Outcomes of critically ill trauma patients associated with missed ICU admission at Mulago National Referral Hospital

Abstract

Trauma is the 6th leading cause of mortality globally with more than 90% is in Africa. It’s a significant cause of admission in Ugandan hospitals and outcomes are largely negative as compared to high income countries. This is due to lack of critical care services for trauma patients of whom missed critical care opportunities are more than 35%. This study informs policy and practice on the status of critical care needs for trauma patients in similar settings. Objective: To determine the outcomes of critically ill trauma patients associated with missing ICU admission at Mulago National Referral Hospital (MNRH). Methods: This was a prospective cohort study of critically ill adult trauma patients admitted to MNRH Accidents and Emergency (A&E) unit. Participants were enrolled consecutively at presentation and followed up for mortality within 24 hours and 30 days. Multinomial logit regression was used to evaluate the association of missed ICU admission with mortality. Generalized Linear Model with a gaussian family and a log link was used to evaluate the association of patients who missed ICU admission with length of stay. Ethical approval was obtained from the School of Medicine Research and Ethics committee. Results: In-hospital mortality within 24 hours was observed in 160 (44.1%) of the patients who missed ICU admission, when compared to 4 (14.8%) of those admitted into ICU. The median survival time for critically ill trauma patients who missed ICU admission was 1.5 days compared to 19 days for those who got admitted into ICU. Patients admitted into ICU had a 90% increase (adjusted exp(β) = 1.90, 95% CI: 1.29-2.82, p-value = 0.001) in the length of stay when compared to those who missed ICU admission. Missing ICU admission multiplied the relative risk of death within 24 hours 8.9 times (adjusted RRR = 8.90, 95% CI: 2.64-29.98, p-value = <0.001) compared to being admitted to ICU. Conclusion: Missing ICU admission is associated with a 3-fold increase in in-hospital mortality. The leading causes of in-hospital mortality were traumatic brain injury, hemorrhagic shock, and hypoxia. Expansion of critical care capacity (including possibilities of establishing a dedicated trauma ICU) is needed to accommodate the increased burden of critical illness from trauma which may reduce mortality and morbidity.