TABLE OF CONTENTS
DEFINITION OF TERMS''''''''''''..3
ARDS-Adult Respiratory Distress Syndrome
CVA-Cerebral Vascular Accident
CCU-Critical Care Unit
DNR-Do Not Resuscitate
GCS-Glasgow Coma Scale
ICU-Intensive Care Unit
ITU-Intensive treatment unit
SCCM-The Society of Critical care Medicine
SPSS-Statistical Package for Social Sciences
MNH-Muhimbili National Hospital
MUHAS-Muhimbili University of Health and Allied Sciences
USA-United States America
An intensive care unit (ICU), also known as a critical care unit (CCU), intensive therapy unit or intensive treatment unit (ITU) is a special department of a hospital or health care facility that provides intensive care medicine. ICUs were developed for coronary care later their role expanded to include all critically ill patients. The ICU concept was adopted by most large, tertiary referral as well as by community hospitals in 1960s.Intensive care units cater to patients with the most severe and life threatening illnesses and injuries, which require constant, close monitoring and support from specialist equipment and medication in order to ensure normal bodily functions. They are staffed by highly trained doctors and critical care nurses who specialize in caring for seriously ill patients. Common conditions that are treated within ICUs include trauma, multiple organ failure and sepsis.
Patients may be transferred directly to an intensive care unit from an emergency department if required, or from a ward if they rapidly deteriorate, or immediately after surgery if the surgery is very invasive and the patient is at high risk of complications. Hospitals may have ICUs that are specific to certain specialty or patient, example of these are neonatal intensive care unit, Paediatrics intensive care unit, psychiatric intensive care unit also there is out of hospital ICU which is called Mobile intensive care unit.
Some equipments used at ICU are mechanical ventilators, cardiac monitors including those with telemetry; external pacemakers; defibrillators; dialysis equipment;equipment for the constant monitoring of bodily functions; a web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains, and catheters; and a wide array of drugs to treat the primary condition(s) of hospitalization. Medically induced comas, analgesics, and induced sedation are common ICU tools needed and used to reduce pain and prevent secondary infections. Bed Head Unit/Panel, Medical Rail System also called as Wall Utilizer.
ICU admission criteria should select patients who are likely to benefit from ICU care .Situations involved patients who were at the two extremes of the risk of death spectrum; relatively low risk of death and exceedingly high risk of death. These groups can be referred to as "too well to benefit" and "too sick to benefit" from critical care services. ICU care has been demonstrated to improve outcome in severely ill, unstable patient populations. Defining the "too well to benefit" and "too sick to benefit" population may be difficult solely based on diagnosis. For example, drug overdose patients are commonly admitted to an ICU. The following are some specific conditions or diseases that are appropriate for ICU admission, Acute myocardial infarction with complications, cardiogenic shock, complex arrhythmias requiring close monitoring and intervention, acute congestive heart failure with respiratory failure and/or requiring hemodynamic support, hypertensive emergencies, unstable angina, particularly with dysrhythmias, hemodynamic instability, or persistent chest pain, cardiac arrest, cardiac tamponade or constriction with hemodynamic instability, dissecting aortic aneurysms, complete heart block, acute respiratory failure requiring ventilatory support, pulmonary emboli with hemodynamic instability, massive hemoptysis, respiratory failure with imminent intubation, acute stroke with altered mental status, coma: metabolic, toxic, or anoxic, intracranial hemorrhage with potential for herniation, acute subarachnoid hemorrhage, meningitis with altered mental status or respiratory compromise, central nervous system or neuromuscular disorders with deteriorating neurologic or pulmonary, brain dead or potentially brain dead patients who are being aggressively managed while determining organ donation status, vasospasm, hemodynamically unstable drug ingestion, drug ingestion with significantly altered mental status with inadequate airway protection, seizures following drug ingestion, Life threatening gastrointestinal bleeding including hypotension, angina, continued bleeding, or
with comorbid conditions, fulminant hepatic failure, diabetic ketoacidosis, complicated by hemodynamic instability, altered mental status, respiratory insufficiency or severe acidosis, thyroid storm or myxedema coma with hemodynamic instability, hyperosmolar state with coma and/or hemodynamic instability, severe hypercalcemia with altered mental status, requiring hemodynamic monitoring,hypo or hypernatremia with seizures altered mental status, hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias,hypo or hyperkalemia with dysrhythmias or muscular weakness, hypophosphatemia with muscular weakness<.
