University of Cape Town

Transcription

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2 The copyright of this thesis vests the uthor. No quottion from it or formtion derived from it is to be published without full cknowledgement of the source. The thesis is to be used for privte study or noncommercil reserch purposes only. Published by the (UCT) terms of the non-exclusive license grnted to UCT by the uthor.

3

4

5 on

6 t"rf'l,tY\Q mesures

7 D"h;",,,,t outcomes 1

8 S. 5.

9 units 9 re to s In cute II scores

10 5 score M ~I

11 6 nnl'ni"l'v E: F: H: I: J:

12 L L

13 8 ill s ws were worse (4;5) o 1 3. to ill on s: to on current to nurse to ",,,,irjo.,j- 1:1

14 re on 1. costs cost ws not ill n over

15 10 is to mount is on re n (29) to more it costs (12) to ron,,,,,,,,c n on L mix (33) nurse to

16 (35) outcome. (20;34) II not on outcome is (38-40) 1. IOlr,,,,,,,,,.,. to ssess (33) too room. ssessment use on s consciousness. n

17 12 B score no E severe on (51) 1 tensive n (6;27;2.9) re severe to on 1:1; (52)

18 3 costs were n re no It is n nrr,,,,,,,,' is ",... ru"r..,.. cn sector. re use to

19 to is 4 ( re re re on is

20 15 ws ws

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22 17 l b. c. to nl" 'ryl,"'!-o resources... to were ensure were to: terms onto n.. o~nr' to Crhi!:lt'rlO events ws

23 18 more on ws were s i) or venous ii) our on were s serum or serum I",'rnn,,~<: were more

24 9 were r'''''c:cl't'i'''1'i s s i) It Twve were not or were or were s or to or n ws or

25 II score ws rhr"\c&:l,n reson it II score ws II score ws is were E. Inr:.t"O,f'j score zero. II 1. s to ws mesures were ssessment or or is t or ws

26 21 II scores were were or ws no on to

27 1

28 or

29 3.1 by or on or re. re 3. or

30 re is A 3.1 re n.. n\l,n,::>c' or re re ill or 3.1 not re or if re not

31 A were sttus ws were were to to were ws were ws were 1 turnover or 7 ws or more. 3. 2

32 c:.!11 1ii 140. ' l E ::J 100 Z <24 hrs NurrtJe r of dy s Figure 3.1 Length of sty the HCU Mjor dignostic ctegories Figure 3.2 shows the spectrum of disese seen ptients dmitted to the HCU. Acute coronry syndromes, dibetic emergencies, sepsis nd overdoses/poisongs constituted the mjor work lod of the HCU. Tble 3.2 outles the mjor dignostic ctegories. A complete list of dmission dignoses is conted Appendix H. Results for these mjor dignostic ctegories will be discussed seprtely.

33 28 Metbolic disorders (n= 257) 29.9% Non-fective respirtory (n=77) 9.0% Acute coronry syndromes (n= 247) 28.8% Sepsis (n=91) 10.6% Neurologicl disorders (n=18)2.1% Figure 3.2 Mjor dignostic ctegories Tble 3.2 Dignostic ctegories nd dignoses Dignostic ctegory Acute coronry syndrome Acute Metbolic disorders Overdose or poisong Acute Neurologicl disorders Acute Crdiovsculr disorders Overdose nd poisong (n=92)10.7% Dignoses cluded this ctegory CVS Emergencies (n=77) 9.0% Myocrdil frction (STEMI nd NSTEMI) nd unstble ng pectoris Dibetic emergencies (DKA, hypoglycemi nd hyperglycemi), renl filure, electrolyte bnormlities Overdoses or poisong Sttus epilepsy, Mystheni grvis nd Guill-Brre syndrome Stroke, pulmonry oedem, crdic rrhythmis, mlignnt hypertension Non-fective respirtory Asthm, COPD, other non-fective chronic lung disese disorder Sepsis syndrome Pneumoni, septic shock, mengitis

