Introduction: Trauma is the fourth leading cause of death globally and constitutes a huge burden on limited critical care resources. Aim This study aimed to identify the trauma patient burden in terms of resources used in the surgical intensive care unit (SICU) of Aga Khan University Hospital in Pakistan which also included characteristics and outcomes of trauma and non-trauma patients.Methods: We retrospectively reviewed all patient data for adult patients (\u3e16 years old) admitted to the SICU from July through December 2014.Results: Of 141 SICU cases included in our study period, 32 (22.7%) trauma patients were identified. On further stratification of trauma patients, road traffic injuries (43.8%), gunshot injuries (43.8%), and blast injuries (6.3%) were the most common, and about 73% of all trauma patients underwent emergency surgical interventions, comprising a huge burden on all resources. The average age of the trauma patients was significantly lower than non-trauma patients (36 years ± 13 vs. 49 years ± 19; p \u3c 0.01). The male-to-female ratio was 7:1 in trauma cases and 2:1 in non-trauma cases (p = 0.019). There was no statistically significant difference in mortality (31.3% vs. 42.2% p \u3e 0.05) and median length of stay [Median (interquartile range), 5(8) vs. 4(7); p \u3e 0.05] between trauma and non-trauma patients.Conclusions: Trauma constitutes a significant burden in terms of resources used for the SICU of the Aga Khan University, Pakistan. Trauma victims are predominantly young men in whom gunshot injuries are as common as road traffic injuries. Emergency surgical interventions comprise the largest draw on resources, followed by use of blood products, radiological, and laboratory investigations

