Introduction

Initially, the intensive care unit (ICU) was referred to as intensive nursing care, but since the mid-1950s, due to the development of medical therapy over the years, it changed to an ICU. The ICU has significantly improved the quality of care and outcomes for critically ill patients, mostly in developed countries [1]. The ability to perform continuous patient status monitoring is a key factor differentiating the ICU from the general wards in the hospital. In the ICU, data are continuously displayed, recorded, and readily accessible to all medical personnel caring for the patient. This is aimed at helping doctors and nurses monitor a patient’s vital trends and respond appropriately according to the patient’s needs [2].

Access to the ICU is a vital component of healthcare systems; hence, critically ill patients are admitted to the ICU to reduce morbidity and mortality [3]. Critically ill patients are medically challenging and may benefit from a multidisciplinary approach, but they are usually treated in the ICU, where the hospital has the highest mortality rates [4].

Mortality in the ICU is a global burden and varies globally depending on the disease pattern, infrastructure, and ICU staff. In developed countries such as the United States of America and European countries, the ICU mortality rate is low, with rates between 9.3% and 18.7%, respectively, while in less developed countries such as South American countries and Middle Eastern countries, the mortality rate is 21.7% and 26.2%, respectively [5, 6]. In sub-Saharan Africa (SSA), the mortality rate is high because the availability of ICU services is limited due to a lack of financial resources, technology, and well-trained staff. These remain major obstacles to providing optimal care to critically ill patients [7].

Describing disease patterns and clinical outcomes will help make better use of the limited resources available in developing countries like Tanzania. Therefore, we describe the admission patterns and outcomes among patients admitted to the medical intensive care unit (MICU) at KCMC. The obtained information will provide solid evidence on what should be done to improve the general direction of the MICU at KCMC.

Materials and methods

Results

A total of 1445 patients were admitted from January 2018 to December 2020 into the MICU. Twenty patients had incomplete data; therefore, 1425 patients were included in the study (Table 1). Males (54.7%) were more frequent compared with females. The common age group was 26–50 years (38.8%), with a mean age of 49.4 years. More patients were admitted during the weekdays (61.7%) compared to the weekend.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Demographic and admission characteristics of patients admitted to MICU.

https://doi.org/10.1371/journal.pone.0282269.t001

The common comorbid conditions were type 2 diabetes mellitus and hypertension, at 14.7%, respectively. HIV was seen in 4.2% of the MICU admissions. Most of the admissions to the MICU (61.5%) were admitted from the emergency department or during admission, with 33.7% of transfers occurring after the patient’s admission. The overall mortality of the MICU was 37.6%. Most patients spent 1–3 days in the MICU (43.9%) with a mean length of stay (LOS) of 4.1 days (Table 1).

The most common specific diagnosis at MICU admission was esophageal varices (13.5%), followed by diabetic ketoacidosis (11.7%), heart failure (7.9%), chronic kidney disease (5.8%), and cardiogenic shock (5.5%) (Table 2). The mortality rate was high for acute leukemia (80.0%), followed by acute bacterial meningitis (77.8%), septic shock (77.4%), organophosphate poisoning (76.0%), and cardiogenic shock (73.1%).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. In-Hospital mortality of the leading causes of death in the MICU.

https://doi.org/10.1371/journal.pone.0282269.t002

The proportion of deaths among males (39.1%) was higher than that of females (35.8%). However, there were no significant sex differences in mortality (OR 1.15, P 0.202). The odds of mortality increased with age. The age group of 51–75 years had 1.46 higher odds of mortality (P <0.001). However, patients aged more than 75 years had 1.66 odds of mortality (P 0.002) (Table 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Predictors of mortality among patients admitted to MICU.

https://doi.org/10.1371/journal.pone.0282269.t003

Patients admitted from the emergency department or during admission had lesser odds of mortality (OR 0.73, P 0.006), compared with patients transferred from the medical ward, who had higher odds of mortality (OR 1.46, P 0.001) (Table 3). Patients who stayed in the MICU for <24 hours were ten times more likely to die (P <0.001) than patients who stayed for more than seven days. Patients admitted to the MICU for a communicable disease had 2.6 higher odds of mortality (P <0.001), while patients admitted for a cardiovascular disease had 1.4 higher odds of mortality (P 0.002).