The modern intensive care unit (ICU) is the highest mortality unit in any hospital. There are approximately 5 million ICU admission in USA and the incidence is still rising in developing countries like Tanzania it is not documented but it might be higher than we expect. The ICU is also one of the sites in which medical errors are most likely to occur because of the complexity of care. Since the patient population is severely ill and undergoes multiple complex interventions at the same time, these patients are extremely vulnerable to experiencing adverse outcomes
A study done by T. Baker et al on emergency and critical care services in Tanzania found that Emergency care was similarly lacking in structure and facilities at most hospitals also seven out of ten hospitals involved in the study had no ICU.1
A 5 year study of 1308 patients done on outcome from intensive care from 1979 to 1983 at Harlev Hospital Denmark, results shows male to female ratio is 1:1, respiratory diseases (43%) and cardiovascular diseases(16%) were the most primary indication for ICU admission. Increasing age was associated with more frequent cardiovascular diseases.10
In a study of BP Lwezimula, Determinants of outcome for medical cases admitted at MNH ICU(2003) results show that tetanus is the leading admitted case at ICU(44.2).Similar result was documented in a study of Mwafongo V et al, Tetanus and treatment outcome in Dar es Salaam: need for male vaccination(2005).6,7
In a study published by university of San Fransisco California showed that average mortality rate reported ranging from 8-19%, or about 500,000 deaths annually.6
The Society of Critical Care Medicine (SCCM) reports that overall mortality rates in patients admitted to adult ICUs average 10% to 29%.Also reports the leading causes of death in the ICU are multiorgan failure, cardiovascular failure, and sepsis. Multiorgan failure has a mortality rate of 11% to 18%. Sepsis, the second leading cause of death in noncoronary ICUs, carries a mortality rate of 25% to 30%. Of patients who are diagnosed with sepsis, up to 51% will develop acute renal failure, up to 18% will have acute respiratory failure, and up to 80% will develop a myopathy or polyneuropathy.8
In a study Causes of death and determinants of outcome in critically ill patients by Viktoria Mayr and colleagues from Innsbruck Medical University collaborated with colleagues from other institutions in Austria results show that 47% of patients who died in the ICU died of multiple organ dysfunction.4
Although patients in intensive care units (ICUs) receive care for a large variety of disease states, the leading causes of death in the ICU are multiorgan failure, cardiovascular failure, and sepsis. Multiorgan failure has a mortality rate of 11% to 18%. Sepsis, the second leading cause of death in noncoronary ICUs, carries a mortality rate of 25% to 30%. Of patients who are diagnosed with sepsis, up to 51% will develop acute renal failure, up to 18% will have acute respiratory failure, and up to 80% will develop a myopathy or polyneuropathy. Overall mortality rates in patients admitted to adult ICUs average 10% to 29%. Recent studies have shown that the pediatric mortality rate associated with sepsis is 13.5%, whereas the overall mortality rate for pediatric ICU patients ranges from 2% to 6%. A mortality rate of 6.04% has been reported in ICUs with intensivist staffing compared with 14.4% when a non-intensivist attending provides care.6
A study on stroke patients in Australian teaching hospital ICU was done between January 1994 and December 1999 to determine the mortality rate and functional outcome of stroke patients admitted to the ICU.Stroke was found to be associated with high mortality rate and high likelihood of dependent life style after ICU discharge.9
Medical patients suffer a high mortality after critical illness however the causes of mortality after intensive care management are unclear.
