The National Audit on

Adult Intensive Care Units

(NAICU)

Report of a 12-month audit from

1st July 2002 to 30th June 2003

Prepared by

The National Committee on NAICU

Ministry of Health, Malaysia

November 2003

EXECUTIVE SUMMARY

The National Audit on Adult Intensive Care Units (NAICU) is a quality

improvement initiative under the Medical Development Division, Ministry of

Health Malaysia. Its objectives are to assess the current status of adult

intensive care service in Ministry of Health hospitals and to make

recommendations to improve the quality of care in intensive care units. The

audit is coordinated by a National Committee comprising of senior

anaesthetists and intensivists. A special software “Synapse” was developed

for data entry and analysis. Fourteen state hospitals participated in this 12-

month audit from 1.7.2002 to 30.6.2003.

The key findings of the National Audit on Adult Intensive Care are:

1. Currently there are 509 ICU beds in Malaysia and only 54.2% of these

were in the government hospitals. The ICU beds in the state hospitals

constitute 1% of the hospital beds. The existing intensive care facilities

in the Ministry of Health hospitals are unable to cope with the

increasing demand and the burden of cases.

2. One in every two patients deserving intensive care could not be

admitted to ICU due to the unavailability of beds. Almost 5000 patients

were denied ICU admission in the Ministry of Health’s state hospitals

during the 12-month audit. Approximately another 100 beds are

needed to care for these patients.

3. The staffing of one to one nursing was achieved during the morning

and afternoon shifts but not during the night. 36.5% of nurses working

in ICU had undergone post-basic training in intensive care nursing.

4. The clinical practice in the Malaysian ICUs was no different from the

rest of the world with an average length of ICU stay of 4.9 days and

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hospital stay of 19.8 days. The in-ICU and in-hospital mortality rates

were 22.1% and 31.1% respectively which were comparable with UK

and other developing countries. The standardised mortality ratio

(SMR) was 0.85 indicating a better mortality rate than predicted.

5. The incidence of ventilator-associated pneumonia was 26.9 per 1000

ventilator days. This was significantly higher than the acceptable

standards and needs to be improved on.

Recommendations of the National Committee are: 1. There is an urgent need to increase the number of ICU beds in the

hospitals in MOH as soon as possible. This can be achieved by expanding

existing facilities or establishing new ICUs in the state hospitals under the

Dasar Baru programme or a special allocation.

2. To ensure efficient bed management, there should be written admission

and discharge guidelines and regular in-unit audits on resource utilisation.

3. To ensure optimal utilisation of resources and staff, the ICU and High

Dependency Unit (HDU) should form part of the continuum of critical

care rather than existing as separate units. The HDU should be aligned

with intensive care service. The networking of ICUs within a geographical

region should be encouraged. This will ensure that any deserving patient

who cannot be admitted to an ICU due to unavailability of bed can be

transferred to an ICU in another hospital.

4. ICU care providers can minimise the length of patient stay through

efficient treatment by practising a “closed” system of ICU organisation,

having a clear management plan for every patient and improving

measures on infection control. More specialists need to be trained in

intensive care medicine to ensure efficient patient management.

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5. Clinicians must recognise and practice withdrawal or with-holding of life-

support therapy when continued ICU care is deemed futile. This will

reduce unnecessary demands for intensive care beds.

6. The NAICU is to be extended to all ICUs in the country including the

private sector to allow a comprehensive view of the intensive care service

in the country.

ACKNOWLEDGEMENT

The National Committee for the NAICU wishes to express their appreciation

to the Medical Development Division of the Ministry of Health, in particular

the Director, Dato’ Dr Abdul Ghani bin Mohammed Din and his deputy

Dr Abdul Rahim Bin Mohamed for their continuous support and advice for

the study. We also thank Dr Paa Nasir Abdul Rahman and Dr Mohd Fauzi

bin Abu Bakar for the secretariat support.

We are grateful to all the site coordinators and data collectors for their

commitment, hard work and untiring support for this study. The strength

and quality of this study lies in the continuous commitment shown by all the

staff involved.

We also wish to thank the Malaysian Society of Anaesthesiologists for the

yearly grant of RM10 000 for this study, Abbott Laboratories (M) Sdn. Bhd. for

funding the data manager and Heal Marketing Sdn. Bhd. for a financial

contribution.

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PARTICIPATING HOSPITALS

1. Hospital Alor Setar

2. Hospital Ipoh

3. Hospital Kota Bharu

4. Hospital Kuala Lumpur

5. Hospital Kuala Terengganu

6. Hospital Melaka

7. Hospital Pulau Pinang

8. Hospital Queen Elizabeth, Kota Kinabalu

9. Hospital Selayang

10. Hospital Seremban

11. Hospital Sultanah Aminah, Johor Bahru

12. Hospital Tengku Ampuan Afzan, Kuantan

13. Hospital Tengku Ampuan Rahimah, Klang

14. Hospital Umum Sarawak

SPONSORS OF THE NAICU

Anaesthetic and Intensive Care Services, Ministry of Health Malaysia

Medical Development Division, Ministry of Health Malaysia

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THE NATIONAL COMMITTEE, NAICU Chairperson Dr Ng Siew Hian

Head & Consultant Anaesthetist

Department of Anaesthesia & Intensive Care

Hospital Kuala Lumpur

Coordinator Dr Tai Li Ling

Consultant Intensivist

Department of Anaesthesia & Intensive Care

Hospital Kuala Lumpur

Dr Tan Cheng Cheng

Consultant Intensivist

Department of Anaesthesia & Intensive Care

Hospital Sultanah Aminah, Johor Bahru

Dr Jenny Tong May Geok

Head & Consultant Anaesthetist

Department of Anaesthesia & Intensive Care

Hospital Seremban

Members

Dr Augustine Yew (resigned in January 2003)

Consultant Anaesthetist

Department of Anaesthesia & Intensive Care

Hospital Kuala Lumpur

Dr Paa Nasir Abdul Rahman

Ketua Penolong Pengarah

Dr Mohd Fauzi bin Abu Bakar

Penolong Pengarah

Secretariat Medical Development Division, Ministry of Health

Puan Azizah Murid

Ketua Jururawat

Data Manager Ms Ng See See (1.7.2002 to 15.3.2003)

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LIST OF SITE COORDINATORS AND DATA COLLECTORS

No Hospital Site coordinator Data collectors

1 Alor Setar Dr Ahmad Shaltut (1.7.02 - 30.10.02) Dr Amran Ahmad

SN Azura Che Don SN Hamidah Abdullah

2 Ipoh Dr Mortadza Ramli

SN Vijaya Kumari SN Rohani bt Zainal Abidin

3 Kota Bharu Dr Mat Ariffin Saman

SN Maznah Razak SN Maimun Muhamad SN Azilah Ishak

4 Kuala Lumpur Dr Augustine Yew (1.7.02-30.11.02) Dr Tai Li Ling

SN Prema Chitrasenan SN Azaliah bt Haeb

5 Kuala Terengganu

Dr Mohd Ridhwan Md Noor SN Che Lailani Yahya SN Paridah Sulong

6 Melaka Dr Tew Geok Poh (1.7.02-7.8.02) Dr Siti Zuraidah Abdul Karim

SN Norazila Kamal SN Arba’i Abu Bakar

7 Pulau Pinang Dr Lim Chiew Har (1.7.02 – 30.6.03)

SN Chin Lai Gan SN Bahayah Mohamed Bakari

8 Queen Elizabeth, Kota Kinabalu

Dr Kamaruddin Mudin (1.7.02 – 30.6.03)

SN Doren Abel SN Yee Nget Yin

9 Selayang Dr Ahmad Azmil (1.7.02 – 30.6.03)

SN Yushaniza Yusof SN Noorliza Othman

10 Seremban Dr Jenny Tong SN Chew Bee Ngoh SN Shanthadavi

11 Sultanah Aminah, Johor Bharu

Dr Tan Cheng Cheng

SN Sayiah Basri

12 Tengku Ampuan Afzan, Kuantan

Dr Nordin Shafiei (1.7.02 – 30.6.03)

SN Tan Sow Lian SN Rosma Idrus

13 Tengku Ampuan Rahimah, Klang

Dr Seet Sok Noi SN Latifah Omar SN Norlaili Ismail

14 Umum Sarawak Dr Izzah bt Abdul Aziz (1.7.02 -7.8.02) Dr Intan Zarina Fakir Mohamed

SN Winnie Suai SN Jati AK Jampong

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CONTENTS

Executive Summary………………………………………………………………

Acknowledgement………………………………………………………………

Participating hospitals and sponsors…………………………………………...

National committee and secretariat…………………………………………….

List of site coordinators and data collectors……………………………………

Contents……………………………………………………………………………

Abbreviations……………………………………………………………………..

List of tables……………………………………………………………………….

List of graphs……………………………………………………………………...

Introduction……………………………………………………………………….

Study Design and Data Management…………………………………………..

Results and Discussion

A. Resource Survey

1. Availability of intensive care resources ……………………….

2. Demand for intensive care………………………………………

3. Human resources and workload……………………………….

4. Support facilities………………………………………………….

B. Review of Clinical Practice

1. Patient profile……………………………………………………

2. Interventions……………………………………………………..

3. Monitoring……………………………………………………….

4. Complications……………………………………………………

C. Outcome and Performance ……………………………………………...

Summary…………………………………………………………………………..

Recommendations………………………………………………………………...

References………………………………………………………………………….

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ABBREVIATIONS

CRRT Continuous Renal Replacement Therapy

CT Computerised Tomography

DVT Deep Vein Thrombosis

ECHO Echocardiography

ENT Ear, Nose and Throat

HD Haemodialysis

HDU High Dependency Unit

ICU Intensive Care Unit

LSCS Lower Segment Caesarean Section

MOH Ministry of Health

MRI Magnetic Resonant Imaging

PDF Patient Data Form

SAPS Simplified Acute Physiology Score

SMR Standardised Mortality Ratio

TISS Therapeutic Intervention Severity Score

U/S Ultra-sonography

VAP Ventilator-associated Pneumonia

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LIST OF TABLES No Table Page

