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ORIGINAL ARTICLE
Year : 2015  |  Volume : 18  |  Issue : 6  |  Page : 775-779

Pattern of admission and outcome of patients admitted into the Intensive Care Unit of University of Nigeria Teaching Hospital Enugu: A 5-year review


Department of Anaesthesia, University of Teaching Hospital, Ituku Ozalla, Enugu State, Nigeria

Date of Acceptance26-Feb-1950
Date of Web Publication20-Aug-2015

Correspondence Address:
F A Onyekwulu
Department of Anaesthesia, University of Teaching Hospital, Ituku Ozalla, Enugu State
Nigeria
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Source of Support: Nil., Conflict of Interest: None


DOI: 10.4103/1119-3077.163291

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   Abstract 

Objective: The objective was to determine the pattern of admission and outcome of patients in the Intensive Care Unit (ICU) of University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria. Materials and Methods: A retrospective review of all patients admitted into the general ICU at UNTH from 2008 to 2012. Data were collected from the ICU admission and discharge registers, and data analysis was done using Microsoft Excel 2007. Results: A total of 766 patients were admitted during the period, consisting of 501 (65.4%) males and 265 (34.6%) females. Ages ranged from 1-day to 89 years with a mean age of 38.2 ± 18.2 years. The most common cases admitted were neurosurgical patients of which there were 316 (41.2%). Patients admitted as a result of critical incidents in anesthesia formed the lowest number of cases admitted 10 (1.3%). Of the 316 neurosurgical cases, 224 (70.9%) were due to severe traumatic brain injury (TBI). An overall admission of 92.4% (207) was for severe TBI due to motor-vehicular accident (MVA). The average length of stay was < 24 h to 72 days with a mean of 4.9 ± 3.2 days. A total of 16.7% (128) patients received invasive mechanical ventilation during their stay in ICU. Only 15% (34 patients) of all the cases of severe TBI patients received invasive mechanical ventilation. Mortality rate was 34.6% in this study. Conclusion: The highest number of admissions into the ICU was for severe TBI following MVA. Developing a viable trauma team and separately equipped neurosurgical ICU with adequately trained and motivated staff will help improve the outcome of patients.

Keywords: Admission, Intensive Care Unit, outcome


How to cite this article:
Onyekwulu F A, Anya S U. Pattern of admission and outcome of patients admitted into the Intensive Care Unit of University of Nigeria Teaching Hospital Enugu: A 5-year review. Niger J Clin Pract 2015;18:775-9

How to cite this URL:
Onyekwulu F A, Anya S U. Pattern of admission and outcome of patients admitted into the Intensive Care Unit of University of Nigeria Teaching Hospital Enugu: A 5-year review. Niger J Clin Pract [serial online] 2015 [cited 2022 Jan 22];18:775-9. Available from: https://www.njcponline.com/text.asp?2015/18/6/775/163291




   Introduction Top


Intensive Care Unit (ICU) is a special department of a tertiary hospital for patients with the most severe and life-threatening conditions which will often require constant and close intensive monitoring, support from specialist equipment and medications in order to maintain normal physiological functions.[1]

Patients' may be admitted into the ICU from the emergency department or from the general ward following deteriorating clinical condition or as a postoperative case from the operating theatre following major invasive surgeries with high risk of complications.[1]

The concept of an "advance support of life" which is the foundation for intensive care was developed in the 1950s.[2] In 1953, Bjorn Aage Ibsen established thefirst ICU in Copenhagen where patients received intermittent positive pressure ventilation.[3]

In 1960s, the importance of cardiac arrhythmias as a source of morbidity and mortality in myocardiac infarction was recognized, and this led to the routine use of cardiac monitoring in ICUs and the development of coronary care unit.[4]

Intensive care medicine is still evolving in developing countries and many tertiary hospitals in Nigeria have developed critical care facilities for the care of the critically ill patients. Critical care is a major challenge in developing countries where health needs often outstrip available resources and, unfortunately, most of the critical health care facilities are still in their primordial stages of development.[5][6][7]

The University of Nigeria Teaching Hospital (UNTH) is the largest tertiary institution in the South-east of Nigeria providing specialist care as well as training of other specialties. Currently, it is the only tertiary health facility with an ICU providing advanced level of intensive care in the entire south-east sub-serving over 17 million people.[8]

It is a 700 bedded tertiary hospital and was established in 1976 as an independent hospital with its autonomous management board. During the period under review, the hospital had a 5 bedded general ICU, which offered only level 1 care as described by London department of health.[9]

The unit is equipped with modern mechanical ventilators, multi-parameter monitors, and invasive arterial, central venous and pulmonary artery pressure measurement devices, point of care machines for full blood count, serum electrolytes, blood gas analysis, and coagulation profile. Bedside X-ray, echo and thermoregulatory mattress are also available.

