doi: 10.56294/shp2024129

Short communication

Severity assessment in critically ill patients: challenges for the Argentine system in 2024

Evaluación de la gravedad en pacientes críticos: desafíos del sistema argentino en 2024

Francisco Gómez Carazo¹ *, Facundo Correa¹ *

¹Universidad Abierta Interamericana, Facultad de Medicina y Ciencias de la Salud, Carrera de Medicina. Buenos Aires, Argentina.

Cite as: Gómez Carazo F, Correa F. Severity assessment in critically ill patients: challenges for the Argentine system in 2024. South Health and Policy. 2024; 3:129. https://doi.org/10.56294/shp2024129

Submitted: 23-07-2023                  Revised: 03-11-2023                   Accepted: 20-03-2024                 Published: 21-03-2024

Editor: Dr. Telmo Raúl Aveiro-Róbalo

Corresponding author: Francisco Gómez Carazo *

ABSTRACT

The text analyzed the use of the APACHE II and SOFA prognostic scales in the Argentine context during the year 2024, highlighting their relevance in the evaluation of severity and mortality in critically ill patients admitted to intensive care units. The components of both scales were described in detail and it was explained how each one allowed quantifying the clinical condition of the patient by means of physiological and biochemical variables. However, the limitations encountered for their effective application in the Argentine health system, marked by the economic crisis, shortage of medical supplies, lack of trained personnel and structural deficiencies in public hospitals, were also exposed. The research addressed how these barriers hindered the full implementation of such tools, leading to a greater dependence on the clinical judgment of the health professional. In addition, the crucial role played by medical expertise, diagnostic sensitivity and communication with family members was highlighted, especially in an unequal social and healthcare environment. The role of technology was also mentioned as a potential support in the automatic calculation of the scales, although its availability was limited and uneven. Finally, the text emphasized that, although scales such as APACHE II and SOFA were useful as a guide, they did not replace the critical eye or the vocation of health care personnel. Their effective use depended on a strengthened system, sufficient resources and a humanized vision of intensive care.

Keywords: APACHE II; SOFA; Intensive Care; Clinical Severity; Health System.

RESUMEN

El texto analizó el uso de las escalas pronósticas APACHE II y SOFA en el contexto argentino durante el año 2024, destacando su relevancia en la evaluación de la gravedad y mortalidad en pacientes críticos internados en unidades de terapia intensiva. Se describieron detalladamente los componentes de ambas escalas y se explicó cómo cada una permitía cuantificar la condición clínica del paciente mediante variables fisiológicas y bioquímicas. Sin embargo, también se expusieron las limitaciones encontradas para su aplicación efectiva en el sistema de salud argentino, marcado por la crisis económica, la escasez de insumos médicos, la falta de personal capacitado y las deficiencias estructurales en hospitales públicos. La investigación abordó cómo estas barreras dificultaron la implementación completa de dichas herramientas, provocando una mayor dependencia del juicio clínico del profesional de salud. Además, se destacó el papel crucial que jugaron la experiencia médica, la sensibilidad diagnóstica y la comunicación con los familiares, especialmente en un entorno social y sanitario desigual. También se mencionó el rol de la tecnología como apoyo potencial en el cálculo automático de las escalas, aunque su disponibilidad fue limitada y desigual. Finalmente, el texto subrayó que, si bien las escalas como APACHE II y SOFA fueron útiles como guía, no sustituyeron la mirada crítica ni la vocación del personal de salud. Su uso efectivo dependió de un sistema fortalecido, recursos suficientes y una visión humanizada del cuidado intensivo.

Palabras clave: APACHE II; SOFA; Terapia Intensiva; Gravedad Clínica; Sistema de Salud.

BACKGROUND

In modern medicine, especially in intensive care, quantifying the severity of a patient’s clinical condition has become both a technical necessity and an ethical one.⁽¹⁾ Translating a human being’s condition into numbers allows for more objective decision-making, the distribution of limited resources, and improved healthcare planning. However, in 2024, a constant tension between medical theory and hospital practice becomes evident when we place this need within the current Argentine context.⁽²⁾ Despite the indisputable value of scales such as APACHE II and SOFA, their application faces significant limitations due to structural, social, and political factors that define the state of the Argentine healthcare system.⁽³⁾

During 2024, Argentina experienced a year marked by economic recession, adjustments in public spending, and a profound restructuring of the healthcare system.⁽⁴⁾ This led to a decrease in supplies in public hospitals, a reduction in specialized personnel, and a progressive deterioration in the working conditions of doctors and nurses. In this scenario, applying complex scales such as APACHE II, which depends on multiple laboratory tests and constant monitoring, becomes a daily challenge for healthcare professionals. In some hospitals in the Buenos Aires suburbs or the country’s interior, obtaining a blood gas or creatinine test can take hours or may not be available on weekends. This lack of access directly impacts the ability to accurately assess severity, often forcing doctors to make decisions based on experience and intuition rather than concrete data.⁽⁵⁾