The highest mortality rate (45.0%) was observed in December, followed by October (43.6%) and September (43.1%). The lowest mortality rate (24.5%) was observed in August (Fig 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Monthly analysis of admission versus death over three years in the MICU.

https://doi.org/10.1371/journal.pone.0282269.g001

Discussion

The clinical outcome of patients admitted to the MICU is determined by their clinical condition at the time of admission, the level of experience and training of the staff, the ICU’s resources, infrastructure, and capacity [5, 6]. In this study, the overall mortality rate for patients in the MICU was 37.6%. This finding is comparable with another study in Tanzania (41.4%) [7]. This is also similar to the studies conducted in Nigeria (34.6%), Ethiopia (38.7%), Uganda (40.1%), and Kenya (53.6%) [6, 9–11]. However, this result was higher than studies done in developed countries such as the United States of America (5.6%), Scandinavian countries (9.1%), and Korea (13.8%) [3, 12, 13]. This difference might be due to a lack of necessary medical equipment, infrastructure, and training [6, 7].

The LOS can assess the efficacy of hospital management, quality of care, and functional evaluation. ICU LOS is determined by the cause of admission, which differs among diagnoses. Reduced LOS is associated with fewer hospital-acquired infections and medication side effects, including a reduced burden of medical fees and increased bed turnover time [14]. In this study, the median length of MICU stay was 3 days, which is relatively similar to the other African countries [6, 11]. There is a slight difference in the LOS between developed and developing countries, with the latter having an increased LOS. Because of advancements in medical therapy in the early 2010s, the mean LOS is now 3.5 days [15]. In developing countries, such as Brazil and Ethiopia, the mean LOS observed is 5 and 4.1 days, respectively [16, 17]. Patients who stayed in the MICU for less than 24 hours were 10 times more likely to die. This may not be an adequate representation since the reason they stayed for less than 24 hours is because they died. It is rare for critically ill patients to be in the ICU for less than 24 hours and be transferred out. This difference might be due to factors such as late arrival at the ICU and delay in intervention, shortage of critical emergency drugs, resuscitation ability of the MICU, and absence of airway management equipment in the emergency department [6]. However, this result was different from the study conducted in Ethiopia, where the LOS of ICU mortality was more than 14 days [18].

Disease patterns tend to vary according to age, race, lifestyle, immune status, co-morbidity, and region. The mean age in this study was 49.4 years, with male predominance. In the ICON study, low- and lower-middle-income countries tend to have a slightly younger population (55 years) compared to high-income countries (62 years) [5]. The age distribution of ICU admissions in developing countries, such as Nigeria, shows a mean age of 38.2 years with a higher male predominance [9]. The mean ages in developed countries, such as the United States of America and the United Kingdom, are 60.4 years and 57.4 years, respectively, with a slightly higher male predominance.

Over 10 years ago, the trends were different in developing countries, as can be observed in Taiwan. Although the mean age and male predominance were similar to those of developed countries, the infectious disease related causes of admission were 47.1% and cardiac-related causes were 5.6% [19]. Currently, in developing countries such as Brazil and Ethiopia, the trends are different from those of developed countries and those over from 10 years ago. In Brazil, 19.2% of ICU admissions are cardiac-related, followed by infectious diseases (18.6%) and neurological diseases (9.6%) [16]. Similarly, in Ethiopia, the ICU admission trends were observed as being cardiac (26.1%), infectious (20.3%), and neurological (19.8%) [17]. In Tanzania, infectious diseases led the admission category (19.5%), followed by cardiovascular (6%) and metabolic (6.1%) diseases. In KCMC, the ICU admission category was based mainly on infectious (20.5%) and cardiac (9%) diseases [7]. In this study, emergencies such as upper gastrointestinal bleeding and NCDs such as diabetic ketoacidosis and heart failure dominated the admission charts. The observed trend shows that developing countries have a dual burden of NCDs as well as communicable diseases. Previously, medical admissions were mainly for communicable diseases in developing countries, but now there is a shifting pattern of diseases toward NCDs, especially in the tropics [20].

Conclusion

The overall mortality rate in the MICU was considerably high, with medical emergencies and cardiovascular disorders being the most common causes of admission and death. Elderly patients, transfers from the medical ward to the MICU, and short ICU stays were significantly associated with the poor outcome of MICU patients. Most critically ill patients died within 24 hours of admission. Therefore, further studies need to be conducted to understand the cause of the high mortality rate. This may help reduce the mortality rate among critically ill patients admitted to the MICU.

Acknowledgments

The authors are grateful to the internal medicine department for their work and support of all patients that they have managed.