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Reasons for Admission and outcome among under fives in Paediatric Intensive Care Unit at Bugando Hospital in Past one Year (July 2006-June 2007)

ABSTRACT

         An intensive care unit, or ICU, is a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically ill and who can benefit from treatment. The aim of this Research was to determine the Reasons for Admission and outcome among underfives in Paediatric Intensive Care Unit at Bugando Medical Centre from July 2006 to June 2007. ICU services at BMC are provided in two units, the NICU and AICU .Study Design; Retrospective Cross sectional study.

Methodology; Data concerning age,refferal source ,time of admission, diagnosis and duration of stay and  outcome were collected from July 2006 to June 2007 and analyzed using EPI info programme developed by CDC, a 2005 version. RESULTS: Of 471 patients were admitted in NICU and 249 Patients in AICU from July 2006 to June 2007.NICU Patients: 56.6% were Male and 43.4% were Female. Mortality was high among Females (59.3%).The overall mortality among Neonates admitted in NICU for past one year is 58.1%.Prematurity and Birth Asphyxia were the most common causes of admission in NICU,36.7% and 25.1% respectively. Others involved congenital heart diseases, Aspiration pneumonia, Hypothermia, Anemia e.t.c.70.2% and 72.4% of patients admitted due to Prematurity and Septicemia respectively died in NICU.The mean duration of stay was 4.73 hours. AICU Patients: 52.6% were Male while 47.4% were Female. Majority of patients are those developed need for ICU services while admitted in wards and in both Referral sources Majority of patients Survived. Overall mortality in AICU was 45.4% and Mortality was high among Male Patients (46.6%) compared to Female patients (44.1%).Majority of patients were admitted during Afternoon hours (32.5%),while mortality was high among patients admitted during Night hours (60.3%).Malaria and Pneumonia were the Predominant cause of admission in AICU,27.7% and 24.1% respectively. Other causes included Head injuries, Congenital Heart Diseases, Post Surgical care, Septicemia, Meningitis, Malnutrition, Diarrheal, Burn, Poisoning,TB/Pleural effusion e.t.c.94.1% of all patients admitted due to Malnutrition died in APCU.The mean duration of stay for all patients was 60 hours.

 CONCLUSION: Although the ICU was established for the aim of reducing mortality among children especially underfives, the mortality rate among underfives admitted in NICU at BMC is still high (58.1%) however Mortality among underfives in AICU is low (45.4%) compared to that of NICU.

INTRODUCTION AND LITERATURE REVIEW

        An intensive care unit, or ICU, is a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically ill and who can benefit from treatment. It’s a Hospital facility for care of critically ill patients at a more intensive level than is needed by other patients. Staffed by specialized personnel, the intensive care unit contains a complex assortment of monitors and life-support equipment that can sustain life in once-fatal situations, including adult Respiratory Distress Syndrome,Kidney Failure, multiple organ failure, and sepsis. The purpose of the intensive care unit (ICU) is simple even though the practice is complex. Healthcare professionals who work in the ICU or rotate through it during their training provide around-the-clock intensive monitoring and treatment of patients seven days a week. Patients are generally admitted to an ICU if they are likely to benefit from the level of care provided. Intensive care has been shown to benefit patients who are severely ill and medically unstable—that is, they have a potentially life-threatening disease or disorder.Although the criteria for admission to an ICU are somewhat controversial—excluding patients who are either too well or too sick to benefit from intensive care—there are four recommended priorities that intensivists (specialists in critical care medicine) use to decide this question.

       Generally, ICU care requires a multidisciplinary team that consists of but is not limited to intensivists (clinicians who specialize in critical illness care); pharmacists and nurses; respiratory care therapists; and other medical consultants from a broad range of specialties including surgery, pediatrics, and anaesthesiology. The ideal ICU will have a team representing as many as 31 different health care professionals and practitioners who assist in patient evaluation and treatment. The intensivists will provide treatment management, diagnosis, interventions, and individualized care for each patient recovering from severe illness.

      When patients are transferred to the ICU from another hospital department, treatment orders and planning must be reviewed and new treatment plans written for the patient's current status. For example, a chronically ill inpatient may grow markedly worse within a few hours and may be transferred to the ICU, where the staff must reevaluate  orders for his or her care.

