|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 2 | Page : 62-67
Improvement in intensive care unit: Effect on mortality
Adeniyi Adesida1, Olanrewaju Akanmu1, Rita Oladele2, Oyebola Olubodun Adekola1, Ibironke Desalu1
1 Department of Anaesthesia, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
2 Department of Microbiology, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
|Date of Web Publication||18-Apr-2017|
Department of Anaesthesia, College of Medicine, University of Lagos/Lagos University Teaching Hospital, P.M.B 12003, Surulere, Lagos
Source of Support: None, Conflict of Interest: None
Background: The Lagos University Teaching Hospital's Intensive Care Unit (ICU) was founded in 1975. It was designed as an eight-bedded ICU, a previous review of outcome of surgical admissions in the ICU in 2002 placed mortality at 40.3%, however, presently run as a five-bed unit with new ICU equipment procured in 2012, arterial blood gas machines, patient monitors, and ventilators with sustained multidisciplinary approach to patient management. We compared the number of admissions, mortality, and discharges to the ward 1 year before (Period I) and after the upgrade of the ICU facilities (Period II). Methods: This was a retrospective study of all patients admitted into the ICU between June 2011 and May 2013. We looked at the admission register of the ICU and retrieved biometric data, diagnosis, age, pattern of units admitting patients into ICU, length of stay (LOS), and outcome of ICU care whether the patient died in ICU or was discharged to the ward. Results: There were 122 patients admitted into the ICU in Period I and 156 patients were admitted in Period II with a mean LOS of 6.3 ± 5.4 days and 7.8 ± 7.3 days, respectively. Mortality rate in Period I was 74.6% while mortality fell to 57.7% in Period II (P = 0.005). Conclusion: There was a significant improvement in the ICU outcome with the upgrade of the ICU facilities.
Keywords: Intensive Care Unit, length of stay, mortality rate
|How to cite this article:|
Adesida A, Akanmu O, Oladele R, Adekola OO, Desalu I. Improvement in intensive care unit: Effect on mortality. J Clin Sci 2017;14:62-7
| Introduction|| |
In many developing countries in the Sub-Saharan Africa, there is shortage of health-care workers and very limited resources. The Nigerian government funds all the federal tertiary institutions in Nigeria, 21 federal teaching hospitals, 22 federal medical centers, eight federal neuropsychiatric hospitals, and other subspecialty hospitals. Many of these centers do not have Intensive Care Units (ICUs) and those existing have thinned out resources resulting in unnecessary pressure being placed on available resources.
Where an ICU exists, the need for performance and improved quality of care informed the call for rational human resource allocation, organization, number of trained nurse intensivists, technology, and supplies. Resources have been documented to be better allocated and managed in units managed by intensive care specialist and run as a closed model than units running as open model.
The ICU services operated at the Lagos University Teaching Hospital is a semiopen facility, which care for a mixed cohort of medical, surgical, and pediatric patients., We investigated the outcome of patients admitted into our ICU before the upgrade of the ICU facilities (June 2011 – May 2012) and after upgrade of the ICU facilities (June 2012 – May 2013). This is an 800-bed government funded hospital with an eight-bed ICU before June 2012. It is located in a cosmopolitan city, with an estimated population of over 20 million, Nigeria's estimated population stood at 173,615,000. The ICU runs on limited resources with consumables procured by the patients from private stores while ICU bills are picked up by the patients' relations on discharge or waved by the hospital management for severely indigent patients. Before May 2012, there were two working ventilators in ICU, two wall monitors while others had broken down, suction machines were exchanged between patients, suction catheters and endotracheal tubes were in short supply, infection control was difficult to enforce, and the ICU was covered administratively by the anesthesia department.
An upgrade of the ICU took place by June 2012 with the provision of a ventilator, monitor, and suction machine for each patient. Two new arterial blood gases devices were procured with the introduction of a new pack system for single-use consumables. Infection control strategies were also introduced.
