regular admission fee, similar to the emergency service. All services provided are charged at a reasonable rate. Patients who are unable to pay these fees may be exempted from payment. The salaries of the nurses and one doctor will be paid by SFRH, while two local medical doctors and one ICU nurse will be paid by the project. The project will be handed over to the hospital after 3-4 years. As revenues increase over the course of the project, the IMC should be able to generate enough income to pay for the maintenance of the IMC staff. All staff will continue to be employed, as the majority of staff will have their salaries paid by the hospital from the outset. Collaboration between the partners will remain as it has been for decades, and training and teaching will continue through daily bedside teaching and regular courses by trained local nurses and doctors. A 'train the trainers' approach will enable knowledge and skills to be transferred to more health workers in the future.

The IMC will complement the local health care system of referral from primary health care facilities - ED - surgical theatre - IMC and reduce morbidity and mortality of critically ill patients. It will be a national model to be replicated in other hospitals.

This will be the first intermediate care unit in rural areas in Tanzania.