Hashmi, Madiha

Rizwan, Muhammad

Zafar, Hasnain

English

eCommons@AKU

eCommons@AKUDepartment of Anaesthesia Medical College, PakistanAugust 2018A six-month retrospective study of resourcesburden by trauma victims in the surgical intensivecare unit of a university hospital in PakistanMuhammad RizwanKing Faisal Specialist Hospital and Research Center, Riyadh, SAU.Madiha HashmiAga Khan University, madiha.hashmi@aku.eduHasnain ZafarAga Khan University, hasnain.zafar@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesiology Commons, and the Surgery CommonsRecommended CitationRizwan, M., Hashmi, M., Zafar, H. (2018). A six-month retrospective study of resources burden by trauma victims in the surgicalintensive care unit of a university hospital in Pakistan. Cureus, 10(8), e3236.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/353Received 06/15/2018 Review began  07/25/2018 Review ended  08/28/2018 Published 08/30/2018© Copyright 2018Rizwan et al. This is an open accessarticle distributed under the terms ofthe Creative Commons AttributionLicense CC-BY 3.0., which permitsunrestricted use, distribution, andreproduction in any medium,provided the original author andsource are credited.A Six-month Retrospective Study ofResources Burden by Trauma Victims in theSurgical Intensive Care Unit of a UniversityHospital in PakistanMuhammad Rizwan  , Madiha Hashmi  , Hasnain Zafar 1. Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Center Riyadh (SaudiArabia), Riyadh, SAU 2. Anaesthesiology, The Aga, Karachi , PAK 3. Surgery, Aga Khan UniversityHospital, Karachi, PAK Corresponding author: Muhammad Rizwan, doctor_rizwan@yahoo.com Disclosures can be found in Additional Information at the end of the articleAbstractIntroductionTrauma is the fourth leading cause of death globally and constitutes a huge burden on limitedcritical care resources.AimThis study aimed to identify the trauma patient burden in terms of resources used in thesurgical intensive care unit (SICU) of Aga Khan University Hospital in Pakistan which alsoincluded characteristics and outcomes of trauma and non-trauma patients.MethodsWe retrospectively reviewed all patient data for adult patients (>16 years old) admitted to theSICU from July through December 2014.ResultsOf 141 SICU cases included in our study period, 32 (22.7%) trauma patients were identified. Onfurther stratification of trauma patients, road traffic injuries (43.8%), gunshot injuries (43.8%),and blast injuries (6.3%) were the most common, and about 73% of all trauma patientsunderwent emergency surgical interventions, comprising a huge burden on all resources. Theaverage age of the trauma patients was significantly lower than non-trauma patients (36 years ±13 vs. 49 years ± 19; p < 0.01). The male-to-female ratio was 7:1 in trauma cases and 2:1 innon-trauma cases (p = 0.019).There was no statistically significant difference in mortality (31.3% vs. 42.2% p > 0.05) andmedian length of stay [Median (interquartile range), 5(8) vs. 4(7); p > 0.05] between trauma andnon-trauma patients.ConclusionsTrauma constitutes a significant burden in terms of resources used for the SICU of the AgaKhan University, Pakistan. Trauma victims are predominantly young men in whom gunshotinjuries are as common as road traffic injuries. Emergency surgical interventions comprise the1 2 3 Open Access OriginalArticle  DOI: 10.7759/cureus.3236How to cite this articleRizwan M, Hashmi M, Zafar H (August 30, 2018) A Six-month Retrospective Study of Resources Burdenby Trauma Victims in the Surgical Intensive Care Unit of a University Hospital in Pakistan. Cureus 10(8):e3236. DOI 10.7759/cureus.3236largest draw on resources, followed by use of blood products, radiological, and laboratoryinvestigations.Categories: Anesthesiology, Emergency Medicine, Internal MedicineKeywords: intensive care, resources use, developing country, traumaIntroductionTrauma is a worldwide public health problem and the fourth leading cause of death in thewestern world, especially in young people (i.e., those under 40 years old). Severe trauma cases,although small in number, may need urgent lifesaving interventions, damage control surgicalinterventions or life-sustaining organ support in an intensive care unit (ICU), consumingsignificant resources and causing a huge economic burden to the patient, healthcare system,and society [1].The 48-bed state-of-the-art Emergency Department at Aga Khan University Hospital is a WorldHealth Organization Collaborating Center for Trauma and handles around 60,000 patientsannually. The surgical ICU (SICU) has a capacity of seven beds, and major trauma victimsrequiring close monitoring or organ support with or without surgical intervention comprise30% of surgical admissions.We conducted a retrospective study from July to December 2014 to determine