Referral and admission to intensive care: A qualitative study of doctors’ practices in a Tanzanian university hospital

Autoři: Sofia Engdahl Mtango aff001;  Edwin Lugazia aff002;  Ulrika Baker aff003;  Yvonne Johansson aff001;  Tim Baker aff003
Působiště autorů: Department of Acute Internal Medicine and Geriatrics in Linköping, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden aff001;  Department of Anaesthesia & Intensive Care, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania aff002;  College of Medicine, University of Malawi, Blantyre, Malawi aff003;  Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden aff004
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224355



Intensive care is care for critically ill patients with potentially reversible conditions. Patient selection for intensive care should be based on potential benefit but since demand exceeds availability, rationing is needed. In Tanzania, the availability of Intensive Care Units (ICUs) is very limited and the practices for selecting patients for intensive care are not known. The aim of this study was to explore doctors’ experiences and perceptions of ICU referral and admission processes in a university hospital in Tanzania.


We performed a qualitative study using semi-structured interviews with fifteen doctors involved in the recent care of critically ill patients in university hospital in Tanzania. Inductive conventional content analysis was applied for the analysis of interview notes to derive categories and sub-categories.


Two main categories were identified, (i) difficulties with the identification of critically ill patients in the wards and (ii) a lack of structured triaging to the ICU. A lack of critical care knowledge and communication barriers were described as preventing identification of critically ill patients. Triaging to the ICU was affected by a lack of guidelines for admission, diverging ideas about ICU indications and contraindications, the lack of bed capacity in the ICU and non-medical factors such as a fear of repercussions.


Critically ill patients may not be identified in general wards in a Tanzanian university hospital and the triaging process for the admission of patients to intensive care is convoluted and not explicit. The findings indicate a potential for improved patient selection that could optimize the use of scarce ICU resources, leading to better patient outcomes.

Klíčová slova:

Critical care and emergency medicine – Hospitals – Intensive care units – Medical doctors – Nurses – Surgical and invasive medical procedures – Tanzania – Triage


1. Fullerton JN, Perkins GD. Who to admit to intensive care? Clin Med (Lond). 2011;11(6):601–4.

2. Smith G, Nielsen M. ABC of intensive care. Criteria for admission. BMJ. 1999;318(7197):1544–7. 10356016

3. Guidelines for intensive care unit admission, discharge, and triage. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 1999;27(3):633–8. 10199547

4. Attitudes of critical care medicine professionals concerning distribution of intensive care resources. The Society of Critical Care Medicine Ethics Committee. Crit Care Med. 1994;22(2):358–62. 8306698

5. Vincent JL. European attitudes towards ethical problems in intensive care medicine: results of an ethical questionnaire. Intensive Care Med. 1990;16(4):256–64. doi: 10.1007/bf01705162 2358559

6. Singer DE, Carr PL, Mulley AG, Thibault GE. Rationing intensive care—physician responses to a resource shortage. N Engl J Med. 1983;309(19):1155–60. doi: 10.1056/NEJM198311103091905 6413862

7. Strauss MJ, LoGerfo JP, Yeltatzie JA, Temkin N, Hudson LD. Rationing of intensive care unit services. An everyday occurrence. JAMA. 1986;255(9):1143–6. 3945032

8. Marshall MF, Schwenzer KJ, Orsina M, Fletcher JC, Durbin CG Jr. Influence of political power, medical provincialism, and economic incentives on the rationing of surgical intensive care unit beds. Crit Care Med. 1992;20(3):387–94. doi: 10.1097/00003246-199203000-00016 1541100

9. Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A, et al. Evaluation of triage decisions for intensive care admission. Crit Care Med. 1999;27(6):1073–9. doi: 10.1097/00003246-199906000-00021 10397207

10. Garrouste-Orgeas M, Montuclard L, Timsit JF, Misset B, Christias M, Carlet J. Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes. Intensive Care Med. 2003;29(5):774–81. doi: 10.1007/s00134-003-1709-z 12677368

11. Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM, Values E, et al. Rationing critical care beds: a systematic review. Crit Care Med. 2004;32(7):1588–97. doi: 10.1097/01.ccm.0000130175.38521.9f 15241106

12. Azoulay E, Pochard F, Chevret S, Vinsonneau C, Garrouste M, Cohen Y, et al. Compliance with triage to intensive care recommendations. Crit Care Med. 2001;29(11):2132–6. doi: 10.1097/00003246-200111000-00014 11700409

13. Truog RD, Brock DW, Cook DJ, Danis M, Luce JM, Rubenfeld GD, et al. Rationing in the intensive care unit. Crit Care Med. 2006;34(4):958–63; quiz 71. doi: 10.1097/01.CCM.0000206116.10417.D9 16484912

14. Blanch L, Abillama FF, Amin P, Christian M, Joynt GM, Myburgh J, et al. Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care. 2016;36:301–5. doi: 10.1016/j.jcrc.2016.06.014 27387663

