ICU burden in a tertiary care hospital in Pakistan; a descriptive analysis

Peer Asad Aziz1, Zeeshan Nasir2, Ghazala Shahzad3, Arslan Mahmood4, Sanaullah Pathan5, Riaz Ahmed Raja6
Correspondence: Peer Asad Aziz, Registrar, Neurosurgery Department, Liaquat University Hospital, Hyderabad (Pakistan); Cell: +92 333 2760161; E-mail: pirasadaziz@hotmail.com

ABSTRACT
 Introduction: ICU acts as a station for critically ill patients referred form different medical disciplines for rigorous observation and intervention for a potentially curable disease. In Pakistan, a previous study showed the mortality to be 16.1% in one year. We conducted this study to record the data of patients admitted to our ICU regarding the medical condition requiring such admission, and the outcome.
Methodology: As a descriptive study, the data were collected from main ICU of Liaquat University Hospital Hyderabad. Every patient referred from different medical disciplines for admission in the ICU, for a period of four months, from July to October 2018, was included in the study. The data were taken from the registration logs of ICU and were entered into a specially prepared datasheet. Statistical analysis was done and the results given as means, percentages or ranges, as appropriate.
Results: A total of 503 patients were admitted, with a female preponderance of 52%; 45% of the patients being younger than 30 years; and a mortality of 55%. Regarding the flow, medicine department seems to have the highest flow. Neurosurgery and gyne & obs disciplines seem to have the highest mortality i.e. 77% and 63% respectively.  CVA, hepatobiliary disease, meningitis, lung problems, road traffic accidents (RTA), eclampsia, puerperal sepsis, postpartum hemorrhage and gut perforations were some of the important causes with worst outcome.
Conclusion: The concept of calculating ICU mortality may offer some insights regarding the management of patients based upon a multidisciplinary approach. Early identification of the most common diseases associated with the highest morbidity and mortality is utterly important. The burden of ICU should be shared through a combined approach.
Keywords: Intensive care; Mortality; Burden
Citation: Aziz PA, Nasir Z, Shahzad G, Mahmood A, Pathan S, Raja RA. ICU burden in a tertiary care hospital in Pakistan; a descriptive analysis. Anaesth Pain & Intensive Care 2018;22(4):431-437
Received – 22 Nov 2018; Reviewed – 30 Dec, 31 Dec 2018; Corrected & Accepted – 2 Jan 2018

INTRODUCTION

In early 1900s, some areas of hospitals were delegated for the patients, who were recovering from anesthesia or traumatic injuries; but the post-epidemic disaster of poliomyelitis in 1950s changed the fate of critical medicine for ever and it became the pivotal constituent of hospital care.1-3 ICU serves as a service agent for those patients, who can be recovered from critical condition with rigorous observation and invasive treatment, as its perquisites are potential and established organs failure especially lungs.4
Over the time, mortality in developed nations seems to be projected downwards as compare to low income countries, where financial constraints are difficult to supervene.5-7 ICU contributes a large portion of mortality compared to other sections of hospital on the contrary of being an expensive pillar, which is directly related to longer stay and intercession.8,9 In Pakistan, a recent Islamabad based study showed 16.12% mortality rate among ICU patients with more than 60% deaths related to sepsis.7
Senescence seems to have an alluring relationship of higher mortality as compared to young ones and it is getting stronger with time along with the demand of ICU in exponentially increasing population.10,11 An advancement of critical care also raised the bars of expectations for patients, although the psychosocial burden, including anxiety, depression and post-traumatic stress disorder (PTSD) also found inroads among survivors.12
The primary objective of our study was to gather the data that have much importance in relation to mortality or morbidity outcome in ICU patients related to different disciplines of hospital.

