Transcript Under Five Mortality (UFM) in a Pediatric Intensive Care Unit (PICU) Serving Urban and Rural Population in India D Ranganath1, B Sita.

Under Five Mortality (UFM) in a Pediatric Intensive Care Unit (PICU)
Serving Urban and Rural Population in India
D Ranganath1, B Sita Rama Rao1, N Beligere2 and D Vidyasagar2
1Pediatrics/Neonatology,
Niloufer Hospital, Hyderabad, A.P., India. 2Pediatrics/Neonatology, University of Illinois at Chicago Medical Center, Chicago, Illinois, USA
ABSTRACT
Background: Although high IMR has received global attention, less is known about mortality of children Under Five years (UFM) in
developing countries. We studied the UFM in patients admitted to PICU attached to a teaching hospital, in India.
Objective: Objectives were to study; 1) The pattern of admissions and outcome of children admitted to PICU; 2) To study the proportion
of UF mortality and the diagnoses associated with death; 3) To study the relation of distance traveled to seek critical care service and
the mortality.
Design/Methods: We reviewed all consecutive admissions to PICU (January 2003-June 2006) at Niloufer Hospital for Women and
Children in Hyderabad AP, India. We studied: Age of patient, gender, diagnosis, distance traveled, and the final outcome. Deaths were
analyzed by age. The data was gathered from admission logs and collected on computer for analysis.
Results: Total of 1515 patients were admitted to PICU during the period. Age ranged from 1 month to 12 yrs. Parents from urban and
rural areas brought children using variety of transportations. 409/1515 (26%) of patients died. 35 % of deaths were due to respiratory
problems, and 30% were due to Neurologic conditions (Viral or bacterial meningo encephalitis). Table shows deaths, by age, distance
traveled, and survival hours after admission to PICU.
Age/Month
<12
13-60
>60
% of all deaths
40
32
28
Distance to hospital in Km
<10
<20
<50
% of deaths
12
37
53
Time of death after admission to PICU in hrs
< 12
13-24
>24
% of all deaths
39
29
20
Conclusions: The above data show 60% of admissions to PICU were UF (945/1515) and 75% of (313/409) deaths were Under Five
years. Deaths increased with increasing distance from the hospital. 43 patients traveled 300-600KM to seek services. Mortality
pattern: 67% died within 24 hrs of admission, half of them within12 hrs of admission suggesting they were extremely sick on arrival.
These findings indicate; 1) There is severe shortage of critical care services for pediatric patients in the region; 2) There is a urgent
need to improve infant and pediatric transport; and 3) There is need to improve pediatric critical care services (space, equipment and
staffing) at the receiving hospital to further improve child survival.
Results
PATIENT TRANSPORT SYSTEM
• No organized patient transport system available
during the study period
• Patients were transported by parents using
various modes of transportation:
Auto rickshaw, car, mass transport system
without any life support systems: oxygen,
warmer, airway support
NILOUFER HOSPITAL INPATIENT
AND OUTPATIENT VOLUME
2003
YEAR
TOTAL – OUT
PATIENT VISITS
TOTAL
ADMISSIONS
PEDIATRIC
ADMISSIONS
State of Andhra Pradesh
PICU ADMISSIONS
• Area - 276,754 sq. km,
population 76 millions
• HYDERABAD - Capital
of AP has a population
of 7 millions
NEONATAL
ADMISSIONS
2004
2005
Distance and Deaths
• 1,515 cases were admitted to PICU for various diagnoses
over a period of 42 months
• Ages ranged from 1 month to 12 years
• 411 / 1,515 (26%) patients died
• 35% of deaths were due to respiratory problems
• 30% were due to Neurological conditions (viral or bacterial
meningo-encephalitis)
• Poisoning cases: 4% of total 53 / 1,515
37 were under-five and 16 were above-five.
• Of the 37 poisoning cases in the under-five group, 28 (75%)
survived, 8 died and one left against medical advice
• Of the 16 poisoning cases in the above-five group, 15 (93%)
survived and one died
Distance
travelled (KM)
% Deaths
38,692
38,241
38,473
38,467
Neena Rao PICU
•
•
•
•
•
Established in Dec-2002.
Of 350 pediatric beds, 8 are PICU
4 ventilators
One Head nurse, 7 staff nurses and 2 helpers.
Day time: One post-graduate student, one
Associate Professor
• Night coverage: One MD Assistant Professor
with one post-graduate student
16
Time of death (hrs)
% Deaths
<12
13-24
>24
39
29
20
< 5 years
N=945
19,418
462
21,333
460
21,868
404
21,581
174*
7,282
8,163
8,573
9,022
Summary of Findings
5.3 %
49
600
PICU CENSUS
N=1515
63.4 %
68
411
69 %
296
31.3 %
4%
1036
Niloufer Hospital is the premier center for women and
children in the state of Andhra Pradesh
21-50
25
Deaths After Admission to PICU
27 %
Deaths
AMA
Survived
OBJECTIVES OF THE STUDY
• High infant (IMR) and under 5 mortality rates (UFM) in
developing countries are of great concern.