15. Orsini J, Blaak C, Yeh A, Fonseca X, Helm T, Butala A, et al. Triage of Patients Consulted for ICU Admission During Times of ICU-Bed Shortage. J Clin Med Res. 2014;6(6):463–8. doi: 10.14740/jocmr1939w 25247021

16. van Zyl-Smit R, Burch V, Willcox P. The need for appropriate critical care service provision at non-tertiary hospitals in South Africa. S Afr Med J. 2007;97(4):268, 70, 72. 17446951

17. Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the intensive care unit. Lancet. 2010;376(9749):1347–53. doi: 10.1016/S0140-6736(10)60143-2 20934213

18. Chen LM, Render M, Sales A, Kennedy EH, Wiitala W, Hofer TP. Intensive care unit admitting patterns in the Veterans Affairs health care system. Arch Intern Med. 2012;172(16):1220–6. doi: 10.1001/archinternmed.2012.2606 22825806

19. Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349(12):1123–32. doi: 10.1056/NEJMoa030083 13679526

20. Garland A, Connors AF. Physicians’ influence over decisions to forego life support. J Palliat Med. 2007;10(6):1298–305. doi: 10.1089/jpm.2007.0061 18095808

21. Cooper AB, Sibbald R, Scales DC, Rozmovits L, Sinuff T. Scarcity: the context of rationing in an Ontario ICU. Crit Care Med. 2013;41(6):1476–82. doi: 10.1097/CCM.0b013e31827cab6a 23474676

22. Guyatt G, Cook D, Weaver B, Rocker G, Dodek P, Sjokvist P, et al. Influence of perceived functional and employment status on cardiopulmonary resuscitation directives. J Crit Care. 2003;18(3):133–41. 14595566

23. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet. 2010;376(9749):1339–46. doi: 10.1016/S0140-6736(10)60446-1 20934212

24. Kwizera A, Dunser M, Nakibuuka J. National intensive care unit bed capacity and ICU patient characteristics in a low income country. BMC research notes. 2012;5:475. doi: 10.1186/1756-0500-5-475 22937769

25. Manda-Taylor L, Mndolo S, Baker T. Critical care in Malawi: The ethics of beneficence and justice. Malawi medical journal: the journal of Medical Association of Malawi. 2017;29(3):268–71.

26. Data U. Country statistics United Republic of Tanzania 2017 [Available from:

27. Baker T, Lugazia E, Eriksen J, Mwafongo V, Irestedt L, Konrad D. Emergency and critical care services in Tanzania: a survey of ten hospitals. BMC Health Serv Res. 2013;13:140. doi: 10.1186/1472-6963-13-140 23590288

28. Sawe HR, Mfinanga JA, Lidenge SJ, Mpondo BCT, Msangi S, Lugazia E, et al. Disease patterns and clinical outcomes of patients admitted in intensive care units of tertiary referral hospitals of Tanzania. BMC international health and human rights. 2014;14:26. doi: 10.1186/1472-698X-14-26 25245028

29. Baker T, Schell CO, Lugazia E, Blixt J, Mulungu M, Castegren M, et al. Vital Signs Directed Therapy: Improving Care in an Intensive Care Unit in a Low-Income Country. PLoS One. 2015;10(12):e0144801. doi: 10.1371/journal.pone.0144801 26693728

30. Baker T, Blixt J, Lugazia E, Schell CO, Mulungu M, Milton A, et al. Single Deranged Physiologic Parameters Are Associated With Mortality in a Low-Income Country. Critical care medicine. 2015;43(10):2171–9. doi: 10.1097/CCM.0000000000001194 26154933

31. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985–2000: An analysis of bed numbers, use, and costs. Critical care medicine. 2004;32(6):1254–9. doi: 10.1097/01.ccm.0000128577.31689.4c 15187502

32. Kruisselbrink R, Kwizera A, Crowther M, Fox-Robichaud A, O’Shea T, Nakibuuka J, et al. Modified Early Warning Score (MEWS) Identifies Critical Illness among Ward Patients in a Resource Restricted Setting in Kampala, Uganda: A Prospective Observational Study. PloS one. 2016;11(3):e0151408. doi: 10.1371/journal.pone.0151408 26986466

33. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. doi: 10.1177/1049732305276687 16204405

34. Baker T. Critical care in low-income countries. Trop Med Int Health. 2009;14(2):143–8. doi: 10.1111/j.1365-3156.2008.02202.x 19207174

35. Baker T L E, Eriksen J, Mwafongo V, Irestedt L & Konrad D Emergency and critical care services in Tanzania: a survery of ten hospitals. BMC Health Services Research 2013;13(140).

36. Aloyce R, Leshabari S, Brysiewicz P. Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam, Tanzania. African Journal of Emergency Medicine. 2014;4(1):14–8.