METHODOLOGY
It was a descriptive study conducted at Liaquat University Hospital, Hyderabad (Pakistan), which is a 1450 beds tertiary care hospital and one of the largest teaching hospital in Pakistan, providing medical care to patients from Sindh and Balochistan provinces. The study was conducted among the patients that were admitted in the ICU, from July 2018 to October 2018 through non-probability i.e. convenience sampling technique with no control over sample size. The inclusion criteria were all patients, except pediatric patients, referred from different disciplines to ICU, regardless of their severity. The data were collected from ICU registration logs and simple evaluation of patient factors through questionnaire based approach and outcome surveillance during the stay of patient in the hospital. The data were spread on the statistical program to perform analytical approach and channeled into tables and graphs.

RESULTS
A total of 503 cases were admitted in the ICU from different disciplines of hospitals from July 2018 to October 2018. Monthly distribution of the admissions is highlighted in Table 1)

Table 1: Monthly distribution of the admissions
Gender July August September October Total
Male 63 58 61 61 243
Female 61 57 77 65 260
Total 124 115 138 126 503
Patients were divided into three categories based upon age; <30, 30-50 and >50 years; and according to gender of cases (Table 2)

Table 2: Distribution according to age and gender
Gender Age categories (years) Total
< 30 30-50 > 50
Male 112 74 57 243
Female 117 97 46 260
Total 229 171 103 503
 

As noted above, younger age has more flow then middle and older age in the ICU. Patient population is shown according to referring departments of hospital to ICU in relation to age in graphic form (Figure 1).


 

Figure 1: Distribution according to age and referring departments of hospital

The flow of patients from medicine seems to be high as compare to other disciplines, especially the younger patients. No patient older than 50 years of age was admitted from gynecology and obstetrics department during the study period. Other disciplines included orthopedics, urology and nephrology, ENT, cardiology, dentistry and burns wards. As concerns the mortality, the monthly distribution in relation to different disciplines is shown in Table 3.

Table 3: Monthly distribution in relation to different disciplines
Month Neurosurgery Medicine Gyne Obs Surgery Others Total
July 23 24 17 1 1 66
August 20 22 19 4 2 67
September 20 29 18 3 5 75
October 21 25 18 3 2 69
Total 84 100 72 11 10 277
Neurosurgery, medicine and gynecology & obstetrics contributed larger share of deaths as compare to other disciplines. Calculation of discipline-wise mortality and overall mortality is shown in Table 4).

Table 4: Discipline-wise distribution of mortality
Discipline Patients admitted Deaths Mortality rate*
Neurosurgery 114 84 0.73 or 73%
Medicine 238 100 0.42 or 42%
Gyne & Obs 109 72 0.66 or 66%
Surgery 25 11 0.44 or 44%
Others 17 10 0.58 or 58%
Total 503 277 0.55 or 55%
*mortality rate calculated by number of deaths per total number of patients admitted in ICU
The mortality rate of neurosurgery is the highest of all with overall mortality rate greater than 50. On the contrary, despite high flow from medicine, the overall mortality seems to be lower than others. Gynecology and obstetrics falls in the second position in contributing the overall mortality of ICU. Comparison of mortality of patients in relation to age is shown in Figure 2.

Figure 2: Comparison of mortality of patients in relation to age in different disciplines
Younger patients from medicine disciplines seem to have higher mortality as compared to neurosurgery which shows middle aged population to be effected more. Gynecology and obstetrics shows equal level of age mortality, as no case recorded in older age.

Considering specific disease / condition the mortality is shown in Table 5.