       A large and comprehensive study conducted in 1992 by the Society of Critical Care Medicine  in collaboration with the American Hospital Association found that approximately 8% of all licensed hospital beds in the United States were designated for intensive care. Small hospitals with fewer than 100 beds usually had one ICU, whereas larger hospitals with more than 300 beds usually had several ICUs designated for medical, surgical, and coronary patients. Smaller hospitals do not usually have a full-time board-certified specialist in critical care medicine, whereas larger medical centers generally employ certified intensivists.   

           Arias G, Taylor and Marcin J conducted a study to determine whether an association between the time of admission (weekday versus weekend and daytime versus evening) and the risk of death exists among pediatric patients included in a cohort of children admitted to a national sample of PICUs in USA.They discovered that  Pediatric patients admitted to the PICU during evening hours had higher odds of death than did those admitted during daytime hours. There was no association between mortality rates and the day of admission (weekend admissions versus weekday admissions). Here we can see that An increased risk of death exists for some pediatric patients admitted to the PICU during evening hours.

        A retrospective analysis study conducted by Cooper S,Lyall H,Walters S et al to assess the outcome of children with HIV admitted and treated in paediatric intensive care unit  UK  revealed that, Sixteen (38%) children died in PICU, and 26 (62%) survived their last PICU admission. Of these, 5 died at a later date (between 1 and 32 months after discharge from PICU) and 21 survived to the time of reporting. The most frequent reason for PICU admission was respiratory failure, due either to Pneumocystis carinii pneumonia (45% of admissions) or to other respiratory pathogens (32%). Over 80% of current survivors had good outcomes in terms of growth and development; 6 children had evidence of spastic diplegia.There is significant mortality among children with HIV infection admitted to PICU,although many of them survive their admission, and over 80% of the survivors have good outcomes with the currently available highly active ARV.

     Another study conducted by Jeena PM,Wesley AG and Coovadia HM  to describe admission and outcome patterns of diseases managed at a paediatric intensive care unit (PICU) in a developing country .The overall mortality rate was 35.44% ,over 90% of the children admitted were intubated and 80% required intermittent positive pressure ventilation. The mean duration of ICU stay per survivor over the study period was 13.891 days. Tetanus, septicemia and HIV related diseases required the longest ICU stay per survivor, while accidental injuries, neonatal apnea and asthma required the shortest duration of ICU stay per survivor ; 23.9% of all deaths occurred in the first 24 h.

          A Prospective cohort study on Outcome of children with different accessibility to tertiary pediatric intensive care in a developing country  was conducted by Goh AY,Abdel-Latif Mel-A,Lum LC and Abu-Bakar MN. From this study we can say the outcome of critically ill children transferred from community hospitals did not differ from that of those who develop ICU needs in the wards of a tertiary center, despite being transported by non-specialized teams. Outcome was not affected by initial inaccessibility to intensive care if the children finally received care in a tertiary center.

PROBLEM STATEMENT and RATIONALE

 Patients who are admitted in Paediatric ICU are critically ill that if they are not cared of seriously death may occur at any time, however the medical team in PICU have to utilize their knowledge maximally to reduce Underfive mortality in PICU, however the role of PICU in Paediatric outcomes At BMC was not yet well researched compared to other countries and So this study was needed to explore the actual situation in our settings..

       Studies revealed that Pediatric patients admitted to the PICU during evening hours had higher odds of death than did those admitted during daytime hours. Here we can see that an increased risk of death exists for some pediatric patients admitted to the PICU during evening hours (Arias G et al) .It was necessary to determine whether this finding results from differences in the structure of care, processes of care, or both. This study tried to associate relationship between time of admission and outcome in BMC settings.

     Children admitted in PICU may be admitted directly from the community and /or may be those who develop needs while in wards. However the outcome between the two groups has not been well established. Studies are needed to generate data on outcome of these two groups.

 OBJECTIVES

 Broad Objective

 The main objective of this study was to determine the Reasons for Admission and outcome of Underfives in Paediatric Intensive Care Unit at Bugando Medical Centre in from July 2006 to June 2007.