There is a need to conduct a study to explore the factors affecting outcomes and identify the most common causes of ICU admission in our settings.
The outcome of ICU patients is well studied and documented in developed countries it is less documented in developing countries like Tanzania.Tanzania is low resource country having a large burden doctor to patent ratio which contribute to the poor outcome to patients admitted to the ICU as well as in general ward also caring for admitted patient to ICU is costflul interms of money both to the institution and the patients all of these contribute to the outcome of the patient.
There is a need to conduct a study so as to fill the existing clinical information gap and thus critical and quality care can be provided to the patient.
To determine common indications for admission and mortality outcome at MNH main ICU
1. To assess common indications for ICU admission at MNH main ICU.
2. To determine the influence of patients age on mortality outcome at MNH main ICU.
3. To determine the influence of sex on patient mortality outcome at MNH main ICU.
4. To determine the influence of length of stay on patient mortality outcome at MNH main ICU.
5. To determine the influence of diagnosis on the patient mortality outcome at MNH main ICU.
The study type descriptive retrospective study.
MNH main ICU.
Patients admitted to the main ICU at MNH
Will be computed from the following formula
N = Z2 p (1 ' p)
N = sample size
Z = percentage of normal distribution corresponding to the level of significance.
Taking significance level to be 5% then Z = 1.96
p = prevalence of patients prescribed analgesics postoperative following caesarean section.
Taking p = 50% for maximum sample size.
e = margin error which is 5%
N = (1.96)2 x 0.5(1 ' 0.5)
Due to time limitation for data collection sample size will be 100
Simple random sampling will be used to get admitted patients at the main ICU in MNH.
The study will involve all patients who are admitted to the main ICU at MNH and are willing to participate also who are above 18 years old,ICU stay equal or more than 4 hours
All patients admitted to the main ICU at MNH and are not willing to participate and are bellow 18 years old.Burn patients,readmitted,ICU stay less than 4 hours and trauma patients.For those who are unconscious if their relative refuse to participate.
Data collection technique;A check list which record patient's age,sex,diagnosis,length of stay and patient's outcome will be noted.
Data will be analyzed by using SPSS 17.
Real names will not be used during data collection instead code numbers will be used so as to ensure confidentiality also ethical clearance will be obtained from MUHAS ethical clearance committee.
Poor patient recorded information and unwillingness of the patient to participate
The study will be conducted in 8 weeks period, in accordance with the following plan.
ACTIVITY Week 1&2 Week 3&4 Week 5&6 Week 7&8
1 Collection of basic information from MUHAS Administration
2 Data collection
3 Data entry and analysis
4 Report writing
BUDGET ESTIMATION (in Tshs)
ITEM QUANTITY UNIT PRICE TOTAL COST
Proposal preparation 02 7500 15,000
Photocopying (checklist) 100 150 15,000
Pencils 04 100 400
Rubber 02 250 500
Pens 04 200 800
Rim papers 01 12,000 12,000
Scientific calculator 01 30,000 30,000
Spring files 02 4,000 8,000
Punching machine 01 5,000 5,000
Stapler machine 01 5,000 5,000
Office pins 01 2,000 2,000
DATA COLLECTION, ANALYSIS AND REPORT WRITING
Meals and accommodation allowance (56 days) 56 8,000 448,000
Report preparation 01 20,000 20,000
Contingency (10%) 1 56,170 56,170
GRAND TOTAL 617,270
A.) Patient age is or greater than 18 years during admission at ICU ' YES ' NO/Unknown
B.) Is this his/her first ICU admission'? YES ' NO/Unknown
C.) Did the patient cared more than 4 hours at ICU? ' YES ' NO/Unknown
D.) Was the patient admitted due to Trauma or Burns, ' YES ' NO/Unknown
Part II;Patient Identification
a. Patient's code : ___________________________________
b(i). DOB: ___/___/____ b(ii). Age:_____
c. SEX: Male ' Female '
Part III. Hospital Arrival / Index ICU Admission
The index ICU admission is the first ICU admission (of ' 4 hours) during a hospitalization.