1 Number of ICU beds by sector in Malaysia .......................................................... 2 Number of ICU beds by state ………………………………………….………… 3 Number of general ICU beds in state hospitals for 1998 and 2003 ..…………. 4 ICU beds as percentage of hospital beds………………………………………… 5 Comparison of ICU beds among countries……………………………………… 6 ICU admissions and bed occupancy rates from 1998-2003……………………. 7 Hospital admissions and operations performed from 1998-2002 …………….. 8 Cancellation of elective operations………………………………………………. 9 ICU referral and denial of admission…………………………………………… 10 ICU specialist and medical officer to patient ratio……………………………... 11 Nurse to patient ratio ……………………………………………………………... 12 Staff to patient ratio………………………………………………………………... 13 Therapeutic Intervention Severity Score, TISS-28………………………………. 14 Supporting services in intensive care …………………………………………… 15 ICU admissions by participating hospital .……………………………………… 16 Gender………………………………………………………………………………. 17 Age groups…………………………………………………………………………. 18 Ethnic groups………………………………………………………………………. 19 Length of ICU stay ………………………………………………………………… 20 Length of hospital stay ……………………………………………………............. 21 Referring units……………………………………………………………………… 22 Category of patients……………………………………………………………….. 23 Location before admission to ICU .………………………………………………. 24 Indication for admission………………………………………………………….. 25 Readmission rate ………………………………………………………………….. 26 Cardiac arrest within 72 hours prior to ICU admission………………………... 27 Trauma within one week prior to ICU admission……………………………… 28 Main organ failure on ICU admission…………………………………………… 29 Main organ failure on ICU admission by hospital …………………………….. 30 Number of organ failure on ICU admission…………………………………….. 31 Number of organ failure on ICU admission by hospital .……………………... 32 Main diagnosis leading to ICU admission by system………………………….. 33 List of diagnoses leading to ICU admission ……………………………………. 34 List of surgical operations ……………………………………………………....... 35 Surgical operations by systems ………………………………………………….. 36 Presence of co-morbid diseases …………………………………………….......... 37 Types of co-morbid diseases ……………………………………………………... 38 SAPS II score by hospital …………………………………………………………. 39 Invasive mechanical ventilation………………………………………………….. 40 Duration of mechanical ventilation. .…………………………………….............. 41 Interventions in ICU……………………………………………………………….. 42 Stress ulcer prophylaxis…………………………………………………………… 43 Vasoactive drugs…………………………………………………………………… 44 Use of heparin……………………………………………………………………… 45 Renal replacement therapy………………………………………………………... 46 Tracheostomy……………………………………………………………………….. 47 Comparison of monitoring modalities with other countries…………………... 48 Incidence of ventilator-associated pneumonia, percentage…………………….

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49 Incidence of ventilator-associated pneumonia, per 1000 ventilator-days …… 50 National nosocomial infection surveillance (NNIS) benchmarking on

ventilator-associated pneumonia for quality mprovement…………………….

51 Bacteriologic cultures for ventilator-associated pneumonia…………………... 52 Incidence of unplanned extubation, percentage……………………………....... 53 Incidence of unplanned extubation, per intubated day ……………………….. 54 Unplanned extubation as a quality indicator …………………………………... 55 Other complications ………………………………………………………………. 56 ICU outcome………………………………………………………………………. 57 Hospital outcome………………………………………………………………….. 58 In-ICU and In-hospital mortality rates by hospital…………………………….. 59 Comparison of in-ICU and in-hospital mortality rates among countries……. 60 Characteristics of survivors and non-survivors ……………………………….. 61 Standardised mortality ratio by hospital……………………………………….. 62 Standardised mortality ratio by risk group…………………………………. 63 Standardised mortality ratio by category of patients…………………………. LIST OF GRAPHS No Graphs Page

1 ICU admissions and bed occupancy rates from 1998 to 2003…………………. 2 ICU referral and denial of admission……………………………………………. 3 Age groups…………………………………………………………………………. 4 Length of ICU stay by country…………………………………………………… 5 Length of hospital stay by country………………………………………………. 6 SAPS II score by hospital…………………………………………………………. 7 Incidence of ventilator-associated pneumonia by hospital……………………. 8 Incidence of unplanned extubation by hospital………………………………… 9 Standardised mortality ratio by hospital……………………………………….. 10 SAPS II score and standardised mortality ratios……………………………….. 11 Standardised mortality ratio by category of patients………………………….

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INTRODUCTION

Intensive care is a specialised, labour intensive, resource dependent, complex

and technologically advanced area of healthcare service. Intensive care

service is directed towards assisting patients with impending or established

organ failure in whom recovery is favourable. The majority of these critically

ill patients require advanced respiratory and other organ systems support.

Intensive care service in the Ministry of Health (MOH) hospitals started in the

1960s as a spin off from the activities of the post-anaesthesia recovery room.

Since then it has established itself as an essential component of a continuum

in acute care catering specifically for the critically ill requiring advanced life

support.

Although intensive care practice is well established in Malaysia, there is a

scarcity of information on its clinical practice, performance and outcome. To

date, no clinical audits have been done on a national level. Clinical audits can

provide objective assessments of performance, effectiveness of therapy and

utilisation of resources.

In the last few years, there was evidence from peri-operative mortality

reviews (POMR) and maternal mortality reviews (MMR) that the demand for

intensive care outpaced its supply and this had adversely affected patient

outcome. Unit audits had also shown that a significant number of patients

referred for intensive care were denied admission and a substantial number of

these patients were ventilated in the general wards with dismal outcome.

The situation in the United Kingdom in the early 1980s was similar to what

we are currently experiencing in Malaysia. There was tremendous stress on

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the hospital service as the demand for intensive care beds spiraled. More ICU

beds were opened up and high dependency units mushroomed without

proper assessment of their needs. This haphazard development which

resulted in unequal distribution of facilities and poor patient outcome

prompted a call for a national audit. Thus in 1994, the Intensive Care National

Audit & Research Centre (ICNARC) was established in UK. Co-funded by the

Intensive Care Society and the Department of Health, its main task was to

conduct a review on intensive care practice using a case mix programme and

to make recommendations to the relevant health authorities. Based on the

findings of ICNARC and those of the National Expert Group for the

Department of Health, the British government released a special fund of

₤142.5 million in the year 2000 to improve the intensive care facilities

throughout the country.

In Australia and New Zealand, clinical indicators in intensive care were

developed by representatives of the Australian and New Zealand intensive

care professional bodies and the Australian Council on Healthcare Standards

to assess key aspects of intensive care functions within a hospital.

Concerned with the negative impact on patient care due to the shortage of

intensive care facilities and the need for a national audit in intensive care

service provided by the MOH hospitals, a group of senior anaesthetists with a

special interest in intensive care in the MOH established a study group to look

into the outcome of intensive care patients. In 2001, the outcome study group

completed the validation of the Simplified Acute Physiology Score II (SAPS II)

in Malaysian ICU patients. In 2002, the group re-assessed the needs and

decided to conduct a nationwide audit on adult general intensive care units

(ICU) in the MOH hospitals. This audit is termed the National Audit on

Adult Intensive Care units (NAICU).

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The main objective of the NAICU is to systematically review the current

status of intensive care service with special reference to its demand, clinical

practice, performance, outcome of patients and resource utilisation. It also

aims to establish a national database on intensive care practice in Malaysia.

The NAICU is modeled on the UK experience. It is a quality improvement

activity endorsed and supported administratively and financially by the

Medical Development Division of MOH. It is coordinated by a national

committee comprising of intensivists and senior consultant anaesthetists in

the MOH. This audit consists of two sections. The first section assesses three

fundamental aspects of intensive care functions within a hospital. They are

(1) the adequacy of the intensive care resource to meet hospital requirements

(2) the workload of intensive care units and (3) comparison of patient

outcome with national and international standards. The second section

describes the clinical practice of intensive care. Fourteen adult general ICUs in

major MOH hospitals participated in the audit.

The NAICU is designed to be an on-going audit for ICUs and an important

component of the quality improvement programme in the MOH. When fully

implemented over a period of three years (2002-2004), all ICUs within the

MOH will participate in the programme.

An interim report of the first five months of the audit was earlier submitted to

the Director General of Health in February 2003. This is the first

comprehensive report of the findings of a one year audit from 1st July 2002 till

30th June 2003.

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STUDY DESIGN AND DATA MANAGEMENT

The study was coordinated by a National Committee comprising of

intensivists and senior consultant anaesthetists. This committee is responsible

for the overall conduct of the study including implementation, training,

monitoring of the data collection, analysis, report writing and publications of

the audit. This committee is supported by a secretariat from the Medical

Development Division of the MOH.

The coordinating centre was initially at the General ICU of Hospital Ipoh but

was subsequently moved to the General ICU of Hospital Kuala Lumpur in

April 2003.

This was an observational cohort study involving 14 adult general ICUs in the

MOH. The study duration was for one year from 1st July 2002 until 30th June

2003. The sample population comprised of all consecutive admissions to the

participating ICUs. Each participating ICU had a site coordinator (an

anaesthetic specialist) and two data collectors (ICU nurses/medical

assistants). All the site coordinators and data collectors underwent formal

training in two separate workshops (April 2002 and June 2002) before the

study commenced. They were the only personnel authorised to collect data

for this study.

Five types of forms were used for the study. They were (1) Patient data form

(PDF) (2) Resource survey form (3) Referral form (4) Elective operation

booking form (5) Therapeutic Intervention Severity Score (TISS-28) form.

The PDF contained demographic data, reason for ICU admission, types of

organ failure, presence of co-morbid diseases, types of intervention and

14

monitoring, complications, in-ICU and in-hospital outcomes and SAPS II

score. The PDF was completed within 48 hours of a patient’s discharge from

hospital and signed by both the data collector and site coordinator before

being despatched to the coordinating centre in batches of ten. A despatch

form was also completed and sent to the coordinating centre in a separate

envelope. This was to ensure that no patient data was lost in the event that the

original PDF was missing in post.

The referral form was filled by the ICU medical officer to whom the referral

was made. All referrals were recorded regardless of the indication for referral.

The resource survey form was filled twice a month. The dates for the survey

were randomized. On those days, the TISS-28 forms for all the ICU patients

were filled.

The elective operation booking form was filled up whenever an ICU bed was

requested for any elective surgery. It was maintained monthly.

All the above forms were verified and signed by the site coordinator before

being despatched to the coordinating centre. A despatch form for the resource

survey, TISS-28 and booking list forms was completed and despatched with

the completed forms to the coordinating centre by the first week of the

following month.

A data manager engaged during the duration of the study period was

responsible for data entry, data integrity, and data “cleaning”. Data from the

hard copies were entered by the data manager or trained staff at the

coordinating centre into a dedicated computer using a specially developed

software (Synapse). This software has features of security, audit trail and

15

auto-generation of reports. The data manager prepared a quarterly report

which was sent to the respective participating centres.

Data quality assurance was conducted at three to four months after the

commencement of the audit by the members of the National Committee in all

the fourteen hospitals. The inter-rater and intra-rater accuracy tests were

used. A coefficient of more than 0.9 was taken to ensure accuracy of data

collection and this value had to be attained before data from the participating

centre were accepted into the database for analysis. Five participating centres

which did not meet the accuracy for data collection in SAPS II score had their

first three months of data excluded from the analysis of the standardised

mortality ratio. However, the data were included in the analysis of clinical

practice. A second accuracy test which was conducted two months later for

these five centres showed an improvement in accuracy in data collection and

subsequent data were accepted into the database.

A telephone survey on the availability of ICU beds throughout the country

was conducted on 15th and 16th of August 2003. The list of private hospitals

was obtained from the web site of the Malaysian Association of Private

Hospital.

The data were analysed by the National Committee. Chi-square tests were

used to test for statistical significance in categorical variables and Student’s

t-test or One-way analyses of variance in continuous variables. A statistical

significance level of 0.05 was used except when stated otherwise.