the characteristicsof patients admitted to the SICU secondary to traumatic injuries and highlighted the criticaltherapeutic interventions, advanced radiological procedures, and laboratory and bloodproducts utilized during their stay. This study also looked at the type of trauma, the source ofadmission, length of stay, and outcomes.The impact of trauma on our limited resources of time, critical therapeutic interventions,advanced radiological interventions, laboratory workload, and blood product utilization has notbeen documented in Pakistan. This study emphasizes the resources required to safely andefficiently manage critically ill trauma patients and can be used to plan future traumamanagement facilities and improve the care of major trauma patients in our country in acomprehensive way.Materials And MethodsThis study was conducted retrospectively in period already mentioned. After receiving theEthical Review Committee’s exemption for approval, all patients over age 16 years admittedduring the study period were included.Patient medical records were reviewed for age, gender, diagnosis, the source of admission,length of stay, and outcome.The above record also confirmed by the patient care inquiry (PCI) system on a remote desktopprogram on the intranet maintained by the Health Information Management Service. The PCIsystem further maintains data that includes a source of admission, types of trauma, and otherresources used by patients in the SICU like surgical interventions, insertion of artificial airways,mechanical ventilation, invasive lines, renal replacement therapies (continuous renalreplacement therapy), tube feeding, noninvasive ventilation, and laboratory investigations.2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 2 of 9The specific interventions outside the SICU such as magnetic resonance imaging (MRI),computed tomography (CT) scans, and ultrasound imaging were obtained from the PCI systemas well. Blood and blood product use data were produced by the Pathology department onspecial request based on trauma patient medical records identification numbers.Statistical analyses were performed using SPSS for Windows, Version 16.0 (SPSS Inc., Chicago,IL). The frequency and percentage were computed for qualitative observation and analyzed bychi-square test. The mean and standard deviation (SD) were estimated for quantitativeobservation and analyzed by t-test. The Mann-Whitney U-test was used for data that was notnormally distributed. P ≤ 0.05 was considered statistically significant.ResultsA total of 141 SICU admissions were reviewed for the six-month study period. Of those, 22.7%(32/141) were trauma patients. The average age of the trauma patients was 35 ± 13 years. Themale-to-female ratio was 7:1 in the trauma cases. The overall mortality of the SICU was 39.7%,and the mortality for the trauma patients was 31.3%; the difference in mortality was minimal.The median length of stay was five days (interquartile range [IQR], eight days) as shown inTable 1.Variables Trauma n = 32 Non-Trauma n = 109 P-ValueAge (Years) 36 ± 13 49 ± 19 0.0005Gender (male/female)28/4 72/370.01987.5%/12.5% 66.1%/33.9%Length of stay (days) 19.34 ± 14.09 17.43 ± 18.15 0.58Outcome (Alive/Death)22/10 63/460.2668.8%/31.3% 57.8%/42.2%TABLE 1: Comparison of outcomes between trauma and nontrauma patients (n = 141).Figure 1 compares the incidence of the major types of trauma for admitted SICU patients.Gunshot and road traffic injuries were the most common reasons with equal incidences,followed by injuries from blasts, burns, and falls.2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 3 of 9FIGURE 1: Type of trauma (n = 32).RTI: Road traffic injuries.Figure 2 compares the sources of admission to the SICU. Most trauma patients in the SICUarrived from the operating room, while a smaller percentage of trauma patients arrived from theward, emergency room, and special care unit (SCU).FIGURE 2: Sources of admission (n = 32).OR: Operating room; ER: Emergency room; SCU: Special care unit.2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 4 of 9Approximately 75% of all trauma patients underwent surgical interventions, whether before orafter the admission, and only 3% of those were elective. The remaining 72% had emergencysurgical procedures, which is a huge proportion and a major draw on resources.Figure 3 presents the percentage of nonsurgical therapeutic interventions for all traumapatients in the study. Mechanical ventilatory support was the most prominent (96.9%) followedby intubation (87.5%).FIGURE 3: Therapeutic interventions in patients with trauma (n= 32).CVC: Central venous catheterization; CRRT: Continuous renal replacement therapy; NIV:Noninvasive ventilation; MV: Mechanical ventilation.Table 2 presents the number of the patients who used blood products. The