Strategic Framework for modernisation of tertiary services - Part 6

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					APPENDIX 4                                                      IDEAL / MINIMUM UNIT SIZES

Minimum Staffing Requirements for an Ideal Unit – as per specialty reports

Anaesthetics                    Report not submitted

Cardio thoracic surgery         Not specified

Cardiology                      Not specified

Clinical immunology             1 clinical immunologist/medical school
                                2 specialist scientists
                                1 MO/hospital
                                1 clinical immunology trained nurse/referral centre
                                Use NHLS for personnel issues
Clinical pharmacology           Not specified

Dermatology                     National referral centre
                                Super specialists with expertise e.g. gene therapy
                                Tertiary hospital
                                Adequate ratio of specialists and registrars (numbers and type not
                                Regional hospitals
                                Full time specialists (numbers and type not specified)

Diagnostic radiology            Number of staff will depend on the size of department and work load
                                Baseline 24 hr busy general X-ray unit:
                                7 radiographers
                                2 radiologists who could cover a group of hospitals
                                3 nurses
                                2 typists
                                2 cleaners
                                1 regional clinical engineer (to be shared with other centres)
                                3 darkroom staff
                                3 clerks
                                3 porters
                                Low-activity unit without after hour cover:
                                3 radiographers
                                Central hospital
                                2 Medical Physicists
                                Radiology workload calculation
                                0.45 FTE radiologist / 1,000 examinations / month
                                0.25 FTE radiologists / additional service point added e.g. 0.25 FTE for
                                1 mammographic unit, 0.25 FTE for 1 fluoroscopic unit
                                1 FTE / CT scanner in use to be added. If ≥ 1,000 CT examinations are
                                performed / month and additional 1 FTE radiologist to be added

APPENDIX 4                                               IDEAL / MINIMUM UNIT SIZES

                       0.5 FTE should be added if the radiology department performs images
                       for full radiotherapy / oncology departments
                       2 FTE added / MRI
                       For registrars a factor of 1.5 registrars / consultant
                       Radiographers: ≈ 2.7 radiographers / doctor (registrar and consultant)
Endocrinology          Requirements for 200 out patients and 15 inpatients/week:
                       Endocrinologist 3 (ideal) 1 (minimum)
                       Specialist physician 2 (ideal) 1(min)
                       MO/registrars 3 (ideal) 2 (min)
                       Trainee 1
                       Diabetes nurse educators 4 (ideal) 2 (min)
                       Other sisters 2 (ideal) 1 (min)
                       Nurses in training 2 (ideal) 1 (min)
                       Clerks 2 (ideal) 1 (min)
                       Secretary 1 (ideal) 1 (part-time)
                       Dietician 2 (ideal) 1 (min)
                       Podiatrist 1 (ideal) 1 (part-time)
                       Biokineticist 1 (ideal)
                       Ophthalmologist (ideal) 1 (part-time)
ENT                    1 x Chief Specialist
                       2 x Specialists
                       8 x Registrars
                       2 x Medical Officers
                       1 x Research assistant
                       1 x Secretary
Gastroenterology and   Tertiary Liver Units:
                       It was felt that at this stage, two liver units were enough. Each centre
                       should have at least 3 clinical hepatologists, 2 hepatic surgeons and
                       one pathologist whose main pathological interest should be the liver. All
                       Liver Transplant Units should be attached to a Liver Unit.
                       Acceptable Norms regarding tertiary GIT Units:
                       It was necessary to obtain figures as to what are acceptable norms as
                       regards the number of the population needed for one gastroenterologist
                       or one tertiary GIT unit or one tertiary Liver unit. It was noted that these
                       would be figures derived in Western countries and it needed to be
                       decided whether these would be appropriate for South Africa or not.
                       Each of the present GIT units should have 3 medical and 3 surgical GIT
                       consultants. It is hoped that both the Department of Health and the
                       clinicians should try and obtain these figures.
                       It would appear that we are short of the British norms as regards