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RESULTS AND DISCUSSION

Results and discussion will be presented under the following headings: A Resource Survey

1. Availability of intensive care resources 2. Demand for intensive care 3. Human resources and workload 4. Support facilities B Clinical Practice

1. Patient profile 2. Interventions 3. Monitoring 4. Complications C Outcome and Performance A. RESOURCE SURVEY In our survey, an intensive care bed is defined as a bed in an area designated for critically ill patients with specially trained staff and facilities for haemodynamic monitoring and invasive mechanical ventilation. This includes beds in organ-specific units with the above capabilities e.g. Neurosurgical, Nephrology and Cardiothoracic ICUs. The fourteen ICUs in the audit are General ICUs which admit both medical and surgical patients. Some of these units also admit paediatric patients. A.1. Availability of intensive care resources Table 1: Number of ICU beds by sector in Malaysia Number of

ICU Number of

ICU beds Average

number of beds

Percentage

MOH state hospitals * 15 142 9.5 27.9 MOH District Hospitals 24 80 3.3 15.7 University / Military Hospitals 5 54 10.8 10.6 Private Hospitals 40 233 5.8 45.8 Total 84 509 6.1 100.0 As on 15.8.2003 (Figures were obtained through a telephone survey in August 2003) *Include Hospital Selayang, Neurosurgical, Nephrology and Cardiothoracic intensive care beds

17

In spite of the heavier burden of patient care in the government hospitals, the total number of ICU beds was only marginally higher than in the private sector (276 vs. 233). The average number of beds in our ICUs was relatively small at 6.1 beds per unit for all ICUs in the country and 9.5 beds per unit for ICUs in the state hospitals. The average number of ICU beds was 14.93 + 12.09 in the European countries [1]. Table 2 : Number of ICU beds by state State Government

Hospitals Private Hospitals Total

Johor 33 14 47 Kedah 19 6 25 Kelantan 25 3 28 Melaka 8 23 31 Negeri Sembilan 8 1 9 Pahang 13 5 18 Perak 19 13 32 Perlis 2 0 2 Pulau Pinang 21 38 59 Sabah 18 6 24 Sarawak 27 9 36 Selangor 46 44 90 Terenggannu 5 0 5 Wilayah Persekutuan 34 71 105 Total 276 233 509 As on 15.8.2003 The number of ICU beds tended to be higher in the more developed states. In these states, the number of ICU beds in the private hospitals was higher than in the government hospitals. Table 3: Number of general ICU beds* in state hospitals for 1998 and 2003

Participating Hospitals

1998 2003

Hospital Alor Setar 7 7 Hospital Ipoh 6 6 Hospital Kota Bahru 7 7 Hospital Kuala Lumpur 8 15 Hospital Kuala Terengganu 4 5 Hospital Melaka 4 6 Hospital Pulau Pinang 8 8 Hospital Q.Elizabeth, K.Kinabalu 7 7 Hospital S.Aminah,Johor Bahru 9 16 Hospital Seremban 4 4 Hospital T. Ampuan Afzan, Kuantan 6 6 Hospital T.Ampuan Rahimah, Klang 6 6 Hospital Umum Sarawak 6 7 Total 82 100

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As on 15.8.2003 *General ICU refers to multidisciplinary ICU and excludes organ specific (eg Neursurgical ICU, Nephrology ICU, CardiothorcicICU ) and paediatric ICUs Between 1998 and 2003, apart from Hospital Kuala Lumpur and Hospital Sultanah Aminah, Johor Bahru, there was virtually no increase in the number of beds in the general ICUs in the other state hospitals. Table 4 : ICU beds as percentage of hospital beds

Participating Hospitals Number of hospital beds

Number of ICU beds

ICU beds as % of hospital beds

Hospital Alor Setar 812 7 0.9 Hospital Ipoh 990 6 0.6 Hospital Kota Bahru 835 7 0.8 Hospital Kuala Lumpur 2612 26 1.0 Hospital Kuala Terengganu 761 5 0.7 Hospital Melaka 806 6 0.7 Hospital Pulau Pinang 1276 17 1.3 Hospital Q.Elizabeth, K.Kinabalu 589 7 1.2 Hospital S.Aminah, Johor Bahru 989 22 2.2 Hospital Selayang 960 8 0.8 Hospital Seremban 800 4 0.5 Hospital T.A.Afzan, Kuantan 625 6 1.0 Hospital T.A. Rahimah, Klang 811 6 0.7 Hospital Umum Sarawak 736 13 1.8 Total 13 542 140 1.0 As on 15.8.2003 The percentage of ICU beds varied from 0.5% to 2.2 %, with an average of 1.0% of total hospital beds. This is an extremely low figure when compared to the current norms. (see table below) Table 5 : Comparison of ICU beds among countries Country Number of ICU beds % hospital beds ICU beds / 100,000

population Australia 1596 3.0 7.5 France 22,000 3.2 38.4 Germany 23,000 2.7 28.5 Italy 5,480 1.2 9.4 Japan 14670 2.7 11.8 Spain 5,800 3.0 14.8 United Kingdom 5,000 2.7 8.5 United States 77,600 6.3 30.5 Singapore 180 2.7 7.0 Malaysia 509 1.1 2.0

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Malaysia had the lowest ratio with only two ICU beds per 100 000 population. In contrast, the developed countries had a ratio ranging from 7.5 in Australia to 38.4 beds per 100 000 in France [2]. The number of ICU beds as percentage of hospital beds for the whole country was 1.1% as compared to 2.7% in UK and 6.3% in the U.S. Figures in developing countries were not available for comparison. Conclusion: There is severe shortage of ICU beds in Malaysia especially in the government hospitals. The number of general ICU beds in the state hospitals has remained unchanged in the last five years. A.2. Demand for Intensive Care Table 6 : ICU admissions and bed occupancy rates from 1998-2003 1998 1999 2000 2001 2002 Jul 2002 -

June 2003 Admissions 5,440 5,696 6,601 6,989 6,906 6791 Patient days 26,597 26,557 29,343 32,962 33,841 33,276 Bed occupancy rate (BOR)

88.9

83.6

80.0

85.2

85.8

84.4

Graph 1 : ICU admissions and bed occupancy rates from 1998 to 2003

0

5000

10000

15000

20000

25000

30000

35000

1998 1999 2000 2001 2002 20030102030405060708090100

BOR %

Admissions Patient Days BOR

The admissions into the intensive care units had increased by 20% in the last 5 years as evidenced by the increase in the number of admissions (20.5%) and patient-days

20

(20.1%). The average bed occupancy rate (BOR) had been consistently higher than 80% over the last 5 years, indicating that the state ICUs are functioning at their full capacity and there is little room for further increase in bed occupancy. We note that the BOR in the MOH hospitals were calculated based on mid-night count and would have been higher if calculated based on admission through-put. The recommended mean BOR is 70-75% [3]. Table 7: Hospital admissions and operations* performed from 1998-2002 1998 1999 2000 2001 2002

Hospital admissions 502,663 526,595 521,192 540,833 NA Hospital surgical operations 77,704 89,541 91,469 94,752 99,562 *Operations performed under general anaesthesia Number of hospital admissions and surgical operations are proxies for demand of intensive care beds. We note that there had been an increase in the surgical operations by 22.0% over the last five years but the increase in the number of beds in the general ICUs was only 18%. (refer Table 3) Table 8 : Cancellation of elective operations

Cases not done Cases not done due to unavailability of

ICU bed

Participating Hospitals

Cases booked

No. % No. %

A 49 0 0.0 0 0.0 B 99 4 4.0 3 75.0 C 71 4 5.6 0 0.0 D 233 60 25.8 17 28.3 E 15 4 26.7 1 25.0 F 55 13 23.6 2 15.4 G 55 13 23.6 1 7.7 H 65 3 4.6 0 0.0 I 213 61 28.6 31 50.8 J 102 32 31.4 22 68.8 K 10 2 20.0 0 0.0 L 31 11 33.3 2 18.2 M 135 32 23.7 10 31.3 N 59 12 20.3 9 75.0

Total 1192 251 21.1 98 39.0

There was a cancellation rate of 21.1% among cases for elective surgery where an ICU bed was booked at least a day before the scheduled operation. Two fifths of these cases were cancelled due to unavailability of beds.

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Table 9 : ICU referrals and denial of admission

Participating Hospitals

Number referred for intensive care

Number denied admission

Percentage denied admission

A 446 254 60.0 B 637 439 68.9 C 752 642 85.4 D 1199 422 35.2 E 145 75 51.7 F 553 319 57.7 G 722 513 71.1 H 356 203 57.0 I 1511 889 58.8 J 352 135 38.4 K 373 111 29.8 L 729 464 63.6 M 511 222 43.4 N 329 223 67.8

Total 8615 4911 57.0 57% of patients referred for intensive care were denied admission due to unavailability of intensive care beds and this amounted to approximately 5000 patients a year. A substantial number of these patients required ventilatory support. However, the outcome of these patients was not looked into in this study. Graph 2: ICU referral and denial of admission

0

200

400

600

800

1000

1200

1400

1600

A B C D E F G H I J

Hospitals

Num

ber

K L M N

Not AdmittedAdmitted

22

Conclusion: One in every two patients deserving intensive care could not be admitted to ICU due to the unavailability of beds. Almost 5000 patients were denied ICU admissions in the MOH state hospitals during he study period.

A.3. Human Resources and Workload Table 10 : ICU specialist# and medical officer to patient ratio

MO to patient ratio Participating Hospitals

Specialist to patient ratio* Office hour After office

hours Average

A 1 : 4.3 1 : 11.5 1 : 16.1 1 : 13.8 B 1 : 7.1 1 : 7.4 1 : 7.6 1 : 7.5 C 1 : 5.7 1 : 3.1 1 : 5.7 1 : 4.4 D 1 : 10.1 1 : 4.2 1 : 6.6 1 : 5.4 E 1 : 7.1 1 : 7.5 1 : 17.4 1 : 12.5 F 1 : 6.3 1 : 6.6 1 : 13.9 1 : 10.3 G 1 : 5.8 1 : 8.7 1 : 12.7 1 : 10.7 H 1 : 4.8 1 : 4.8 1 : 4.8 1 : 4.8 I 1 : 10.8 1 : 5.2 1 : 11.6 1 : 8.4 J 1 : 5.4 1 : 20.0 1 : 15.5 1 : 17.8 K 1 : 4.3 1 : 9.9 1 : 12.2 1 : 11.1 L 1 : 9.8 1 : 8.1 1 : 21.8 1 : 15.0 M 1 : 6.5 1 : 4.3 1 : 3.9 1 : 4.1 N 1 : 11.1 1 : 5.9 1 : 7.2 1 : 6.6

Total 1 : 7.2 1 : 7.7 1 :11.2 1 : 9.5 * Includes during office and after office hours # ICU specialist refers to either an intensivist or anaesthetist. There was a wide variation in the staffing of specialists and medical officers in the ICUs in Malaysia. In Australia and New Zealand, there were 4.60 and 3.09 beds per specialist respectively [4]. Table 11 : Nurse to patient ratio by shift

Nurse to patient ratio Participating Hospitals AM PM Night Average

% of intensive care trained nurses*

A 1 : 1.1 1 : 1.0 1 : 1.0 1 : 1.0 68.2 B 1 : 0.8 1 : 0.9 1 : 1.2 1 : 1.0 18.0 C 1 : 1.0 1 : 0.9 1 : 1.6 1 : 1.2 47.3 D 1 : 1.0 1 : 1.0 1 : 1.5 1 : 1.2 45.3 E 1 : 0.9 1 : 0.9 1 : 1.1 1 : 1.0 8.0 F 1 : 1.4 1 : 1.4 1 : 2.7 1 : 1.8 37.2 G 1 : 1.6 1 : 1.5 1 : 2.0 1 : 1.7 77.7 H 1 : 0.9 1 : 0.9 1 : 1.0 1 : 0.9 42.9 I 1 : 1.1 1 : 1.2 1 : 2.1 1 : 1.5 26.8

23

J 1 : 0.9 1 : 0.9 1 : 1.5 1 : 1.1 28.0 K 1 : 0.9 1 : 0.9 1 : 1.0 1 : 0.9 52.2 L 1 : 1.3 1 : 1.4 1 : 1.4 1 : 1.3 34.0 M 1 : 0.7 1 : 0.7 1 : 0.8 1 : 0.7 44.6 N 1 : 1.4 1 : 1.5 1 : 1.6 1 : 1.5 39.2

Total 1 : 1.1 1 : 1.1 1 : 1.5 1 : 1.2 36.5 * Refers to nurses who had undergone formal post- basic course in intensive care nursing.

