CRITICAL ADMISSION IN SEBHA ICU
A El Tawati* and K Salih**, Mutwakil
G. Ahmed
* Head Surgeon
Sebha University
Hospital
** Neurosurgeon Sebha
University Hospital
*** Physician Sebha
University Hospital
Abstract
Objectives: To analyze all patients admitted to the Intensive
care unit over a two-year
period.
Design: A retrospective
hospital based study.
Setting: 2nd March
Hospital.
Subjects: All patients
admitted to the Intensive Care Unit.
Results: Four hundred and nine critically
ill patients presented to the ICU. The majority of admissions were through
Medical department (231 patients, 56%), and Surgical department (159 patients,
39%). There were 127 females (31%) and 282 males (69%). Foreigners were only 43
patients (12%). About thirty nine percent of the patients were referred from
other hospitals. Thirty two percent of the patients were between 21-65 years
(132 patients), 22.3 percent above 65 years of age (51 patients). Patients aged
twenty and below were 20 percent (46 patients).
The overall mortality was (229
patients) 55.9, the majority mortality were 29.7% under the age of 26 years.
The most common causes of death was Cerebrovascular diseases CVD (67 patients,
22.4%), to lowed by Road Traffic Accident (45 patients, 20%).
Ward wise the highest moralities
were among the pediatric admission. 21% of children in age group 0-15 died
because of road traffic accident, falls and burns. Other avoidable pediatric
conditions such as scorpion stings, organo-phosphorus poisoning, hepatitis and
gastro-enteritis were lethal were the cause of pediatric moralities. Lethal
neoplastic conditions represent only 4.4% of total ICU moralities, hematemsis
(5 patients) represents 25% of non-traumatic surgical moralities. A seasonal
variations in ICU admissions was found. Emergency ICU admission increased in
autumn and summer. Mondays were the heaviest days of emergency admission. The
average ICU admission was 6 days. About 20% of patients died on the same day of
admission.
These data suggest that the institution of
pre-and in-hospital resuscitation and improvement of intensive care education
for physicians might reduce mortality. Prevention of RTA needs a trauma center
and trained team to deal with such death toll.
Conclusion: The ICU is the
pacemaker of a hospital. This calls for urgent and concerted action aimed at
minimizing the moralities to at least near the universal rats.
Introduction:
Intensive care has been defined as a
service for patients with potentially recoverable diseases who can benefit from
detailed observation and treatment than is generally available in the standard
wards and departments. Thus the goals of the Intensive care are, first, the
preservation of life, second the restoration of the patients to his maximal
functional capacity, and third a decrease in overall morbidity12. In
1888, Robert Jones organized what was probably the first system of accident
services in the world when he organized this system for Manchester Ship Canal3.
In
its infancy, intensive care practice was an unknown science attracting
practitioners who were intrigued by the uncharted waters of critical care. In
the earliest intensive care units, the sickest patients were grouped together
for close visual observation, rudimentary ventilatory support and consolidation
on nursing care.
Now, technologic advances in diagnostic and
therapeutic interventions at bed side have replaced the older methods of
monitoring critically ill patients. However, the technologic advances have
leaped beyond society’s ability to cope with the financial, and ethical
dilemmas that have been induced. Critical care accounts for over 20% of acute
care hospital charges and for about 1% of the nation gross domestic product.
These estimates place Intensive Care at the higher end of health care
expenditure4 5 6.
Critical care is, thus, an expensive
resource that must be managed effectively. To ensure a humane approach to the
management of the critically ill and that limited resources are appropriately,
it is important to identify those patients who are most likely to benefit from
intensive care. It is also important to avoid admitting those who will make a
good recovery without intensive care7.
Regardless of the resources, unnecessary
ICU admission may cause unnecessary suffering for the patients and his relatives.
In some cases the risk of intervention may outweighed the potential benefit
furthermore, skilled medical and nursing staff may be diverted from the caring
for patients ales where in the hospital, and the ability of staff on general
wards to manage seriously ill patients is diminished. (Jannett 1984)
It is necessary to measure the
effectiveness of an ICU to estimate the cost-effect values. This medical
evaluation is an essential component to know the efficacy of the staff who is
dealing with the sophisticated equipment and critically ill patients.
