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Half the number of ICU patients in public hospitals die: Study

Wednesday February 20 2019

emergency response

A shooting victim in Mandera being prepared ready for the long journey to Nairobi for specialised treatment. Medical care must start from when the health worker meets the patient and not at the ICU PHOTO | FILE | NATION MEDIA GROUP 

By ELIZABETH MERAB
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At some point in life, one will most likely end up in an ambulance. It is this quick intervention or lack of it that determines if we live or not.

Now, imagine you do not get it. This, unfortunately, is the fate of many patients in Kenya.

A survey by a team of doctors shows that half the number of patients receiving critical care in public hospitals die.

A study at Moi Teaching and Referral Hospital found that 54 per cent of patients taken to the intensive care unit did not survive.

SURVIVAL CHANCES

This high death rate, the study found, is at par with similar hospitals in resource-limited settings worldwide.

The researchers included Ms Wangari Waweru-Siika, then the head of the MTRH intensive care unit and Mr Protus Kituyi, the chairman of the Department of Anesthesia at the Moi University School of Medicine.

The “Intensive Care Outcomes and Mortality Prediction at a National Referral Hospital in Western Kenya” was published in the National Institutes of Health journal in November.

Whereas the ICU at the hospital has undergone improvements, the study said the workers are stretched thin. The unit has relatively modern equipment, experienced nurses and physicians. It is capable of advanced therapy.

“MTRH has less than one ICU bed per 100 hospital beds, compared with an average of nine ICU beds in the United States,” Peter Kussin, the co-principal investigator and professor of medicine at Duke Global Health Institute, said.

Essential interventions are not consistently available and a shortage of ICU beds keeps some critically ill patients in the wards for too long, leading to irreversible clinical deterioration.

The authors say events that take place before patients arrive at the ICU play a big role on their survival chances.

INTERVENTIONS

Prof Kussin says a strong support among Kenyans to increase ICU bed capacity would provide only a partial solution to the problems leading to poor critical care outcomes.

“While it is important to expand ICU resources, it is also crucial to examine and address the challenges in the pre-ICU setting that contribute to high mortality among patients,” he said.

There are just 106 ICU beds in public hospitals across the country, but only 42 can take care of patients whose lives are at risk.

He also takes issue with the inadequate emergency transport from outlying hospitals, delays in administering antibiotics and other critical interventions.

Dr Benjamin Wachira, an assistant professor of emergency medicine at Aga Khan University Hospital, Nairobi says while challenges in the ICU contribute to deaths, what happens before a patient arrives may have just as much, if not more, impact on the outcome.

Dr Wachira argues that a number of patients in the ICU are often attended to by medical officers, anaesthetists and nurses who are not trained to offer critical care.

“An ICU is more than a bed, a ventilator and a monitor. You need a room that is well equipped and has infection control. Many people think the sophisticated equipment in private hospitals are decoration. They are not. They are supposed to keep the patient alive. That is why public hospitals record many deaths,” Dr Wachira said.

Ideally, an ICU room should have negative pressure. Some public hospitals do not have such. As a result, patients in ICU die from infections picked at the hospital, and not necessarily what took them there, the study continues.

EVALUATION

Patients are placed in negative pressure rooms to reduce the risk of airborne infections.

“When, for instance, you put a patient with a head injury whose brain tissue is leaking in the ICU, knowing very well he will not recuperate, he becomes a petridish of infections,” Dr Wachira added.

Hospitals in Kenya also lack formalised triage protocols, further contributing to deaths in the ICU.

At MTRH, like many other public hospitals in Sub-Sahara, admission to the ICU generally is on a first-come, first-served approach, reducing the chances of survival, the authors note.

“Often, people are admitted to the ICU very late in their illness, and by most evidence-based criteria, they will not benefit from the care,” Prof Kussin said.

“They end up languishing in the ICU. Unfortunately, others who would benefit from critical care don’t.”

Since ICU outcomes at public hospitals are unknown — but could potentially be high — he says it is important to expand resources.

"It is also crucial to examine and address the challenges in the pre-ICU setting that contribute to high mortality rates," the report says.

“No one leaves home or even an accident scene straight to the ICU. The ICU is not the first point of care but the last. It is where continuation of treatment is given. It is not the start of care like what our system does,” Dr Wachira said.

In South Africa, doctors determine which patient goes to the ICU after an evaluation.

Medical care must start from when the health worker meets the patient and not at the ICU, the study says.

It includes pre-hospital care, stabilising the patient and arranging for referral in cases where the health provider or the first call does not have the necessary facilities.

DE-ESCALATED

“Patients need to be evaluated before being referred to the ICU. Unfortunately, our system is not designed this way,” Dr Wachira said.

He is, however, quick to add that hospital leadership and health researchers must take cultural factors into account when thinking about developing triage and patient management protocols.

Stroke patients, for example, have up to four hours to receive therapy. If they do not get the treatment within the required time, they end up paralysed.

“Every hour a health worker delays administering antibiotics to a patient in septic shock, the chances of dying increase by 7.4 per cent. By the time this patient is being transferred to the ICU, it may be too late to save him. That is why the care the patient receives at the point of contact is crucial,” Dr Wachira said.

Some factors contributing to the high death rate of patients are beyond the scope of health workers, the study goes on.

Dr Wachira says Kenya lacks properly laid down procedures and laws that can guide and protect health workers when they have to make the decision to de-escalate the care provided to a patient.

He says the challenge contributes to congestions in hospitals by patients whose recovery is highly unlikely.

Ideally, patients who can survive should be referred to the ICU while those whose survival chances are less than one per cent should be given de-escalated care.

“A child diagnosed early with pneumonia will spend two or three days in the ICU after which she will be transferred to the general wards. Compare that with a patient brought in with a gunshot wound to the head with brain tissue leaking. The latter will not survive, even if he still has a heartbeat. In Kenya, patients who are unlikely to recover are stuffed in the ICU,” Dr Wachira said.