Clinical Audit of Cases and Outcomes of Patients Admitted to the Intensive Care Unit at Kamuzu Central Hospital, Lilongwe, Malawi

Clinical Audit of Cases and Outcomes of Patients Admitted to the Intensive Care Unit at Kamuzu Central Hospital, Lilongwe, Malawi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Clinical Audit of Cases and Outcomes of Patients Admitted to the Intensive Care Unit at Kamuzu Central Hospital, Lilongwe, Malawi Akim Nelson Bwanali, Leonard Munthali, Upile Napolo, Adriano Focus Lubanga, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4242898/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Aug, 2024 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract In 2016 a new, improved and modern intensive care unit was constructed at Kamuzu Central Hospital in Lilongwe, Malawi. Having been operational for about 4 years, there has not been a systematic audit to gauge its performance. Therefore, this a quantitative retrospective cohort study aimed at investigating the performance of the intensive care unit at Kamuzu Central Hospital in Lilongwe, Malawi. We analysed the patterns of admission through 250 clinical cases and their respective outcomes spanning from 1st January 2019 to 31st December 2019 using STATA. Descriptive and inferential statistics were computed. Out of the 250 admissions, we evaluated 249 samples. About 30.8% of all patients were referred from the main operating theatre, 20.7% from the casualty and 10.5% from maternity high dependence unit. Head injury (26.7%) and peritonitis (15.7%) were the commonest causes of admission. The overall mortality was 52% with more females (57.5%) dying than males (47.9%). Head injury and peritonitis had the highest contribution to the mortality accounting for 25.3% and 16.9% of all deaths respectively. In conclusion, the intensive care unit registered an improved performance compared to previous years. However, it is still grappling with a number of challenges that need immediate attention including few working beds, shortage of critical care specialists and nursing staff and lack of standard admission criteria. Health sciences/Diseases Health sciences/Health care Critical care Intensive Care Unit ICU Malawi Figures Figure 1 Figure 2 Figure 3 Figure 4 1.1 Introduction An Intensive Care Unit (ICU) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care. It harbours enhanced capacity for monitoring, and multiple techniques for physiologic organ support such as mechanical ventilation to sustain life during a period of life-threatening organ system insufficiency [ 1 ]. To function optimally, such an ICU must be complemented with a good infrastructure, consistent supply of drugs, advanced medical equipment and well trained personnel [ 2 ]. Since the onset of critical care provision, the global community has witnessed dramatic improvements in recovery of those with critical illnesses and injuries [ 3 ]. This is precisely true for developed countries whose resources enable ICUs to function optimally [ 4 ]. Developing countries, in contrast, often fail to operationalize the same high quality of care [ 3 – 5 ]. In sub-Saharan Africa (SSA), ICUs often run on limited equipment and healthcare providers usually with no specialized training in critical care [ 5 ]. These differences on the quality of critical care provision between developed and developing countries have led to profound differences. Not surprising, their ICUs register mortality rates as low as 8% in comparison to 64% as reported by other low-income country studies [ 6 – 8 ]. Unfortunately there is limited data on impact that subpar critical care is having on the performance of the whole health sector [ 9 ]. Mortality and outcomes of ICU admission have been variable across studies in Africa. For instance, a Ugandan found an overall mortality of 25% in comparison to 41% found in Tanzania [ 3 , 10 ]. Multiple studies in sub Saharan Africa have reported numerous factors associated with poor outcomes in ICU which include advanced age, urgency of admission and development of in-hospital complications [ 11 – 14 ]. The challenges and poor critical care performance highlighted above could be heightened in Malawi due to an especially increased demand of critical care to provide for the rapidly growing population, thereby placing a further burden on the already strained healthcare workforce. However, there is limited local data on factors that influence outcome of patients admitted to the ICU in Malawi. Malawi built her first 5 bed ICU in 1990, at Kamuzu Central Hospital (KCH)[ 16 ]. In 2016, the ICU at KCH was transferred to a new building with more space, beds and equipment, to cater for the population of the central region. The new ICU has 8 beds with 1 presidential suite bed against a total number of 1200 hospital beds within KCH thus allocating 0.7% of the beds to critical care for a population of 7,523,340 in the Central Region of Malawi [ 17 ]. A previous study at KCH showed that the ICU admits an average of 22 patients per month with 5 functional beds a time due to limited staff. Alarmingly, one study in 2012 at KCH ICU revealed a general mortality of 60.9% with sepsis as the commonest causes of death [ 18 ]. Since commencement of the newly constructed ICU there is no systemic study done to assess its performance and ascertain any improvement from the old ICU. Therefore, we aimed to assess clinical outcomes of patients and commonest causes of mortality for patients admitted at KCH ICU. 1.2 Materials and methods 1.2.1 Study setting This study was conducted at Kamuzu Central Hospital newly built Intensive Care Unit described above. It is the ICU that caters for the population of the Central Region of Malawi. 1.2.2 Study design This was a descriptive cross-sectional study conducted at KCH ICU. We aimed to review 250 case files of patients ever admitted in this ICU between January 2019 and December 2019. They were conveniently sampled. 1.2.3 Data collection All data was collected by the primary investigators for the study (ANB, LM and UN). The data collection period span from 1 September, 2021 to 14th September 2021.We collected data from the ICU register book onto a case reporting form. Variables included patient’s code number (that we assigned), referring unit, age, sex, diagnosis, interventions done, length of admission and their outcome. The length of stay in the ICU was measured in calendar days based on the admission and discharge dates. Further, we had an interview with the head of the ICU to understand operational matters with the ICU. 1.2.4 Data management and analysis The data was then leaned and transferred to an Excel 2016 electronic file which was kept on a password secured personal laptop and backed up on a secure online drive. We employed descriptive statistics to describe our sample. Categorical variables were summarized into frequencies and percentages and presented in frequency distribution tables, graphs and pie charts. Continuous data was summarized as means, standard deviations and medians and further summarized and displayed into frequency polygons/histogram. Comparison of categorical variables was performed using Chi squared test. Correlation between the variables were tested using the Pearson correlation co-efficient. A P-value of less that 0.05 was considered significant. Statistical analyses were conducted using STATA 16. 