Central Annals of Public Health and Research

Cite this article: Salah MS, El Gaeedy G (2018) Intensive Care Unit Admissions and Outcomes in Gaza Strip. Ann Public Health Res 5(1): 1069.

*Corresponding authorMotasem S. Salah, University College of Applied Sciences, Palestine, Email:

Submitted: 29 January 2018

Accepted: 21 February 2018

Published: 23 February 2018

Copyright© 2018 Salah et al.

OPEN ACCESS

Keywords•Intensive care unit•Admission•Outcome

Research Article

Intensive Care Unit Admissions and Outcomes in Gaza StripMotasem Said Salah1* and Gehad El Gaeedy2

1University College of Applied Sciences, Palestine2Head of Critical Care Unit, Al Shifa Medical Complex, Palestine

Abstract

Background: The complexities of the critical ill patients in the Intensive care unit (ICU) require huge resources with high level of care. Assess the trends of outcome of an ICU on a regular basis, we not only analyses the profile of patients getting admitted to a particular ICU but also the quality of care given to them.

Objectives: To provide information about the trend of admissions to the ICU and to compare mortality rate from different etiologies in Al Shifa Medical Complex (SMC) in Gaza Strip (GS).

Methods: From January 2017 to December 2017, ICU records of all admissions, discharges, and deaths were utilized for the purpose of this study. Data extracted from the records included age, gender, diagnosis and outcome.

Results: A total of 711 patients were admitted to ICU, males were 453 (63.7%) and females were 258 (36.3%). About 668 (93.9%) were survived and 43 (6.1%) were died. Most of the patients (57.9%) were between 19-65 years. The mortality rate in surgical hospital (58.1%), medical hospital (41.9%) and in obstetrics and gynecology hospital was zero.The majority of patients 144 (59.7%) were shifted from emergency of medical hospital to ICU. A sever traumatic brain injury accounted for 202 (47.0%) of all surgical admission to ICU. Falling down and road traffic accidents accounted 82 (40.6%) and 46 (22.8%) respectively from neurosurgical cases.

Conclusions: Majority patients admitted to ICU were of surgical hospital and neurosurgical cases. The survival rate is higher than in the past years. The mortality rate in our ICU decreased from 8.6% towas6.1% and in obstetrics and gynecology hospital zero. Increase awareness of the community and enhanced commitment among policy makers to prevent falling down and road traffic injury.

INTRODUCTIONIntensive care units (ICU) are the areas where patients

with severe and life-threatening illnesses and injuries require constant, close monitoring and support from specialist equipment and medications in order to ensure normal bodily functions. An ICU and multi-disciplinary team management have evolved improving the survival of critically ill patients [1]. ICUs are also different from normal hospital wards by a higher staff-to-patient ratio and access to advanced medical resources and equipment that is not routinely available elsewhere. However, ICU beds are scarce hospital resources reserved for a select subset of hospital patients. Underlying the scarcity of ICU beds is the high start-up and operating cost of the unit as well as the highly specialized training required of the staff [2]. Not all patients who have potentially recoverable disease can afford the expenditure of ICU. Similarly, the outcome of a critically ill patient is also not certain as it depends on multiple factors [3]. However if we assess the trends of outcome of an ICU on a regular basis, we not only analyses the profile of patients getting admitted to a particular ICU but also the care given to them [4]. Al Shifa

Medical Complex (SMC) is the main trauma hospital and tertiary referral center in Gaza Strip, it includes 741 beds, distributed as: 255 beds at surgical hospital, 245 at medical hospital and 241 beds in obstetric hospital. The type of ICU in Al SMC includes general, medical, surgical, neurosurgical, pediatric, obstetrics and trauma. We have 9 bedded ICU with all modern machines and equipment’s. The ICU is staffed by 14 consultant anesthetists and trainee doctors at various levels of training. There are 28 well-trained intensive care nurses [5].

The current situation in the Gaza Strip is best described as acute on top of chronic, man-made and can only be politically resolved. The SMC staff were better prepared and trained for casualties through an extreme historical period. The two Intifadas, the isolation Israeli military attacks in 2008, 2012, 2014 and the siege from 2007 until now, the military attacks in 2008, 2012, and 2014 have together placed almost overwhelming burdens and extreme challenges of the daily medical work. The health system faced great difficulties due to lack of resources, lack of needed drugs and equipment, depletion of supplies and failure of equipment due to inappropriate maintenance services.