Specific Objectives were:

• To determine admission patterns in PICU including age, sex, diagnosis, time of admission and referral source.
• To describe outcome patterns of diseases managed at APCU
• To determine number and causes of mortality and morbidity among underfives in PICU
• To determine duration of stay from admission to discharge or death.

 METHODOLOGY

 Study Design

A Retrospective Cross sectional study

Study Area

The study was conducted in NICU and AICU at BMC.BMC is located in Mwanza city and it serves as a referral hospital for Mara, Kagera, and Shinyanga and Mwanza region. Mwanza is located south of Lake Victoria, bordering Shinyanga on its southern part, Mara Region on its Eastern part and Kagera on it Northern West. Most Residents of Mwanza are Sukuma, Kerewe, Zinza and other tribes are a result of economic activities which are Fishing (Main), Mining, Small Business Enterprises e.t.c.

Neonatal ICU is located in H2 Building and receives patients from labour ward, premature unit and peripheral Hospitals. The staffs are Pediatrician (1), Resident Doctor (1), Intern Doctor (1), Nurses (10) and Assistants (3).It have 5 Beds and 2 Extra Beds (Kangaroo mother bedÿÿ,3 Infusion pumps,6 Drip stands,1 Phototherapy Machine,5 Heaters,1 Air Conditioner,2 Tables,5 Cupboard,1 Weighing Machine,1 Ventilator,6 Monitors,1 ECG Machine and 2 Trolleys.

Adult ICU: Is also located in H2 Building and it receives both adult and children except neonates who are cared at NICU. The staffs in AICU ARE Doctors (3),Enrolled Nurses (2),Registered nurses (16) and Attendants(3).It have one big rooms offices and Laboratory ,12 Beds,9 Drip stands,2 ECG machines,1 Stabilizer,1 starilizer,1 Autoclave,1 Microscope ,1 Centrifuge,1 Defibrillator,3 Infusion pumps,15 Monitors,5 Ventilators,1 echo machine,1 suction machine,1 oxygen concentrator and other life supporting equipments.

 Sample size

The sample size was all underfives admitted in both NICU and AICU as were documented in registers from July 2006 to June 2007.471 neonates were admitted in NICU and patients were admitted in AICU.

 Data Collection

Chart records of all patients less than 5 years of age from July 2006 to June 2007 were collected and retrospectively analyzed. Information regarding sex, age, length of stay, admission, diagnosis, and the discharge or death outcome were recorded.

Ethical Issues

A permission to conduct this study was sought from MUCHS, BMC Authority and heads of respective sections.

Study Limitations

1. The outcome of patient who was transferred to the general ward could not be assessed. Most patients may die soon after discharge from the PICU and due to study settings these were not included in my study which may have effect on sample size.
2. Due to age limit a significant number of patients above five years of age who were admitted in AICU were omitted from my study, this may affect the sample size.
3. Errors and/or incomplete entry in registers especially in NICU have affected my study, that some of objectives are not met due to incomplete data as documented in Registers.

Data Analysis

Data was analyzed by a CDC version of Epi info and presented in form of tables where associations were tested mathematically.

RESULTS

1: NICU DEPARTMENT

NB;The total number of Patients admitted in NICU for the past one year is 471,however during data analysis the ‘Total’ column and/or rows may change due to missing entry in one or both exposure and outcome variables as encountered in Registers at NICU.

TABLE OF RESULTS CANNOT BE DISPLAYED

    Majority of neonates in NICU were male. Significant deaths in NICU occurred in female and overall death in NICU was 58.8%.

 Majority of Neonates who developed need while in wards and those admitted from Home and Peripheral hospital, Died in APCU. The progress of transferred patients to general paeditric ward was not known.

Prematurity, Birth Asphyxia, Hypothermia, Septicemia and congenital anomalies were the most causes of admission in the NICU. Others included Malaria, Resuscitation, Observation, Hypoglycemia, HIV=4, Low score e.t.c e.t.c.

Majority of patients stayed in NICU in less than 10 hours.

The total time of stay of all patients for one year was 1816.32 hours. The mean time of stay of each patient regardless of the outcome (death, discharge or transfer to the general paediatric ward was 4.73 hours.