1.2.5 Ethical considerations The Approval to conduct the study was obtained from Kamuzu University of Health Sciences research and ethics committee. Further approval was obtained from the hospital director and the Head of ICU at Kamuzu Central Hospital. The study was conducted in accordance to the ethical rules and regulation as stipulated in the KUHES ethics guidelines. The need of informed consent was waived by KUHES research ethics since the study did not involve any physical interaction with the patient. The study has no anticipated risk, as it involved secondary analysis of routinely collected data. To ensure confidentiality and anonymity, we de-identified and disaggregated the data. Only the primary researchers accessed the data. 1.3 Results 1.3.1 Characteristics of the ICU KCH has an 8 bed capacity ICU with only 5 operational beds to serve a population of 7,523,340 in the central region of Malawi [ 17 ]. This creates a ratio 1 bed available for every 1.5 million people. The ratio of the ICU beds to the total number of hospital beds at is 1:150. The unit is currently being run by the head of the anaesthesia department. However, there is no intensivist. At any point in time, there is a clinician/anaesthetist on call and 5 nurses on duty. Thus a nurse to patient ratio of 1:1 is usually maintained. Among the 21 nurses allocated to the ICU only one of them underwent special critical care training. Additionally, there is no established team that carries out ward rounds. As such, the referring units periodically come to evaluate their respective patients. Each ICU bed has a ventilator, perfuser, an infusion pump, a multi-parameter monitor and an oxygen concentrator. A defibrillator and a 12-lead ECG are available for use at any bed needed. However, the ICU does not have the following; a portable X-ray, an ultrasound machine and an arterial blood gas analyser. 1.3.2 Demographic profile A total of 250 case files for patients of all age groups admitted to the ICU in a period spanning from January 1st, 2019 to December 31st, 2019 were reviewed. Males made up 57% of the cases (Table 1 ). The age of the patients ranged from less than 1 to 87 with a mean of 30 ± 18.4 years and had a mean length of admission of 4.93 + 5.06 days. Of the 250 cases, some patients had missing variables. 0.4% were missing sex, another 0.4% had no outcome recorded, 0.8% had undocumented age, 1.2% did not have referring unit and another 1.2% did not have diagnosis The commonest diagnoses at admission were head injury and peritonitis which contributed 26.7% and 15.7% respectively (Fig. 1 ) . Most of the patients were referred from the main operating theatre (30.8%), followed by the Casualty (20.7%) and the Ethel Mutharika (EM) Maternity High Dependency Unit (HDU) (10.5%) (Fig. 2 ). Most of the patients required mechanical ventilation (90.8%). A smaller proportion were given catecholamines (24.8%) and an even smaller proportion underwent Cardiopulmonary Resuscitation (CPR) (2.4%). Over half of the admissions took place in the second half of the year (54.4%) (Fig. 3 ). 1.3.3 Treatment outcomes The study revealed an in-ICU mortality rate of 52%. The mortality was higher amongst females with a mortality rate of 57.5% (compared to 47.9% in males) (Table 1 ) Cardiac arrest and pulmonary oedema were conditions with the highest in-ICU mortality of over 70% each. However, head injury and peritonitis had the highest contribution to the mortality accounting for 25.3% and 16.9% of all deaths respectively. The highest mortality rate was observed in those older than 50 years (65.1%) and the paediatric group (62.5%) (Fig. 4 ) Table 1 Patient characteristics and outcomes VARIABLE TOTAL (%) DIED (%) P VALUE All admissions 249 (100) 130 (52.2) Sex (n = 249) 0.132 Male 142 (57) 68 (47.9) Female 107 (43) 61 (57.5) Age in years (n = 248) 0.067 Under 5 24 (9.7) 14 (58.3) 5–17 32 (12.9) 20 (62.5) 18–29 72 (29.0) 29 (40.3) 30–49 77 (31.1) 39 (50.6) Above 50 43 (17.3) 28 (65.1) Referring unit (n = 247) 0.132 Main OT 76 (30.8) 33 (43.4) Casualty 51 (20.7) 26 (51.0) EM HDU 26 (10.5) 11 (42.3) Surgical HDU 24 (9.7) 12 (50.0) Paediatric HDU 16 (6.5) 12 (75.0) EM OT 11 (4.5) 5 (45.5) Medical short stay 7 (2.8) 5 (71.4) EM Maternity wing 7 (2.8) 3 (42.9) Medical HDU 4 (1.6) 3 (75.0) Other 24 (9.7) 18 (75.0) Diagnosis (n = 247) 0.418 Head injury 66 (26.7) 33 (50.0) Peritonitis 39 (15.7) 22 (56.4) Septic shock 23 (9.3) 13 (56.5) Post-operative complications 18 (7.3) 6 (33.3) Poly trauma 17 (6.9) 10 (58.8) Respiratory distress 14 (5.7) 7 (50.0) Post-partum haemorrhage 9 (3.6) 5 (55.6) Pulmonary oedema 8 (3.2 6 (75.0) Severe pneumonia 8 (3.2) 4 (50.0) Visceral rupture/injury 8 (3.2) 4 (50.0) Cardiac arrest 5 (2.0) 4 (80.0) Eclampsia 5 (2.0) 1 (20.0) Chest injury 3 (1.2) 2 (66.7) Poisoning 3 (1.2) 0 (0) Pre-eclampsia with pulmonary oedema 3 (1.2) 3 (100.0) Organ failure 3 (1.2) 2 (66.7) Burns 2 (0.8) 2 (100.0) Pre-eclampsia 1 (0.4) 1 (100.0) Other 12 (4.9) 5 (41.7) KEY: EM- Ethel Mutharika HDU- High Dependency Unit OT- Operating theatre “Other” on referring units: referrals from outside KCH “Other” on diagnoses: snake bites and drowning 1.4 Discussion This study aimed at bringing to light the performance of the ICU, and we found that it generally reveals a suboptimal performance with a mortality of over 50%. Our study portrayed inadequacy of ICU beds with a shocking ratio of only 1 bed available for every 1.5 million people. Another study done at another tertiary hospital in the same country showed a similar ratio [ 6 ]. Elsewhere, in Uganda and other parts of Africa, the ratio still stands at 1 to 1 million [ 5 ]. This is in massive contrast to Western countries. For example, there is 1 bed for every 293 people in the USA and 1 for every 163 people in Germany. Surprisingly, the demand for critical care services is arguably more enormous in sub-Saharan Africa. This is because the high incidence of road traffic accidents and infectious diseases in developing countries places an additional burden on critical care services [ 19 ]. Sadly, the discipline of critical care is heavily eluded from priority in these settings as it gets minute proportion of the health sector funding [ 4 ]. The results of our study portrayed head trauma to be the common diagnosis within the ICU with a total percentage of 26% of cases of which 86% of the head injury patients were male. This could be attributed to a rising incidence of Road Traffic Accidents (RTA). A study conducted in 2017 showed that there has been a rapidly growing burden of RTAs at KCH in Lilongwe with a prediction that the burden will double by 2030 [ 19 ]. 