Table 12: Staff to patient ratio

1: 7.2 patients

We were able to achieve the staffing of one-to-one nursing during the morning and afternoon shifts but not during the night shift. About one third of the nurses working in the units had undergone post-basic course in intensive care nursing. Williams & Clarke suggested that ideally 100% of all bedside nurses should hold a post basic intensive care nursing certificate; optimally 75% and minimally 50% [5]. Table 13 : Therapeutic Intervention Severity Score , TISS-28

TISS-28 score Participating Hospitals

AM PM Night

Average TISS per patient

Average TISS per nurse

A 25.9 22.6 22.3 23.6 23.2 B 24.7 23.9 25.1 24.6 23.0 C 25.1 25.5 24.6 25.1 26.5 D 25.9 25.0 24.3 25.0 27.7

(Range 1:4.3 to 1: 11.1)Specialist

1: 9.5 patientsMedical Officer

(Range 1: 4.1 to 1: 17.8)

1: 1.2 patients

Nurse

(Range 1: 0.7 to 1: 1.8)

24

E 28.3 27.3 26.6 27.4 26.0 F 24.2 23.9 23.4 23.9 39.7 G 22.3 20.4 20.3 21.0 34.1 H 25.9 23.5 21.9 23.8 22.2 I 25.2 24.5 24.0 24.6 32.7 J 23.7 23.0 23.6 23.5 24.1 K 29.6 27.7 26.8 28.1 26.2 L 23.6 23.7 24.0 23.8 31.7 M 22.7 21.5 21.2 21.8 15.8 N 22.2 22.0 21.4 21.8 32.8

Total 25.0 24.1 23.7 24.3 27.6 The calculated TISS-28 score indicates the nursing workload in the care of a particular patient during the last 24 hours. The number of points can be converted into nursing time; one TISS-28 point equals 10.6 minutes of each 8 hour nurse's shift. The average TISS-28 score per nurse was within the range of the average score in Europe and United States i.e. 21-40 points. [6] Conclusion: The workload among the specialists and medical officers in ICU was greater than in the developed countries. The staffing of one-to-one nursing was achieved in the daytime and the nursing workload per patient was comparable to the developed countries. The number of nurses with post-basic intensive care nursing should be increased. A.4. Support Facilities Table 14 : Supporting services in intensive care*

Physiotherapist Supporting services Participating Hospitals Working

days

Weekends / Public holidays

CT MRI ECHO U/S HD CRRT

A √ × √ × √ √ √ × B √ √ √ √ √ √ √ √ C √ √ √ √ √ √ √ √ D √ √ √ √ √ √ √ √ E √ × √ √ √ √ √ √ F √ × √ × √ √ √ √ G √ √ √ × √ √ √ √ H √ √ √ √ * √ √ √ √ I √ √ √ √ √ √ √ √ J √ × √ √ √ √ √ √ K √ × √ √ * √ √ √ √ L √ × √ × × × √ √ M √ √ √ √ √ √ √ √ N √ × √ × √ √ √ √

* from March 2003 CT computerised tomography

25

MRI magnetic resonant imaging ECHO bedside trans-thoracic echocardiography U/S bedside ultra-sonography HD intermittent haemodialysis CRRT continuous renal replacement therapy Physiotherapy provided by trained physiotherapists was available in all units during weekdays but not during weekends in half of the units. It is recommended that the affected units negotiate for physiotherapy service to be made available during weekends and public holidays. CT scan was available in all the units while MRI was only available in 64% of the units. Bedside ultra-sonography and ECHO facilities were available in 93% of the units. Intermittent haemodialysis was available in all the centres while CRRT was available in 93% of the centres. We should aim to achieve 100% availability of these facilities in all ICUs in the state hospitals. In addition, trans-oesophageal echocardiography and ultra-sonography should be available in selected ICUs. B. CLINICAL PRACTICE A total of 6791 patient data forms (PDFs) from the 14 participating centres were received. After excluding the PDFs with invalid data for admission dates, 6739 PDFs were eligible for analysis. Data were then exported from Synapse to SPSS 11.5 for statistical analysis. B.1. Patient Profile Table 15: ICU admissions by participating hospital Participating Hospital Number of admissions

Percentage

A 394 5.8 B 482 7.2 C 395 5.9 D 909 13.5 E 366 5.4 F 335 5.0 G 325 4.8 H 479 7.1 I 980 14.5 J 454 6.7 K 293 4.3

26

L 455 6.8 M 426 6.3 N 446 6.6

Total 6739 100.0 The total number of admissions in the twelve month study period was 6739. Hospital D and Hospital I had the most number of admissions. Table 16 : Gender Gender Number

Percentage

Male 3901 57.9 Female 2833 42.0 Missing 5 0.1 Total 6739 100.0 Table 17 : Age groups Age

Number Percentage

Below 10 513 7.6 10-19.9 788 11.7 20-29.9 1048 15.6 30-39.9 923 13.7 40-49.9 870 12.9 50-59.9 948 14.1 60-69.9 887 13.2 70-79.9 539 8.0 80 and above 156 2.3 Unknown 67 1.0 Total 6739 100.0 Graph 3: Age groups

27

0

200

400

600

800

1000

1200

<10 10-19.9 20-29.9 30-39.9 40-49.9 50-59.9 60-69.9 70-79.9 >80Age group (years)

The mean age for all patients admitted to ICU was 40.7 + 21.8 years. When patients less than 18 years of age were excluded, the mean age of the adult patient was 46.6 + 18.2 years. Table 18: Ethnic groups Ethnic group Number

Percentage

Malay 3831 56.8 Chinese 1298 19.3 Indian 730 10.8 Orang Asli 41 0.6 Bumiputra (East Malaysia) 394 5.8 Other Malaysians 159 2.4 Foreigner 271 4.0 Unknown 9 0.1 Missing 6 0.1 Total 6739 100 The distribution of patients admitted to ICU reflected the distribution of the ethnic groups in the general population in Malaysia. Table 19 : Length of ICU stay

Participating Hospitals

Mean (SD), days

95% CI

A 3.5 (5.4) 3.0 - 4.0 B 5.3 (8.1) 4.5 – 5.8 C 5.1 (6.6) 4.5 - 5.8 D 5.1 (8.9) 4.5 - 5.7 E 6.2 (8.3) 5.4 - 7.1 F 6.1 (8.1) 5.3 - 7.1 G 4.4 (7.2) 3.6 - 5.2 H 3.5 (4.5) 3.1 - 3.9 I 5.4 (8.0) 4.9 - 5.9 J 4.1 (4.7) 3.6 - 4.5 K 4.9 (5.8) 4.2 - 5.5 L 5.0 (7.0) 4.4 - 5.7 M 4.3 (6.3) 3.7 - 4.9 N 5.0 (8.5) 4.2 - 5.8

Total 4.9 (7.4) 4.7 – 5.1 The average length of stay in ICU was 4.9 + 7.4 days. This was comparable to most countries in the world.[7]

28

Graph 4: Length of ICU stay by country [7]

0

2

4

6

8

10

12

Finland

Netherl

ands Uk

Italy

Portugal US

Hong KongBraz

il

Malaysia

days

Table 20 : Length of hospital stay

Participating Hospitals Mean (SD) days

95% CI

A 17.3 (25.2) 14.8 – 19.8 B 26.5 (25.0) 24.3 – 28.8 C 19.8 (22.8) 17.5 – 22.0 D 22.6 (26.4) 20.9 – 24.4 E 20.3 (22.9) 18.0 – 22.7 F 18.8 (20.0) 16.6 – 20.9 G 17.7 (20.9) 15.4 – 20.0 H 16.1 (17.0) 14.6 – 17.7 I 17.9 (15.8) 16.9 – 18.9 J 16.6 (17.0) 15.1 – 18.2 K 19.5 (19.9) 17.3 – 21.8 L 17.4 (18.1) 15.7 – 19.0 M 20.4 (19.8) 18.5 – 22.3 N 24.0 (26.0) 21.6 – 26.4

Total 19.8 (21.7) 19.3 – 20.3 The average length of stay in hospital was 19.8 + 21.7 days. This was comparable to other countries in the world [7].