This study will provide information about the pattern of admission and outcome in our ICU. This will contribute to the literature on the provision of intensive care facilities in Nigeria.


   Materials and Methods Top


This is a 5-year retrospective review carried out in the UNTH Enugu Nigeria between 1st January 2008 and 31st December 2012. Data were collected from ICU admission and discharge registers and included demographic characteristics, diagnosis on admission, reason for admission, duration of admission, medical/surgical specialty requesting admission, nature of interventions, and outcome of patients admitted.

The data were recorded on a proforma format sheet designed for the study and data analysis was done using Microsoft Excel 2007.


   Results Top


A total of 766 patients were admitted into the ICU, there were 501 males and 265 females giving a male to female ratio of 1.9:1.

The ages ranged from 1-day to 89 years with a mean of 38.24 ± 18.17 years and a median age of 56 years. The young and the middle-aged group (20 − 59 years) accounted for 63.4% of all the ICU admissions as shown in [Table 1].
Table 1: Age distribution of patients admitted into ICU (January 2008 - December 2012)

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The ages of 12 patients were unknown during their stay in admission, and this was due to incomplete documentation as shown in [Table 1].

The study showed that neurosurgical cases accounted for 41.2% (316) of all admissions into ICU while the lowest was due to critical incidents arising from anesthesia [Table 2]. Out of the 316 neurosurgical admissions 70.9% (224) was due to severe traumatic brain injury (TBI) while other neurosurgical cases (intracranial tumors, spinal cord injury, and moderate brain injury) accounted for the remaining 29.1%. Patients diagnosed with intracranial tumors were admitted into the ICU postoperatively. Postoperative cases accounted for 49.3% (378) of all admissions [Figure 1].
Table 2: Pattern of admission according to specialty

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Figure 1: Postoperative cases by surgical specialty

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Patients referred from the specialty of Internal medicine made up 9.4% (72) of the total ICU admissions, while the most common indication for admission was complete heart block (44.4%) as shown in [Table 3].
Table 3: Indication for admission into ICU from internal medicine

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The average length of stay ranged from < 24 h to 72 days with a mean of 4.9 ± 3.2 days. A patient with multiple sclerosis co-existing with myasthenia gravis was admitted into the ICU. She was discharged after 72 days on admission only to relapse 2 months later. She was re-admitted into ICU and spent another 70 days.

A total of 66 (8.6%) patients admitted spent < 24 h in the ICU, out of which 66.7% (44) mortality was recorded. Postoperative cases were 43 patients (65.1%) treated as emergencies, out of which 21 deaths was recorded. In this group (patients that spent < 24 h in the ICU) 14 patients received mechanical ventilation with 85.7% (12) mortality; five of the fatal cases were postoperative cases.

A total of 128 (16.7%) patients admitted into ICU received invasive mechanical ventilation during their stay, while 82 (64%) of these patients died on admission. Majority of the deaths recorded in this group were nonpostoperative patients (48) as compared to postoperatively ventilated patients (34).

The overall ICU mortality rate was 34.6% [Table 4], 67.5% (179 patients) were males while 32.5% (86 patients) were females. Severe TBI accounted for 45.7% (121 patients) of ICU mortality, postoperative cases accounted for 40.7% (108 patients) while medical admissions accounted for 13.6%. Patients referred from the specialty of internal medicine [Table 3] recorded 50% mortality (36 deaths out of 72 patients).
Table 4: Analysis of outcome

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During the period of study, 15% (34) of all severe TBI patient received invasive mechanical ventilation, and 6.3% (14) of these patients were poly-traumatized.

A total of 1.3% (4) of all neurosurgical cases admitted into ICU was purely due to high spinal cord injury with respiratory failure. The spinal cord injury was due to fracture of the 3rd and 4th cervical spine resulting in respiratory failure due to phrenic nerve injury.

There were two cases of rabies with 100% mortality and four cases of Guillain–Barres syndrome with documented 75% (3) mortality.