number of packedred blood cell (PRBC) units was the most commonly used blood product, and only two patientsused a large amount of cryoprecipitate.2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 5 of 9Blood product Number of patients (%) Median Max-MinPRBC 19 (59%) 11 79-1FFP 11 (34%) 22 105-10Platelets 12 (38%) 14.5 48-2Cryoprecipitates 2 (6%) 57 100-54TABLE 2: Blood product use in trauma patients (n = 32).PRBC: Packed red blood cell; FFP: Fresh frozen plasma.Table 3 presents the number of advanced radiology investigations. CT scans were the mostcommon advanced radiologic diagnostic tool for trauma patients.Radiology TotalNumber of Radiology/Patients1 2 3 4CT 31 9 9 9 4MRI 5 4 1 NA NAUS 19 11 8 NA NATABLE 3: Major radiological procedures in trauma patients (n = 32).CT: Computed tomography; MRI: Magnetic resonance imaging; US: Ultrasonography; NA: Not applicable.The common laboratory investigations in terms of numbers of times performed are presentedin Table 4.2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 6 of 9Test Mean frequency of test performance (SD) Minimum MaximumCBC 17.03 (13.87) 3 60BUN 16.56 (14.85) 2 58Creatinine 18.69 (17.17) 2 70Electrolytes 21.44 (18.14) 3 72PT (s) 11.75 (12.81) 1 51APTT (s) 11.41 (12.80) 1 51LFT 1.31 (2.28) 0 8ABGs 18.13 (18.78) 1 77Lactic acid 2.09 (2.41) 0 8Procalcitonin 0.00 (0.00) 0 0Blood CS 4.28 (4.62) 0 16Tracheal CS 1.06 (2.14) 0 8Urine CS 1.81 (1.75) 0 7TABLE 4: Frequency of laboratory investigations in trauma patients (n = 32).CBC: Complete blood count; BUN: Blood urea nitrogen; PT: Prothrombin time; APTT: Activated partial thromboplastin time; LFT:Liver function test; ABG: Arterial blood gas; CS: Cultures.The electrolyte measurement test had the highest mean frequency (performed 21.44 times; SD,18.14) followed by creatinine, arterial blood gas, complete blood count, and blood ureanitrogen.DiscussionThe ICU is the main stem of every tertiary health care center where the sickest patients aregiven organ support and require a high degree of resources. We studied the use of resources bytrauma patients in some detail in an SICU and found road traffic injuries (14/32) and gunshotwounds (14/32) were the two most common reasons for admission (comprising 87.5% of theworkload). The average mortality was 39.7% in both trauma and non-trauma patients.Abubakar et al. performed a similar study in a combined ICU of a developing country. Most ICUadmissions in their study (90.3%) were related to surgical specialties, of which trauma cases(45.6%) were most common [2]. Their reported incidence was higher than ours (22.7%), andthey had a 65% survival and 35% deaths with an overall mortality rate of 35%, which wassimilar to our findings.Chalya et al. reported a higher incidence of trauma cases (37.1%) compared to our study but a2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 7 of 9similar male-to-female ratio of 5.5:1 compared to our 7:1. Road traffic crash was the mostcommon cause of injuries in their study, affecting 70.8% of patients and of those, 68.6%required surgical intervention [3]. In our study, gunshot and road traffic had the highestincidence rate (43.8% each). We found similar mortality rates between trauma (31.3%) andnontrauma patients (42.2%; P = 0.26), whereas Chalya et al. reported trauma patients had asignificantly higher mortality rate than that of all ICU admissions (32.7% vs. 18.8%,respectively; P = 0.0012) [3].Radjou et al. found road traffic injuries caused the highest mortality (84%) which is acorrelation of the patient admitted and type of injury. Our admitted trauma patients mostconsisted of road traffic injuries and gunshots wounds (87.5%) [4].PRBC use was the most prominent in our study (59%). A study from a developed country with alarge study population in an acute care inpatient setting reported 4805 (5.3%) patients receivedat least one unit of PRBCs [5]. However, blood and blood products should be used according tohospital guidelines [6].While our radiological data may not have presented conclusive information, radiology use is acontributing factor in the overall burden on resources, especially given only trauma patientsused these resources. One major study reported the overall rate of advanced imaging utilizationdecreased significantly from 172 per 100 ICU admissions in 2007 to 149 per 100 ICU admissionsin 2011 (p = 0.012) [7]. The authors report the change was likely attributable to a major decreasein the use of CT (Poster Session, Epidemiology/Outcomes: Jarone L, Geyer B, Kaafarani H:Trends in Advanced Imaging Utilization in Intensive Care Units at Two Major AcademicHospitals. Critical Care Medicine, 2013, 41:12. 