29

Graph 5: Length of hospital stay by country [7]

0

5

10

15

20

25

Europe UK Spain USA Malaysia

days

Table 21 : Referring units Referring unit Number Percentage Medicine 1872 27.8 General Surgery 2000 29.7 Orthopaedics 600 8.9 Obstetrics & Gynaecology 603 8.9 Vascular surgery 79 1.2 Paediatric surgery 98 1.5 Neurosurgery 665 9.9 Plastic surgery 47 0.7 Ear, Nose & Throat 171 2.5 Ophthalmology 19 0.3 Urology 97 1.4 Dental surgery 46 0.7 Paediatric medicine 278 4.1 Cardiology 6 0.1 Haematology 21 0.3 Nephrology 51 0.8 Neurology 38 0.6 Cardiothoracic surgery 5 0.1 Missing 4 0.1 Others 39 0.6 Total 6739 100 About two-thirds (65.7%) of admissions to ICUs were from surgical-based disciplines. Table 22: Category of patients* Category Number Percentage #In-hospital

mortality % Non-operative 3171 47.1 41.3 Operative-elective 1125 16.7 11.3 Operative-emergency 2440 36.2 27.4

30

Missing 3 0 - Total 6739 100 - # p = 0.0001 *Non-operative: Refers to patients in whom no surgery was done out within 7 days before ICU admission or during the

first 24 hours after ICU admission Operative elective: Refers to patients in whom surgery was done within 7 days before ICU admission or during the first 24

hours after ICU admission on a scheduled basis Operative-emergency: Refers to patients in whom surgery was done within 7 days before ICU admission or during the first 24

hours after ICU admission on an unscheduled basis There were an almost equal number of admissions of non-operative (47.1%) and operative patients (52.9%). 68% of the operative patients were admitted following emergency surgery. Table 23: Location before admission to ICU Location Number Percentage #In-hospital

mortality % Ward* 2249 33.4 41.8 OT* 2881 42.8 19.6 A&E* 604 9.0 37.8 Other critical care areas* 798 11.8 38.5 Other locations* 15 0.2 13.3 Other hospitals* 188 2.8 32.6 Missing 4 0.1 - Total 6739 100 - # p =0.0001 *Ward: Refers to general wards in the same hospital OT: Refers to operating theatres in the same hospital A&E: Refers to the accident and emergency department Other critical care areas Refers to areas in the same hospital such as coronary care unit, cardiothoracic,

neonatal/paediatric, urological ICUs, haemodialysis unit, high dependency unit, labour rooms Other locations: Refers to areas in the same hospital other than wards, OT, A&E, critical care areas. Includes

radiology, endoscopy suites and clinics in the hospital Other hospitals: Refers to other private or public hospitals Most patients were admitted to the units from the operating theatres (42.8%) and the wards (33.4%). This was in contrast to ICUs in developed countries where the majority of admissions were from the emergency rooms [7]. Patients admitted directly from the operating room or emergency department generally had the lowest mortality rate, whereas patients admitted from the wards and particularly from other hospitals exhibited the highest mortality rate [8]. Our in-hospital mortality for patients admitted from the A&E was relatively high, and this requires further evaluation. Table 24 : Indication for admission Indication Number Percentage Mechanical ventilation 3084 45.8 Planned post-operative ventilation 1993 29.6 Unplanned post-operative ventilation 510 7.6

31

Planned post-operative monitoring 516 7.7 Unplanned post-operative monitoring 201 3.0 Non-operative monitoring 424 6.3 Missing 11 0.2 Total 6739 100 *Planned admission refers to an admission where the decision to admit the patient to ICU was made before the induction of anaesthesia. Unplanned admission refers to an admission where the decision to admit the patient to ICU was made after induction of anaesthesia. The percentage of unplanned admission to ICU was 22.1% of the total admission to ICU following surgery. Unplanned admission to the ICU is a quality indicator for anaesthetic and operative services in the National Indicator Approach (NIA) programme. Table 25 : Readmission rate

NAICU

3.3%

Review of 80 ICUs [9]

7%

range 4-14%

The readmission rate in Malaysian ICUs was low when compared to the rest of the world. The reason for the low rate is unknown but it may be related to our constraints in intensive care resources. Table 26 : Cardiac arrest within 72 hours prior to ICU admission

Number Percentage #In-hospital mortality

Yes 600 8.9 44.6% No 6134 91.0 29.9% Missing 5 0.1 - Total 6739 100.0 - #p=o.ooo1 The percentage of patients with cardiac arrest prior to ICU admission was higher (8.9%) than in the United States i.e. 5.3% [7]. These patients had a survival rate of 55.4%. However, the functional status and the quality of life of these patients following discharge from hospital was unknown. Table 27 : Trauma* within one week prior to ICU admission

Number Percentage #In-hospital mortality %

Yes 1277 18.9 26.9

32

No 5455 80.9 32.3 Missing 7 0.1 - Total 6739 100.0 - # p =0.02 *Trauma: Refers to accidental or non-accidental injury from motor vehicle accident, fall, assault, near-drowning and burns About one fifth of patients admitted to ICU had trauma within one week prior to ICU admission. These patients had lower in-hospital mortality when compared to non-trauma patients. Table 28 : Main organ failure on ICU admission *Organ failure Number Percentage #In-hospital

mortality % No organ failure 2540 37.7 8.6 Respiratory failure 2424 36.0 39.8 Cardiovascular failure 812 12.0 61.5 Neurological failure 490 7.3 47.7 Renal failure 190 2.8 41.8 Hepatic failure 44 0.7 65.9 Haematological failure 218 3.2 33.0 Missing 21 0.3 - Total 6739 100.0 - Refer William A.Knaus for definitions of organ failure[10] # p= 0.0001 About one third of patients admitted were without any organ failure while another one third had single organ failure with respiratory failure (36%) being the commonest followed by cardiovascular failure (12%). In a study on 5815 randomly selected ICU admission from 13 major medical centres in the United States, 51% had no organ failure [11]. We note that there was an in-hospital mortality of 8.6% in our patients with no organ failure and a future study is required to study the contributing factors. Table 29 : Main organ failure on admission by hospital Participating

Hospitals

No organ failure

(%)

Respira-tory (%)

Cardio- Vascular

(%)

Neuro-logical

(%)

Renal

(%)

Hepatic

(%)

Hema-tological

(%)

Missing

(%) A 51.8 33.2 8.1 2.5 1.3 0.5 2.0 0.6 B 47.1 30.1 10.4 3.9 5.0 1.0 2.3 0.2 C 36.5 35.4 12.2 12.4 1.3 0.5 1.3 0.6 D 40.0 28.6 14.5 7.5 4.0 0.4 4.7 0.2 E 26.2 30.9 18.9 14.5 3.6 3.3 2.5 0.0 F 20.3 53.1 9.9 9.9 2.4 0.6 3.9 0.0 G 37.2 40.6 8.8 5.8 3.1 0.9 3.4 0.0 H 39.7 27.6 15.9 10.6 2.1 0.8 2.7 0.0 I 30.6 38.1 15.2 7.4 3.1 0.7 4.8 0.6 J 42.5 37.0 10.4 6.2 3.5 0.4 0.0 0.1 K 34.1 35.2 12.6 10.6 2.0 0.0 4.1 0.0 L 26.4 60.4 4.6 2.0 1.5 0.0 4.4 1.4

33

M 47.2 23.7 15.7 7.5 1.9 0.0 3.8 0.2 N 47.5 38.8 4.9 3.4 2.7 0.2 2.2 0.2

Total 37.7 36.0 12.0 7.3 2.8 0.7 3.2 0.3 The type of organ failure reflected the type of services provided by the respective hospitals e.g. hospitals with neuro-surgical services had a higher percentage of patients with neurological failure. Respiratory failure remained the most important organ failure in all centres. Table 30 : Total number of organ failure on ICU admission Number Percentage *In-hospital

mortality No organ failure 2540 37.7 8.6 One organ failure 2190 32.5 29.0 Two 1232 18.3 59.8 Three 568 8.4 75.5 Four 166 2.5 86.1 Five 21 0.3 90.5 Six 1 0.0 100 Missing 21 0.3 - Total 6739 100.0 - *p = 0.0001 The in-hospital mortality increased with increasing number of organ failure and the differences were statistically significant. In a 1989 study on 5248 admissions involving 40 hospitals in France and United States, the mortality rates for single, two and three organ failure were 28%, 54% and 82% respectively [11]. Table 31 : Number of organ failure on ICU admission by hospital

Participating Hospitals Mean number SD A 0.7 0.8 B 0.8 1.0 C 1.0 0.9 D 1.0 1.0 E 1.4 1.2 F 1.4 1.0 G 1.1 1.1 H 1.2 1.2 I 1.2 1.1 J 0.9 1.0 K 1.2 1.1 L 1.3 1.1 M 1.0 1.2 N 0.8 0.9

34

Total 1.1 1.1 The mean number of organ failure ranged from 0.7 to 1.4 in the participating hospitals. Table 32 : Main diagnosis leading to ICU admission by system Diagnosis Number Percentage Trauma 1429 21.2 Respiratory system 995 14.8 Gastro-intestinal system 947 14.1 Systemic infection 657 9.7 Central nervous system 644 9.6 Cardiovascular system 439 6.5 Obstetrics 377 5.6 Others 376 5.6 Adverse peri-operative events 246 3.7 Musculo-skeletal / connective tissue system 238 3.5 Renal / genito-urinary system 193 2.9 Endocrine / metabolic 121 1.8 Haematological system 63 0.9 Missing 14 0.2 Total 6739 100 21.2% of admissions were related to trauma. When infections of all systems were grouped together, 21.6% of admissions were related to sepsis. Hence, sepsis was the most common diagnosis leading to ICU admission in our study. (Refer to the list of diagnoses below) Table 33 : List of diagnoses leading to ICU admission Diagnosis

Number Percentage

Head injury 844 12.5 Sepsis (gram positive, gram negative and septic shock) 367 5.4 Community acquired pneumonia 270 4.0 Gastrointestinal perforation (including anastomotic leak) 219 3.2 Bronchial asthma 180 2.7 ENT/oral conditions 171 2.5 Intra-abdominal injury 170 2.5 Intra-abdominal/pelvic malignancy 167 2.5 Meningitis/encephalitis/myelitis/intracranial abscess/ spinal cord abscess

162 2.4

Dengue fever 155 2.3 Chest injury 154 2.3 Cerebrovascular disease (infarct, thrombosis, haemorrhage)

152 2.3

Ante/postpartum haemorrhage 131 1.9

35

Injury to extremities including fractures 131 1.9 Intracranial tumour 128 1.9 Chronic lower respiratory disease (COAD, bronchiectasis, restrictive lung disease)

120 1.8

Gastrointestinal obstruction 118 1.8 Pregnancy-induced hypertension/eclampsia 116 1.7 Infection/gangrene of limb (including osteomyelitis, necrotising fascitis)

115

1.7

Heart failure 112 1.7 Hepatobiliary disease 111 1.6 Ischaemic heart disease/acute coronary syndrome 106 1.6 Gastrointestinal bleeding 102 1.5 Non-cardiogenic pulmonary oedema (post upper airway obstruction, neurogenic, fluid overload)

97 1.4

Other obstetric conditions 96 1.4 Hospital-acquired pneumonia 83 1.2 Adverse peri-operative events - respiratory related events (eg. failed intubation, desaturation, pneumothorax, inadequate reversal etc)

79 1.2

Aortic aneurysm or dissection 78 1.2 Other renal/genito-urinary conditions (UV prolapse, TURP syndrome)

75 1.1

Other abdominal/pelvic conditions 74 1.1 Acute poisoning/drug overdose 74 1.1 Other respiratory conditions 72 1.1 Pancreatic disorder (including acute pancreatitis) 71 1.1 Adverse peri-operative events - bleeding 68 1.0 Aspiration pneumonia 60 0.9 Epilepsy 60 0.9 Tuberculosis 55 0.8 Dorsopathies (prolapsed intervertebral disc, scoliosis) 55 0.8 Diabetes mellitus 53 0.8 Other surgical conditions 49 0.7 Acute renal failure 45 0.7 Other disorders of the musculoskeletal system 45 0.7 Other CNS conditions 42 0.6 Disorder of the thyroid gland 41 0.6 Burns/electrocution 38 0.6 Gastrointestinal ischaemia/gangrene 38 0.6 Encephalopathy (hypoxic, alcoholic, hepatic) 37 0.5 Chronic renal failure/end-stage renal failure 37 0.5 Urosepsis 36 0.5 Diseases of the upper respiratory tract (epiglottitis, retropharyngeal abscess)