34 1 II scores II scores were II score ws 9 0 II scores 9 9 APACHE II A were

35 Ptient outcomes HCU nd -ptient mortlity More thn three qurters (77%) of ll HCU dmissions were dischrged live. The high unit mortlity ws 10.7% (n=92). Totl -hospitl mortlity of ptients dmitted to the HCU ws 14.8% (n=127). (Figure 3.4) A detiled tble of outcomes for ll dignostic groups cn be found Appendix H. Dischrge (n=666) 77.5% Figure 3.4 Outcomes of HCU dmissions Trnsfer (n= 101) 11.8% Deth HCU -- (n= 92) 10.7% The mortlity rte for ptients with the first 24 hours the HCU ws significntly higher thn for ptients survivg the first dy 19.3% vs. 8.7% (p=0.0003). This ws true of ventilted nd non-ventilted ptients. (Tble 3.3) Tble 3.3 Outcome of ptients with 24hrs of dmission to HCU Deth with 24 hrs (%) Deth beyond 24 hrs (%) P vlue Required mechnicl Ventiltion 31 (47.0%) 33 (22.4%) p<0.003 Non- ventilted 15 (6.8%) 13 (3.0%) p=0.023

36 A ws were were outcome t'\o;;ltlon1rc is not A "'""li'"ri"ct~c or were were A ws

37 Ptient demogrphics The med ge of the ptients ws 35 yers (rnge, yers). The men ge of this group ws significntly lower thn the men ge of other ptients dmitted to the HCU (Tble 3.4) More thn one third (42%) were under the ge of 30 yers, n lmost two thirds (60%) of the OKA ptients were under the ge of 40 yers. (Figure 3.5) Tble 3.4 Summry of OKA ptients vs. non-oka ptients OKA (n= 159) Non-OKA (n=700) p vlue Men ge (50,95% CI) 36.9 (15.6, ) 47.2 (16.7, ) p<o.oool yers Men APACHE II score 12 (7, 11-13) 10 (7, 9-10) p=0.002 (50, 95%CI) Required mechnicl 11.3% 27.9% p<o.oool ventiltion In-hospitl mortlity 11.9% 15.4% p= l!l 30 c:.g!! z < Age of ptients Figure 3.5 Age of OKA ptients

38 ws men II score ws worse nonws no Inll\ln,"c terms score. cuse ws to II

39 outcomes ( n ws one were to were

40 Tble 3.8 Modifible risk fctors for ischemic hert disese cute coronry syndrome HCU dmissions Risk fctor Number of ptients (%) Hypertension 131 (62.4%) Current smoker 103 (49%) Dibetes mellitus 78 (37%) - Hyperlipidemi* 29 (13.8%) * Only 44 ptients (17.8%) hd serum cholesterol levels checked. Of these ptients 66% hd level greter thn 5.5mmol/l Mngement of ACS Figure 3.6 shows the distribution of ACS dmitted to the HCU. Of STEMI ptients 42% (n=40) received trvenous thrombolysis with streptokse. The med time followg the onset of p to receivg thrombolysis ws 5.0 hours (rnge, hours). 90% of the NSTEMI nd UAP ptients received low moleculr weight hepr. ST-elevtion myocrdil frct (STEM I) (n=95) 45.2% Non ST- elevtion myocrdil frct (NSTEMI) (n=33) 15.7% Unstble ng pectoris (UAP) (n=b2) 39.0% Figure 3.6 Acute coronry syndrome events More thn hlf of ptients (58.7%) received both spir nd bet-blocker therpy. Aspir, bet-blocker nd ACE hibitor therpy ws given to 40%. At lest one of the drugs ws prescribed more thn hlf of ptients: spir 85.2%, bet-blocker 62.5% nd ACE hibitor 66.7%.

41 n IITClrClnrClC were 6 outcomes ws 1 """''''':>,",1 A or men or

42 37 The substnces gested vried widely, but prescription mediction mde up the mjority (Figure 3.7). Tricyclic ntidepressnt therpy (TCA) (n=32), ws the commonest prescription mediction gested. A detiled tble of ll the gested substnces cn be found Appendix 1. Prescri ption mediction 65.9% Non- prescription Mediction 25.3% Unknown substnces 8.8% Figure 3.7 Substnces gested (ccidentl/tentionl) by HCU dmissions Severity of illness The men APACHE II score for overdose or poisong ptients ws not sttisticlly different when compred to other HCU dmissions (Tble 3.9). The men (SO, 95%C1) APACHE II score of the 39 ptients (42%) who required ventiltion ws however significntly higher thn for the non-ventilted overdose or poisong ptients 14 (4, 12-15) vs. 5 (5, 4-6) (p<o.ool). Of these ptients, 39 (18.3%) required ventiltion. This represents the lrgest sgle dignosis requirg ventiltion durg the study period. Over hlf (53.8%) of " overdose or poisong ptients who required mechnicl ventiltion hd gested TCA, this represented 65% of the ptients dmitted followg gestion of TCA therpy.