 2: AICU DEPARTMENT
Table 1; Under fives admitted in AICU from July 2006 to June 2007 considering age and sex

   Majority of Patients were below the age of 12 months. Male were 52.6 % while female were 47.4%

Majority of patients were admitted during afternoon hours. Majority of Patients admitted during Night hours died in APCU (60.3%).

Malaria and Pneumonia were the most common causes of admission in the AICU.

Others includes- Epilepsy,Neoplasms, Bleeding Disorders, Foreign Body e.t.c.

 Majority of patients admitted due to Malnutrition died in AICU.

Majority of patients stayed in AICU in less than 24 hours.

The total time of stay of all patients for one year was 14941 hours.

 The mean time of stay of each patient regardless of the outcome (death, discharge or transfer to the general paediatric ward was 60 hours.

Discussion

      From this study of which data were collected retrospectively, underfives records of admission in NICU and Adult ICU, 471 Neonates and 249 underfives were admitted in NICU and AICU respectively in the past one year. We can discover that admission in NICU was as twice as that of AICU however the recording system in NICU is weak as there is many incomplete data while the recording system in AICU is adequate. In NICU, about 56.6% neonates were Male and 43.4% were Female. Majority (89%) were below the age of 7 days. The overall Mortality in Neonates admitted in NICU for past one year is 58.1%, Mortality was high among Females (59.3%), this does not conform with a study conducted by Jetske ten Berge et al on Circumstances surrounding morbidity and mortality in the paediatric intensive care unit in which only 87 (4.4%) of the 1995 admitted patients died. The mortality is still high compared to the same study conducted at MNH by Isangula K in which 54.1% of admitted patients died in APCU. The high percentage of death observed at NICU may be because of delays for life support services and/or inadequate life saving skills and/or Scarcity of the physicians and nurses in NICU.

     In AICU, 52.6% were Male while 47.4% were Female .The overall mortality in AICU was 45.4%,although this finding does not conform with a study conducted by Jetske ten Berge et al on Circumstances surrounding morbidity and mortality in the paediatric intensive care unit in which only 87 (4.4%) of the 1995 admitted patients died. The mortality is low compared to the same study conducted at MNH by Isangula K in which 54.1% of admitted patients died in APCU.The may be contributed to team working and organization of service delivery in AICU at BMC Compared to MNH.

 In NICU,Majority of patients were those developed need for ICU services while in wards especially from Labour Ward this observation is the same for patients admitted in AICU and in both units Majority of patients Survived regardless of referral source.

     In AICU Overall and Mortality was high among Male Patients (46.6%) compared to Female patients (44.1%).Majority of patients were admitted during Afternoon hours (32.5%),while mortality was high among patients admitted during Night hours (60.3%).This finding conforms with the same study conducted at MNH by Isangula K,in which  Majority of patients were admitted during afternoon hours and Majority of Patients admitted during Mid Night hours died in APCU. This findings also conforms with another study conducted by Arias G, Taylor and Marchin G to determine whether an association between the time of admission  and the risk of death exists among pediatric patients included in a cohort of children admitted to a national sample of PICUs in USA.They discovered that  Pediatric patients admitted to the PICU during evening hours had higher odds of death than did those admitted during daytime hours. However in their study they found no association between mortality rates and the day of admission. Here we can see that they observed an increased risk of death for some pediatric patients admitted to the PICU during evening hours. Although in my study I didn’t elicit association between weekend admission and weekdays admission and paediatric outcome, but I was able to discover that majority of patients were admitted in AICU during after noon hours and majority of patients who were admitted during night (60.3%) died, this may be attributed to fact that during this time the physician on call may not be readily available. From this study it can be seen that time of admission have effect on patients outcome. However more studies are needed to establish the actual relationship between time of admission and outcome.