• Acute respiratory illnesses and infectious diseases are
the major contributors to UFM.
• The global ARI program initiated by WHO has made an
impact in early recognition and management of
respiratory problem.
• In spite of the success of the ARI program infants with
severe ARI continue to succumb because of lack of
critical care facilities at the referral centers
• The purpose of this study was to quantify the
utilization of Niloufer hospital for critical care
services for under five children with ARI and other
critical illnesses
11-20
12
2006
164,527 168,059 181,954 173,717
*6 months
BACKGROUND
<10
Deaths
AMA
1. Analyze the pattern of admissions and
outcome of children admitted to PICU
2. To study the proportion of under five
mortality and diagnosis associated with
death
3. To study the relationship between the
distance travelled to seek critical care
services and the outcome
4. To analyze the deaths by the age, gender,
and the diagnostic groups
Methods and Material
• All consecutive admissions to PICU between
January 2003 to June 2006 at the Niloufer
Hospital were reviewed
• The data were collected from admission and
discharge logs and entered into computer
database for analysis
• Survival and Mortality Data were analyzed by:
Gender, Age, Diagnosis, Distance Travelled,
and the Final Outcome
Survived
5 years
N=570
• The above data show 60% of admissions to PICU
were UF (945/1,515)
• 75% of (313/409) deaths were under five years.
• Most of the deaths were from respiratory illnesses
• Deaths increased with increasing distance traveled
to the hospital.
• 43 patients traveled 300-600 KM to seek critical care
services.
• Mortality pattern: 67% died within 24 hrs of
admission, half of them within 12 hrs of admission
suggesting they were extremely sick on arrival.
3.5 %
19
20 %
115
436
76.5 %
Deaths
AMA
Mortality Due to
Respiratory Diseases
•
•
•
•
Age Distribution:
52% mortality in under one year
33% mortality in one to five years
33% mortality in above five years
•
•
•
•
Ventilator Data:
Total of 142 patients were ventilated
21 for Respiratory Failure: 15/21 (71%) died
Ventilation for CNS problems: 45 were
ventilated 21/45, (47%) died
Survived
Conclusions
1. There is severe shortage of critical care services for
pediatric patients in the region
2. There is an urgent need to improve infant and
pediatric transport
3. There is need to improve pediatric critical care
services (space, equipment and staffing) at the
receiving hospital to further improve child survival.
Current Developments
• A state wide emergency system is being
implemented by the Government of Andhra
Pradesh
• A toll free call 108 emergency number for
medical, fire emergencies is in place through
a public/private organization, Emergency
Medicine Research Institute (EMRI),
HyderabadThese programs are being adopted
for efficient pediatric transport across the
state
Research partially supported by the Neena Rao Foundation
ABSTRACT
Background: Although high IMR has received global attention, less is known about mortality of children Under Five years (UFM) in
developing countries. We studied the UFM in patients admitted to PICU attached to a teaching hospital, in India.
Objective: Objectives were to study; 1) The pattern of admissions and outcome of children admitted to PICU; 2) To study the proportion
of UF mortality and the diagnoses associated with death; 3) To study the relation of distance traveled to seek critical care service and
the mortality.
Design/Methods: We reviewed all consecutive admissions to PICU (January 2003-June 2006) at Niloufer Hospital for Women and
Children in Hyderabad AP, India. We studied: Age of patient, gender, diagnosis, distance traveled, and the final outcome. Deaths were
analyzed by age. The data was gathered from admission logs and collected on computer for analysis.
Results: Total of 1515 patients were admitted to PICU during the period. Age ranged from 1 month to 12 yrs. Parents from urban and
rural areas brought children using variety of transportations. 409/1515 (26%) of patients died. 35 % of deaths were due to respiratory
problems, and 30% were due to Neurologic conditions (Viral or bacterial meningo encephalitis). Table shows deaths, by age, distance
traveled, and survival hours after admission to PICU.
Age/Month
<12
13-60
>60
% of all deaths
40
32
28
Distance to hospital in Km
<10
<20
<50
% of deaths
12
37
53
Time of death after admission to PICU in hrs
< 12
13-24
>24
% of all deaths
39
29
20
Conclusions: The above data show 60% of admissions to PICU were UF (945/1515) and 75% of (313/409) deaths were Under Five
years. Deaths increased with increasing distance from the hospital. 43 patients traveled 300-600KM to seek services. Mortality
pattern: 67% died within 24 hrs of admission, half of them within12 hrs of admission suggesting they were extremely sick on arrival.
These findings indicate; 1) There is severe shortage of critical care services for pediatric patients in the region; 2) There is a urgent
need to improve infant and pediatric transport; and 3) There is need to improve pediatric critical care services (space, equipment and
staffing) at the receiving hospital to further improve child survival.
State of Andhra Pradesh
• Area - 276,754 sq. km,
population 76 millions
• HYDERABAD - Capital
of AP has a population
of 7 millions
BACKGROUND
• High infant (IMR) and under 5 mortality rates (UFM) in
developing countries are of great concern.