Central

Salah et al. (2018)Email:

Ann Public Health Res 5(1): 1069 (2018) 2/4

Several institutions provide training on emergency & critical care particularly the organization managed by Red Cross, Medical Aid for Palestinians (MAP), Medecins du Monde- France(MDM-F), Physicians Syndicate and Nursing Syndicate. In addition, the focus of World Health Organizations’ intervention was to strengthening the quality of health service delivery in the critical care units, preposition of life-saving drugs and disposables and procures fuel for generators.

The aim of this study is to provide information about the trend of admissions and to compare mortality rate from different etiologies in the ICU of SMC in Gaza Strip (GS). This will help to identify factors that influence the quality of care and focus on areas in need of improvement that will benefit patients admitted for ICU care.

METHODSThis retrospective study reviewed the admissions into the

general ICU of Al Shifa Medical Complex in Gaza- Palestine from January 2017 to December 2017. ICU records of all admissions, referred, discharges, and deaths were utilized for the purpose of this study. Data extracted from the records included age, gender, diagnosis, occupancy rate, length of stay and outcome. Outcome is classified as discharge, death, analysis of the death according to the cause of admission. Ethical approval was obtained from Ethical Committee in Human Resource Development Unit at Ministry of Health. There was not loss of data or nay missing data from patient’s records during 2017.The data entry was done after over-viewing of the filled data abstract sheets, designing data entry model using the computer statistical package for social sciences (SPSS 22) and EXCELL software 2007.

RESULTSDuring 2017, a total of 711 patients were admitted to the ICU.

There were total 453 (63.7%) males and 258 (36.3%) females giving male: female ratio of 1.76:1. Regarding the hospitals distribution, the majority of patients 430 (60.5%) were admitted from surgical hospital, medical hospital 241 (33.9%) and only 40 (5.6%) patients were admitted from obstetrics hospital. The majority of patients 318 (73.9%) male from surgical hospital while about 135 (56.0%) were male from medical hospital. Amongst the patient admitted to ICU, age range was 6 months

to 94 years with mean of 42.4 years. The age distribution reveals that 185 (26.0%) patients were below 18 years of age, 412 patients (57.9%) were between 19-65 years of age, and 114 (16.1%) patients were more than 66 years of age. The length of stay in the ICU ranged from 1 day to 26 days with mean of 3.7 ± 4.5 days (Table 1).

Out of 711 patients admitted to ICU, about 668 (93.9%) were survived and a total of 43 (6.1%) were died (Figure 1). The male had the highest mortality 26(60.5%) than female 17 (39.5%). Our study further show, the (19-65 years) age group had the highest mortality 41.8%, while the mortality above (66 years) and below (18 years) accounting for 37.2% and 21.0% respectively. The majority of mortalities from the surgical hospital 25 (58.1%), 18 (41.9%) from medical hospital while the mortality amongst the obstetrics and gynecology hospital was zero. Amongst the medical hospital mortality, the distribution of nephrology, cardiology, general medicine, pulmonary and neurology were 5 (27.8%), 4 (22.2%), 4 (22.2%), 4 (22.2%) and 1(5.6%) (Table 2).

From 241 patients admitted to the medical hospital, majority of patients 144(59.7%) were shifted to ICU from emergency while 97 (40.3%) patients from medical departments. The study show that general medicine accounted 70 (29.1%) of all medical indication for admission in ICU, which is followed by cardiology 58 (24.1%), nephrology 32 (13.3%), pulmonary 29(12.0%), endocrinology 26 (10.8%), neurology 14 (5.8%), gastroenterology 7 (2.9%) and oncology 5 (2.0%) (Figure 2).

Severe traumatic brain injury accounted for 199 (28.0%) of all ICU admission during the study and others accounted 512 (72.0%), while severe traumatic brain injury accounted for 202 (47.0%) of all surgical admission and others accounted 228 (53.0%) of surgical admission.

Regarding the cause of admission for neurosurgical cases, the study shows that falling down accounted 82 (40.6%), road traffic accidents 46 (22.8%), assaults and blast injuries 34 (16.8%), brain tumor 16 (7.9%), hemorrhagic stroke 16 (7.9%), subarachnoid hemorrhage 4 (2.0%), hydrocephalus blocked shunt 2 (1.0%) and brain abscess 2 (1.0%) (Figure 3).