      Prematurity and Birth Asphyxia were the most common causes of admission in NICU, 36.7% and 25.1% respectively. Others involved congenital heart diseases, Aspiration pneumonia, Hypothermia, Anemia e.t.c. But 70.2% and 72.4% of patients admitted due to Prematurity and Septicemia respectively died in NICU. The mean duration of stay in NICU was 4.73 hours. In AICU, Malaria and Pneumonia were the Predominant causes of admission in AICU,27.7% and 24.1% respectively. Other causes included Head injuries, Congenital Heart Diseases, Post Surgical care, Septicemia, Meningitis, Malnutrition, Diarrheal, Burn, Poisoning, TB/Pleural effusion e.t.c. About 94.1% of all patients admitted due to Malnutrition died in APCU. The mean duration of stay in AICU was 60 hours which is equivalent to 2.5 days. The study  conducted by Jeena PM,Wesley AG and Coovadia HM to describe admission and outcome patterns of diseases managed at a paediatric intensive care unit (PICU) in a developing country .The overall mortality rate was 35.44% The mean duration of ICU stay per survivor over the study period was 13.891 days. Tetanus, septicemia and HIV related diseases required the longest ICU stay per survivor, while accidental injuries, neonatal apnea and asthma required the shortest duration of ICU stay per survivor .In the same study at MNH the overall mortality in APCU is 54.1%. The mean time of stay of each patient regardless of the outcome (death, discharge or transfer to the general paediatric ward was 114.5 hours which is equivalent to 4.8 days. Severe Pneumonia, Septicemia and Meningitis were the most causes of admission in the APCU at MNH.Other causes involved PCP, Oral candidiasis, Poisoning, Hepatic failure, multiple congenital anomalies, malaria e.t.c. The short duration of stay at BMC may be due to patterns of diseases and service organization and since BMC receives patients from Lake Zone areas while MNH receives patients from all over Tanzania and in Most cases ‘Complicated’ Patients.

Conclusion and Recommendations

 This study shows some differences with studies conducted in other settings. This may be either due to geographical, social, cultural and economical differences in the settings were those studies were conducted. However the ICU was established for the aim of reducing mortality among children especially underfives, the mortality rate among underfives admitted in NICU and AICU at BMC still high (58.1%) and 45.1% respectively. That there is a need to improve the overall life saving health care in NICU  and AICU in terms of Equipment  and regular update of the physicians and nurses knowledge on management of children who need emergency care. However The Patient care and record keeping systems in NICU must be reviewed to reduce the mortality and improve the record keeping in this department. More studies are needed to generate knowledge on how patient care especially underfives at BMC may be maximally provided.

 References.

1. Althabe M, Cardigni G, Vassallo JC, Allende D, Berrueta M, Codermatz M, Cordoba J, Castellano S, Jabornisky R, Marrone Y, Orsi MC, Rodriguez G, Varon J, Schnitzler E, Tamusch H, Torres JM, Vega L. Dying in the intensive care unit: collaborative multicenter study about forgoing life-sustaining treatment in Argentine pediatric intensive care units. Pediatr Crit Care Med. 2003;4:164–9.
2. Arias Y, Taylor DS, Marcin JP: Association between evening admissions and higher mortality rates in the pediatric intensive care unit.Pediatrics 2004, 113:e530-4.
3. Van der Wal ME, Renfurm LN, van Vught AJ, Gemke RJ: Circumstances of dying in hospitalized children.Eur J Pediatr 1999, 158:560-5.
4. Cooper S,Lyall H,Walters S, Tudor-Williams G,Habibi P,de Munter C,Britto J,Nadel S:Children with immunodeficiency syndrome virus admitted to a paediatric intensive care unit in the United Kingdom over a 10-year period.Eur J Pediatr 1999,168:504-9.
5. Jeena PM,Wesley AG, Coovadia HM: Admission patterns and outcomes in paediatric intensive care unit in South Africa over a 25-year period(1971-1995):PMID:10051O84.
6. Isangula K:Reasons for Admission and Outcome among Underfives in APCU at Muhimbili National Hospital, April-June 2007.(Unpublished)
7. Goh AY,Abdel-Latifmel-A, Lum LC, Abu-Bakar MN: Outcome of children with different accessibility to tertiary Paediatric Intensive Care Unit in a developing country-a prospective cohort study:Pediatrics 2004:235-8

About the Author

Dr.Kahabi Isangula
Zonal HIV/AIDS and Malaria Coordinator
WORLD VISION TANZANIA

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