76.4% of those with road traffic injuries in RTA were males with an average age of 24.2. With young productive males losing days at work, devastating injuries and their lives, this leading to a reduction in the productive population of the nation. ¾ of deaths of associated with road traffic injuries were also male. This ultimately affects the economy. It is said that in Malawi there is an estimated impact of 5% to the GDP [ 19 ]. Our study revealed an overall mortality of 52%. A study conducted in 2012 at KCH’s previous ICU found an overall mortality of 60.9% [ 18 ] thus signifying a reduction of approximately of 8% with the new ICU. This may be attributed to the increase in human resource. However, a study conducted at another tertiary level hospital Queen Elizabeth Central Hospital (QECH) displayed an overall mortality was 23.6% [ 6 ] which is significantly lower than that of KCH although QECH had a lower bed capacity. The differences may be explained by the fact that at KCH’s ICU patients are not seen by physicians on a daily basis. Additionally, the lack of an ICU criterion means some patients are admitted in a moribund state, which only serves to increase the overall mortality. A study in South Africa showed an overall mortality of 13.6% [ 20 ], again another alarming difference. The study ICU has 16 beds and full time specialist cover which seems to make a big difference to the outcome of patients. Of note is that they also use a scoring system known as the Simplified Acute Physiology Score (SAPS 3) to assess severity of patients presenting to the ICU. The scoring system helps predict the realistic outcome of the patients, at KCH the admission criteria does not have any scoring system resulting in subjective admission of patients into the ICU. We should therefore have an anaesthesiologist to do daily rounds on patients and implement an ICU scoring system. This study revealed a mortality rate of 62% among the paediatric patients admitted in the ICU. In a study done at another tertiary hospital in the same country, the paediatric mortality rate was 32% [ 6 ]. These findings are comparable to similar studies done across Africa. The mortality rates reported lie within the range 20–60% [ 21 , 22 ]. This is alarming, considering the fact that children comprise a quarter or less of the ICU patients. Interestingly, some studies done in resource-rich settings have demonstrated better outcomes in critically ill children managed in dedicated Paediatric Intensive Care Unit (PICU) as compared to those managed in general ICU [ 23 ]. However, studies in dedicated PICU in Rwanda and South Africa contradict such a finding with mortality rates of 50% and 56% respectively [ 24 ]. This highlights the general subpar provision of critical care in developing countries. Keys to improving the overall intensive care provision could prove utile in reducing child mortality during care. 1.5 Conclusion Our study established that critical care medicine is still underdeveloped in low resource settings. For Malawi, it showed that over 50% of the patients die. Most of the patients were admitted due to surgical conditions with head injury and peritonitis being the commonest causes of admission and head injury contributing the highest to mortality. Most of the patients were referred from the main operating theatre. The study supported claims that the availability of medical and nursing staff is associated with the survival of critically ill patients. Meanwhile the KCH ICU is understaffed hence this study unveils this problem and ultimately recommends improving ICU staffing. Lack of specialist care and scoring systems for severity still remain the big issues. There is therefore a need to establish a legitimate scoring system and an admission criterion. We would further recommend recruiting anaesthesiologists at KCH to take a principle role in management of the critically ill patients. We also recommend an improved electronic documentation system for an easier and effective evaluation of the performance of the ICU. 1.6 Study limitations Some of the required data about the patients was missing from the registry. This just goes to show how poor the level of documentation within the hospital is. Secondly, we were unable to determine the cause of death due to unavailability of autopsy data. Furthermore, we were unable to follow up on the patients that were transferred out, to determine their survival rate as their files were not in the ICU. Additionally, due to the lack of a clear admission criteria or scoring system we do not know which patients truly qualified for ICU care. Last but not least, data was only collect for the year 2019 despite the new ICU being operational for 4 years hence the results are subject to confounding factors associated with the year 2019. Besides, the study was conducted at one hospital, hence, generalization of the findings is limited. Declarations Availability of data The data obtained and/analysed during the study is available and can be provided upon a reasonable request made to the corresponding author. Acknowledgements The authors also acknowledge the Manuscript Writing Workshop funded by ACEPHEM which provided the authors with timely technical support and expertise when preparing the manuscript. Funding This study was supported by funding provided by the Kamuzu University of Health Sciences. Conflict of interest Though two of the authors are currently affiliated to the facility where the study was conducted, they were not yet employed at the facility during the study period. Thus, they had no influence on the study. All the other authors declare no conflict of interest. Author contribution statement Study conception and design: ANB, LM, UN, RG. Data collection and management: ANB, LM, UN. Data analysis and interpretation: ANB, AFL, LM, UN, SLM, RG. Manuscript drafting and writing: ANB, AFL, LM, UN, SLM, RG. Manuscript reviewing, revising and final approval: ANB, AFL, LM, UN, SLM, RG. Supervision: SLM, RG. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4242898","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":294059137,"identity":"6f17f1d9-87e0-477d-a150-027293fbd7c7","order_by":0,"name":"Akim Nelson Bwanali","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIie3PsQrCMBCA4crBdTntGqjoK1gKRRDxVRQhLukbiGPcdPUxnJyFYFz6AB1cpNDBSRDcLLadnGq7CeYfcst9JLEsk+knQyxHB+CYD9atTxBwWhBqQCwaFPM7cdaaJ7S89NGmxy1eDsmy1WlfRVjEzz7p1JPQPoyEzh9GnMeV18S2dAWqVkF8gTlhFFSSfkkyNZFAqS+yGmQQo3ZDqWY5gSSUNYgX8YX/2qi5BAwg3DDCb3/pnXVw3T3VeOuo5CGeq55jK139/Y+QlWfd9SK4N9k2mUym/+kNrE5BWw45YakAAAAASUVORK5CYII=","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Akim","middleName":"Nelson","lastName":"Bwanali","suffix":""},{"id":294059138,"identity":"fd2a308d-b476-4b2a-9191-96f64ddcc4cc","order_by":1,"name":"Leonard Munthali","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Leonard","middleName":"","lastName":"Munthali","suffix":""},{"id":294059139,"identity":"771b2a7d-1073-4b51-a708-ff063c6ff503","order_by":2,"name":"Upile Napolo","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Upile","middleName":"","lastName":"Napolo","suffix":""},{"id":294059140,"identity":"c4fcd81f-dfba-45a8-b3b3-3e7e3e11d131","order_by":3,"name":"Adriano Focus Lubanga","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Adriano","middleName":"Focus","lastName":"Lubanga","suffix":""},{"id":294059141,"identity":"a6bd03f2-2feb-43bc-b0f0-7bdcbe096d04","order_by":4,"name":"Rodwell Gundo","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rodwell","middleName":"","lastName":"Gundo","suffix":""},{"id":294059142,"identity":"ab48f10c-826b-4e1c-a15a-648a6a338c5d","order_by":5,"name":"Samuel L. Mpinganjira","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"L.","lastName":"Mpinganjira","suffix":""}],"badges":[],"createdAt":"2024-04-09 15:16:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4242898/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4242898/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-66810-7","type":"published","date":"2024-08-16T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55515584,"identity":"1e748527-7ce2-4c63-ba8d-faadc6ab4866","added_by":"auto","created_at":"2024-04-29 13:11:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13361,"visible":true,"origin":"","legend":"\u003cp\u003eCauses of admission to the ICU\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4242898/v1/964246e316abacbe5d63745e.png"},{"id":55516794,"identity":"8ca3e791-a4d5-4f44-920d-38e4d9ae6ef1","added_by":"auto","created_at":"2024-04-29 13:19:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":12701,"visible":true,"origin":"","legend":"\u003cp\u003eRelative contributions of various referring units to the ICU admissions\u003c/p\u003e","description":"","filename":"Onlinedrawingimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4242898/v1/681ce61e0e635f6db6ba7330.png"},{"id":55515585,"identity":"f11cd46e-af25-4d9a-9327-1d57a0f25cb0","added_by":"auto","created_at":"2024-04-29 13:11:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5272,"visible":true,"origin":"","legend":"\u003cp\u003eFrequencies of admissions in quarters of the year\u003c/p\u003e","description":"","filename":"Onlinedrawingimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4242898/v1/b128db68622ecd4ed04b3c0b.png"},{"id":55515587,"identity":"2b31fa1d-8f2d-427e-962c-95458965a8da","added_by":"auto","created_at":"2024-04-29 13:11:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":6165,"visible":true,"origin":"","legend":"\u003cp\u003eComposition of age groups in the overall mortality\u003c/p\u003e","description":"","filename":"Onlinedrawingimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4242898/v1/2cdbb98bd54decc2a93c5baa.png"},{"id":63070877,"identity":"7f9767c5-5a85-48dd-aaf4-63a9c1f9f2ff","added_by":"auto","created_at":"2024-08-22 19:56:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":489978,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4242898/v1/c71ee20b-4ef5-4ed9-a1e4-234654ade754.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Audit of Cases and Outcomes of Patients Admitted to the Intensive Care Unit at Kamuzu Central Hospital, Lilongwe, Malawi","fulltext":[{"header":"1.1 Introduction","content":"\u003cp\u003eAn Intensive Care Unit (ICU) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care. It harbours enhanced capacity for monitoring, and multiple techniques for physiologic organ support such as mechanical ventilation to sustain life during a period of life-threatening organ system insufficiency [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo function optimally, such an ICU must be complemented with a good infrastructure, consistent supply of drugs, advanced medical equipment and well trained personnel [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Since the onset of critical care provision, the global community has witnessed dramatic improvements in recovery of those with critical illnesses and injuries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This is precisely true for developed countries whose resources enable ICUs to function optimally [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDeveloping countries, in contrast, often fail to operationalize the same high quality of care [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In sub-Saharan Africa (SSA), ICUs often run on limited equipment and healthcare providers usually with no specialized training in critical care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These differences on the quality of critical care provision between developed and developing countries have led to profound differences. Not surprising, their ICUs register mortality rates as low as 8% in comparison to 64% as reported by other low-income country studies [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Unfortunately there is limited data on impact that subpar critical care is having on the performance of the whole health sector [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMortality and outcomes of ICU admission have been variable across studies in Africa. For instance, a Ugandan found an overall mortality of 25% in comparison to 41% found in Tanzania [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Multiple studies in sub Saharan Africa have reported numerous factors associated with poor outcomes in ICU which include advanced age, urgency of admission and development of in-hospital complications [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe challenges and poor critical care performance highlighted above could be heightened in Malawi due to an especially increased demand of critical care to provide for the rapidly growing population, thereby placing a further burden on the already strained healthcare workforce. However, there is limited local data on factors that influence outcome of patients admitted to the ICU in Malawi.