STUDY ON ADMISSION PROFILE AND OUTCOME IN MEDICAL INTENSIVE CARE UNIT IN CENTRAL KERALA DURING THE MONTH OF APRIL 2009
David K Simson, Bagatheesh.S, Deepthi.Vinayan.C, Iwin David, Ajish Verghese C
Studies concerning the admission pattern, outcome and its prognostic factors in Medical Intensive Care Unit have not been analyzed in detail in this part of the state. Our aim was to find out the admission profile in MICU and also to trace the avoidable causes of death in the same.
A prospective study was conducted during the month of April 2009, in the Medical Intensive Care Unit of Amala Institute of Medical Sciences, Thrissur, Central Kerala. The data was collected directly from the patients, bystanders and their respective charts. It was analyzed using epi-info software provided by the Centre for Disease Control (CDC).
16.7% (15 patients) died during the month of April, of which, majority were suffering from CVA (3cases); the rest of the diagnosis include COPD (2cases), pneumonia (2cases), Rheumatic heart disease (2cases), poisoning (1case), metastasis (1 case), MDS (1 case), LVF (1 case), and interstitial lung disease (1 case). Out of the 15 died 10 cases (58.4%) were considered DIL and on the contrary 7 cases (33.3%) who were put under the category DIL survived. 15 patients were found to have delirium, out of which 8 died. The average length of stay of a patient is 2.58 days which ranges from a minimum of 1 hour to a maximum of 13 days.
Mortality rate was found to be 16.7%. The avoidable causes of death include poisoning and pneumonia. There is a strong association between ICU delirium and increased mortality (risk ratio – 3.07). There was a poor prognosis for those patients who were put on ventilators and central lines (risk ratio- 7.69). Among the patients who died, one-third (33.3%) of the patients met with an unexpected death for they were not considered as DIL (Dangerously Ill).
It is always the dream and passion of every medical professional to save lives. Intensive care units (ICUs), first introduced in the 1960s, now account for approximately 7% of total U.S. hospital beds, 20% to 30% of hospital costs, and 1% of the U.S. gross domestic product[i] [ii] [iii]. These economic and institutional consequences have increased the need for outcome evaluation and guidance regarding efficient utilization.
The project was designed as a cohort study, conducted from 1st to 30th April 2009, in the medical intensive care unit of Amala institute of medical sciences, Thrissur. The data was collected from the patients, bystanders and the patient charts, so as to get the most accurate details.
All the patients who got admitted from 1st April 12 am to 30th April 11.59pm had been considered. Those patients who were admitted in that stipulated time were followed up, till they were discharged from the MICU.
Patients who were readmitted in MICU during that month itself had been excluded. Post surgical patients were also not considered.
The data, was fed in to epi-info software provided by the centre for disease control, and was analyzed. The association between various factors had been checked using relevant tests like chi-square, student t test etc. Only those values in which the associations were proved has been taken in to consideration.
There were a total of 90 patients admitted during the month of April, 2009. Majority of the patients were males (64.4%)(Graph 1) and were between the age group of 61-70 years (24.4%)(Graph 4). Out of the total 90 cases, 53.3% of the patients were Hindus, 25.6% Christians and 21.1% Muslims (Graph 2). Cerebro vascular accidents topped the list with 15 cases followed by coronary artery diseases and COPD (7 cases each). There were 7 cases of poisoning, all being, either organophosphorous or zinc phosphide poisoning. Most of the patients were transferred from the casualty (73.3%; 95% CI 63% – 82.1%)(Graph 5). The maximum number of cases came on Thursdays (17 cases) and the time of admission being from 9pm to 1 am (24 cases)(Graph 3). 4 out of 12 (25%; RR – 2.31) COPD cases, got admitted on Mondays and 6 out of 15 (35.3%; RR – 2.84) CVA cases, got admitted on Thursdays. Majority of poisoning cases turned up on Wednesdays (3/7; 23.1%; RR – 4.51).
Provisional diagnosis differed from the final diagnosis in 15.6% of cases (14 cases). Central lines were put on 2 patients and 3 patients had to have ventilator assistance. All the 3 patients who were put on ventilators were males (Table 1). Of all the 5 patients who were put on central lines and ventilators, no one survived. 16.7% (15 patients) died during the same month of which majority were suffering from CVA (3cases); the rest of the diagnosis includes COPD (2cases), pneumonia (2cases), Rheumatic heart disease (2cases), poisoning (1case), metastasis (1 case), MDS (1 case), LVF (1 case), and interstitial lung disease (1 case). One patient died even before any diagnosis was reached. Out of the 15 died 10 cases (58.4%; RR – 8.64) were considered DIL and on the contrary 7 cases (33.3%) who were put under the category DIL survived. 15 patients were found to have delirium, out of which 7 died (46.7%; RR – 3.07)(Table 2). The cardio pulmonary resuscitation is not done as per the universal guidelines. Only one patient got stabilized by doing CPR out of the total 16 CPR's being done in that month. But that patient also died subsequently the next day.