DISCUSSIONThe outcome of intensive care depends not only on the

facilities provided in the unit, the skill and timing with which Figure 1 ICU outcome of totally admitted.

Figure 2 Distribution of Medical Hospital Admissions.

Central

Salah et al. (2018)Email:

Ann Public Health Res 5(1): 1069 (2018) 3/4

Figure 3 Distribution of Neurosurgical admission.

Table 1: General patients' characteristics regarding gender, age, original hospital, gender distribution, and length of stay.

General patients' characteristics

No. (%)

Gender Female 258 36.3Male 453 63.7Total 711 100

Age group

< 18 185 2619-65 412 57.9> 66 114 16.1Total 711 100

Total hospital Surgical 430 60.5

admission Medical 241 33.9

Obstetrics 40 5.6

Total 711 100

Surgical hospitalFemale 112 26.1Male 318 73.9

Medical Female 106 44

hospital Male 135 56

Length of stay, mean 1-26 day 3.7 - 4.5

Table 2: Distribution of mortalities according to gender, age group and hospital.

No. (%)

Gender Male 26 60.5

Female 17 39.5

Age group < 18 16 37.2

19-65 18 41.8

> 66 9 21.0

Hospital Surgical 25 58.1

Medical 18 41.9

Obstetrics 0 0.0

Total 43 100

they are administered, but also on the case mix of problems presented by the surgeons and physicians, who make the initial decisions, which results in their patients requiring intensive care [6]. Actually, it demands a tremendous amount of time and

efforts of the medical and nursing staff to treat and improve survival of the critically ill patients [7]. The National Institute for Health and Care Excellence defines clinical audit as quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change [8]. The outcomes of this study contribute to development and improve the quality of care provided in the Gaza Strip.

In this study, we had 711 admissions to our ICU in a year, the male patients accounted 63.7% with male: female ratio 1.76:1, the age ranged between 6 months to 94 years with occupancy rate accounted more than 95% and the (19-65 years) age group had the highest admission and mortality. In addition, and the mean of ICU stay was 3.7 to 4.5. In the study by Isamade, about 54.6%of patients were male, male: female ratio was 1.2:1, the age ranged from 1 day to 98 days and the mean of ICU stay was 4.5 to 5.1 days [9]. The age distribution of patients in SMC during 2016 were similar to the age distribution presented for 2017. Our study show, most of the patient’s admission 60.5% from the surgical hospital while medical and obstetric cases accounting for 33.9% and 5.6% respectively. Similarly, in a study of Sagamu, the surgical patients were mainly patients with trauma and burns which accounted for about 84% of admission [10]. However, no admissions from obstetrics/gynecology. The high rate of admitted surgical cases is due to location of Al Shifa Medical Complex as they receive for the falling down and a lot of road traffic accident victims.

Despite the large number of patients, the mortality rate from total admission drop from 8.6% in 2016 to 43 (6.1%) in 2017. Internationally, there is wide variation in mortality rates, from6% in Germany and 10% in the U.S., to 29% in the U.K [11]. It demands a tremendous amount of time and efforts of the medical and nursing staff to treat and improve survival of the critically ill patients and this reflect the quality of care provided in our ICU, applied protocol for admission and well trained doctors and nurses staff.

The study shows that, the majority of mortalities 58% from surgical hospital, 42% from medical hospital and the obstetrics and gynecology hospital is zero. This result is difference to a study of Desikan, where ICU mortality in medical patients 26.4% and ICU mortality in surgical patients 13.3% [12]. Also, study in India showed the maternal mortality rate was 16.6% and the main cause of maternal death was obstetric hemorrhage [13]. Al SMC in 2017 had not recorded any maternal mortality case not only in ICU but also in obstetrics and gynecology hospital, the improvement of maternal outcomes through strengthened programs of antenatal and postpartum care focused on the prevention and recognition of complications of pregnancy and childbirth

The most common source of patients to ICU at the medical hospital was from emergency (59.7%) and least number of transfer in was from medical departments. Amongst medical admissions, our study showed general medicine patients accounted for 29.1% and only 5.8% from neurological patients. This is almost difference to a study in Poluyi, where neurological patients accounted 53.8% of all ICU admission for medical problems [14].