\u003c/p\u003e \u003cp\u003eMalawi built her first 5 bed ICU in 1990, at Kamuzu Central Hospital (KCH)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In 2016, the ICU at KCH was transferred to a new building with more space, beds and equipment, to cater for the population of the central region. The new ICU has 8 beds with 1 presidential suite bed against a total number of 1200 hospital beds within KCH thus allocating 0.7% of the beds to critical care for a population of 7,523,340 in the Central Region of Malawi [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A previous study at KCH showed that the ICU admits an average of 22 patients per month with 5 functional beds a time due to limited staff. Alarmingly, one study in 2012 at KCH ICU revealed a general mortality of 60.9% with sepsis as the commonest causes of death [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Since commencement of the newly constructed ICU there is no systemic study done to assess its performance and ascertain any improvement from the old ICU. Therefore, we aimed to assess clinical outcomes of patients and commonest causes of mortality for patients admitted at KCH ICU.\u003c/p\u003e "},{"header":"1.2 Materials and methods","content":"\u003ch2\u003e1.2.1 Study setting\u003c/h2\u003e\u003cp\u003eThis study was conducted at Kamuzu Central Hospital newly built Intensive Care Unit described above. It is the ICU that caters for the population of the Central Region of Malawi.\u003c/p\u003e\u003ch2\u003e1.2.2 Study design\u003c/h2\u003e\u003cp\u003eThis was a descriptive cross-sectional study conducted at KCH ICU. We aimed to review 250 case files of patients ever admitted in this ICU between January 2019 and December 2019. They were conveniently sampled.\u003c/p\u003e\u003ch2\u003e1.2.3 Data collection\u003c/h2\u003e\u003cp\u003eAll data was collected by the primary investigators for the study (ANB, LM and UN). The data collection period span from 1 September, 2021 to 14th September 2021.We collected data from the ICU register book onto a case reporting form. Variables included patient’s code number (that we assigned), referring unit, age, sex, diagnosis, interventions done, length of admission and their outcome. The length of stay in the ICU was measured in calendar days based on the admission and discharge dates. Further, we had an interview with the head of the ICU to understand operational matters with the ICU.\u003c/p\u003e\u003ch2\u003e1.2.4 Data management and analysis\u003c/h2\u003e\u003cp\u003eThe data was then leaned and transferred to an Excel 2016 electronic file which was kept on a password secured personal laptop and backed up on a secure online drive.\u003c/p\u003e\u003cp\u003eWe employed descriptive statistics to describe our sample. Categorical variables were summarized into frequencies and percentages and presented in frequency distribution tables, graphs and pie charts. Continuous data was summarized as means, standard deviations and medians and further summarized and displayed into frequency polygons/histogram.\u003c/p\u003e\u003cp\u003eComparison of categorical variables was performed using Chi squared test. Correlation between the variables were tested using the Pearson correlation co-efficient. A P-value of less that 0.05 was considered significant. Statistical analyses were conducted using STATA 16.\u003c/p\u003e\u003ch2\u003e1.2.5 Ethical considerations\u003c/h2\u003e\u003cp\u003e The Approval to conduct the study was obtained from Kamuzu University of Health Sciences research and ethics committee. Further approval was obtained from the hospital director and the Head of ICU at Kamuzu Central Hospital. The study was conducted in accordance to the ethical rules and regulation as stipulated in the KUHES ethics guidelines. The need of informed consent was waived by KUHES research ethics since the study did not involve any physical interaction with the patient. The study has no anticipated risk, as it involved secondary analysis of routinely collected data. To ensure confidentiality and anonymity, we de-identified and disaggregated the data. Only the primary researchers accessed the data.\u003c/p\u003e"},{"header":"1.3 Results","content":"\u003ch2\u003e1.3.1 Characteristics of the ICU\u003c/h2\u003e\u003cp\u003eKCH has an 8 bed capacity ICU with only 5 operational beds to serve a population of 7,523,340 in the central region of Malawi [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This creates a ratio 1 bed available for every 1.5\u0026nbsp;million people. The ratio of the ICU beds to the total number of hospital beds at is 1:150. The unit is currently being run by the head of the anaesthesia department. However, there is no intensivist. At any point in time, there is a clinician/anaesthetist on call and 5 nurses on duty. Thus a nurse to patient ratio of 1:1 is usually maintained. Among the 21 nurses allocated to the ICU only one of them underwent special critical care training. Additionally, there is no established team that carries out ward rounds. As such, the referring units periodically come to evaluate their respective patients.\u003c/p\u003e\u003cp\u003eEach ICU bed has a ventilator, perfuser, an infusion pump, a multi-parameter monitor and an oxygen concentrator. A defibrillator and a 12-lead ECG are available for use at any bed needed. However, the ICU does not have the following; a portable X-ray, an ultrasound machine and an arterial blood gas analyser.\u003c/p\u003e\u003ch2\u003e1.3.2 Demographic profile\u003c/h2\u003e\u003cp\u003eA total of 250 case files for patients of all age groups admitted to the ICU in a period spanning from January 1st, 2019 to December 31st, 2019 were reviewed. Males made up 57% of the cases (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The age of the patients ranged from less than 1 to 87 with a mean of 30 ± 18.4 years and had a mean length of admission of 4.93 + 5.06 days.\u003c/p\u003e\u003cp\u003eOf the 250 cases, some patients had missing variables. 