The aim of this retrospective study
is to demonstrate the profile of our ICU admission in two consecutive years in
order to evaluate the service and to improve the out come.
Material and Methods:
Fazan is the southern region of the
Great Gamahiria, its population is 314.29. The 2nd March Hospital is
the largest Teaching hospital in the region. It has 480 beds and provided by CT
scan unit.
Sebha ICU is serving the four
general hospitals of Fazan Region (Braak, Obari, Morzok, Gat). It also serves
the heavily populated Sebha town. In this 8 bed unit, patients are usually
admitted either directly from the casually or transferred from the words, where
necessary consultant and anesthetist are involved in the initial evaluation of
the patients. However, patients referred from the words are usually under the
care of their word consultants. In our ICU the criteria for ICU admission is
not usually applied except for cases of head injury where Glasgow Coma Scale is
used.
Over the two years period from 1998
to 1999, data from 409 patients admitted to the ICU were analyzed
retrospectively. Patients were divided according to age, sex, nationality,
referral hospital, ward, diagnosis and fate into medical, surgical, pediatric,
obstetric and gynecological cases. ICU stay, day and month of admission has
been considered for each admission. Values are expressed as means.
Results:
Out of 409 patients admitted during
the period of the study 229 died (55.9%), and 143 (35%) patients were
discharged to the wards, the rest were referred to Tripoli or Benghazi for
further management or left against medical advice (LAMA), Table 1. 29.7% of
mortality were under the age of 26 years, about 8% of them were in the age
group 16-20 years, Table 2. There were 127 females (31%) and 282 males (69%).
The male to female ratio of these patients was 2.2, Table 3. Foreigners were
only 43 patients (12%), Table 4.
About thirty nine percent of the
patients were referred from other hospitals, the majority of patients were from
Sebha Table 5.
Ward wise the highest moralities
were among the pediatric admission. Table 6 showed the cause of death in the
age 0-15 years. The moralities among surgical and neuro-surgical patients were
59% of these patients. Fatalities among patients admitted with critical medical
conditions were the least in this series (59%), Table 7.
There were 134 deaths due to
non-surgical causes and attended by the physicians. Cardiovascular diseases
(58%) were the most common cause of death. These were followed by respiratory
(9%), diabetes (8%), and renal disease (7%) as shown in Table 8. The eight
cases of cancers were terminal and were taken under the care of physicians.
These included 2 patients with cancer lung. The other five patients had cancer
breast, cancer liver, cancer prostate, a lymphoma and brain tumor, all were
males except one lady who had a cancer cervix. One patient with cancer uterus
died in the ICU and was attended by gynecologists the other case of cancer head
of pancreas died under the care of surgeons, Table 9. These lethal neoplastic
conditions represent only 4.4% of total ICU moralities.
Twenty percent of the deaths
generally occurred below the age of twenty years and 22.3% of these deaths
occurred above 65 years of age.
There were 159 patients (39%)
presented with surgical critical conditions and were under the care of the
surgical staff and/or the neurosurgeon. Trauma was the major cause of admission
in the ICU. There were 120 (29%) patients admitted because of some sort of
trauma, Table 10.
Seventy-eight patients (49%) died
because of a surgical cause, monthly due to road traffic accident. The majority
of these them had been involved in road traffic accidents RTA, ten of whom were
below 15 years of age. Falls were the second leading cause of death in the
trauma patients. Surgical non-traumatic causes of death were five patients with
hematemsis and rectal bleeding, 2 patients with burns, three patients with
hernias, three patients with diabetic sepsis and one patients with cancer head
of pancreas, and another patients with obstructive jaundice.
A
seasonal a variation in ICU admissions was found, table 11. In decreasing order
of frequency, the seasons were autumn (123 patients, 30%), Summer (117 patients,
28.6%), winter (101 patients, 24.7%) and spring (68 patients, 16.7%). Monday
was the heaviest day, when 17% of patients were admitted.