37. Molyneux E, Ahmad S, Robertson A. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting. Bull World Health Organ. 2006;84(4):314–9. doi: 10.2471/blt.04.019505 16628305

38. Rice K, Zwarenstein M, Conn LG, Kenaszchuk C, Russell A, Reeves S. An intervention to improve interprofessional collaboration and communications: a comparative qualitative study. J Interprof Care. 2010;24(4):350–61. doi: 10.3109/13561820903550713 20540614

39. Mathauer I, Imhoff I. Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Hum Resour Health. 2006;4:24. doi: 10.1186/1478-4491-4-24 16939644

40. Abera GG, Alemayehu YK, Herrin J. Public-on-private dual practice among physicians in public hospitals of Tigray National Regional State, North Ethiopia: perspectives of physicians, patients and managers. BMC Health Serv Res. 2017;17(1):713. doi: 10.1186/s12913-017-2701-6 29126453

41. Russo G, McPake B, Fronteira I, Ferrinho P. Negotiating markets for health: an exploration of physicians’ engagement in dual practice in three African capital cities. Health Policy Plan. 2014;29(6):774–83. doi: 10.1093/heapol/czt071 24077880

42. Ashmore J, Gilson L. Conceptualizing the impacts of dual practice on the retention of public sector specialists—evidence from South Africa. Hum Resour Health. 2015;13:3. doi: 10.1186/1478-4491-13-3 25600159

43. Paina L, Bennett S, Ssengooba F, Peters DH. Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda. Health Res Policy Syst. 2014;12:41. doi: 10.1186/1478-4505-12-41 25134522

44. Manongi RN, Marchant TC, Bygbjerg IC. Improving motivation among primary health care workers in Tanzania: a health worker perspective. Hum Resour Health. 2006;4:6. doi: 10.1186/1478-4491-4-6 16522213

45. Mkoka DA, Mahiti GR, Kiwara A, Mwangu M, Goicolea I, Hurtig AK. "Once the government employs you, it forgets you": Health workers’ and managers’ perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania. Hum Resour Health. 2015;13:77. doi: 10.1186/s12960-015-0076-5 26369663

46. Songstad NG, Rekdal OB, Massay DA, Blystad A. Perceived unfairness in working conditions: the case of public health services in Tanzania. BMC Health Serv Res. 2011;11:34. doi: 10.1186/1472-6963-11-34 21314985

47. Khamis K, Njau B. Health care worker’s perception about the quality of health care at the outpatient department in Mwananyamala Hospital in Dar es Salaam, Tanzania. Tanzania Journal of Health Research. 2016;18(1).

48. Nates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, Birriel B, et al. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med. 2016;44(8):1553–602. doi: 10.1097/CCM.0000000000001856 27428118

49. Kahan BC, Koulenti D, Arvaniti K, Beavis V, Campbell D, Chan M, et al. Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries. Intensive Care Med. 2017;43(7):971–9. doi: 10.1007/s00134-016-4633-8 28439646

50. Workgroup VD. Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency. Atlanta, GA: Centers for Disease Control and Prevention, 2011.

51. Sebat F, Musthafa AA, Johnson D, Kramer AA, Shoffner D, Eliason M, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care Med. 2007;35(11):2568–75. doi: 10.1097/01.CCM.0000287593.54658.89 17901831

52. Cardoso LT, Grion CM, Matsuo T, Anami EH, Kauss IA, Seko L, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care. 2011;15(1):R28. doi: 10.1186/cc9975 21244671

53. Brown RM, Semler MW. Fluid Management in Sepsis. J Intensive Care Med. 2018:885066618784861.

54. Leshabari MT, Muhondwa EP, Mwangu MA, Mbembati NA. Motivation of health care workers in Tanzania: a case study of Muhimbili National Hospital. East Afr J Public Health. 2008;5(1):32–7. 18669121

55. Mostert S, Njuguna F, Olbara G, Sindano S, Sitaresmi MN, Supriyadi E, et al. Corruption in health-care systems and its effect on cancer care in Africa. Lancet Oncol. 2015;16(8):e394–404. doi: 10.1016/S1470-2045(15)00163-1 26248847

56. Dunser MW, Baelani I, Ganbold L. A review and analysis of intensive care medicine in the least developed countries. Crit Care Med. 2006;34(4):1234–42. doi: 10.1097/01.CCM.0000208360.70835.87 16484925

57. Dunser MW, Festic E, Dondorp A, Kissoon N, Ganbat T, Kwizera A, et al. Recommendations for sepsis management in resource-limited settings. Intensive Care Med. 2012;38(4):557–74. doi: 10.1007/s00134-012-2468-5 22349419

58. Wheeler I, Price C, Sitch A, Banda P, Kellett J, Nyirenda M, et al. Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study. PLoS One. 2013;8(3):e59830. doi: 10.1371/journal.pone.0059830 23555796

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2019 Číslo 10