35 0.5

Intra-abdominal/pelvic abscess 35 0.5 Adverse peri-operative events - haemodynamic instability (hypo/hypertension-cause undetermined)

34 0.5

Fracture spine 31 0.5 Other cardiovascular conditions 30 0.4 Myeloproliferative disorder (leukaemia, lymphoma) 30 0.4 Spinal cord injury 30 0.4 Pelvic/perineal injury 29 0.4 Disease of pleura (pleural effusion, haemothorax, 28 0.4

36

pneumothorax) Facio-maxillary injury 26 0.4 Adverse peri-operative events – others 22 0.3 Disease of spinal cord (myelopathy, tumour, degenerative disease)

21 0.3

Other endocrine/metabolic disorders 21 0.3 Cardiac disease in pregnancy 20 0.3 Fat embolism 19 0.3 Disease of myoneural junction (myasthenia gravis) 19 0.3 Tetanus 19 0.3 Adverse peri-operative events - myocardial ischaemia 18 0.3 Other haematological conditions 17 0.3 Connective tissue disorders 17 0.3 Pulmonary thromboembolism 17 0.3 Leptospirosis 17 0.3 Valvular heart disease 16 0.2 Adverse peri-operative events - iatrogenic complications 16 0.2 Disease of nerve (neuropathy, Gullain Barre syndrome, motor neurone disease)

15 0.2

Malaria 15 0.2 Congenital heart disease 14 0.2 Cardiac arrhythmia or conduction disorder 14 0.2 Carcinoma of lung/mediastinal tumour 14 0.2 Other systemic infections 13 0.2 Arterial embolism or thrombosis of arteries 13 0.2 Acute lung injury/ARDS 13 0.2 Inflammatory bowel disease 12 0.2 Snake/insect bite 12 0.2 Hypertensive heart disease 12 0.2 Inflammation/infection of heart (pericarditis, endocarditis, myocarditis)

12 0.2

Near-drowning 11 0.2 Iatrogenic complications unrelated to surgery 10 0.1 Pulmonary heart disease 10 0.1 Adverse peri-operative events - anesthetic-related reaction including anaphylaxis

9 0.1

Typhoid fever 9 0.1 Herpes infection 9 0.1 Vascular injury 8 0.1 Drug reactions including anaphylaxis 8 0.1 Hemolytic anaemia 6 0.1 Myopathy/muscular dystrophy/myositis 6 0.1 Airway injury 6 0.1 Morbid obesity including Pickwickian Syndrome 6 0.1 Amniotic fluid embolism 6 0.1 Cardiomyopathy 5 0.1 Disseminated intravascular coagulation 5 0.1 Pulmonary embolism in pregnancy 4 0.1 Puerperal sepsis 4 0.1 Lung abscess 4 0.1 Purpuric disorder (idiopathic thrombocytopaenic purpura, thrombotic thrombocytopaenic purpura, haemolytic uraemic syndrome)

3 0.0

37

Sleep apnea 3 0.0 HIV infection 3 0.0 Heat stroke 3 0.0 Aplastic anaemia 2 0.0 Missing 14 0.2 Table 34 : List of surgical operations Number Percentage

Other gastro-intestinal (abdominal) surgery 538 13.3 Other orthopaedic surgery 457 11.3 Upper gastro-intestinal surgery 323 8.0 Craniotomy for evacuation of haematoma 310 7.7 ENT surgery 271 6.7 Colorectal surgery 253 6.3 LSCS 239 5.9 Other surgery not mentioned above 182 4.5 Other intracranial surgery 152 3.8 Hepatobiliary surgery 151 3.7 Craniotomy for debulking of tumour 134 3.3 Above knee/ below knee amputation 115 2.8 Spinal surgery 114 2.8 Other urological surgery 105 2.6 Gynaecological surgery 102 2.5 Other obstetric surgery 102 2.5 Caesarean hysterectomy 90 2.2 Repair of abdominal aortic aneurysm 71 1.8 Whipple’s or pancreatic surgery 55 1.4 Plastic surgery 54 1.3 Craniotomy for clipping of aneurysm/excision of arterio-venous malformation

41 1.0

Dental surgery 38 0.9 Other thoracic surgery 38 0.9 Percutaneous nephrolithotripsy 26 0.6 Breast /endocrine surgery 24 0.6 Oesophagectomy 20 0.5 Other vascular surgery 18 0.4 Ilio-femoral-popliteal bypass surgery 10 0.2 Transurethral resection of prostate 7 0.2 Pneumonectomy /lobectomy 7 0.2 Total 4047 100 Table 35 : Surgical operations by system

Number Percentage Gastrointestinal (abdominal) surgery 1320 32.6

38

Neurosurgery 637 15.7 Orthopaedic surgery 572 14.1 Obstetric surgery 431 10.6 ENT surgery 271 6.7 Other surgery not mentioned above 182 4.5 Urological surgery 138 3.4 Spinal surgery 114 2.8 Gynaecological surgery 102 2.5 Vascular surgery 99 2.4 Thoracic surgery 65 1.6 Plastic surgery 54 1.3 Dental surgery 38 0.9 Breast and endocrine surgery 24 0.6 Total 4047 100 The most common surgery performed were laparotomies, craniotomies followed by orthopaedic operations. Table 36 : Presence of co-morbid diseases* Number Percentage #In-hospital

mortality % Yes 2553 37.9 41.0 No 4156 61.7 25.1 Missing 30 0.4 - Total 6739 100.0 - #p = 0.0001 *Co-morbid disease: Refers to pre-existing disease/s which did not contribute to ICU admission Nearly 40% of the patients had co-morbid diseases. Patients with co-morbid diseases had a significantly higher mortality compared to those without. Table 37 : Types of co-morbid diseases Number Percentage Diabetes mellitus 962 23.0 Hypertension 1340 32.1 Ischaemic heart disease 501 12.0 Asthma 243 5.8 Chronic obstructive airway disease 162 3.9 History of cerebrovascular accident 101 2.4 Chronic renal failure 140 3.4 Connective tissue disease 18 0.4 Others 709 17.0 Total 4176 100 Hypertension, diabetes mellitus and ischaemic heart disease were the three most common co-morbid diseases.

39

Table 38 : SAPS II score [12] by hospital

Participating Centres

Number of ICU admissions *

SAPS II score (SD)

95% CI

A 219 30.5 (13.2) 28.7 – 32.2 B 396 32.4 (17.3) 30.6 – 34.1 C 316 32.9 (14.3) 31.3 – 34.5 D 737 35.1 (18.3) 33.7 – 36.4 E 207 41.3 (19.3) 38.7 – 43.9 F 252 39.3 (18.7) 36.9 – 41.6 G 237 38.8 (18.0) 36.5 – 41.1 H 350 36.9 (16.4) 35.1 – 38.6 I 783 38.2 (20.6) 36.7 – 39.6 J 340 37.7 (17.3) 35.8 – 39.5 K 168 42.1 (20.4) 39.0 – 45.2 L 162 36.2 (17.3) 33.5 – 38.9 M 316 35.6 (17.3) 33.7 – 37.5 N 242 31.1 (15.3) 29.1 – 33.0

Total 4725 36.1 ( 18.1) 35.6 – 36.6 *Exclude patients below the age of 18 years

Graph 6 : SAPS II score by hospital

10

15

20

25

30

35

40

45

50

A B C D E F G H I J K L M N Overall

SAPS

II s

core

The average SAPS II score was 36.1 + 18.1, which carried a predicted risk of in-hospital mortality of 35.9%.

40

B.2. Intervention Table 39 : Invasive mechanical ventilation Number

Percentage

Yes 5589 82.9 No 1140 16.9 Missing 10 0.1 Total 6739 100 Table 40 : Duration of mechanical ventilation Participating Hospitals Number Mean duration of mechanical

ventilation (days) + SD A 355 3.9 + 8.7 B 360 5.4 + 7.6 C 340 6.4 + 9.7 D 745 4.7 + 8.3 E 307 6.5 + 8.7 F 282 6.9 + 8.7 G 256 4.6 + 7.6 H 402 4.2 + 8.1 I 795 6.1 + 9.2 J 394 3.9 + 4.8 K 251 5.2 + 8.7 L 387 5.5 + 7.5 M 331 3.9 + 5.5 N 347 6.1 + 10.2

Total 5561 5.2 + 8.3 82.9% of patients required mechanical ventilation. This high percentage indicated that most of the patients could not be admitted to ICU unless they required mechanical ventilation. The average duration of invasive mechanical ventilation was 5.2 + 8.3 days. Table 41 : Interventions in ICU Intervention* Number

Percentage

A Non-invasive ventilation 364 6.5 B Reintubation 575 10.3 C Stress ulcer prophylaxis 5515 81.8 D Paralysis with muscle relaxant 664 11.9 E Bronchoscopy 293 4.3

41

F Use of vasoactive drugs 3050 45.3 G Use of heparin 1036 15.4 H Renal replacement therapy 613 9.1 I Use of albumin 591 8.8 J Use of blood/blood products 3160 46.9 K Use of total parenteral nutrition 242 3.6 L Tracheostomy 901 16.1 A: Refers to the continuous use of a non-invasive ventilator for > 24 hours B: Refers to reintubation after intended or accidental extubation C: Refers to the use of drugs for the purpose of prevention of stress induced ulcers or upper gastrointestinal bleeding D: Refers to the continuous use of non-depolarising muscle relaxants for > 24 hours E: Refers to fibreoptic bronchoscopy done in ICU for therapeutic or diagnostic purposes F: Refers to the continuous use of vasoactive drugs for > 1 hr G: Refers to the use of heparin in ICU for any indication H: Refers to the use of peritoneal dialysis, intermittent haemodialysis, continuous veno-veno haemodiafiltration for treatment of acute or chronic renal failure K: Refers to continuous use of total parenteral nutrition for > 72 hrs Non-invasive ventilation was used in 364 patients or 6.5%of patients receiving mechanical ventilation. This low percentage could be due to the unavailability of these ventilators in some hospitals. The reintubation rate was 10.3%. Reintubation is a risk factor associated with ventilator-associated pneumonia and this could have contributed to the high incidence of ventilator-associated pneumonia seen in our patients. 81.8% of patients received stress ulcer prophylaxis. According to a randomised controlled trial, about 6% (range 0.1-39%) of adult medical and surgical patients at risk for stress ulcers who did not receive prophylaxis had clinically important bleeding [13]. Hence the high percentage of patients who received stress ulcer prophylaxis was consistent with the current practice. Muscle relaxants have been implicated in the development of critical illness polyneuropathy in the critically ill patients [14]. The use of muscle relaxant (11.9%) is expected to decrease with time. Fibreoptic bronchoscopy was performed in 4.3% of patients. The low percentage might have been due to the unavailability of the equipment in some ICUs. Deep vein thrombosis remains an underestimated problem in ICU patients [15]. 15.4% of our patients received heparin (standard and/or low molecular weight heparin). A study by Hirsch reported the incidence of DVT of 33% in a medical ICU where 61% of patients received DVT prophylaxis [16]. 9.1% of the patients required renal replacement therapy during their stay in ICU. This would mean that about one in ten of ICU patients developed acute renal failure, requiring some form of dialysis. Since the publication of the Cochrane Injuries Group’s systematic review of the use of albumin in the critically ill patients in which the use of albumin was associated