This study was informed by the need to compare ICU performance in terms of outcome before and following the improvements made in the ICU facilities and organizational structure (Period I and Period II, respectively).
| Methods|| |
This was a retrospective study of all patients admitted into the ICU between June 2011 and June 2013. The study period was divided into 1 year before facility upgrade June 2011 to May 2012 (Period I) and June 2012 to May 2013 (Period II). The study was approved by the Hospital Research and Ethics Committee. A pro forma designed for this study was completed for all the patients from the ICU record book kept strictly in the ICU. Data collected were hospital identification number, primary diagnosis, specialty from which patient was admitted, length of ICU stay (LOS), and the outcome of ICU care either discharged, dead, or alive. Statistical analysis was performed using the statistical program for the social sciences (SPSS ® 20 Inc., Chicago, Illinois, USA) and the EPI-INFO 7.0 where appropriate. Probability value <0.05 was considered statistically significant and analyzed data were presented as mean ± standard deviation or percentages as well as tables and graphical representation where appropriate. Test of significance was by 2 × 2 test of significance, Student's t-test, and Pearson's Chi-square tests with Yates correction when applicable.
| Results|| |
[Table 1] shows the frequency of admission into the ICU between Period I and Period II. It also showed the total hospital admissions during the two periods. ICU admission was 1.04% in Period I and 1.3% in Period II of total hospital admission in the 2 years under review. The total number of admissions in Period I was 122 compared to 156 in Period II (P = 0.07); this represents a 12.4% increase in the total number of admissions despite a 37.5% reduction in available ICU beds.
[Figure 1] shows the mortality rate in the 2 years under review. There was a significant difference in mortality rate between Period I (74.6%) and (57.7%) Period II with a P = 0.005.
The highest mean length of stay (LOS) in Period I among the dead was 8.5 ± 9.4 (1–28) days in cardiothoracic surgical patients and 8.0 ± 4.6 (4–13) days in pediatric surgical patients while the highest mean LOS among those who were discharged was 11.8 ± 6.5 (4–23) days and 26 days for neurosurgical and a burn and plastic patient, respectively. In Period II, neurosurgical patients of 5.5 ± 6.3 (1–30 days) and cardiothoracic surgical patients of 5.3 ± 4.5 (1–10 days) had the highest LOS among those who died while the highest LOS among those discharged was 13.9 ± 11.2 (2–39 days) among neurosurgical patients and 13.0 ± 4.2 (10–16 days) among burns and plastic patients. Overall, the mean LOS in Period I was 6.3 ± 5.4 days and in Period II 7.8 ± 7.3 days [Table 2].
|Table 2: The Comparison of the length of stay in Intensive Care Unit based on Intensive Care Unit outcome between Period I and Period II|
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[Figure 2] shows frequencies (n) of mortality and discharges to the ward in Period I, mortality remained persistently higher than discharges to the ward among neurosurgery (24, 9), obstetrics and gynecology (12, 4), general surgery (8, 4), cardiothoracic surgery (8, 7), internal medicine (15, 2), sepsis (15, 2), burns (5, 1), and pediatric surgery (3,1) patients. Pediatrics and oral maxillofacial surgery had no admission into the ICU while ear, nose, and throat (ENT) had (1, 1) patients.
|Figure 2: The distribution of discharge and mortality in the Intensive Care Unit during Period I|
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[Figure 3] shows frequencies (n) of mortality and discharges to the wards in Period II where mortality rate became less than discharges to the ward among obstetric and gynecological patients (10,13), cardiothoracic surgery (3,5), and oral and maxillofacial surgery patients (0,2). While mortalities remain higher than discharges in neurosurgery (33, 21), general surgery (17, 12), internal medicine (15, 8), sepsis (4, 1), burns (4, 2), pediatrics (4, 2), ENT, and pediatric surgery had no admission into the ICU.
|Figure 3: The distribution of discharge and mortality in the Intensive Care Unit Period II|
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| Discussion|| |
The management of the Lagos University Teaching Hospital had made substantial improvement in the facilities and services available in our ICU; we set to compare the outcome of ICU care before and after the changes in the ICU.