10.1097/01.ccm.0000439811.28707.44).Lee and Maslove reported a decline in the expected amount of novel information provided bylaboratory testing [7]. The Canadian Agency of Drug and Technologies for Health conducted arapid response report for daily blood testing in the ICU from five nonrandomized studies (NRS).Three of the five NRS showed the number of routine laboratory tests decreased significantly,resulted in less anemia and substantial cost savings without compromising patient outcomes[8].Given our study only used six months of data, we could not infer the utility of daily routinelaboratory testing. However, the utility of laboratory testing is worth exploring when evaluatingareas to reduce wasted resources.We were unable to collect data on the cost of different variables, and our study period of sixmonths was too brief to determine meaningful trends. Nevertheless, considering this firsteffort in our country, this study represents a meaningful opportunity to further explore anddocument new protocols and policies in our many hospitals.ConclusionsTrauma patients constitute a significant burden in terms of resources used for the SICU of AgaKhan University Hospital. Most trauma victims are young men suffering from either gunshot orroad traffic injuries. Emergency surgical interventions are the largest burden on hospitalresources, followed by blood product use, radiological resources, and laboratory investigationresources. By understanding the major sources of burden on hospital resources, importantchanges to policies and guidelines can be discussed by lawmakers and health care providers.Some changes, including the availability of firearms, vehicle safety precautions, driver skills,and traffic laws require input from policymakers outside of the health care system.2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 8 of 9Additional InformationDisclosuresHuman subjects: Consent was obtained by all participants in this study. Ethical ReviewCommittee, Aga Khan University Hospital, Karachi, Pakistan issued approval 3222-ANA-ERC-14. PI, Muhammad Rizwan. This study was approved exemption from ethical approval on 22ndSep, 2014, with slight different title which I changed on mutual understanding of my co-authorand supervisor of fellowship Dr. Madiha Hashmi. A copy of exemption approval can beproduced on demand. Animal subjects: All authors have confirmed that this study did notinvolve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniformdisclosure form, all authors declare the following: Payment/services info: All authors havedeclared that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships atpresent or within the previous three years with any organizations that might have an interest inthe submitted work. Other relationships: All authors have declared that there are no otherrelationships or activities that could appear to have influenced the submitted work.References1. Chaira O, Cimbanissi S: Organized trauma care: does volume matter and do trauma centerssave lives?. Curr Opin Crit Care. 2003, 9:510-514. 10.1097/00075198-200312000-000082. Abubakar AS, Ojo EO, El-Nafaty AU, Edomwonyi NP: An audit of one-year intensive carepractice in a developing country. Int J Anesthesiol. 2007, 18:1-5.3. Chalya PL, Gilyoma JM, Dass RM, et al.: Trauma admissions to the Intensive care unit at areference hospital in Northwestern Tanzania. Scand J Trauma Resusc Emerg Med. 2011, 19:61.10.1186/1757-7241-19-614. Radjou AN, Balliga DK, Pal R, Mahajan P: Injury-related mortality audit in a regional traumacenter at Puducherry, India. J Emerg Trauma Shock. 2012, 5:42-48. 10.4103/0974-2700.931115. Trentino KM, Farmer SL, Swain SG, et al.: Increased hospital costs associated with red bloodcell transfusion. Transfusion. 2015, 55:1082-1089. 10.1111/trf.129586. Klein AA, Arnold P, Bingham RM, et al.: AAGBI guidelines: the use of blood components andtheir alternatives 2016. Anaesthesia. 2016, 71:829-842. 10.1111/anae.134897. Lee J, Maslove DM: Using information theory to identify redundancy in common laboratorytests in the intensive care unit. BMC Med Inform Decis Mak. 2015, 15:59. 10.1186/s12911-015-0187-x8. Canadian Agency for Drugs and Technologies in Health: Routine blood tests for patients inthe intensive care unit: clinical effectiveness, cost-effectiveness, and guidelines. CADTH.2013, Accessed: May 31, 2018: https://www.cadth.ca/media/pdf/htis/aug-2013/RB0607%20Routine%20tests%20in%20ICU%20Final.pdf.2018 Rizwan et al. Cureus 10(8): e3236. DOI 10.7759/cureus.3236 9 of 9

A six-month retrospective study of resources burden by trauma victims in the surgical intensive care unit of a university hospital in Pakistan

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1352&amp;context=pakistan_fhs_mc_anaesth

A six-month retrospective study of resources burden by trauma victims in the surgical intensive care unit of a university hospital in Pakistan

Abstract

Similar works

Full text

Available Versions

eCommons@AKU