APPENDIX 4                                         IDEAL / MINIMUM UNIT SIZES

                   endoscopy units.
General medicine   In-patient:
                   60 patients / specialist physician
                   2 interns and 2 MO or registrars / specialist
General surgery    At least two sub-specialists, or the equivalent FTE’s.
                   A norm of specialist per beds for tertiary general surgery should be
                   about one-specialist/ 12 beds. It should however be noted that all
                   tertiary units must have a training responsibility; some will be for
                   generalist specialists and other for subspecialty training. Therefore a
                   system providing for academic increments must be incorporated. The
                   norm for specialists at LII one specialist for 15 – 20 beds is appropriate.
                   To determine unit sizes by patient volumes will lead to many of the
                   inequities that have given rise to this process. We should rather be
                   developing our own South African norms for the number of specialists
                   per 100 000 population. Based on this and the available human
                   resources one can then start to allocate units. This however cannot
                   ignore the historically developed units, which have shown proven
                   sustainability. These units must be incorporated into any new system
                   where appropriate. (e.g. don’t close down three of the four
                   gastroenterology units in Johannesburg, rather shrink to two and ensure
                   better referral patterns from nearby surrounding provinces)
Geriatrics         For 100 patients / week
                   In-patient services:
                   Acute beds: 24 beds
                   Stroke unit: 10 beds
                   Psycho geriatrics beds: 24 managed with psychiatrists
                   Rehabilitation services
                   Out patient services;
                   Multi disciplinary assessment clinics
                   Specialised clinics e.g. dementia, osteoporosis, falls etc.
                   1 Chief specialist
                   1 Principal specialist
                   1 Specialist
                   2 Career registrars
                   1 Medical officer
                   1 Rotating registrars
                   1 Secretary
                   Trained nurses, PT, OT, speech therapists, social worker, dietician,
                   clinical psychologist, chiropodist (to be shared with other subspecialties)
Haematology        Not specified

APPENDIX 4                                               IDEAL / MINIMUM UNIT SIZES

Human genetics          Four medical geneticists and 16 Genetic Nurses/counsellors
                        20 Scientists/medical technologists for laboratory testing
ICU/ Critical care      Full range of medical and surgical subspecialties (especially paediatric
                        subspecialties for paediatric intensive care. For adult women full time
                        obstetrics and gynaecological services. Physiotherapy and pharmacy
                        Regional hospitals
                        Minimum 6-bed high care with capacity for ventilation for 24-48 hours.
                        Provincial tertiary hospitals
                        8-12 beds (minimum)
                        12 bed (ideal)
                        High care beds
                        National referral centre
                        12 ICU beds (minimum)
                        20 ICU beds (ideal)
                        High care beds (overall 4-8% of hospital beds)
                        Ideal ICU nurse: patient ratio
                        1 ICU trained staff: 2 (preferably) 1 patient
                        1 non ICU trained RN: 1 patient
                        Ideal high Care Unit nurse: patient ratio
                        1 RN: 1-2 patients depending on severity of illness and turnover
Infectious diseases     Sizes of units should be estimated using the number of Infectious
                        diseases physicians looking after them and the rest of the staff should
                        be in proportion.
                        For every infectious disease physician the unit should manage eight to
                        ten patients.
Medical and radiation   Not specified

Mental health           Not specified

Neonatology             Level III (NICU) facilities should have a minimum of 4-6 beds per unit.
                        Given the low birth weight rates, high sepsis rates and the need for
                        neonatal surgery, the requirements for NICU beds appropriate for South
                        Africa should not less than 1 to 1,5 per 1000 annual delivery.
                        Nurses: baby ratio:
                        Neonatal ICU care unit 1:1
                        Neonatal High Care unit 1:3
                        Neonatal Low Care unit 1:5

APPENDIX 4                                                      IDEAL / MINIMUM UNIT SIZES

Nephrology                   All dialysis units should be supervised or serviced by a registered
                             nephrologist and managed on a day-to-day basis by a specialist
                             physician with recognised expertise in dialysis.

                             Medical staff should be readily available to deal with emergencies and
                             review chronic patients every 3 months (min) and 1 month (ideal).

                             Staff: patient ratio for chronic dialysis should be 1:4 (including nurses
                             and clinical technologists): Expanded care 1:2, Basic care 1:3

                             Acute dialysis; special care 1:1

                             A registered nurse with haemodialysis experience should be present at
                             all times in the unit.

Neurology                    Not specified

Neurosurgey                  1 HOD,
                             2 Principal Specialists
                             4 Specialists
                             6 Registrars minimum

                             2-4 Medical Officers (Alternatively, a minimum of 8

                             Rotating interns for teaching (currently no rotating
                             interns are present).

