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Obstetric admissions and outcomes in an intensive care unit in Malawi.

ABSTRACT: BACKGROUND:Despite international commitment to Millennium Development Goal 5, maternal mortality remains high in low- and middle-income countries (LMICs) of sub-Saharan Africa. This is in part due to infrastructure gaps, including availability of intensive care units (ICUs). We sought to use obstetric ICU utilization as a marker of severe maternal morbidity and provide an initial characterization of its relationship with in-hospital mortality. METHODS:A prospective observational cohort study of all obstetric subjects admitted to the ICU of Kamuzu Central Hospital in Malawi from September 2016 to March 2018. We reviewed charts at the time of ICU admission to assess the indication for admission, clinical characteristics and laboratory values. Subjects were followed until death or discharge. The primary outcome was in-hospital mortality. RESULTS:One-hundred-and-five obstetric patients were admitted to the study ICU (23% of all admissions). The median age was 26?years. The majority (79%) had undergone recent surgery; 40 (52%) an abdominal postnatal or cesarean hysterectomy and 31 (40%) a cesarean delivery without hysterectomy. Ninety-five percent required mechanical ventilation and 48% required vasopressors. Overall in-hospital mortality was 49%. CONCLUSIONS:The proportion of obstetric subjects admitted to the ICU in Malawi is nearly 1 in 4, which exceeds that found in high-income countries by orders of magnitude. Intensive care unit admission was associated with high mortality in this population. Investments in improving infrastructure and care gaps may include addressing available ICU bed and blood-banking needs, and increasing the number of providers trained in managing critical illness among obstetric patients.

SUBMITTER: Prin M

PROVIDER: S-EPMC6626685 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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Obstetric admissions and outcomes in an intensive care unit in Malawi.

Prin M M Kadyaudzu C C Aagaard K K Charles A A

International journal of obstetric anesthesia 20190328

<h4>Background</h4>Despite international commitment to Millennium Development Goal 5, maternal mortality remains high in low- and middle-income countries (LMICs) of sub-Saharan Africa. This is in part due to infrastructure gaps, including availability of intensive care units (ICUs). We sought to use obstetric ICU utilization as a marker of severe maternal morbidity and provide an initial characterization of its relationship with in-hospital mortality.<h4>Methods</h4>A prospective observational c ...[more]

PMID: 31010611

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Project description:IntroductionObstetric intensive care unit admission (ICU) suggests severe morbidity. However, there is no available data on the subject in Ghana. This retrospective review was conducted to determine the indications for obstetric ICU admission, their outcomes and factors influencing these outcomes to aid continuous quality improvement in obstetric care.MethodsThis was a retrospective review conducted in a tertiary hospital in Ghana. Data on participant characteristics including age and whether participant was intubated were collected from patient records for all obstetric ICU admissions from 1st January 2010 to 31st December 2019. Descriptive statistics were presented as frequencies, proportions and charts. Hazard ratios were generated for relations between obstetric ICU admission outcome and participant characteristics. A p-value <0.05 was deemed statistically significant.ResultsThere were 443 obstetric ICU admissions over the review period making up 25.7% of all ICU admissions. The commonest indications for obstetric ICU admissions were hypertensive disorders of pregnancy (70.4%, n = 312/443), hemorrhage (14.4%, n = 64/443) and sepsis (9.3%, n = 41/443). The case fatality rates for hypertension, hemorrhage, and sepsis were 17.6%, 37.5%, and 63.4% respectively. The obstetric ICU mortality rate was 26% (115/443) over the review period. Age ≥25 years and a need for mechanical ventilation carried increased mortality risks following ICU admission while surgery in the index pregnancy was associated with a reduced risk of death.ConclusionHypertension, haemorrhage and sepsis are the leading indications for obstetric ICU admissions. Thus, preeclampsia screening and prevention, as well as intensifying antenatal education on the danger signs of pregnancy can minimize obstetric complications. The establishment of an obstetric HDU in CCTH and the strengthening of communication between specialists and the healthcare providers in the lower facilities, are also essential for improved pregnancy outcomes. Further studies are needed to better appreciate the wider issues underlying obstetric ICU admission outcomes.Plain language summaryThis was a review of the reasons for admitting severely-ill pregnant women and women who had delivered within the past 42 days to the intensive care unit (ICU), the admission outcomes and risk factors associated with ICU mortality in a tertiary hospital in a low-resource country. High blood pressure and its complications, bleeding and severe infections were observed as the three most significant reasons for ICU admissions in decreasing order of significance. Pre-existing medical conditions and those arising as a result of, or aggravated by pregnancy; obstructed labour and post-operative monitoring were the other reasons for ICU admission over the study period. Overall, 26% of the admitted patients died at the ICU and maternal age of at least 25 years and the need for intubation were identified as risk factors for ICU deaths. Attention must be paid to high blood pressure during pregnancy.