Table 5: Case mortality distribution of Medicine Discipline         
Case diagnosis Number of patient died Case mortality*
Meningitis 12 0.12 or 12 %
Hepatobiliary 12 0.12 or 12 %
CVA 17 0.17 or 17 %
Lung problems 11 0.11 or 11 %
DKA & HONK 5 0.05 or 5 %
CKD 9 0.09 or 9 %
Shock 6 0.06 or 6 %
Black stone 8 0.08 or 8 %
Snake bite 5 0.05 or 5 %
AGE 3 0.03 or 3 %
OP poisoning 5 0.05 or 5 %
Alcohol intoxication 1 0.01 or 1 %
SLE 3 0.03 or 3 %
Myxedema coma 1 0.01 or 1 %
Drowning 1 0.01 or 1 %
Epilepsy 1 0.01 or 1 %
Total 100 0.42 or 42%
*calculated by number of patient died from case with total number of patient died in ICU with respective discipline. Abbreviations: (CVA: Cerebrovascular Accident, DKA: Diabetic Ketoacidosis, Honk: Hyperosmoler non-ketotic state, CKD: chronic kidney disease, AGE: Acute gastroenteritis, SLE: Systemic lupus erythematosus, OP: Organophosphate)

Meningitis, hepatobiliary, CVA and lung problems had higher mortality as compared to others. Hepatobiliary problems included acute liver failure, chronic liver failure and hepatic encephalopathy. Lung problems included acute respiratory failure, lung abscess and pneumonia. Shock included hypovolemic shock and electric shock. The overall mortality was calculated from the number of patient deaths to admitted ones in ICU with respect to specific discipline (See Table 4).

Mortality in different neurosurgical conditions, is shown in  Table 6.

Table 6: Case mortality distribution of neurosurgical conditions

Case diagnosis No. of deaths Case mortality*
RTA 54 0.64 or 64 %
Fall 13 0.15 or 15 %
Assault 12 0.14 or 14 %
SAH 03 0.03 or 3 %
Brain Abscess 02 0.02 or 2 %
Total 84 0.73 or 73 %
*calculated by number of case deaths per total number of patient died in ICU with respective discipline.
Abbreviations: (RTA: Road traffic accident, SAH: Subarachnoid hemorrhage)
RTA, fall and assault comprised most of cases and it included diffuse axonal injury, extradural hemorrhage, subdural hemorrhage and traumatic brain contusion.

Gynecology and obstetric discipline contributed second largest share in the mortality of ICU. Case distribution is show in Table 7.

Table 7: Case mortality distribution of gynecology & obstetrics disciplines 
Case diagnosis No. of deaths Case mortality*
Eclampsia 24 0.33 or 33 %
APH 7 0.09 or 9 %
PIH 1 0.01 or 1 %
Ectopic pregnancy 2 0.02 or 2 %
Puerperal sepsis 17 0.23 or 23 %
Labor 2 0.02 or 2 %
Placenta abruption 3 0.04 or 4 %
PPH 16 0.22 or 22 %
Total 72 0.66 or 66 %
*calculated by number of case deaths per total number of death with respect to discipline
Abbreviations: (APH: Ante partum hemorrhage, PIH: Pregnancy induced Hypertension, PPH: Post partum hemorrhage)

Eclampsia, puerperal sepsis and PPH contributed more to mortality as compared to others, especially eclampsia. Labor includes obstructive labor and cesarian section. The overall mortality is calculated and given in Table 4. The remaining disciplines are merged into one table e.g. Table 8.

Table 8: Case mortality distribution of general surgery and other disciplines

Discipline Case diagnosis No. of deaths Case mortality *
General surgery Gut perforation 6 0.54 or 54%
Gut obstruction 4 0.36 or 36 %
Hernia 1 0.09 or 9 %
Total 11 0.44 or 44 %
Other disciplines Cellulites 4 0.4 or 4 %
ARF 2 0.2 or 2 %
Cardiac problems 4 0.4 or 4 %
Total 10 0.58 or 58 %
*calculated by number of case deaths per total number of deaths in relation to respective disciplines

Gut perforation and obstruction had a high mortality. The cardiac problems included ischemic heart disease, heart failure or cardiogenic shock. The most important cases are highlighted above in their respective disciplines and through this department approach we can readily decrease the mortality of ICU through effective ward management.