The United States Institute of Medicine highlighted the serious problem of patient safety and importance of evidence-based quality improvement initiatives to reduce adverse events. Our ICU is a semiopen general ICU. In January 2012, the ICU coordinator and a trained ICU nurse received 1-month training in intensive care in Germany. Our report from Hannover centered on changes in the following areas, ICU overcrowding, unavailability of consumables, lack of ICU equipment, and inappropriate cost of ICU stay.
The management of our hospital approved to convert the eight-bedded ICU to a five-bedded ICU. The traffic into ICU by medical students, residents, and consultants was reduced; street clothes were banned while uniform gowns and outfits were provided to improve infection control. These measures were in addition to strict enforcement of application of universal precaution, regular hand washing, and aseptic care of catheters and catheter sites.
The ICU established the single-use policy to reduce infection and cross infection in ICU, for devices such as suction catheters, endotracheal tubes, nasal prongs, intravenous cannulae, oropharyngeal airways, nasopharyngeal airways, and the suction hoses. This was made possible by an imprest of ₦150,000 ($600) at the time as required for direct purchasing from the suppliers during acute shortages. The hospital procured three arterial blood gas machines, two new ICU ventilators, and repaired three existing ones such that each bed had a functioning ICU ventilator, suction machine, and multiparameter monitor. The hospital then increased ICU admission fees from ₦100,000 equivalent to $400 to ₦250,000 equivalent to $1,000.
Lipitz-Snyderman et al. adopted a similar comprehensive approach to improve patient safety by improving communication between providers, and implementing evidence-based practices to reduce rates of catheter-related bloodstream infections and ventilator-associated pneumonia. These included hand washing, full barrier precautions, skin antisepsis with chlorhexidine, avoiding the femoral site during catheter insertion and removal of unnecessary catheters. He concluded that implementation of these simple measures in the keystone ICU project was associated with a significant decrease in hospital mortality in Michigan, compared with the surrounding region.
Resources form an essential part of the ICU structure; human resources contributed about 45%–60% of ICU costs everywhere in the world while supplies, including drugs, account for 30%–35%. Other factors to be considered include patient population to be admitted, pathology case mix, human resources organization, process definition, and local resource availability. The ICU burden was reduced to match the local resources availability in this study.
In our study, during the Period I interval, the surgical and nonsurgical patients were 62.3% and 24.6%, respectively, compared with Period II interval with 61.5% and 23.7%, respectively. On the contrary, 13 years earlier, Merah et al. reported that there were more surgical admissions (86.6%) than nonsurgical admissions (13.4%) in the ICU. The obstetrics and gynecology patients who included operated and nonoperated eclamptic or severe ante- or post-partum hemorrhage patients were classified separately and were 13.1% in Period I and 14.7% in Period II. This has illustrated surgical patients constituted a higher proportion of our ICU admissions since inception. We also noticed an increase of 12.2% in the ICU admission from Period I to Period II despite a 37.5% reduction in ICU bed space.
The pattern of ICU admission in our center is similar to that reported at the Jos University Teaching Hospital Nigeria, a two-bed ICU with a mixed cohort of surgical patients (48.2%), medical patients (15.2%,), burns (23.2%), polytraumatized (11.6%), and obstetrics and gynecological patients (8.7%).
The mortality rate of 74.6% in Period I was reduced significantly to 57.7% in Period II with a P = 0.005. This reduction in ICU mortality rate may have resulted from the changes put in place during the period of upgrade. Merah et al. in an earlier 6-year (1997–2002) review at the same center observed a lower mortality of 40.3% among surgical patients admitted into the ICU while a decade earlier Oke  recorded a mortality of 69% among the medical population admitted into the ICU, these varying result portray the stratification of the sample population in these studies; however, Isamade et al. recorded a mortality rate of 42.8%, surprisingly the patients' cohort at the two centers were similar though the distribution between the units was in varying proportions. This may suggest that there may be cofounding variables implicated in ICU mortality; unfortunately, this is beyond the scope of the present study.