Nuclear medicine             Difficult to state however, the international guide is 1000-1200
                             Also, the minimum size of a unit in terms of patient work load depends
                             on the kind of service the unit is expected to deliver (e.g. limited or
Obstetrics and gynaecology   Generic criteria (HPCSA)
                             Sub specialty requirements (College of Medicine)
Ophthalmology                2-4 Ophthalmologists per million population,

                             4-8 MO/Registrars,

                             1 x orthoptist,

                             2 x nurses/ OMA per doctor

                             Nursing staff (registered, enrolled and OMA) for theatre and ward
Orthopaedics                 Regional level
                             1 specialist
                             4 MOs

APPENDIX 4                                                        IDEAL / MINIMUM UNIT SIZES

                               Tertiary and National referral units (not specified)
                               Dependent on size of institution and services rendered
Other Rehabilitation           Not specified, however should be based on patient classification
                               systems, workload measurement systems and or patient needs.
Paediatric Allergology         1 Specialist
                               1 Medical Officer (Diplomate in Allergy)
                               Specialised Nurse
Paediatric Cardiology          Minimum
                               2 paediatric cardiac surgical operations/surgeon/week
                               > 500 echocardiographic studies p.a. (most units are performing 1000-
                               2000 paediatric cardiac echo studies p.a.
                               ≥ 50 cardiac catheterisation procedures/cardiologist p.a.
                               2 Trained Paediatric Cardiologists
                               1 Fellow
                               1 Registrar
                               ≈ 100 congenital heart operations/mil needed p.a.
                               10 operations/mil for acquired valve disease
Paediatric Critical Care/ICU   National referral centres
                               Minimum: 4 intensivists/18-20 beds/unit
                               Tertiary Hospitals
                               24 hrs intensivist to cover ICU @ all times, this is 4-5 intensivists on site
                               Smaller centres e.g. Bloemfontein
                               Minimum: 1 Full time intensivist as unit director
                               Paediatric intensivists to coordinate regional critical care services
                               Nurse: patients ratio
                               1 sister and 1 nurse: 2 patients
                               8 –10 PICUs needed in the country
                               Maximum size of unit
                               20- 25 beds, 4 – 5 step down beds 20 ICU

APPENDIX 4                                                          IDEAL / MINIMUM UNIT SIZES

Paediatric Child Development   Minimum
                               1 General specialist and 1 career MO at regional level
                               2 sub specialist at supra regional level
                               1 sub specialist and 1 training post (Snr. Registrar) at supra provincial
                               1 sub specialist at quaternary level
                               3 skilled generalists and 1 career MO at regional level
                               3 sub specialists and 1 career MO at supra regional level
                               2 sub specialists, 2 training posts (snr. Registrars) and 1 career MO at
                               supra provincial level
                               1 sub specialist, 1 career MO at quaternary level
Paediatric Endocrinology       Establish ”joint” multi disciplinary clinics.
                               Each teaching hospital should have a paediatrics endocrinology unit
                               (with support staff and other sub specialist services including radiology
                               and surgery). Unit size and staffing requirements not specified.
Paediatric Gastroenterology    Minimum
                               At least 2 specialists and a senior registrar for training per unit.
Paediatric                     Minimum
                               2 full time sub specialists / unit
                               Specialty nurses
                               2–5 dedicated consultants and sub specialists depending on size of unit
                               1-2 training posts per registered unit
                               Dedicated nursing staff trained in Haematology/oncology/paediatrics
                               Higher nurse: patient ratios (as most is HC)
                               Outreach and home visiting nurse
Paediatric medicine            Regional Hospital:
                               3 Paediatrician
                               6 Registrar / MO
Paediatric Nephrology and      Minimum:
                               2 consultants/unit
                               ICU back up
                               GIT team
                               Transplant surgeons (number not specified)
                               Transplants: 50 kidneys p.a. and liver 15-20 p.a.
Paediatric Neurology           Not specified

Paediatric Respiratory         2 Pulmonologists
                               Auxiliary staff