Severe TBI was most commonly due to motor-vehicular accident (MVA) as shown in [Figure 2].
Figure 2: Causes of severe traumatic brain injury

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The highest number of admissions into the ICU during the period of study was in 2012 with 197 patients, and the lowest mortality rate of 24.4% was observed in 2011 [Figure 3].
Figure 3: Admission pattern and mortality rate per year

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   Discussion Top


Intensive Care Unit requires a vast use of up to date equipment and highly skilled staff. The outcome of patients admitted into the ICU will also depend on the level of training and experience acquired by staff. In developing countries where financial resources are limited training and re-training of staff may not be adequate. Intensive care also demands a tremendous amount of time and effort on behalf of the medical and nursing staff to treat and improve survival of the critically ill patients.[10]

Postoperative cases across the various surgical specialties accounted for 49.3% of all admission into the ICU followed by neurosurgery 41.2%. This result is similar to previous studies done by Isamade et al.[11] and by Bolaji and Kolawale.[12] In centers with functional high dependency unit (HDU), the number of postoperative cases managed in the ICU would be greatly reduced as some of these cases could have been treated in the HDU.

Medical admissions accounted for 9.4% [Table 3] of all ICU admissions. Previous studies across the country have shown that medical admissions constituted around 4.3 − 21.3%.[6], 7, [11][12][13] Complete heart block (44.4%) was the most common indication for medical admission into the ICU. The patients later had a permanent pacemaker inserted. This was different from earlier studies were respiratory insufficiency and tetanus were observed to be the highest indication for admission.[7],[12]

Neurosurgical specialty was observed to be the highest surgical specialty utilizing the ICU bed spaces. This was different from the study done by Mato et al. where the Obstetrics department was the highest specialty utilizing the ICU bed space.[14] MVA is the most common cause of severe TBI in this study, and this agrees with a study done in Britain where high-velocity injury involving rapid acceleration and deceleration was noted to be the most common cause of severe TBI.[15] In a study by Adenekan and Faponle[16] road traffic crashes were responsible for most deaths in major trauma admissions to the ICU.

The high prevalence of severe TBI in this study is due to the high level of reckless driving and poor maintenance of the highway. The availability of a neurosurgical unit and the location of the hospital along the expressway (UNTH is situated along Enugu-Port-Harcourt expressway, the major road connecting Northern Nigeria and the South-East and South-South Nigeria with heavy traffic load) provides close proximity to victims of road traffic accident along the highway. Management strategy should include increased public enlightenment campaign, enforcement of safety rules and improved pre and in-hospital care of trauma victims.[16]

The length of stay in ICU ranged from ≤24 h to 72 days with a mean of 4.9 ± 3.2 days. The longest duration of stay (72 days) was for a patient who had multiple sclerosis with co-existing myasthenia gravis. Admission of patients with poor prognosis and/or prolonged use of the ICU facility results in other patients with a better prognosis being denied care; many of these die, as a result.[10] Resources are also used up, and this adds further stress on the health care system in a developing country.

In this review, 8.6% of patients admitted into the ICU spent < 24 h with 66.7% mortality in this group. On the contrary, a study done in Saudi Arabia showed that this group of patients formed 27.8% of all ICU admissions, with an ICU mortality rate of 26.3%.[17] This difference was largely due to better targeting of ICU admission protocols to patients most likely to benefit, making "do not resuscitate" decisions early during their hospital stay and functional HDUs. It was also observed that the clinical events that occurred, the quality of care provided prior to stay in ICU and the length of stay in ICU are all factors that inter-relates in determining the outcome of patients.[15],[18]

The percentage of ventilated patients observed in this study is far less compared to the study by Wunsch et al.[19] where more than 50% of all patients admitted into the ICU received mechanical ventilation in thefirst 24 h.[19] Only 15% of patients with severe TBI received invasive ventilatory support which is an integral part of the management of patients with severe head injury. This was largely due to shortage of mechanical ventilators in the center during the study period. Furthermore, the absence of a clear-cut protocol on whom and when to institute mechanical ventilation could have contributed to these wide differences observed.

A mortality rate of 34.6% (226 patients) was observed, and 67.5% were males and 32.5% were females. The mortality rate and sex distribution observed in this series is similar to previous studies.[10][11][12]

A lower mortality rate was observed by Mato et al. (24.3%) but in their study over 42% of admissions into the ICU were nonjustifiable as most patients were admitted into ICU for lack of bed space in the general wards and for better comfort.[14] In this study, the yearly mortality rate along with the number of admissions during the period under study showed the lowest mortality rate to be in 2011. The findings of differences on admissions, of course, translate into differences in outcomes.

Severe TBI accounted for the highest number of mortality in this study and this is accounted by the fact that most of the severe TBI patients receive very poor prehospital trauma care, ineffective ambulance system for transportation of patients to the hospital and the time lag between illness and intervention. This additional stress further exacerbates an already established primary brain injury and therefore worsened their prognosis.

In this series, 6.2% (14) of severe TBI patients were poly-traumatized. This differs significantly from other studies where it was observed that severe TBI patients (58%) had polytrauma.[20] This wide margin of difference was due to better evaluation and documentation of patients with trauma in the setting of a prospective study in Israel.