II-1 HOSPITAL Arrival (MNH)DATE ___/___/____ TIME: _ _ : _ _
II-2 ICU Admission DATE ___/___/____ TIME: _ _ : _ _
II-3 Number of day at ICU:_____________
PART IV. PLACE BEFORE ICU ADMISSION
III-1 Please indicate the care place before ICU Admission (Choose One Below, i-vi)
' i. MNH ' v. Rehabilitation Unit (Skip to IV-A)
' ii. Another Acute-Care Hospital ' vi. Direct Admit ' Physician (Skip to IV-A)
' iii. Home (move to IV-A)
' iv. Other _________ (move IV-A)
IV-1a If you chose 'i' (MNH) ' Indicate the department/unit care site prior to ICU
' Ward ' Operating Theatre or Recovery Room
' Emergency Department ' Other ICU
Section V. Patient condition on ICU Admission
IV-A Was the patient receiving mechanical ventilation at ICU admission or 'YES 'NO 'UNKNOWN
within one hour after arrival to the ICU?
IV-B Cardiopulmonary resuscitation within 24 hours prior to ICU admission? 'YES 'NO'UNKNOWN
IV-C Did the patient have surgery before ICU admission? ' YES'N0 'UNKNOWN
IV-D(a) If YES to IV-4 Was the Surgery:
IV-D( b) If Unscheduled 'Was the Surgery:
IV-E Life support status at admission to the ICU: (Choose One)
' Full Code
' Limited Interventions/Withholding Therapy
' DNR/ No CPR
' Withdrawing Therapy/ Comfort Care
' Maintenance of circulatory support ' Unknown
for organ procurement
Section V. immediate Diagnoses
At ICU admission, please indicate whether any of the following acute diagnoses are present (Select ALL that apply):
Cardiac Arrhythmias / Rhythm Disturbance (do NOT include chronic, stable arrhythmias)
' Atrial fibrillation / flutter with rapid ventricular response (HR ' 100)
' Other supraventricular: SVT / PSVT / WPW
' 2nd degree or 3rd degree heart block
' Ventricular tachycardia / fibrillation
' Other rhythm disturbance, not chronic / not stable
' Patient admitted to ICU after cardiac surgery
Gastrointestinal Bleeding (includes only clinically apparent GI bleeding. Examples include hematemesis, coffee ground emesis, or melena; a drop in hematocrit or perforated ulcer alone is NOT sufficient)
' Upper GI bleed from esophageal varices / or
' Upper GI Bleed, other source
' Lower GI Bleed
' GI Bleed, unknown source
' Sepsis present
' Acute renal failure OR Acute on chronic renal
failure, Prerenal type
' Acute renal failure OR Acute on chronic renal
failure, Non-prerenal type
' Acute renal failure OR Acute on chronic renal
failure, Unknown type
Coma or Deep Stupor: (Does not include coma/deep
stupor secondary to physician administered paralytic
and/or sedative medications).
' Coma or deep stupor, traumatic
' Coma or deep stupor, non-traumatic
' Coma or deep stupor, due to drug overdose
' Arteriovenous malformation with
subarachnoid hemorrhage or stroke /
' Cerebrovascular accident / CVA /stroke
(embolic and/or thrombotic)
' Epidural hematoma
' Subarachnoid hemorrhage / intracranial
' Subdural hematoma
' Intracranial hemorrhage / hematoma, other
Section VI. Medical History
Does the patient have any of the following medical conditions / treatments that have been diagnosed, symptomatic,or ongoing in the six months prior to admission? (Select all that apply).