APPENDIX 4                                               IDEAL / MINIMUM UNIT SIZES

                          Cardio thoracic
Paediatric Rheumatology   1 specialist rheumatologist
                          1 dedicated rheumatology nurse practitioner
Paediatric surgery        Ideal
                          Each province to have at least 1- 2 specialised units
                          At least ≥3 regional paediatric surgery units to be developed
Plastic surgery           Ideal norm
                          1 plastic surgeon per 250 000 patients
                          Academic Centre
                          1 Principal Specialist
                          1 Senior Specialist
                          2 Registrars
                          1 MO
                          Metro Supra Regional
                          1 Principal Specialist
                          1 Senior Specialist
                          2 Registrars
                          1 MO
                          Peripheral Supra Regional
                          1 MO
Renal/ Liver transplant   Minimum size: (all personnel P/T = full-time practitioner but part-time
                          commitment to transplantation)
                          1 Surgeon
                          1 physician
                          1 general anaesthetist
                          1 nurse for each of the following, ward, theatre and ICU/HC
                          1 coordinator
                          1 registrar/MO/intern
                          General ward
                          Ideal size (F/T)
                          1 specialist surgeon
                          1 nephrologist
                          1 expert anaesthetist
                          3 nurses for each of the following, ward, theatre and ICU/HC
                          3 coordinator
                          3 registrar/MO/intern

APPENDIX 4                                              IDEAL / MINIMUM UNIT SIZES

                       2 dedicated wards
Respiratory medicine   Tertiary Units
                       The numbers of equivalents required depend upon the patient load in
                       tertiary hospitals, the number of extension programmes and additional
                       administrative and clinical responsibilities. For most provinces at least 5
                       full-time equivalents are required. At least one dedicated sub-speciality
                       trainee in pulmonology and another in critical care are required (see
                       Critical Care document). One training registrar/community medical
                       officer for Pulmonology.
                       The absolute minimum requirements for critical mass and cross-cover in
                       the ICU and extension services are 3 full time individuals in
                       pulmonology. This does not take into account any clinical work in
                       general     medicine,    teaching,   training,   administrative   duties   and
                       University responsibilities or research. There is also a need for trainee
                       posts and junior staff posts as indicated above.
                       Regional Units
                       A Specialist in General Medicine with many special interests but at least
                       a minor interest in Pulmonology who will liase with the visiting
                       Pulmonologist and select cases for additional specialist opinion and
                       referral to the Tertiary Hospital.
                       In provinces where Pulmonology Units are unlikely to be affordable, a
                       general physician may be trained in bronchoscopy. However the poor
                       cost efficiency of trying to maintain optimal equipment and its use
                       without the support of an effective microbiological service, cyto-
                       pathologist, quality assure for handling cleaning and sterilisation of the
                       bronchoscopy equipment and surgical backup for emergencies severely
                       limit the practicalities of this option (which has been tried in several
                       Medical Officers including community service doctors who would have
                       the opportunity for regular supervision and teaching from a visiting
                       pulmonologist. Medical officers will be encouraged to take the Diploma
                       in Pulmonology on a part time basis to enhance their skills
Rheumatology           3 or 4 Consultants
                       2 to 3 Registrars
                       1 to 2 Nursing Sisters
                       1 part-time Medical Officer
                       Specialist sessional posts should be available.             However, these

APPENDIX 4                                                            IDEAL / MINIMUM UNIT SIZES

                                   numbers would vary based on the service volumes and the demand for
                                   services in the different areas.
Spinal injury and rehabilitation   Minimum:
                                   Spinal TB: 500 beds
                                   Rehabilitation: 12 beds/ million population
                                   Units should be attached to regional hospitals with dedicated staff and
                                   access to other specialised services e.g. urology, surgery etc.
Urology                            Ideal unit
                                   Academic head
                                   Ideal staff establishment
                                   Chief specialist
                                   Principal specialist
                                   2 senior specialists
                                   8 registrars
                                   4 medical officers
                                   Ideal number of beds: 70 –100
                                   This ideal unit will be responsible for Urological service to a region
                                   including one or more regional hospitals (level II). Urology Registrars
                                   would rotate to the regional hospital supervised by an urologist e.g.
                                   Durban metropolitan service.
Vascular surgery                   Minimum:
                                   400 operations p.a. (minimum)
                                   2 vascular surgeons
                                   2 registrars
                                   Sufficient nurses, beds, high care and ICU beds, secretaries, duplex
                                   Minimum size vascular training unit:
                                   1 000 operations p.a. (minimum)
                                   2 vascular surgeons
                                   2 registrars
                                   Sufficient nurses, beds, high care and ICU beds, secretaries, duplex
                                   2 vascular surgery fellows (post general surgical training who are
                                   vascular surgery trainees for a two year period)


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