Association between lack of Intensive Care Unit (ICU) access and mortality in patients with combined assessment of risk encountered in surgery (cares) more than 20 points at CHUB and CHUK: a cohort study

Abstract

Background Lack of access to intensive care unit (ICU) for both surgical and non-surgical patients is common in countries with limited resources. In the current literature, there is a paucity of published data on the outcome of patients who lacked access to ICU while they were having criteria for critical management after surgery. The aim of this study was to assess the mortality and length of hospital stay for patients with a combined assessment of risk encountered in surgery (CARES) >20 points who had surgery and lacked access to ICU in comparison to those who got admission to ICU Methods This was a prospective comparative cohort study carried out in two university teaching hospitals which are Butare University Teaching Hospital(CHUB) and Kigali University Teaching Hospital (CHUK) over 10 months’ period, from June 2020 to April 2021. All participants were followed in-hospital till discharge, death or till 30 days postop whichever came first. Mortality and length of in-hospital stay were recorded and compared in ICU access and non -ICU access groups. Data analysis was done using SPSS version 25.0 (IBM Corporation, New York 10504-1722, USA). Percentages and means were used for descriptive statistics. For categorical variables with comparison groups, chi-square test was used. For continuous variables, t-test and ANOVA test were used to compare means among groups. A p–value of 0.05 or less was considered statistically significant. Odds ratio (OR) and 95% confidence interval (CI) were estimated using logistic regression analysis. Results: In total 708 acute care surgery (ACS) patients were evaluated using CARES surgical risk calculator and 213 patients had CARES> 20 points and were enrolled in the study. 82 patients had post-operative ICU access timely or delayed while 130 did not have access to critical care service after operation and 1 patient has died intraoperatively. x Mortality rate among patients who had immediate post-operative ICU admission was 26.4% versus 89.7% for those who had delayed admission and 48.1% in no ICU access group. Delayed ICU admission increases mortality by 24-fold (95% CI, 6.304-92.393, p-value 20 points. Early management, preoperative ICU bed booking and timely ICU admission may considerably decrease mortality and morbidity. We recommend to increase ICU capacity for both CHUB and CHUK, improve preoperative evaluation of all surgical emergencies and create a dedicated area for suitable monitoring and management for critically ill surgical patients when access to ICU is limited or unavailable