42

with a 6% excess mortality [17], the use of albumin in ICU has become controversial. We are awaiting the findings of an on-going randomised controlled trial of saline versus albumin (SAFE trial). In this audit, 8.8% of patients received albumin during their stay in ICU. Almost half of the patients (46.9%) had transfusion of blood/blood products during their stay in ICU. This was a relatively high figure and may warrant further investigations especially in the light of the recent findings by Herbert [18] which showed that critically ill patients who received liberal blood transfusion had a higher mortality when compared to patients who did not. Parenteral nutrition has been implicated in the development of nosocomial sepsis and is only indicated in a small group of patients [19]. Thus the low rate of 3.6% for total parenteral nutrition was not unexpected. 16.1% of patients required tracheostomy during their stay in ICU. A single point prevalence of infection study in European ICUs [EPIC study] revealed that 12.6% of all patients had tracheostomy in situ [20]. Table 42 : Stress ulcer prophylaxis Number Percentage Sucralfate 745 12.5 H2 blocker 4409 74.1 Omeprazole 745 12.5 Missing 48 0.8 Total 5947* 100.0 *The total number exceeded 5515 because the above drugs can be used in combination H2 blocker was a popular choice, being used in 74% of patients. It remains unresolved whether acid-suppressing agents are associated with a higher rate of ventilator-associated pneumonia when compared to sucralfate [21]. Therefore, the choice of drug used was mainly based on personal preference. Table 43 : Vasoactive drugs Number

Percentage

Dopamine 2682 47.2 Dobutamine 986 17.3 Adrenaline 742 13.1 Noradrenaline 271 22.4 Missing 1 0.0 Total 5682* 100.0 *The total number exceeded 3050 because the above drugs can be used in combination Dopamine was the most commonly used vasoactive drug followed by noradrenaline.

43

Table 44 : Use of heparin Number

Percentage

Unfractionated heparin 595 54.5 Low molecular weight heparin 448 41.0 Missing 49 4.5 Total 1092* 100.0 *The total number exceeded 1036 as both drugs can be used in one patient For DVT prophylaxis, unfractionated heparin remained the most commonly used agent in the ICUs, despite the recognised efficacy and safety of low molecular weight heparin [22]. The possible reasons for the low adoption rate of low molecular weight heparin include its porcine nature and the unavailability of the drug. Table 45 : Renal replacement therapy

Number

Percentage

Peritoneal dialysis 200 26.0 Intermittent haemodialysis 363 47.2 Continuous veno-veno haemodialysis 159 20.7 Missing 47 6.1 Total 769* 100.0 *The total number exceeded 613 as more than one type of renal replacement can be performed in one patient The main mode of dialysis was intermittent haemodialysis. Peritoneal dialysis was performed in 26% of the patients. The role of peritoneal dialysis in treating acute renal failure in the critically ill is limited because of its many drawbacks. It is hoped that continuous veno-veno hemodialysis can be widely used to reflect the current practice. Table 46 : Tracheostomy

Number

Percentage

Surgical tracheostomy 562 62.4 Percutaneous tracheostomy 326 36.2 Missing 13 1.4 Total 901 100 The majority of the trachestomies were done using the open surgical technique. Percutaneous tracheostomy is now a well established technique [23] and should be the technique of choice in the ICU setting. The use of the percutaneous technique is expected to increase as more intensive care specialists master the technique.

44

B.3. Monitoring Table 47 : Comparison of monitoring modalities with other countries Invasive BP CVP PAC Malaysia 88.6 71.6 0.9 Italy [24] 51.5 - 7.5 Portugal [25] 30.0 76.3 5.3 Pulmonary artery catheter was used in 0.9 % of the patients. The use of pulmonary artery catheter has been on the decline since the publication by Connors in 1997 which concluded that its use had not been associated with improved outcome [26]. Please note that the figures from Italy and Portugal reflected the practice before the publication by Connors. B.4. Complications Ventilator-associated pneumonia and unplanned extubation are used as quality indicators for monitoring quality of care in the ICU. Table 48 : Incidence of ventilator-associated pneumonia*,percentage

Number Percentage Yes 726 23.2 No 2392 76.3 Missing 18 0.5 Total 3136 100 *Refers to nosocomial pneumonia developing in a patient after 48 hours on mechanical ventilation with radiological evidence of new or progressive infiltrates and a positive bacteriological tracheal or blood culture Table 49 : Incidence of ventilator-associated pneumonia, per 1000 ventilator

days

Participating Hospitals

VAP per 1000 ventilator days

Percentage of VAP

A 7.4 5.7 B 27.6 24.6 C 11.2 10.0 D 41.7 36.7 E 50.8 51.3 F 43.2 43.0 G 22.1 17.9 H 23.0 17.3 I 28.5 26.1

45

J 30.0 19.2 K 26.2 20.0 L 21.3 18.9 M 10.5 7.6 N 8.9 8.0

Total 26.9 23.2

Graph 7: Incidence of ventilator-associated pneumonia by hospital

0

10

20

30

40

50

60

A B C D E F G H I J K L M N

Overall

VA

P pe

r 100

0 ve

ntila

tor d

ays

Perc

enta

ge o

f VA

P

VAP per 1000 ventilator days Percentage VAP

Table 50 : National Nosocomial Infection Surveillance (NNIS) benchmarking

on ventilator-associated pneumonia for quality improvement [27]

NNIS benchmark (percentile) 10% 25% 50% 75% 90%

VAP per 1000 ventilator days (NAICU)

VAP 3.4 6.5 10.1 13.4 17.5 26.9 The incidence of VAP in our ICUs was 23.2% or 26.9 per 1000 ventilator days. This incidence is above the 90th percentile of the NNIS benchmark. The high incidence of VAP is an area of great concern and calls for immediate attention. A well designed quality assurance study should be conducted to determine the factors contributing to the high rate. Where possible, centres with high VAP rates should introduce immediate remedial measures.

46

Table 51 : Bacteriologic cultures for ventilator-associated pneumonia Organism Number % Staphylococcus aureus 57 5.1 Coagulase negative Staphylococcus 44 3.9 Methicillin resistant Staphylococcus aureus 110 9.8 Other gram positive cocci 15 1.3 Acinetobacter species 348 30.9 Pseudomonas aeroginosa 222 19.7 Klebsiella 186 16.5 Enterobacter 12 1.1 Other gram negative organism 70 6.2 Fungus 61 5.4 Total 1125 100 Table 52: Incidence of unplanned extubation*, percentage

Number Percentage Yes 197 3.5 No 5366 96.0 Missing 26 0.5 Total 5589 100 *Refers to unintended removal of tracheal airway Table 53 : Incidence of unplanned extubation, per intubated day

Participating Hospitals Unplanned extubation, per intubated day A 0.4 B 0.1 C 0.05 D 0.5 E 0.7 F 0.6 G 0.1 H 0.2 I 0.9 J 0.7 K 0.9 L 0.1 M 0.1 N 0.8

Mean 0.7

47

Graph 8 : Incidence of unplanned extubation by hospital

0

1

2

3

4

5

6

7

A B C D E F G H I J K L M N

Average

% U

E

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

UE

per i

ntub

ated

day

% UE UE per intubated day

The rate of unplanned extubation among the patients who were mechanically ventilated was 3.5%. When calculated based on the duration of intubation, the rate was 0.7 per intubated day. Table 54 : Unplanned extubation as a quality indicator Unplanned extubation, per intubated day NAICU

0.7

Other studies [28]

1.5-2.5

Australia [29]

0.4

The acceptable rate of unplanned extubation is 0.5 per intubated day [29]. Table 55 : Other complications

Number Percentage Pneumothorax / haemothorax from central venous cannulation

51 1.1

Pneumothorax due to mechanical ventilation 48 0.9 Bedsores 205 3.0 Keratitis* 26 0.4

48

Foot drop* 81 1.2 *Refers to abrasion of cornea *Refers to loss of the ability to dorsiflex the ankle joint The incidence of pneumothorax in our ICUs was 1.1%. Shoemaker reported an incidence of pneumothorax of 0.41% among all cases [30]. Reported incidence of pneumothorax due to mechanical ventilation was 4 -15% [31, 32, 33]. Although the newer strategies in mechanical ventilation have helped to reduce the incidence of barotrauma, we suspect that our low incidence could be to under-reporting.

Bedsores, keratitis and foot drop were uncommon and these incidences can be used as baselines for future comparisons. C. Outcome and performance In-ICU mortality and in-hospital mortality are frequently used as outcome measures. However due to the varying case-mix of different ICUs, this simple comparison of crude mortality rates gives no indication of performance of a particular ICU. Standardised mortality ratio (SMR) compare actual against expected outcome on the basis of a model. In this audit, we used the Simplified Acute Physiologic Score II [12] (SAPS II) to adjust for severity of illness. It is important to note certain points when SMR is used to compare performance among centres. All severity scoring systems have limitations and they do not fully adjust for case mix. For example, mortality of patients with neurological diagnosis may be under-estimated [34]. They are susceptible to treatment effects which include ‘lead time bias’ i.e. the effect of resuscitation prior to ICU admission. Factors unrelated to ICU care e.g. ward care post ICU discharge and availability of step-down units may be important in influencing hospital outcome. Therefore, we do not recommend SMR to be used when comparing performance among centres but it would be useful as a performance indicator for individual units over time. Table 56 : ICU outcome

Number

Percentage

Alive 5158 76.5 Died 1413 21.0 Discharge with grave prognosis* 77 1.1 Transfer to another hospital 61 0.9 Missing 30 0.4 Total 6739 100 *Patients who were discharged with grave prognosis were later reclassified as died in analysis for mortality rates

49

Table 57 : Hospital outcome

Number

Percentage

Alive 4231 62.8 Died 2044 30.3 Discharge with grave prognosis 52 0.8 Transfer to another hospital* 284 4.2 Condition on discharge unknown* 98 1.5 Missing 30 0.4 Total 6739 100 *Patients who were transferred to another hospital or when condition at discharge were unknown were reclassified as alive in analysis for mortality rates. The in-ICU mortality rate was 22.1% while the in-hospital mortality rate was 31.1%. 28.9% of deaths occurred in wards following discharge from ICU. Breakdown of the mortality rates according to hospitals is shown below and the comparison with other countries shown in table 59. Table 58 : In-ICU and in-hospital mortality rates by hospital Participating Hospitals In-ICU mortality %

In-hospital mortality %

A 15.1 22.6 B 12.7 25.6 C 16.6 30.4 D 25.4 32.8 E 37.6 44.8 F 25.7 32.8 G 18.2 28.9 H 24.7 33.2 I 24.6 33.5 J 24.1 33.1 K 23.5 33.8 L 24.2 30.8 M 20.0 30.4 N 14.0 22.4