• Acute respiratory illnesses and infectious diseases are
the major contributors to UFM.
• The global ARI program initiated by WHO has made an
impact in early recognition and management of
respiratory problem.
• In spite of the success of the ARI program infants with
severe ARI continue to succumb because of lack of
critical care facilities at the referral centers
• The purpose of this study was to quantify the
utilization of Niloufer hospital for critical care
services for under five children with ARI and other
critical illnesses
Niloufer Hospital is the premier center for women and
children in the state of Andhra Pradesh
Neena Rao PICU
•
•
•
•
•
Established in Dec-2002.
Of 350 pediatric beds, 8 are PICU
4 ventilators
One Head nurse, 7 staff nurses and 2 helpers.
Day time: One post-graduate student, one
Associate Professor
• Night coverage: One MD Assistant Professor
with one post-graduate student
PATIENT TRANSPORT SYSTEM
• No organized patient transport system available
during the study period
• Patients were transported by parents using
various modes of transportation:
Auto rickshaw, car, mass transport system
without any life support systems: oxygen,
warmer, airway support
NILOUFER HOSPITAL INPATIENT
AND OUTPATIENT VOLUME
YEAR
TOTAL – OUT
PATIENT VISITS
TOTAL
ADMISSIONS
PEDIATRIC
ADMISSIONS
PICU ADMISSIONS
NEONATAL
ADMISSIONS
2003
2004
2005
2006
164,527 168,059 181,954 173,717
38,692
38,241
38,473
38,467
19,418
462
21,333
460
21,868
404
21,581
174*
7,282
8,163
8,573
9,022
*6 months
OBJECTIVES OF THE STUDY
1. Analyze the pattern of admissions and
outcome of children admitted to PICU
2. To study the proportion of under five
mortality and diagnosis associated with
death
3. To study the relationship between the
distance travelled to seek critical care
services and the outcome
4. To analyze the deaths by the age, gender,
and the diagnostic groups
Methods and Material
• All consecutive admissions to PICU between
January 2003 to June 2006 at the Niloufer
Hospital were reviewed
• The data were collected from admission and
discharge logs and entered into computer
database for analysis
• Survival and Mortality Data were analyzed by:
Gender, Age, Diagnosis, Distance Travelled,
and the Final Outcome
Results
• 1,515 cases were admitted to PICU for various diagnoses
over a period of 42 months
• Ages ranged from 1 month to 12 years
• 411 / 1,515 (26%) patients died
• 35% of deaths were due to respiratory problems
• 30% were due to Neurological conditions (viral or bacterial
meningo-encephalitis)
• Poisoning cases: 4% of total 53 / 1,515
37 were under-five and 16 were above-five.
• Of the 37 poisoning cases in the under-five group, 28 (75%)
survived, 8 died and one left against medical advice
• Of the 16 poisoning cases in the above-five group, 15 (93%)
survived and one died
PICU CENSUS
N=1515
68
4%
1036
411
69 %
27 %
Deaths
AMA
Survived
< 5 years
N=945
5.3 %
49
600
296
63.4 %
31.3 %
Deaths
AMA
Survived
5 years
N=570
3.5 %
19
20 %
115
436
76.5 %
Deaths
AMA
Survived
Mortality Due to
Respiratory Diseases
•
•
•
•
Age Distribution:
52% mortality in under one year
33% mortality in one to five years
33% mortality in above five years
•
•
•
•
Ventilator Data:
Total of 142 patients were ventilated
21 for Respiratory Failure: 15/21 (71%) died
Ventilation for CNS problems: 45 were
ventilated 21/45, (47%) died
Distance and Deaths
Distance
travelle d (KM)
% Deaths
<10
11-20
21-50
12
25
16
Deaths After Admission to PICU
Time of death (hrs)
<12
13-24
>24
% Deaths
39
29
20
Summary of Findings
• The above data show 60% of admissions to PICU
were UF (945/1,515)
• 75% of (313/409) deaths were under five years.
• Most of the deaths were from respiratory illnesses
• Deaths increased with increasing distance traveled
to the hospital.
• 43 patients traveled 300-600 KM to seek critical care
services.
• Mortality pattern: 67% died within 24 hrs of
admission, half of them within 12 hrs of admission
suggesting they were extremely sick on arrival.
Conclusions
1. There is severe shortage of critical care services for
pediatric patients in the region
2. There is an urgent need to improve infant and
pediatric transport
3. There is need to improve pediatric critical care
services (space, equipment and staffing) at the
receiving hospital to further improve child survival.
Current Developments
• A state wide emergency system is being
implemented by the Government of Andhra
Pradesh
• A toll free call 108 emergency number for
medical, fire emergencies is in place through
a public/private organization, Emergency
Medicine Research Institute (EMRI),
HyderabadThese programs are being adopted
for efficient pediatric transport across the
state
Research supported by the
Neena Rao Foundation at Niloufer
HospitalHyderabad,
Andhra Pradesh India