ICU mortality is still high in the Sub-Saharan Africa general over 50%., A step-down in the ICU admission to either a high-dependency unit or a postacute facility has been shown to reduce the overall mortality in the ICU. Zimmerman et al. in a study on changes in hospital mortality for the US ICU admissions from 1988 to 2012 observed that the decrease in mortality in 2001–2012 was due to an increase in patients' discharge to postacute facilities and improvement in the quality of care. There is no postacute facility in our institution; hence, ICU mortality may be higher if patients who died on the open ward post-ICU discharge are taken into account. Rubenfeld et al. also observed that critically ill patients are often at a high risk of death and with diseases, such as acute lung injury and sepsis, complicating ICU admissions mortality may range from 25% to 50%.
The 16.9% improvement in our ICU facility is a significant leap. The cost of ICU care in Nigeria is borne by patient as most ICU operate a fee for service module. This is not unexpected considering that the 2015 annual health-care budget of Nigeria was put at N278.8 billion ($1.11 billion), 6.3% of the aggregate budget. While the total expenditure on health annually is 3.7% of gross domestic product (GDP) and total expenditure per capita on health is $207. These social services and health-care services in the US are strongly supported by the American government that in 2000–2005, annual critical care cost increased from $56.6 to $81.7 billion representing 13.4% of hospital costs, 4.1% of national health expenditure, and 6.6% of GDP. The Nigerian government needs to spend more on intensive care services to sustain improvement in health-care delivery in the country. Staffing in the ICU is inadequate, the nurse-patient ratio averages one nurse to two patients, Pronovost et al. observed that 24 h intensivists' staffing reduces the ICU cost and LOS, saving up to $13 million in annual hospital cost if care is delivered by intensivists directed multiprofessional team.
Length of stay
The LOS in ICU was 6.3 ± 5.4 (1–28) days in Period I and 7.8 ± 7.3 (1–39) days in Period II, there was no significant difference (P = 0.78). In both periods, the LOS was observed to be extended among patients discharged to the ward compared with the patients who died. Unit specific LOS showed that pediatric surgical unit in both periods appears to have consistently high LOS with corresponding poor outcome perhaps due to poor availability of pediatric-specific ICU and facilities. Despite prolonged LOS in both periods 11.8 ± 6.5 (4–23) and 13.9 ± 11.2 (2–38) days, patients with neurosurgical disease have the highest LOS among patients discharged to the ward. Isamade et al. observed a range of (1-56) days and a mean LOS of 4.5 ± 5.1 days. The study suggests that patients who stayed longer in ICU have better outcome than those who spent less time in the ICU when unit specific mortality and discharges to the ward were compared in both periods. In general, intensive care facility is still in its rudimentary stages in Sub-Saharan Africa, and the ICU mortality rate of 57.7% is still high. In spite of this, there was a 16.9% improvement in ICU admission facilities in 1 year which shows that a reduction in mortality can be achieved with better facilities and training.
This limitation to our study included the fact that it was a retrospective study; hence, we were unable to determine confounding variables affecting ICU outcome. It is also a single institution study, which may not reflect the general perception of ICU outcome in the country and subregion; therefore, a multicenter study is advised.
The continuous training of more physicians and nurse intensivists coupled with availability of user-friendly and maintenance-friendly technology for mechanical ventilation, hemodialysis, plasmapheresis, and extracorporeal membrane oxygenation will invariably reduce ICU mortality in our center. The need for more ICUs in the country cannot be overemphasized; pediatric ICUs and neonatal ICUs are virtually none existent in our institution and in the country. Specialized units such as burn center, neurosurgery, and cardiothoracic ICUs should be created to allow for subspecialist care. We, therefore, advocate that in-service training for physician staff, nurses, and ICU technicians be made a priority. Since the cost of care is exorbitant, the government through the National Health Insurance Scheme and private organizations can support the ICUs as part of their corporate social responsibility.
| Conclusion|| |
This study showed that improvement in training, provision of equipment for patients support and monitoring contributed to a reduction in ICU mortality in our institution, and an increase in ICU admissions.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]