At Santorini Hospital, as in many other critical care centers in Argentina, professionals face the patient’s illness and a system that limits their diagnostic tools. It is common for an intensive care bed to be occupied longer than necessary because the patient cannot be transferred due to a lack of space in general wards or medical transport available.⁽⁶⁾ This overload delays new critical patients’ admission, worsening their prognosis. Under these conditions, scales such as the SOFA, which allow for daily monitoring of patient progress, could be an ideal tool for prioritizing resources. However, their full implementation requires data that is often impossible to collect continuously.⁽⁷⁾

Another point to consider is staff training. Although APACHE II and SOFA are well known to intensive care physicians, their detailed use still represents a barrier for young nurses or general practitioners in critical care. In 2024, constant staff turnover due to adverse working conditions, low salaries, and emotional overload will make it difficult to maintain a trained and experienced team using these tools.⁽⁸⁾ This will not only affect the quality of care but also the ability to compare clinical data between patients or even between institutions.

At the same time, another phenomenon observed in Argentina this year has been the increased judicialization of healthcare. Legal pressure on doctors for failures in care has led many professionals to seek even more support in objective data, which could have driven the use of prognostic scales such as those described here.⁽⁹⁾ However, once again, the gap between what should be and what is limits this support. What happens when a complete SOFA cannot be calculated due to a lack of bilirubin or no emergency laboratory? How can this be explained to an auditor or in a lawsuit?

In this sense, clinical experience becomes almost as valuable as numerical data. The physician’s judgment and ability to observe, listen, and anticipate complications remain key in managing critically ill patients. In public hospitals such as Santojanni, many physicians trained in adversity develop a keen sensitivity to detect decompensation without needing immediate laboratory results. Although difficult to measure, this “clinical sixth sense” has saved countless lives and is integral to Argentine medicine.⁽¹⁰⁾

On the other hand, the role of new technologies in this context should also be mentioned. Despite budgetary constraints, some hospitals have begun to incorporate software that automatically calculates APACHE II and SOFA scores using data entered by the medical team. This could represent a significant advance in the standardization of critical care, although its implementation remains uneven and often dependent on donations, agreements with universities, or individual initiatives.⁽¹¹⁾

One element that cannot be overlooked is the social impact of these tools on the doctor-patient relationship. In a country with a strong tradition of medical humanism, where many families closely follow the progress of their loved ones in hospital, severity scales also become a form of communication.⁽²⁾ “He has a score of 35 on the APACHE II scale” may be a technical way of saying ‘the situation is critical,’ but it can also be an incomprehensible sentence for family members if it is not accompanied by emotional support and clear explanations. In a context of high emotional tension and work overload, this aspect of communication is often neglected, leading to misunderstandings, distress, and even conflict.⁽⁵⁾

The issue of equity also becomes central. In a fragmented health system such as Argentina’s, access to an adequate severity assessment often depends on where a person is born or lives. While some patients can be assessed with all APACHE II variables as soon as they enter intensive care, others wait in overcrowded emergency rooms without adequate monitoring or are referred late. Severity is not only a medical condition but also a social, economic, and structural reality.⁽²⁾

Given this landscape, ongoing training for healthcare teams, implementing protocols adapted to the real context, and strategic investment in critical infrastructure is essential. Prognostic scales such as APACHE II and SOFA are clearly valuable scientific tools, but their usefulness depends on an ecosystem that supports them: from the laboratory that analyzes the samples to the digital system that records the data to the human resources that interpret the results.⁽⁵⁾

In conclusion, measuring the severity of a patient in intensive care is not just a technical task but a profoundly human act influenced by multiple variables that transcend the biomedical. In Argentina in 2024, where the healthcare system’s challenges are combined with the unwavering dedication of healthcare professionals, these scales represent a compass, not a map. They serve as a guide but do not replace the critical eye, ethical commitment, or sensitivity required to care for others. Strengthening the Argentine healthcare system involves improving supplies and technology and revaluing the daily work of those who, beyond the numbers, fight for life in every intensive care bed.

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FUNDING

None.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

AUTHOR CONTRIBUTION

Conceptualization: Francisco Gómez Carazo, Facundo Correa.

Data curation: Francisco Gómez Carazo, Facundo Correa.

Formal analysis: Francisco Gómez Carazo, Facundo Correa.

Research: Francisco Gómez Carazo, Facundo Correa.

Methodology: Francisco Gómez Carazo, Facundo Correa.

Project management: Francisco Gómez Carazo, Facundo Correa.

Resources: Francisco Gómez Carazo, Facundo Correa.

Software: Francisco Gómez Carazo, Facundo Correa.

Supervision: Francisco Gómez Carazo, Facundo Correa.

Validation: Francisco Gómez Carazo, Facundo Correa.

Visualization: Francisco Gómez Carazo, Facundo Correa.

Writing – original draft: Francisco Gómez Carazo, Facundo Correa.

Writing – review and editing: Francisco Gómez Carazo, Facundo Correa.