DISCUSSION

As the Pakistan is in a developing phase with presence of infectious predominence, financial crisis, increment of man-made disease and poor management, the data presented on mortality associated with causes or diagnoses, doesn’t justify the flow of patients presenting in tertiary care hospitals. On the other hand there is no study on spectral presentation of referrals of cases from different sections of hospital into the ICU. By presenting this kind of approach it will help us to determine the most important entities from different disciplines of our hospitals which need to be worked on. By pointing out specific disease with outcome can help us to develop some preventive protocols, training of individuals for early detection and prevention of that specific disease which can certainly reduce the burden of ICU and/or in mortality.

ICU as a pivotal part of hospital and it provides the last station for critically ill patients from different departments of hospital. A database of outcome can significantly help in improvement of performance and resource usage. It can help us determine the burden of disease, treatment and its role in decreasing the hospital mortality.14,15 In our country ICU functions as a rescuer for younger patients presenting with acutely treatable disease, as compared to high income countries, where flow seems to be high of older patients with progressively exacerbating chronic diseases.10,16 Higher nurse:patient ratio, advanced mechanical ventilation and support of multi-organ at same time are some factors that are credited to the difference in mortality between two economic models.5,6,17,18 The previous data of mortality in Pakistan of 16.1% in one year with male preponderance and old aged population is in contrast to our study, in which the result of four months show the mortality of 55% with female preponderance if we include Gynecology and obstetrics patients.7
Two studies on ICU have been done in the past, either on mortality in specific or general prospect, but none of it shows the flow from different disciplines of hospital. As a lack of advancement in our geographical area the burden of ICU is disproportional to the number of beds and increasing population.3,7,13 None of the studies gives description about hospital factors, e.g. duration of referral, less experienced staff, high flow of patients, poor management in wards or ICU, low standard critical care practice due to lack of proper protocols and guidelines, political influence, lack of follow-up and lack of data auditing.6,16,19,20 Medicine department seems to have high contribution than others. Infectious and rapidly increasing man-made diseases, cerebrovascular accident, meningitis, acute and chronic liver failure related to viral infection, respiratory failure (maybe due to pneumonia and lungs abscess) are major culprits from medical ward. The preventive directories are being followed neither at basic level, nor on critical care level that contributes to mortality.20-24 On the other hand, ingestion of poisonous substances has increased in mortality rates. Proper management protocol need to be work on.25
Neurosurgery is responsible for high mortality then others because of high admission rates of traumatic brain injury, including injury through fall, assault and road traffic accident which constitute 94% mortality of overall discipline.26-28 Second on the list of mortality is gynecology and obstetrics with eclampsia, puerperal sepsis and postpartum hemorrhage, as literature also pointed out these cases with potential complications that can significantly contribute to the mortality of female patients admitted in ICU. Better understanding of physiological or pathological changes in normal or abnormal pregnancies, health personnel training at basic level and continue medical education for the advancement is knowledge is utterly needed to control the mortality within gynecology and obstetrics patients.29-32
Gut perforation seems to be the major cause of surgical patients to be admitted into the ICU, as the past literature showed the infectious component as main culprit of mortality despite the role  for early nutritional intervention.33, 34
As this study helped in the identification of cases with respect to different disciplines except for pediatrics. There is a need to study factors within the hospitals unrelated to patient or disease.

CONCLUSION

The concept of calculating the mortality of ICU as a single unit, doesn’t justify the management and outcomes of patients admitted in ICU except if we are assessing the factors related to ICU. As from the search of literature, ICU is connected with every department of hospital and mortality of patients in relation to type of case should be included in the books of respective disciplines. Our study shows a high mortality rate as compared to previous studies, probably due to lack of drawing the data or lack of proper infra structure for auditing procedures and lack of high dependency units

Conflict of interest: None
Authors’ Contribution:

PAA - Principal author
ZN - Co investigator
GS & AM - Data collector
SP - Statistical analyst
RARM - Study designer

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