Central

Salah et al. (2018)Email:

Ann Public Health Res 5(1): 1069 (2018) 4/4

We also found that sever traumatic brain injury accounting for 47.0% of all surgical admission during the study, falling down and road traffic accidents is the most common indication of admission. This agree with Poluyi, Severe traumatic brain injury accounted for 77.3% (160) of all Neurosurgical admission.14In a study by Adenekan and Faponle, road traffic crashes were responsible for most deaths and major trauma admissions to the ICU [15].

CONCLUSIONThe intensive care unit is a vital component of acute care in

Gaza Strip. It is where critically ill patients receive life-supporting care. This study aimed to review a profile of intensive care unit admissions and outcomes in Al Shifa medical complex in 2017.

The largest bedded ICU of SMC informs us that most number of patients comprised of male, age between 19-65 years with occupancy rate more than 95%. The overall ICU mortality rate in this retrospective study was relatively less than in comparative studies, special the absence of any mortalities in obstetrics and gynecology hospital in 2017. ICU patients are most commonly admitted from the emergency department from surgical hospital, with sever traumatic brain injury due to road traffic accidents and assaults injuries. So, increase awareness of the community and enhance commitment among policy makers to take immediate action towards preventing falling down and road traffic injury is the key indicator to improve the outcomes of ICU. This study can help inform evidence based system improvement efforts by providing a baseline of comparable measures of ICU care in Gaza.

REFERENCES1. Hinds CJ, Watson D. Planning, organization and management of

intensive care. In: A Concise Textbook. 2nd edn. WB Saunders Company Limited: London. 1996.

2. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, et al. Physiotherapy for adult patients with critical illness: Recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008; 34: 1188-1199.

3. Ministry of Health NSW. Costs of care standards 2009/10. 2011.

4. Koirala S, Ghimire A, Sharma A, Bhattarai B. ICU admission and outcomes in a community-based tertiary hospital. Health Renaissance. 2011; 9: 83-87.

5. Sushant K, Sonika K, Nand K, Rakhee S, Aggarwal A. Retrospective review of profile of intensive care unit admissions and outcomes in a tertiary care hospital of Himalayan region. Int J Res Med Sci. 2017; 5: 4715-4718.

6. Park GR. Intensive care in the United Kingdom: Report from the King’s Fund Panel. Anaesthesia. 1989; 44: 998-999.

7. 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.

8. Abraham C, Kelly MP, West R, Michie S. The UK National Institute for Health and Clinical Excellence public health guidance on behaviour change: a brief introduction. Psychol Health Med. 2009; 14: 1-8.

9. Isamade ES, Yiltok SJ, Uba AF, Isamade EI, Daru PH. Intenvise Care Unit admission in the JOS University Teaching Hospital. Nigerian Journal of Clinical Practice. 2007; 10: 156-161.

10. Oyegunle A, Oyegunle VA. The intensive care unit in a young Nigerian Teaching Hospital: The Sagamu (1994-1997) experience- A retrospective study. Afr J Int Care. 1997; 3: 41-43.

11. Wunsch H, Angus DC, Harrison DA, Linde-Zwirble WT, Rowan KM. Comparison of medical admissions to intensive care units in the United States and United Kingdom. Am J Respir Crit Care Med. 2011; 183: 1666-1673.

12. Desikan S, Chappell W, Kurian J. Outcome after ICU admission in patients over 90 years. Anaesthesia. 2008; 11: 1268.

13. Pattnaik T, Samal S, Behuria S. Obstetric admissions to the intensive care unit: a five-year review. Int J Reprod Contracept Obstet Gynecol. 2015; 4: 1914-1917.

14. Poluyi EO, Fadiran OO, Poluyi CO, Alabi EO and Falohun SA. Profile of Intensive Care Unit Admissions and Outcomes in a Tertiary Care Center of a Developing Country in West Africa: A 5 Year Analysis. J Intensive Crit Care. 2016; 2: 3.

15. 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.

Salah MS, El Gaeedy G (2018) Intensive Care Unit Admissions and Outcomes in Gaza Strip. Ann Public Health Res 5(1): 1069.

Cite this article