The average ICU stay was 6days. Only
twenty percent of patients died on the same day of admission to the ICU. Patients
stay more than one week presented about 18% of ICU admission.
|
Table 1: The fate of
409 critical ICU admission 1998-1999
|
||
|
Fate
|
No. of patients
|
%
|
|
Moralities
|
229
|
55.9
|
|
Discharges
|
143
|
35
|
|
Referred
|
31
|
7.6
|
|
LAMA
|
6
|
1.5
|
|
Table 2: Age
Distribution of 409 critical causes admitted in ICU 1998-1999
|
||
|
Age groups
|
No. of patients
|
Moralities
|
|
Less than on year
|
4
|
4
|
|
1-5
|
14
|
7
|
|
6-10
|
27
|
16
|
|
11-15
|
16
|
6
|
|
16-20
|
31
|
13
|
|
21-25
|
40
|
22
|
|
26-30
|
32
|
16
|
|
31-35
|
19
|
13
|
|
36-40
|
17
|
7
|
|
41-45
|
17
|
9
|
|
46-50
|
27
|
11
|
|
51-55
|
27
|
16
|
|
56-60
|
39
|
25
|
|
61-65
|
21
|
13
|
|
66-70
|
31
|
19
|
|
71-75
|
11
|
8
|
|
76-80
|
21
|
13
|
|
81-85
|
5
|
3
|
|
86-90
|
4
|
4
|
|
91-95
|
5
|
3
|
|
96-100
|
1
|
1
|
|
Total
|
409
|
299
|
|
Table 3: Sex
distribution of the 409 critical admission in ICU 1998-1999
|
||
|
|
No. of patients
|
%
|
|
Males
|
282
|
69
|
|
Females
|
127
|
31
|
|
Table 4: Nationalities
of the 43 foreign patients
|
||
|
|
9
|
|
|
|
7
|
Gana 2
|
|
|
6
|
|
|
Philistine
|
4
|
|
|
|
3
|
|
|
|
3
|
Schweis 1
|
|
Table 5: Distribution
of 409 patients admitted to the ICU 1998-1999 according to the referring
hospital
|
||
|
Region
|
No. of patients
|
%
|
|
Sebha
|
251
|
61.4
|
|
Braak
|
61
|
14.9
|
|
Obari
|
35
|
8.6
|
|
Morzok
|
19
|
4.6
|
|
Gat
|
09
|
2.2
|
|
Other areas
|
34
|
8.3
|
|
Table 6: ICU
moralities in the age group 0-15
|
||
|
|
No. of patients
|
%
|
|
RTA
|
10
|
38.5
|
|
Fall
|
2
|
7.7
|
|
Burns
|
1
|
3.8
|
|
Scorpion sting
|
2
|
7.7
|
|
Organo-phosphorus poisoning
|
1
|
3.8
|
|
Congenital heart disease
|
1
|
3.8
|
|
Thrombacytopenia
|
1
|
3.8
|
|
Respiratory diseases and Asphexia neonatorum
|
2
|
7.7
|
|
Coma (diabetic Coma, Undiagnosed)
|
3
|
11.5
|
|
Gastro-intestinal diseases (Enteritis, intestinal obstruction,
Hepatitis)
|
3
|
11.5
|
|
Table 7: Distribution
of moralities among 409 critically ill patients admitted to the ICU 1998-1999
|
||||
|
Ward
|
No. of patients
|
%
|
No. of Deaths
|
%
|
|
ENT
|
1
|
0.2
|
0
|
0
|
|
Medical and infections
|
231
|
56.3
|
136
|
33.3
|
|
Surgical and Neurosurgical
|
159
|
38.9
|
78
|
19.1
|
|
Pediatrics
|
11
|
2.7
|
10
|
2.4
|
|
Obstetrics and Gyaen
|
7
|
1.7
|
5
|
1.5
|
|
Total
|
409
|
100
|
229
|
56.3
|
|
Table 8: Causes of
death in 134 patients with medical critical illness
|
||
|
Disease
|
No. of patients
|
%
|
|
Cerebrovascular diseases
|
67
|
58
|
|
Respiratory diseases
|
12
|
9
|
|
Undiagnosed
|
12
|
9
|
|
Diabetes
|
11
|
8
|
|
Renal diseases
|
10
|
7.5
|
|
Ancers
|
8
|
6
|
|
CNS diseases
|
6
|
4.5
|
|
GIT diseases
|
3
|
2.2
|
|
Autoimmune diseases
|
2
|
1.5
|
|
Scorpion sting
|
2
|
1.5
|
|
Organophosphrous poisoning
|
1
|
0.75
|
|
Table 9: Neoplastic
diseases among ICU deaths 1998-1999
|
|||
|
|
No. of patients
|
|
No. of patients
|
|
Cancer lung
|
2
|
Cancer uterus
|
1
|
|
Brain tumour
|
1
|
Cancer head of pancreas
|
1
|
|
Lymphoma
|
1
|
Hepatoma
|
1
|
|
Cancer prostate
|
1
|
Cancer breast
