Restricted Analysis of Mortality in an Acute Care Facility of a Rural Hospital in Bengal, India

Advances in acute care medicine have increased the chances of survival for patients with severe illness or trauma. The major causes of modifiable and non-modifiable mortality among patients treated in medical or surgical intensive care units (ICUs) are trauma, sepsis, complications of diabetes mellitus type 2 and hypertension, respiratory support, CVA, electrolyte imbalance, poisoning and snake bite. Such analysis will give an insight into the various factors which led to death. The pre-hospital co-morbidities will reinforce the internist to anticipate and take appropriate measures to mitigate their onslaught. In this way, the mortality in the ICU may be curtailed.


Introduction
Advances in critical care medicine have increased the chances of survival for patients with severe illness or trauma [1]. However, such patients consume a large proportion of medical resources [2][3][4][5]. The factors for mortality that have potential to be modified among patients treated in medical or surgical critical care medicine (ICUs) (Figure 1) are sepsis, diabetes mellitus type 2, hypertension, poisoning and snake bite. Understanding the risk factors and their contribution to mortality would support the view that monitoring of patients with above factors is expected to prevent many deaths.

Study population
Patients of both sexes and all ages admitted to the Critical Care Medicine Unit of Glocal Hospital, Krishnanagore were included in this study. Also included were patients transferred from the General Ward to ICU. Post-surgical cases requiring intensive care were also admitted to the ICU. There were no exclusion criteria. All patients admitted to acute critical care were interviewed. When required the patient party or accompanying personnel were interviewed. A thorough physical examination followed by relevant investigations was performed. CT scan, MRI, USG were performed in cases, particularly trauma cases and abdominal pain and other cases as required.

Informed consent
Informed written consent was obtained from all patients or close relatives. In case of children, informed consent was taken from parents.

Sample size
All patients admitted to ICU during one calendar year.

Statutory clearances
The Institutional Scientific Advisory Committee (SAC) and Ethics Committee (EC) cleared the project proposal. Table 1 shows the distribution of admitted cases Vis-à-vis deaths, age groups, gender and month-wise admissions in the acute care unit of Glocal Hospital (ICU), Krishnanagore, India. A total number of 1130 cases of diverse diseases (males 432 and females 532) and 113 patients died. There were more females than males. A case fatality rate of 10% was recorded. Month-wise distribution of admissions showed that more than 100 cases were admitted in January, February, March and October, 2016, Highest number of cases died in the older age group (>60 years). There were no obvious admission and mortality trend month-wise.

Results and Discussion
On admission, the case acuity was high with majority of cases presenting to the Emergency (ER) with signs of hemodynamic impairment and sepsis (40%). While neurology deaths cases including CVA cases constituted about one-third of all ER admissions who needed airway protection on admission. Neurology deaths (20%) accounted for large numbers of Cardio Vascular Accidents (CVA) which were hemorrhagic in nature. Many of the neurology cases needed neurosurgical intervention (30%). Higher mortality was observed in cases those who presented with long delay to the ER, long time to AF was the commonest sustained arrhythmia in emergency (4%). DC cardio version was the preferred method of termination tachyarrhythmia in ER. In poisoning cases Parquet cases had a higher mortality (97%) than Organophosphate intakes. The major comorbidities were diabetes mellitus type 2 and hypertension. The other factors that were noted in the ICU were sepsis, electrolyte imbalance and Venillatory support [6,7]. More deaths were associated with those who required Ventilation support in the ICU.
Comparing the mortality rate amongst some countries worldwide ( Table 2). The national figure for death is about 12% and is dependent upon co-morbidities that were associated with the cases. As expected, the causal factors like diabetes mellitus type 2; hypertension, cardiac arrhythmias and most importantly ventilation support were associated with higher mortality. A study carried out in Singapore for a period of 5 years found a mortality of 7% [8]. In view of these important findings, we conclude that extra-ordinary monitoring is required for critical cases that belong to the categories mentioned above in ICU either alone or in various combinations. Overall, mortality rates in patients admitted to adult ICUs average 10% to 29%, depending on age and severity of illness. The pediatric mortality rate associated with sepsis is 25%, whereas the overall mortality rate for pediatric ICU patients ranges from 2% to 6%. The effects of advanced age per se versus severity of chronic and acute diseases of short and long term in survival of older patients admitted to the intensive care unit (ICU) remains unclear.

Conclusion
In context of a typical rural setting, a critical care unit could achieve a case-fatality rate of 10% as compared to 12% of national figure.
Although the data depicts the picture of one ICU in a rural area in India [8,9], it is representative of the similar ICUs in most ICUs of rural India. This was possible because of adherence to modern guidelines for critical care of ICU [10]. This facility may be utilized for training purposes and theses' work.