Total 22.1 31.1 Table 59 : Comparison of mortality rates among countries [35] Country In-ICU mortality %

In-hospital mortality %

Japan - 16.9 Hong Kong - 36 Brazil 29 34 Saudi Arabia 24 32 Tunisia 22.5 -

50

United Kingdom 20 31 Europe 13 18 US/Canada 12 19.7 Australia 10 16 Malaysia 22.1 31.2 In-ICU mortality and in-hospital mortality rates in our ICUs were comparable with U.K. and other developing countries. Table 60 : Characteristics of survivors and non-survivors Survivors Non-survivors Age (years)* 44.1 51.1 SAPS II score* 29.6 50.4 Total organ failure* 0.7 1.8 Length of mechanical ventilation (days)* 4.6 7.0 Length of ICU stay (days)* 4.5 6.7 Length of hospital stay (days)* 24.0 17.3 *P = 0.0001 ICU patients who survived their hospital stay tended to be younger, had a lower SAPS II score and with fewer organ failure. They also spent less time on invasive mechanical ventilator. The survivors had a shorter ICU stay but a longer hospital stay compared to non-survivors. Table 61 : Standardised mortality ratios by hospital

Participating Hospitals

Mean (SD) 95% CI

A 0.83 (1.71) 0.61 – 1.06 B 1.01 (3.44) 0.67 – 1.35 C 1.13 (3.81) 0.71 – 1.55 D 0.78 (1.92) 0.64 – 0.92 E 0.84 (1.27) 0.67 – 1.02 F 0.59 (1.15) 0.44 – 0.73 G 0.54 (1.01) 0.41 – 0.67 H 0.88 (1.82) 0.69 – 1.07 I 0.74 (1.49) 0.64 – 0.85 J 1.06 (6.22) 0.39 – 1.71 K 0.77 (1.21) 0.59 – 0.96 L 0.89 (2.47) 0.51 – 1.28 M 0.82 (1.80) 0.62 – 1.02 N 1.03 (3.65) 0.56 – 1.49

Total 0.85 (2.72) 0.77 – 0.92 The observed mortality for patients with SAPS II predictions was less (31.6%) than predicted (36.3%), giving a SMR of 0.85.

51

Graph 9 : Standardised mortality ratio (SMR) by hospital

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

A B C D E F G H I J K L M N

Graph 10 : SAPS II and standardised mortality ratios

0

100

200

300

400

500

600

700

<56-

1011

-15

16-2

021

-25

26-3

031

-35

36-4

041

-45

46-5

051

-55

56-6

061

-65

66-7

071

-75

76-8

081

-85

86-9

090

-95

>100

SAPS II

n.

0

0.2

0.4

0.6

0.8

1

1.2

SM

R

nObservedExpected

52

The graph shows that the observed mortality was better than predicted over a wide range of SAPS II except in the higher and lower range of the scores. Table 62 : Standardised mortality ratio by risk group

Risk group Number of ICU

admissions

Mean SMR 95% CI

Low risk SAPS II <20

814 0.91 0.51 -1.31

Intermediate risk SAPS II 21-43

2501 0.79 0.72 – 0.85

High risk SAPS II >44

1410 0.92 0.87 – 0.95

A patient is considered low risk for death when the risk of death is less than 10% which corresponds to SAPS II score of less than 20 and high risk, when the risk of death is more than 50%. Our performance was best with patients with intermediate risk compared to low and high risks. Table 63 : Standardised mortality ratios by category of patients

SMR Category of patients Mean 95% C.I

Non-operative 0.91 0.84 – 0.98 Operative – elective 1.10 0.71 – 1.50 Operative – emergency 0.65 0.59 – 0.72 Overall 0.85 0.77 – 0.92

Graph 11 : Standardised mortality ratios by category of patients

53

0.3

0.5

0.7

0.9

1.1

1.3

1.5

1.7

Non-operative Op-elective Op-emergency Overall

SMR

When adjusted for risks, the elective surgical patients in our ICUs had a higher

mortality than predicted (SMR 1.1). We are unable to determine the contributing

factors and we recommend that further audit to be carried out on this subset of

patients.

54

SUMMARY

The key findings of the audit are summarised below. Unless specified the findings refer to the fourteen ICUs in the state hospitals.

A. Resource survey

1. As of August 2003, the total number of intensive care beds in Malaysia was 509 and only 54% of these beds were in the government hospitals.

2. The ICU bed to population ratio for the country is 2 :

100,000 population.

3. ICU beds made up only 1% of all hospital beds.

4. The bed occupancy rates for the past 5 years were above 80%.

5. Almost 5,000 patients i.e one out of every two deserving

patients were denied admission to ICUs last year.

6. The nurse-to-patient ratio was 1:1.1 during the morning and afternoon shifts and 1:1.5 during the night shift. 36.5% of nurses working in ICU had undergone post-basic training in intensive care nursing.

B. Clinical practice

1. The mean age for all patients admitted to ICU was 40.7 +

21.8 years. For the adult population (equal or more than 18 years old), the mean age was 46.6 + 18.2 years.

2. The average length of ICU stay was 4.9 + 7.4 days. 3. The average length of hospital stay was 19.8 + 21.7 days.

4. About two-thirds (65.7%) of admission to ICUs were

from surgical-based disciplines. 5. There were an almost equal number of admissions of

non-operative (47.1%) and operative patients (52.9%). 36.2% of ICU admissions were emergency operative cases.

55

6. About one third of patients admitted were without organ

failure while another one third had single organ failure with respiratory failure being the commonest followed by cardiovascular failure.

7. The commonest main diagnosis leading to admission was

sepsis, followed by trauma-related injuries.

8. For operative cases, the most common surgery performed were laparotomies, craniotomies followed by orthopaedic operations.

9. The average SAPS II score was 36.1 + 18.1, which carried

a predicted risk of hospital death of 35.9%.

10. 82.9% of patients required invasive mechanical ventilation with an average duration of 5.2 + 8.3 days.

C. Clinical indicators

1. The incidence of ventilator-associated pneumonia was 26.9 per 1000 ventilator days or 23.2%.

2. The incidence of unplanned extubation among the

patients who were mechanically ventilated was 3.5% or 0.7 per intubated day.

3. The incidence of pneumothorax associated with central

venous catheter insertion in ICU was 1.1%.

D. Outcome 1. The in-ICU mortality rate was 22.1% while in-hospital mortality rate was 31.1%.

2. The observed mortality for patients with SAPS II prediction was less (31.6%) than predicted (36.3%), giving a standardised mortality ratio (SMR) of 0.85.

56

3. In-hospital mortality for patients without organ failure was 8.6%. The mortality rates for single, two, three, four and five organs failure were 29.0%, 59.8%, 75.5%, 86.1% and 90.5% respectively

57

RECOMMENDATIONS

The following recommendations aim to overcome the shortage of beds and to improve the performance of ICUs. 1. Increase the number of ICU beds by expanding existing facilities or

establishing new ICUs. This can be achieved through the mid-term review of the 8th Malaysian Plan and Dasar Baru over the next five years. Special funding from the government may be required for this purpose. A total of 100 beds need to be urgently created to meet current demands.

2. Ensure efficient bed management

2.1 Written admission and discharge guidelines

- For effective use of expensive intensive care resources,

only patients who are going to benefit from intensive care

management are admitted. When resources are scarce, it

is necessary to incorporate triage guidelines to admit

patients who will benefit the most.

- There is a need to have clearly written guidelines in every

unit to ensure consistency in care.

2.2 Conduct regular in-unit audit

Regular in-unit audit should be conducted to identify the

percentage of ICU beds that are occupied by patients:

- who are “too ill” and are not expected to recover from

their illness as these patients should not be admitted to

the ICUs.

- who are “too well” to benefit from intensive care as these

patients can be cared for in the ward or high dependency

areas.

58

- whom intensive care admission are required following

inadequate surgical or anaesthetic management

3. Optimise utilisation of resources and staff

3.1 Integrated ICU and HDU

There are some high risk patients who require high

dependency care, not necessarily intensive care. Many

intensive care patients need to be cared for in a high

dependency area before being discharged to the wards.

Having high dependency beds which are integrated into

the intensive care unit area is more cost-efficient for

staffing and equipment as beds are interchangeable

within the same unit or in adjacent areas and patients’

level of care can be upgraded or downgraded wherever

appropriate. It improves continuity of care for patients

and reduces the anxieties among patients and relatives

associated with moving from one environment to

another.

3.2 Networking of ICUs within a geographical region

ICUs within a geographical region can form a network

where deserving patients who cannot be admitted to an

ICU will be transferred to another ICU where a bed is

available. Hospitals in the Klang Valley and its vicinity

i.e. Hospital Kuala Lumpur, Hospital Selayang, Hospital

Tengku Ampuan Rahimah, Klang, Hospital Kajang,

Hospital Putrajaya and Hospital Seremban have been

identified to form a network for this purpose.

59

4. Minimise the length of stay through efficient treatment

4.1 “Closed” system ICU

The “closed” system of organisation practised in some

ICUs should be extended to all ICUs in the country. In

the “closed” system, the ICU clinicians take responsibility

for clinical management of the patient. This helps to

ensure that there is consistency and continuity of care

and has been shown to improve performance compared

to the “open” system concept. More clinicians should be

trained in intensive care medicine so that all ICUs can

practice the “closed” system of organisation.

4.2 Clear management plan for every patient

The intensive care environment is a complex network

involving different people and effective communication

is most important to achieve the best outcome for patients

with the shortest length of stay. For each patient there

should be a clear management care plan which is

regularly reviewed and updated.

4.3 Continuity of nursing care

To improve continuity and quality of nursing care, the

same nurse should be assigned to take care of the same

patient as long as she is on-duty and the patient is in ICU.

4.4 Improve nosocomial infection control measures

Since nosocomial infections prolong patients’ length of

stay in the unit, it is imperative to ensure that infection

control measures are strictly adhered to in the unit.

60

4.5. Recognise when continued intensive care is futile

Although intensive care is often successful at saving and

prolonging life, it can also prolong the process of dying in

some. With-holding or withdrawal of treatment

guidelines are needed to:

- place limits on treatment for those patients for

whom there is little or no hope for survival

- cover the conditions in which treatment

should be withdrawn or withheld

5. Prevent “preventable” admissions to ICU

Improving care outside ICU can reduce demand by preventing some

patients from deteriorating into a need for intensive care.

5.1. Training of ward staff

Ward nurses and junior doctors need to be trained to

recognise the signs of deterioration in patients and to

seek early specialist or consultant advice.

5.2 Medical Emergency Team (MET) or “Patient-at-risk”

Team

The team is led by the ICU doctor and when alerted by

the ward staff attends to the patients in the ward when

their physiological parameters fall outside certain ranges.

These patients are managed aggressively in the ward to

prevent them from deteriorating into a need for intensive

care.

6. Extend NAICU to all ICUs

61

NAICU should be extended to all ICUs in the country including the

private hospitals to provide a more comprehensive picture of the

intensive care service in the country.

62

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