|
1
|
|
Cancer cervix
|
1
|
|
|
|
Table 10: Distribution
of surgical cases admitted in ICU 1998-1999
|
||||
|
|
No. of patients
|
%
|
No. of Deaths
|
%
|
|
Assault
|
16
|
10.1
|
4
|
5.1
|
|
Fall
|
18
|
11.3
|
9
|
11.5
|
|
RTA
|
86
|
54
|
45
|
57.7
|
|
Burns
|
3
|
2
|
2
|
2.6
|
|
Non- traumatic surgical conditions
|
36
|
22.6
|
18
|
23
|
|
Total
|
159
|
100
|
78
|
100
|
|
Table 11: Distribution
of 409 ICU admission according to the month of admission
|
|||
|
Ward
|
No. of patients
|
|
No. of Deaths
|
|
August
|
38
|
June
|
38
|
|
December
|
64
|
Mars
|
17
|
|
February
|
7
|
November
|
38
|
|
January
|
30
|
October
|
42
|
|
July
|
41
|
September
|
43
|
|
April
|
26
|
May
|
25
|
|
Table 12: Distribution
of admission according to the day of the week
|
||
|
Day of the week
|
No. of patients
|
%
|
|
Friday
|
52
|
12.7
|
|
Monday
|
72
|
17.6
|
|
Saturday
|
50
|
12.2
|
|
Sunday
|
66
|
16.1
|
|
Thursday
|
62
|
15.2
|
|
Tuesday
|
54
|
13.2
|
|
Wednesday
|
53
|
13
|
|
Table 13: ICU stay in
409 admission 1998-1999
|
||
|
|
No. of patients
|
%
|
|
Died, or discharged on the same day of admission
|
83
|
20.3
|
|
One day
|
81
|
19.8
|
|
Two day
|
52
|
12.7
|
|
Three day
|
30
|
7.3
|
|
Four day
|
32
|
7.8
|
|
Five day
|
21
|
5.1
|
|
Six day
|
21
|
5.1
|
|
Seven day
|
15
|
3.7
|
|
More
|
74
|
18.1
|
Discussion:
During the period of the study, more
than 25% of patients admitted to 2nd March University Hospital were
discharged. For many critically ill patients, intensive care is undoubtedly
life-saving and resumption of a normal lifestyle is expected. The high rate of
ICU mortality rate may indicate the tendency to admit only the more serious
patients. Most of the Undiagnosed patients (13 patients, 5.7%) in our series
were patients either already dead and transferred to the ICU in the hope that
they may be resuscitated or patients of head injury which dead on arrival to
the emergency department and transferred directly to the ICU.
However, in the more seriously ill
patients, immediate mortality rates are high. In our series 20% died in the
same day admission. Could be start the morality predication model can be used
to estimate probability of hospital mortality for variables, followed by
identification of a smaller subset of the strongest outcome prediction derived
from statistical reduction techniques.
In a recent evaluation of outcome in
a heterogeneous group of critically ill patients admitted to a typical general
intensive care unit in the United
Kingdom
The recent trend to stratify the
intensive care unit that has the advantage of avoiding duplication of expensive
intensive care facilities needs to be implemented. Other hospitals such as
Brak, Morzok and Gat should not waste mony in having their own ICUs. Instead
they have to improve the means of patient triage. This will prevent the
unnecessary duplication of efforts.
Most of the moralities due to
non-surgical causes come from Pediatric and Medical wards. The most common
cause of death in our series were cerebro-vascular diseases. This mandates a
specialized ICU care of cardiac and pediatric patients (1.5%).