Project description:ImportanceIncreased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes.ObjectiveTo determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission.Design, setting, and participantsThis retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019.ExposuresImplementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs.Main outcomes and measuresThe main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission.ResultsA total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217).Conclusions and relevanceImplementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.

Project description:ImportanceHigh health care costs encourage initiatives that avoid overuse of resources and identify opportunities to promote appropriate care.ObjectiveTo investigate the causes of potentially avoidable surgical intensive care unit (SICU) admissions and disposition delays to determine whether targeted interventions could decrease these stays.Design, setting, and participantsThis prospective, observational study focused on potentially avoidable SICU days, as determined by observers with input from the rounding intensivists at a 24-bed open SICU at an urban, academic hospital. The preintervention phase occurred from April 6 through June 21, 2015; after implementation of targeted interventions, the postintervention phase occurred from April 4 through June 28, 2016. Data collected included demographic characteristics, reason for admission, and length of stay. All patients admitted to the SICU during the preintervention and postintervention phases were included in the analysis.InterventionsBased on results collected in the preintervention phase, targeted interventions were designed and implemented from July 1, 2015, through March 31, 2016, including (1) reducing SICU care for minor traumatic brain injury, (2) optimizing postoperative airway management, (3) enhancing communication between services regarding transfers to the SICU, (4) identifying and facilitating more timely end-of-life conversations and supportive care consultations, and (5) encouraging early disposition of patients to floor beds.Main outcomes and measuresChanges in the proportion of potentially avoidable SICU days owing to potentially avoidable admissions and/or disposition delays.ResultsA total of 459 patients (253 men [55.1%] and 206 women [44.9%]; median age, 62 years [interquartile range, 46-75 years]) were admitted during the preintervention and postintervention phases. Of 261 patients admitted during the preintervention period and 245 during the postintervention period, median SICU and hospital length of stay remained unchanged. A reduction was noted in the percentage of postintervention SICU days owing to potentially avoidable admissions (152 of 1168 days [13%] vs 118 of 1338 days [8.8%]; P?=?.001) and disposition delays (138 of 1168 days [11.8%] vs 97 of 1338 days [7.2%]; P?<?.001). During the postintervention period, decreases were noted in the SICU days related to the most common sources of potentially avoidable admissions (SICU stay ?24 hours, airway concerns, and somnolence) and disposition delays (end-of-life decisions and floor bed unavailable) as well as in the overall rate of potentially avoidable days (269 of 1168 days [23%] vs 205 of 1338 days [15.3%]; P?<?.001).Conclusions and relevanceNearly one-fourth of SICU days could be categorized as potentially avoidable. Targeted interventions resulted in a significant reduction of potentially avoidable SICU days.

Project description:IntroductionIntensive care has played a pivotal role during the COVID-19 pandemic as many patients developed severe pulmonary complications. The availability of information in pediatric intensive care units (PICUs) remains limited. The purpose of this study is to characterize COVID-19 positive admissions (CPAs) in the United States and to determine factors that may impact those admissions.Materials and methodsThis is a retrospective cohort study using data from the COVID-19 Virtual Pediatric System (VPS) dashboard containing information regarding respiratory support and comorbidities for all CPAs between March and April 2020. The state-level data contained 13 different factors from population density, comorbid conditions, and social distancing score. The absolute CPA count was converted to frequency using the state's population. Univariate and multivariate regression analyses were performed to assess the association between CPA frequency and admission endpoints.ResultsA total of 205 CPAs were reported by 167 PICUs across 48 states. The estimated CPA frequency was 2.8 per million children in a one-month period. A total of 3,235 tests were conducted of which 6.3% were positive. Children above 11 years of age comprised 69.7% of the total cohort and 35.1% had moderated or severe comorbidities. The median duration of a CPA was 4.9 days (1.25-12.00 days). Out of the 1,132 total CPA days, 592 (52.2%) involved mechanical ventilation. The inpatient mortalities were 3 (1.4%). Multivariate analyses demonstrated an association between CPAs with greater population density (beta coefficient 0.01, p < 0.01). Multivariate analyses also demonstrated an association between pediatric type 1 diabetes mellitus with increased CPA duration requiring advanced respiratory support (beta coefficient 5.1, p < 0.01) and intubation (beta coefficient 4.6, p < 0.01).ConclusionsInpatient mortality during PICU CPAs is relatively low at 1.4%. CPA frequency seems to be impacted by population density. Type 1 DM appears to be associated with increased duration of HFNC and intubation. These factors should be included in future studies using patient-level data.

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Obstetric admissions and outcomes in an intensive care unit in Malawi.

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Obstetric admissions and outcomes in an intensive care unit in Malawi.

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