   Conclusion Top


Neurosurgical cases had the highest number of admissions into the ICU with severe TBI constituting a greater number of all neurosurgical cases and mortality. Developing a viable trauma team and separately equipped neurosurgical ICU with adequately trained staff will help improve the outcome of patients. Furthermore, the development and strict implementation of protocols for use in the management of ICU patients along with improved documentation will foster better prognosis for ICU patients in resource-poor settings.







 
   References Top

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Bjorneboe M, Ibsen B, Astrup P, Everberg G, Harvald B, Sottrup T, et al.Active ventilation in the treatment of respiratory acidosis in chronic diseases of the lungs. Lancet 1955;269:901-3.  Back to cited text no. 3
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Khush KK, Rapaport E, Waters D. The history of the coronary care unit. Can J Cardiol 2005;21:1041-5.  Back to cited text no. 4
    
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Waters DA, Wilson IH, Leaver RJ, Bagshawe A. Care of the Critically Ill Patients in the Tropics and Subtropics. London: Macmillian; 1952. p. 274-311.  Back to cited text no. 5
    
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Oji A. Development of an Intensive Care Unit at Jos University Teaching Hospital (JUTH) from 1982 to 1985. West Afr J Med 1987;6:91-8.  Back to cited text no. 6
    
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Oke DA. Medical admission into the Intensive Care Unit (ICU) of the Lagos University Teaching Hospital. Niger Postgrad Med J 2001;8:179-82.  Back to cited text no. 7
    
8.
Population Division of the Department of Economics and Social Affairs of the United Nations Secretariat. In: World Population Prospects: The 2012 Revision. Vol. 1. New York: United Nations;2013. p. 29.  Back to cited text no. 8
    
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Jacobs P, Rapoport J, Edbrooke D. Economies of scale in British intensive care units and combined intensive care/high dependency units. Intensive Care Med 2004;30:660-4.  Back to cited text no. 9
    
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Chalya PL, Gilyoma JM, Dass RM, Mchembe MD, Matasha M, Mabula JB, et al.Trauma admissions to the Intensive Care Unit at a reference hospital in Northwestern Tanzania. Scand J Trauma Resusc Emerg Med 2011;19:61.  Back to cited text no. 10
    
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Isamade ES, Yiltok SJ, Uba AF, Isamade EI, Daru PH. Intensive Care Unit admissions in the Jos University Teaching Hospital. Niger J Clin Pract 2007;10:156-61.  Back to cited text no. 11
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Bolaji BO, Kolawale IK. The Intensive Care Unit of the University of Ilorin teaching hospital, Ilorin. Nigeria; A 10 year review. South Afr J Anaesth Analg 2005;11:146-50.  Back to cited text no. 12
    
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Oyegunle AO, Oyegunle VA. The Intensive Care Unit in a young Nigeria teaching hospital: The Sagamu (1994-1997) experience - A retrospective study. Afr J Anaesth Intensive Care 1997;3:41-3.  Back to cited text no. 13
    
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Mato CN, Onwuchekwa AC, Aggo AT. Pattern of admission to the University of Port-Harcourt Teaching Hospital (UPTH) Intensive Care Unit - A 10 year analysis. South Am J Crit Care 2009;25:10.  Back to cited text no. 14
    
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Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: Intensive care management. Br J Anaesth 2007;99:32-42.  Back to cited text no. 15
    
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Adenekan AT, Faponle AF. Trauma admissions to the ICU of a tertiary hospital in a low resource setting. Afr J Anaesth Intensive Care 2009;9:5-9.  Back to cited text no. 16
    
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Arabi Y, Venkatesh S, Haddad S, Al Malik S, Al Shimemeri A. The characteristics of very short stay ICU admissions and implications for optimizing ICU resource utilization: The Saudi experience. Int J Qual Health Care 2004;16:149-55.  Back to cited text no. 17
    
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Williams TA, Ho KM, Dobb GJ, Finn JC, Knuiman M, Webb SA, et al. Effect of length of stay in Intensive Care Unit on hospital and long-term mortality of critically ill adult patients. Br J Anaesth 2010;104:459-64.  Back to cited text no. 18
    
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Wunsch H, Linde-Zwirble WT, Angus DC, Harrison DA, Rowan KM. Intensive Care Unit admissions in the United States and United Kingdom. Crit Care Med 2010;38:65-71.  Back to cited text no. 19
    
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Groswasser Z, Cohen M, Blankstein E. Polytrauma associated with traumatic brain injury: Incidence, nature and impact on rehabilitation outcome. Brain Inj 1990;4:161-6.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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