0.4% were missing sex, another 0.4% had no outcome recorded, 0.8% had undocumented age, 1.2% did not have referring unit and another 1.2% did not have diagnosis\u003c/p\u003e\u003cp\u003eThe commonest diagnoses at admission were head injury and peritonitis which contributed 26.7% and 15.7% respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Most of the patients were referred from the main operating theatre (30.8%), followed by the Casualty (20.7%) and the Ethel Mutharika (EM) Maternity High Dependency Unit (HDU) (10.5%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most of the patients required mechanical ventilation (90.8%). A smaller proportion were given catecholamines (24.8%) and an even smaller proportion underwent Cardiopulmonary Resuscitation (CPR) (2.4%). Over half of the admissions took place in the second half of the year (54.4%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003e1.3.3 Treatment outcomes\u003c/h2\u003e\u003cp\u003eThe study revealed an in-ICU mortality rate of 52%. The mortality was higher amongst females with a mortality rate of 57.5% (compared to 47.9% in males) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Cardiac arrest and pulmonary oedema were conditions with the highest in-ICU mortality of over 70% each. However, head injury and peritonitis had the highest contribution to the mortality accounting for 25.3% and 16.9% of all deaths respectively. The highest mortality rate was observed in those older than 50 years (65.1%) and the paediatric group (62.5%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics and outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVARIABLE\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTOTAL (%)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDIED (%)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP VALUE\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll admissions\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e249 (100)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130 (52.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (n = 249)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142 (57)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (47.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (43)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (57.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years (n = 248)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (9.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (58.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5–17\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (12.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (62.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18–29\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (29.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (40.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30–49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (31.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (50.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove 50\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (17.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (65.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferring unit (n = 247)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain OT\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (30.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (43.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCasualty\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (20.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (51.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEM HDU\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (10.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (42.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical HDU\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (9.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (50.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric HDU\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (6.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (75.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEM OT\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (4.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (45.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical short stay\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (71.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEM Maternity wing\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical HDU\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (75.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (9.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (75.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis (n = 247)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"19\" rowspan=\"20\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead injury\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (26.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (50.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeritonitis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (15.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (56.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptic shock\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (9.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (56.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative complications\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (7.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoly trauma\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (6.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (58.8)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory distress\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (5.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (50.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-partum haemorrhage\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary oedema\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (3.2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (75.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere pneumonia\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (3.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (50.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisceral rupture/injury\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (3.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (50.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac arrest\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (80.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEclampsia\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest injury\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoisoning\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-eclampsia with pulmonary oedema\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (100.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgan failure\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurns\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (100.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-eclampsia\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (100.0)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (4.