The average length of stay of a patient is 2.58 days (Graph 6) which ranges from a minimum of 1 hour to a maximum of 13 days. Out of the total 90, 20cases were admitted under M4 unit, 13 cases under cardiology, 12 cases each under M1, M2, M3, 10 cases under pulmonology, 4 cases each under gastroenterology and oncology, 2 cases under nephrology and 1 case under pain and palliative unit. Mortality was the highest in the M1 unit (33.3%; RR – 3.25), followed by M4 unit (26.7%; RR – 1.27), pulmo (20%; RR – 2), M2 unit (13.3%; RR – 1) and the least in M3 unit (6.70%; RR – .46).
There are a total of 16 beds in medical ICU. The bed occupancy rate was 18.75%. 4 patients were shifted to other hospitals for want of expert care and for advanced infrastructural facilities.
It is noted in studies that the mean patient age in ICU is 62.3 +/- 17.6 years[iv]. In our study it has been noted that the mean patient age was 55.22 years which is lower than the international standards. Male preponderance was seen among the patients who were admitted round the globe (57.3%4). However, the value which we have obtained is even more higher (64.4%).
The worldwide ICU mortality rate ranges from 14.5%[v] to 30.7%[vi]. It has also been noted that in high volume patient inflow intensive care units have lower mortality rates5. The mortality rate observed in our study was 16.7%, which is on the lower side; possibly due to the high patient inflow. But in this 16 bedded MICU facility, bed occupancy rate is only 18.5%. The avoidable causes of death include poisoning and pneumonia.
Exacerbations of chronic cardiovascular disease were the most frequent causes of death in the hospitals worldwide (31.3%- 33. 2%)[vii]. The major cause of death in our study was found to be cerebro vascular accidents, even if deaths due to cardiac problems predominate globally. This is partly because; there is a separate facility to manage cardiac patients in this hospital (CCU).
According to studies, day of the week and time of admission of patients to ICU were not associated with significant differences in ICU mortality[viii]. This holds true in our study also. However there was an increased inflow (53.4%) of patients to MICU on Mondays, Thursdays and Saturdays, reasons of which are not known. On the contrary to the fact that, Sundays being the busiest day in casualty, admissions to MICU on Sundays were found to be only 10% of the total admissions in that month.
The mean unadjusted length of ICU stay varied from 3.3 to 7.3 days[ix] according to various reports. But the average length of stay in our project is only 2.58 days. It is observed that the average length of stay will be reduced with the good service of an intesivist. However such a facility was not available in this MICU. High-intensity staffing (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment[x].
There is a strong association between ICU delirium and increased mortality (risk ratio – 3.07) according to our study. Among medical ICU patients, delirium is associated with multiple complications and adverse outcomes, including self-extubation and removal of catheters[xi], failed extubation[xii], prolonged hospital stay[xiii], increased health care costs[xiv], and increased mortality[xv] [xvi] [xvii]. The association between ICU delirium and increased mortality was subsequently confirmed in two other cohort studies16 17 .
[i] Stevens R. In Sickness and in Wealth: American Hospitals in the Twentieth Century. New York; Basic Books; 1989:228-32.
[ii] American Hospital Association. Hospital Statistics, 1991. Chicago; American Hospital Association; 1991.
[iii] Berenson RA. Intensive Care Units(ICUs); Clinical Outcomes, Costs and Decisionmaking. Washington, DC; U.S. Congress of the United States, Office of Technology Assessment; 1984.
[iv] Finkielman JD, Morales J, Peters SG, Keegan MT, Ensminger SA, Lymp JF, Afessa B; Mortality rate and length of stay of patients admitted to the intensive care unit in July; Crit Care Med. 2004 May;32(5):1161-1165.
[v] Jeremy M. Kahn, M.D., Christopher H. Goss, M.D., Patrick J. Heagerty, Ph.D., Andrew A. Kramer, Ph.D., Chelsea R. O'Brien, R.N., and Gordon D. Rubenfeld, M.D; Hospital Volume and the Outcomes of Mechanical Ventilation; New eng j med 2006 jul 6;355 (1) 41-50.