43 outcomes n or 1 two were J

44 39 Crdic disese 63.8% Stroke 3.4% Non-i nfective respirtory disese 10.3% Figure 3.8 Dignostic ctegories of elderly ptients Severity of illness Metbolic 13.8% Sepsis 6.9% Other 1.7% The men APACHE II score for elderly ptients ws significntly higher thn for younger ptients. (Tble 3.10) Mechnicl ventiltion ws required by 23 of the 116 ptients (19.8%). These ptients hd significntly higher men (SO, 95%C1) APACHE II score 19 (7, 16-23) s compred to non-ventilted elderly ptients 11(7, 9-12) (p<o.oool) Ptient outcomes The HCU mortlity ws 11.3% with totl -hospitl mortlity of 21.5%. The hospitl mortlity this group of ptients ws significntly higher thn those ged under 65 yers of ge. (Tble 3.10) Elderly ptients requirg ventiltion did not hve Significntly higher mortlity thn younger ptients; 52.7% vs. 36.8% (p =0.159).

45 40 to exceed vs..6 ( were or severe ".."rl"l"",,::> K

46 41 Non-fective respirtory (n=38)17.8% Acute coronry syndromes (n=14) 6.6% Metbolic disorders (n=35)16.4% Neu rolog icl disorders (n= 11) 5.2% Overdose or poisong (n=38)17.8% Figure 3.9 Ptients requirg mechnicl ventiltion Severity of illness Sepsis ---(n=45) 21.1% CVS Emergencies (n= 32)15.0% The men APACHE II score for the mechniclly ventilted ptients ws significntly higher thn for the non-ventilted ptients. (Tble 3.11) Ptient outcomes The mjority of mechniclly ventilted ptients were mnged the HCU; only 37 ptients (17.4%) required trnsfer to GSH for further tretment. This did however represent greter number s compred to non-ventilted ptients (9.9%). (p<0.003) The HCU mortlity ws 30.1%. The -hospitl mortlity for mechniclly ventilted ptients ws significntly higher thn for non-ventilted ptients. (Tble 3.11) The mortlity for the mjor dignostic groups of ptients requirg ventiltion rnged widely. (Tble 3.12) Appendix K conts detiled tble of hospitl mortlity dt for ll ventilted ptients.

47 outcome

48

49 1

50 is were II scores one nnum. is n or s n s ill is one is not

51 A is t or It re

52 outcomes I"I,Nr.o",,:.nt' n to A ws not on re n ws ws cute severe 8 to is n

53 ill n ill n exrlectecl excess s resources nonill n;:;rian1rc:: E II scores r is. is

54 rte ws on rnn,ntt,c: (61) to n.. on,,'"oc'orrlcc

55 11 over ws t were n cse ill severe n cute were not It is resons or were

56 51 ITl\/nr:U"r!1 (87;90;91) n mesures. use or t CAI'"nnrl::II""\1

57 to s ws worse outcomes n::>r,on'tc (67) not term resources s

58

59 over ITr",rn", if 1'.. """<:1',,,.. to resources ws is ill ill

60 to outcome is resource on nor n s~;es:sment or on roi"!":>.n res. It is ",,,,n,,,,,r ws use score c<'n"",rl1c\[ is were s

61 It to A term outcome to is concern. nlr:~rlrlrl cuses resons

62 ccurte use resources A wreness n:::.rlt>n'rc were ill nrornr.n is It is s

63 no prc)sp'ect now is A on

64 A. C'Hor"",,, n G J l.

65 P, is pn~.lvp III D et ill Rornor J, L to

66 61 outcomes : P, A cost ill J. J R of on E.