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (41.7)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eKEY:\u003c/p\u003e \u003cp\u003eEM- Ethel Mutharika\u003c/p\u003e \u003cp\u003eHDU- High Dependency Unit\u003c/p\u003e \u003cp\u003eOT- Operating theatre\u003c/p\u003e \u003cp\u003e“Other” on referring units: referrals from outside KCH\u003c/p\u003e \u003cp\u003e“Other” on diagnoses: snake bites and drowning\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"1.4 Discussion","content":"\u003cp\u003eThis study aimed at bringing to light the performance of the ICU, and we found that it generally reveals a suboptimal performance with a mortality of over 50%.\u003c/p\u003e\u003cp\u003eOur study portrayed inadequacy of ICU beds with a shocking ratio of only 1 bed available for every 1.5\u0026nbsp;million people. Another study done at another tertiary hospital in the same country showed a similar ratio [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Elsewhere, in Uganda and other parts of Africa, the ratio still stands at 1 to 1\u0026nbsp;million [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is in massive contrast to Western countries. For example, there is 1 bed for every 293 people in the USA and 1 for every 163 people in Germany. Surprisingly, the demand for critical care services is arguably more enormous in sub-Saharan Africa. This is because the high incidence of road traffic accidents and infectious diseases in developing countries places an additional burden on critical care services [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Sadly, the discipline of critical care is heavily eluded from priority in these settings as it gets minute proportion of the health sector funding [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe results of our study portrayed head trauma to be the common diagnosis within the ICU with a total percentage of 26% of cases of which 86% of the head injury patients were male. This could be attributed to a rising incidence of Road Traffic Accidents (RTA). A study conducted in 2017 showed that there has been a rapidly growing burden of RTAs at KCH in Lilongwe with a prediction that the burden will double by 2030 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. 76.4% of those with road traffic injuries in RTA were males with an average age of 24.2. With young productive males losing days at work, devastating injuries and their lives, this leading to a reduction in the productive population of the nation. ¾ of deaths of associated with road traffic injuries were also male. This ultimately affects the economy. It is said that in Malawi there is an estimated impact of 5% to the GDP [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur study revealed an overall mortality of 52%. A study conducted in 2012 at KCH’s previous ICU found an overall mortality of 60.9% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] thus signifying a reduction of approximately of 8% with the new ICU. This may be attributed to the increase in human resource. However, a study conducted at another tertiary level hospital Queen Elizabeth Central Hospital (QECH) displayed an overall mortality was 23.6% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] which is significantly lower than that of KCH although QECH had a lower bed capacity. The differences may be explained by the fact that at KCH’s ICU patients are not seen by physicians on a daily basis. Additionally, the lack of an ICU criterion means some patients are admitted in a moribund state, which only serves to increase the overall mortality. A study in South Africa showed an overall mortality of 13.6% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], again another alarming difference. The study ICU has 16 beds and full time specialist cover which seems to make a big difference to the outcome of patients. Of note is that they also use a scoring system known as the Simplified Acute Physiology Score (SAPS 3) to assess severity of patients presenting to the ICU. The scoring system helps predict the realistic outcome of the patients, at KCH the admission criteria does not have any scoring system resulting in subjective admission of patients into the ICU. We should therefore have an anaesthesiologist to do daily rounds on patients and implement an ICU scoring system.\u003c/p\u003e\u003cp\u003eThis study revealed a mortality rate of 62% among the paediatric patients admitted in the ICU. In a study done at another tertiary hospital in the same country, the paediatric mortality rate was 32% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These findings are comparable to similar studies done across Africa. The mortality rates reported lie within the range 20–60% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This is alarming, considering the fact that children comprise a quarter or less of the ICU patients. Interestingly, some studies done in resource-rich settings have demonstrated better outcomes in critically ill children managed in dedicated Paediatric Intensive Care Unit (PICU) as compared to those managed in general ICU [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, studies in dedicated PICU in Rwanda and South Africa contradict such a finding with mortality rates of 50% and 56% respectively [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This highlights the general subpar provision of critical care in developing countries. Keys to improving the overall intensive care provision could prove utile in reducing child mortality during care.\u003c/p\u003e"},{"header":"1.5 Conclusion","content":"\u003cp\u003eOur study established that critical care medicine is still underdeveloped in low resource settings. For Malawi, it showed that over 50% of the patients die. Most of the patients were admitted due to surgical conditions with head injury and peritonitis being the commonest causes of admission and head injury contributing the highest to mortality. Most of the patients were referred from the main operating theatre.\u003c/p\u003e\u003cp\u003eThe study supported claims that the availability of medical and nursing staff is associated with the survival of critically ill patients. Meanwhile the KCH ICU is understaffed hence this study unveils this problem and ultimately recommends improving ICU staffing.\u003c/p\u003e\u003cp\u003eLack of specialist care and scoring systems for severity still remain the big issues. There is therefore a need to establish a legitimate scoring system and an admission criterion. We would further recommend recruiting anaesthesiologists at KCH to take a principle role in management of the critically ill patients.\u003c/p\u003e\u003cp\u003eWe also recommend an improved electronic documentation system for an easier and effective evaluation of the performance of the ICU.