' Confirmed cirrhosis
' Metastatic disease, solid tumor type (metastasis
' By Biopsy
' Other/Not Known identified by clinical assessment or biopsy proven)
' Portal hypertension
' Chronic myelogenous or chronic lymphocytic
' Jaundice and Ascites leukemia AND active treatment
' Esophageal and/or gastric varices
' Chronic myelogenous or chronic lymphocytic
' GI bleed attributable to portal hypertension leukemia AND at least one of the following (e.g. variceal bleed) complications secondary to the leukemia: sepsis,
' Hepatic encephalopathy anemia, stroke caused by clumping of white blood cells, tumor lysis syndrome, pulmonary edema, or Renal ARDS
' Renal dysfunction w/out dialysis but baseline ' Acute myelogenous or acute lymphocytic leukemia,
creatinine >2.0 mg/dL (>176.8umol/L) multiple myeloma, or other acute hematologic
' Chronic dialysis (Hemo or CAPD/Peritoneal) malignancy
Section VII. Mental Status
Using the Glasgow Coma Score (GCS) table below:
VII-1 What was the patient's GCS at admission to the ICU? For patients under the effects of paralytic or
sedative medications use your best clinical judgment to estimate the GCS prior to initiation of sedation.
(Please use Scale 1 below if not intubated or Scale 2 below if intubated).
EYE ____ MOTOR ____ VERBAL ____
VII-1a Please indicate if GCS from VII-1 is: ' Physician / nurse documented ' Abstractor Estimated
VII-2 Was the patient's level of consciousness significantly depressed due to the
effects of sedative or paralytic agents at admission to the ICU? Yes ' No '
Section VIII. Discharge
VIII-1 ICU Discharge DATE: ___/___/____ TIME: _ _ : _ _
VIII-2 HOSPITAL Discharge DATE: ___/___/____ TIME: _ _ : _ _
VIII-3 Status of patient at ICU discharge:
' Stable ' Heart still beating but under consideration for organ donation
' Dead ' Discharged for comfort care with no expectation of recovery
If the patient died in the ICU 'code status at death (Choose one):
' Full Code ' Limited Interventions/Withholding Therapy
' DNR/ No CPR ' Maintenance of circulatory support
' Withdrawing Therapy/ Comfort Care for organ procurement
VIII-4 Status at HOSPITAL discharge: Alive ' Dead '
If alive at HOSPITAL discharge 'what was the disposition of the patient?
' Home ' Hospice
' Against medical advice ' Other
' Another Acute Care Hospital ' Unknown
' Intermediate Care / Resident Care Facility
1. Lugazia ER et al,Emergency and critical care services in Tanzania:a survey of ten hospitals'www.biomedcentral.com/1472-6963/13/140(April 2013)
2. Parveen Kumar and Michael Clark-Clinical Medicine,3rd edition .Intensive care Medicine pg 709-735 Published by Baillie3re33 Tindall,24-28 Oval Road ,London 1994
3. Yu W,Ash AS,Levinsky NG,Intensive care unit use and mortality in the elderly.J Ge3n Intern Med 2000 Feb;15(2):97-102
4. Viktoria D Mayr et al Causes of death and determinants of outcome in critically ill patients,nov2006.
5. Mabula D Mchembe and Victor Mwafongo, Tetanus and its Treatment Outcome in Dar Es Salaam:Need for Male Vaccination. East African Journal of Public Heath, Vol. 2, No. 2, Oct, 2005, pp. 22-23
7 Dr Boniface RL.Determinant and outcomes for medical cases admitted at MNH ICU 2003.Dissertation in partial fulfillment of the requirements for Award of M.Med.
Anaesthesiology Degree of the University of Dar es Salaam.
9.Fanchawe M,Venkatesh B,Boots RJ:Outcome of stroke patients admitted to intensive care unit .October 2002.
10.Den Dragsted L,Qvist J,Madsen M;Outcome from Intensive care;A 5 years study of 1308 patients,1983.