Intermediate Care Unit at the St Francis Referral Hospital
The St Francis Referral Hospital in Ifakara, Tanzania, serves as a referral center for a rural population of ~1.5 million people. Its emergency department (ED) manages 88’000 patients per year, 10% in a serious condition. To further stabilize seriously sick patients who were successfully managed at the emergency room, and for patients who received surgery, an intermediate care unit is needed.
Therefore, an Intermediate Care (IMC) Unit is to be established for about 1000 patients per year. We aim to substantially reduce the morbidity and mortality of critically ill patients who have been stabilized in the emergency department and need further intermediate care or have undergone surgery.
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 IMC, ED, surgical theatre, and specialized clinics; iii) the implementation of equipment; and iv) the conduct of research to identify indicators of success.
Two 1-week intensive courses are scheduled, as well as e-learning and hands-on training, in collaboration with the University Hospital Basel, Switzerland. Training will cover, among others, treatment of trauma, stroke, sepsis, heart failure, cardiac arrhythmias, respiratory arrest, severe obstetric and gynecologic problems, hemorrhage and other severe conditions, recognition and treatment of deteriorating conditions, blood transfusions, indication and use of vasoactive medications, antibiotic stewardship, use of point-of-care ultrasound, advanced cardiac life support (ACLS), advanced trauma life support (ATLS), performing and interpreting electrocardiograms (ECG), non-invasive ventilation, invasive procedures and physiotherapy.
Organisational measures include a three-shift working roster including nurses and at least one doctor per shift who stays at- and is responsible for IMC-patients, the close collaboration of the IMC doctors with the specialised department teams, the patient flow from the emergency department and theatres to IMC and later to the wards, including the implementation of a communication systems between these units, a rapid diagnosis and therapy for stroke patients who are presenting within 4.5 hours after first symptoms, and the visits of patients' relatives.
Implementation of Equipment
Various 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 lab system, and a suction machine. All equipment is protected by stabilizers.
IMC patients will be charged a regular admission fee – similar to the ER service. All services done will be charged at a reasonable price. Patients who cannot pay these fees, may get a waiver from payment. Salaries for nurses and one doctor will be paid by SFRH, two local medical doctors and one nurse certified in Intensive care nursing will be paid by project money. After 3-4 years, the project will be handed over to the hospital. Since income will increase over the project period, the IMC should be able to generate enough income to pay for maintenance of the IMC staff. All staff will remain employed, because from the beginning, the salary of most staff is already paid by the Hospital. The collaboration between the partners will remain as it is since decades, and training and teaching will go on through daily bed side teaching and regular courses by trained local nurses and doctors. Thanks to the “train the trainers” concept, knowledge and skills can be transferred to more health care staff in future.
The IMC will add to the local health care system consisting of referral from primary health care facilities- ED- surgical theatre-IMC, and reduce morbidity and mortality of severely sick patients. It will be a nation-wide model, to be implemented in other hospitals.
This will be the first intermediate care unit in rural areas in Tanzania.