\u003c/p\u003e\u003ch2\u003e1.6 Study limitations\u003c/h2\u003e\u003cp\u003eSome of the required data about the patients was missing from the registry. This just goes to show how poor the level of documentation within the hospital is. Secondly, we were unable to determine the cause of death due to unavailability of autopsy data. Furthermore, we were unable to follow up on the patients that were transferred out, to determine their survival rate as their files were not in the ICU. Additionally, due to the lack of a clear admission criteria or scoring system we do not know which patients truly qualified for ICU care. Last but not least, data was only collect for the year 2019 despite the new ICU being operational for 4 years hence the results are subject to confounding factors associated with the year 2019. Besides, the study was conducted at one hospital, hence, generalization of the findings is limited.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data obtained and/analysed during the study is available and can be provided upon a reasonable request made to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors also acknowledge the Manuscript Writing Workshop funded by ACEPHEM which provided the authors with timely technical support and expertise when preparing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by funding provided by the Kamuzu University of Health Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThough two of the authors are currently affiliated to the facility where the study was conducted, they were not yet employed at the facility during the study period. Thus, they had no influence on the study. All the other authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: ANB, LM, UN, RG. Data collection and management: ANB, LM, UN. \u0026nbsp;Data analysis and interpretation: ANB, AFL, LM, UN, SLM, RG. Manuscript drafting and writing: ANB, AFL, LM, UN, SLM, RG. Manuscript reviewing, revising and final approval: ANB, AFL, LM, UN, SLM, RG. Supervision: SLM, RG. All authors have substantially contributed to the interpretation of relevant literature, and have been involved in writing the article or revising it for intellectual content.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMaslove DM, Lamontagne F, Marshall JC, Heyland DK. A path to precision in the ICU. 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The epidemiological profile of pediatric patients admitted to the general intensive care unit in an Ethiopian university hospital. 2015;63\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmbu HY, Yiltok SJ, Isamade ES, Nuhu SI, Oyeniran OO, Uba FA. Paediatric admissions and outcome in a general intensive care unit. 2021;8(1):57\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNupen TL, Sa F, Argent AC, Sa F, Morrow BM, Intensive P, et al. Characteristics and outcome of long-stay patients in a paediatric intensive care unit in Cape Town, South Africa. 2017;107(1):70\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSusianawati V, Suryantoro P, Naning R. Prognostic predictor at Pediatrics Intensive Care Unit (PICU) with Pediatric Risk of Mortality III ( PRISM III ) scores. 2014;46(2):71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Critical care, Intensive Care Unit, ICU, Malawi","lastPublishedDoi":"10.21203/rs.3.rs-4242898/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4242898/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn 2016 a new, improved and modern intensive care unit was constructed at Kamuzu Central Hospital in Lilongwe, Malawi. Having been operational for about 4 years, there has not been a systematic audit to gauge its performance. Therefore, this a quantitative retrospective cohort study aimed at investigating the performance of the intensive care unit at Kamuzu Central Hospital in Lilongwe, Malawi. We analysed the patterns of admission through 250 clinical cases and their respective outcomes spanning from 1st January 2019 to 31st December 2019 using STATA. Descriptive and inferential statistics were computed.\u003c/p\u003e \u003cp\u003eOut of the 250 admissions, we evaluated 249 samples. About 30.8% of all patients were referred from the main operating theatre, 20.7% from the casualty and 10.5% from maternity high dependence unit. Head injury (26.7%) and peritonitis (15.7%) were the commonest causes of admission. The overall mortality was 52% with more females (57.5%) dying than males (47.9%). Head injury and peritonitis had the highest contribution to the mortality accounting for 25.3% and 16.9% of all deaths respectively.\u003c/p\u003e \u003cp\u003e In conclusion, the intensive care unit registered an improved performance compared to previous years. However, it is still grappling with a number of challenges that need immediate attention including few working beds, shortage of critical care specialists and nursing staff and lack of standard admission criteria.\u003c/p\u003e","manuscriptTitle":"Clinical Audit of Cases and Outcomes of Patients Admitted to the Intensive Care Unit at Kamuzu Central Hospital, Lilongwe, Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-29 13:11:18","doi":"10.21203/rs.3.rs-4242898/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-21T05:07:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-19T15:37:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-10T12:11:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"d9783530-b772-4d93-9132-2c1005c3d15d","date":"2024-05-02T08:47:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34f0b92e-27b3-46c0-8d5c-84b6d0e3ef6c","date":"2024-05-01T22:14:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147ecf1e-674c-492e-a557-279a29f2f8f2","date":"2024-05-01T17:29:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-29T17:26:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-29T17:12:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-19T03:57:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-19T03:56:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-04-09T15:14:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"17ac0b76-2d79-4385-a27e-39772369c747","owner":[],"postedDate":"April 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":30994048,"name":"Health sciences/Diseases"},{"id":30994049,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2024-08-22T19:29:58+00:00","versionOfRecord":{"articleIdentity":"rs-4242898","link":"https://doi.org/10.1038/s41598-024-66810-7","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-08-16 15:57:06","publishedOnDateReadable":"August 16th, 2024"},"versionCreatedAt":"2024-04-29 13:11:18","video":"","vorDoi":"10.1038/s41598-024-66810-7","vorDoiUrl":"https://doi.org/10.1038/s41598-024-66810-7","workflowStages":[]},"version":"v1","identity":"rs-4242898","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4242898","identity":"rs-4242898","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}