The six ICU admissions of scorpion
stings (1.5%) resulted in two moralities (1%). This may be explained by backed
during the summer season in Fazan Region. Moralities due to hepatitis and
gastro-enteritis had been reported during the summer. This can be explained by
the season of the school activities. Moralities from diabetes (8%) alone or its
complications such as diabetic septic foot (3 patients, 1.3%), may reflect to
lack of education programs.
International standards and
guidelines recommend that intensive care beds account for about 6-11 of all
hospital beds11. The 2nd March has 480 beds and its ICU
is only 8 beds. Therefore, a unit of 29 to 52 beds would be appropriate for
this hospital. The unit must be spacious to allow easy access to patients; 20 M2
per bed is recommended. Each bed space must be equipped with monitors, suction
apparatus, piped oxygen and air, and a vacuum supply. There should also be
low-pressure suction, a bedside light, and plentiful supply of mains sockets,
20-24 per bed.
Monitoring equipment should
preferably have the capacity for data storage and retrieval. The equipment for
the following therapeutic interventions should be immediately available:
tracheal incubation; direct current cardioversion; bronchoscopy; insertion of
chest drains; cardiac pacing; intra-aortic balloon pumping; invasive
haemodynamic monitoring; extra-corporeal renal support and ventilation12.
It is essential that a suitably
trained resident doctor is immediately available throughout the day and night
to deal with emergencies on the unit. Often this doctor is an anesthetist, but
if not available, they must be capable of emergency intubation and have a
through knowledge of the techniques of ventilatory support and their
complications.
Resident Medical Staff must be
closely supervised at all times by a consultant intensive care specialist
available for advice and be ready to attend the unit at short notice. An
adequate complement of suitably trained nurses is crucial to the success of an
intensive care unit. Ideally there should be one nurse for each patient, a
runner and a senior nurse in charge on any one shift. Allowing for holidays,
off-duty and sickness, this requires a total of at least 5-6 nurses per bed as
well as several senior nurses and a nurse manager who assumes overall
administrative responsibility. A clinical teacher who can develop the skills of
the less experienced staff is an invaluable addition to the team13.
The intensive care and
high-dependency units must have agreed, written policies for the admission and
discharge of patients and for dealing with patients referrals. Management
responsibilities and the clinical chains of command must also be clearly
defined. Written protocols for all the common intensive care activities and
procedures must be produced and adhered to and should be regularly reviewed11,12,13.
Acknowledgment:
1)
Lamb, J.I., (1995)
Patient Care
Organization and Ethics. In: Textbook of critical care, eds. A. Grenvike, S.
Ayres, P. Holbrook and W. Shoemaker. W. B. Saunder, Philadelphia
2)
Hinds, C. J. and Watson D. (1996)
Planning,
organization and management. Intensive Care, Saunders, Philadelphia
3)
O. N. Tubbs
Accident
services reviewed: A comment on the report of working party of the Royal
College of Surgeons of England
4) Bellamy P.
and Oye R. (1984)
Adult
respiratory distress syndrome: hospital charges and outcome according to
underlying disease. Critical care Medicine, 12:622.
5) Spivack D.
(1987)
The high cost
of acute health of acute health care. American Review of Respiratory Diseases.
136:1007.
6) Ridley S.,
Biggam M., and Stone P. (1994)
A
cost-validity analysis of intensive therapy.
Anaesthesia,
49:192.
7) Jennett B.
(1984)
Inappropriate
use of intensive care
B.M.J.,
289:1709.
8) Ridley S.,
Jackson R., Findlay J. et al (1990)
Long term
survival after intensive care.
B.M.J., 301:
1127.
9) Dragsted I.
Outcome from
intensive care III. A 5-years study of 1308 patients activity levels.
European
Journal of Anaesthsiology, 6:385.
10) Ahmed H.
Al-Salem and Sayed Qaisaruddin (1996)
Trauma in a
district general hospital
Saudi Medical
Journal, 18 (1): 49-53.
11) Osborne
M. and Evan T.W. (1994)
Allocation of
resources in intensive care: a transatlantic perspective. Lancet, 343:778.
12)
Aitkenhead A.R.
, Booij, L.H.
Dhainaut, J.F., et al (1993)
International
standards for safety in intensive care unit
Intensive
Care Medicine, 19:178.
13) Intensive
Care Society (1990)
The Intensive
Care Service in the UK , London
ليست هناك تعليقات:
إرسال تعليق