67 P. n on M. on is s P. on 'onrv"", MW, E, et to outcomes 11. e'rorq'ti s II score E. use

68 J. A J, H II II score 1 1f,j-,~nCI\'O P, J.

69 consensus on J t costs. re common E, et n J, consensus J. -

70 J J, non~ on ill severe

71 E, L, sttus et l. 1 N I\.IIJ, occurrence. c A severe L, J. 11): on

72 on J outcome com s cuse to S on J/ A N J on J, n on

73 N 1 Ict"o,t"ce,nn L.

74 Appendix A Intensive Cre nd High Cre units the Cpe Town Metropole Hospitl FBH = Flse By GFJH = GF Jooste GSH = Groote Schuur HHH = Hottentots Hollnd KBH = Krl Bremner NSH = Somerset Hospitl TBH = Tygerberg VHW = Victori WH = Wesfleur '" = Drge re for GF Jooste ~ Hospitl Adult beds Level of ICU/HCU Beds (ventilted) 65 No ICU/HCU HCU 8 (4) 819 Level I ICU plus HCU 57 (32) 85 HCU 3 (1) 193 HCU 4 (0) 215 Level III ICU 4 (4) 1030 Level I ICU plus HCU 108 (42) 130 HCU 2 (2) 27 No ICU/HCU 0 Bed numbers re bsed on figures reported by the supertends of the dividul hospitls nd clude specilized units such s Burns Unit, Hemtology Isoltion Unit, Coronry Cre Unit nd Renl Trnsplnt Unit.

75 B A AI AI " AI "... 0 ~ "... 0> v V V v

76 1. 5. M F 7.. b. c. e. f. C B I Y N Y N. 1\1 Y N Y

77 . Y N Y N YN f. Y N c. e. f. L j. k. I. m. n. Y N o. r. Y N s. Y N t.

78 Y N Y N Y N c.. b. c. e. 2, Y N f. L j. k. I. m. n. o.

79 o on to 2 6 is on rce Cl:sseS I ws on 9 on 1 ws were it ws s -e onto ws on f- to n.. "nln:;:.. once on ccu'nn.ri DiSSWOlr

80 s to or home or to ws r1at<arrrll outcome outcome ws.) ws ws on or mortem if s ws ws on 'n"i/o.nr",ri by notes. ws versus ('\'1<,..,1,.. "", ws on - II ws not ws s zero.

81 MAP Hert rte rte e o Score > > > P02 kp Arteril Se if no ABG mmol/l Serum sodium mmol/l Serum mmol/l Serum crete" Dble for ARF umol/l Hemtocrit % HB Totl wee x GCS Totl of APS il of the bove 12 vribles < Chronic helth or emergency 5 APS+ + Chronic Helth II > < 0.6 Totl APS >74 G Elective 2 Neither 0 <20

82 F Dr vn

83 i:::::: Appendix G Ethnic Brek down of Ptients Blck, n=372 (43%) Ind, n=19 (2%) White, n=7 (1%) Mixed-ncestry ~ n=461 (54%) Totl (%) Blck Mle 389 (45.3%) 157 (40.4%) Femle 470 (54.7%) 215 (45.7%) Overll (43.3%) Predomnt popultion group by re Mixed-ncestry Ind 213 (54.8%) 13 (3.3%) 248 (52.5%) 6 (1.3%) 461 (53.6%) 19 (2.2%) White 6 (1.5%) 1 (0.2%) 7 (0.8) I\.. GFJH V Drge re 0o.-...,;;; 12.5 ==5 25 Kilometres Popul11on Group _ Blck Nricn _ Coloured Ind or As,n _ 'MI." _ MJlliple _ None c::> M Plce 0 Municiplity 0 Provce Copyright <EJ Sttistics South Afric. 2003

84 H

85 Appendix I All overdoses nd poisongs t GF Jooste Hospitl Overdoses nd poisongs Theophylle Prcetmol Crbmzepi ne Orgnophosphtes Rt-poisong Anti-hypertensives Poly phrmcy Orl Hypoglycemics Crbon monoxide Alcohol Other Compound Number Compound Number Tricyclic ntidepressnts 32 Alcohol 1 Prcetmol 9 Bclofen 1 Theophylle 9 Benzodizepes 1 Orgnophosphte 8 Coce 1 Unknown 6 Digox 1 Crbmzepe 4 Ecstsy_ 1 Anti-hypertensive 2 Hloperidol 1 Crbon monoxide 2 Lrgctil 1 Orl hypoglycemic 2 Mndrx 1 Orphendre 2 Morphe 1 Rt poison 2 Multiple drugs 1 Trditionl mediction 2 Wfr 1

86 J

87 o o 3 o 2 o 1 1 o o o o o o o o o o