Abstract
Summary
In many developing countries, including those of sub-Saharan Africa, care of the critically ill is poorly developed. We sought to elucidate the characteristics and outcomes of critically ill patients in order to better define the burden of disease and identify strategies for improving care. We conducted a cross sectional observation study of patients admitted to the intensive care unit at Kamuzu Central Hospital in 2010. Demographics, patient characteristics, clinical specialty and outcome data was collected for the 234 patients admitted during the study period. Older age and admission from trauma, general surgery or medical services were associated with increased mortality. The lowest mortality was among obstetrical and gynaecology patients. Use of the ventilator and transfusions were not associated with increased mortality. Patients with head injuries had the highest mortality rate. Rationing of critical care resources, using admitting diagnosis or scoring tools, can maximize access to critical care services in resource-limited settings. Furthermore, improvements of critical care services will be central to future efforts to reduce surgical morbidity and mortality and improving outcomes in all critically ill patients.
Introduction
In many developing countries, including those of sub-Saharan Africa, care of the critically ill is poorly developed 1 and, as such, care is viewed as complex and unaffordable for many of these countries. Critical care, however, is necessary in order to meet the Millennium Development Goals of reducing acute illness, morbidity and mortality in both genders and in all age groups. 2
The majority of hospitals in sub-Saharan Africa have no critical care services and, where it does exist, such facilities are rudimentary. 1 The University of North Carolina (UNC) has had an established presence at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, since 2007 and has observed that many surgical patients meet criteria for intensive care unit (ICU) admission and that many of them die. 3
Our hypothesis for this study is that critically ill surgical patients have a high mortality. We, therefore, sought to elucidate the characteristics and outcomes of critically ill patients admitted to ICU in order to better define the burden of disease and identify strategies for improving critical care services.
Methods
We conducted a retrospective review of all patients admitted to the KCH-ICU from January to December 2010. KCH is a tertiary 600-bed hospital in Lilongwe, Malawi. It is the referral centre for the entire central region of Malawi, with a catchment population of 9 million.
KCH-ICU is a four-bed unit that provides care for critically ill patients from all clinical services. The ICU team is comprised of one full-time non-physician healthcare provider and nine nurses without specialty training and the admitting services consultant provides oversight. The ICU has three ventilators, invasive pressure monitoring equipment and pulse oximetry. Diagnostic capabilities include a clinical laboratory for basic investigations (complete blood count, chemistry and microbiology). Radiology services include only portable radiography and ultrasonography.
Data obtained from the ICU logbook include: patient demographics (age and gender); admitting services (surgery, medicine, obstetrics/gynaecology or trauma); admission diagnosis; ventilator use; and outcome (death versus discharge from ICU). Data was analysed with Stata 11.2. Descriptive statistics were calculated using χ2 test for categorical variables and Wilcoxon rank for the age variable. Both the UNC Institutional Review Board and the Malawi National Health Research Council approved this study.
Results
The ICU admitted 234 patients during the study period. One hundred and two (55%) were female and the median age was 26.5 years (range 4–88). The majority (82%) were admitted from one of the three surgical services: general surgery; trauma; or obstetrics/gynaecology.
The majority (89%) of the patients admitted to the ICU required ventilator support for at least part of their stay. The median length of stay was 3 days (range 1–31; Table 1). There was a high overall mortality rate (44%) with significant differences among the four services (Figure 1). The highest mortality rate was seen in medicine and trauma patients (55% and 57%, respectively) while obstetrics/gynaecology patients had the lowest rate (22%). Of the 102 patients who died, 78 (76%) came from one of the three surgical services. Those who died were significantly older than those who survived, with a median age of 34 versus 30 (P = 0.025).
Bivariate analysis of based on outcome
Distribution of critical care mortality based on the admitting service
Discussion
Among patients admitted to the KCH-ICU, age and admitting service were associated with outcome. Older patients and those from general surgery, trauma surgery and medical services suffered worse outcomes. The use of a ventilator and blood transfusions were not associated with outcome. Surgical patients made up the majority of ICU admissions which is similar to that seen in other ICUs in developing countries. 4
The mortality rate in our study (43.8%) is high compared to other ICUs in the region (27%–30%).4,5 The majority of patients in our study (88.4%) were mechanically ventilated unlike other reports (12%–13.7%). This explanation is supported by the higher mortality rate among the subset of mechanically ventilated subjects in other studies (53%–83%). 5 Obstetrics and gynaecology patients were the least likely to die in ICU, with the diagnosis of postpartum haemorrhage having the lowest mortality rate (23.5%). We believe that this may be attributable to the availability of transfusion capabilities6,7 and a younger age cohort.
Much of the critical care involves relatively inexpensive training in how to recognize, respond to and monitor acute illness. Simple interventions that are known to be effective, such as early fluid resuscitation and antibiotics in septic shock, can be achieved with education and the efficient utilization of available resources. 8
We demonstrated a high mortality rate among patients with head injuries (57.1%) which is similar to that seen in other studies in sub-Saharan Africa. More stringent criteria for admission may be useful in order to appropriately select patients who would be likely to benefit from intensive care. In many developing countries, due to local socio-cultural norms and beliefs, health care practitioners do not universally accept the concept of brain death. 9 A reorientation of the concept of a medical futility may need to be reinforced to medical providers and to the public at large.
Providing critical care in a developing country is extremely challenging. The World Health Organization states that every hospital where surgery and anaesthesia is provided should have an ICU which is defined as a specialized unit with more skilled nursing care than on the general wards, 24 h monitoring and the provision of oxygen. 10 The lack of prioritization of critical care in resource-poor settings is based on a presumed lack of effectiveness in improving the health of the population. This is further compounded by a lack of trained personnel, low nurse-to-patient ratios and higher disease complexity due to delayed presentation. In sub-Saharan Africa, the focus of the local Ministry of Health has been on providing basic and preventative health services as these countries are faced with a choice of either funding prevention efforts or providing funds for tertiary care services. The relegation of critical care services and care of surgical diseases is misplaced.
The limitations of this study include the inability to determine the severity of illnesses on ICU admission using APACHE III scores and the attribution of the cause of death due to the paucity of autopsy data.
Significant improvements are needed in critical care service delivery in sub-Saharan Africa. Increased resources could improve mortality rates in the critically ill and translate into an improvement in the overall health care system to the benefit of all patients.
Conclusion
The burden of surgical diseases in sub-Saharan Africa is high. A cross sectional observational study was conducted in order to assess the burden of surgical diseases on critical care services. Improvements of critical care services will be central to any future efforts to reduce surgical morbidity and mortality and improve outcomes for all critically ill patients.