Study of Morbidity and Mortality Pattern of Children Admitted in Paediatric Intensive Care Unit of Tertiary Care Children’s Hospital

Introduction: Intensive care is predominantly concerned with the management of patients with acute life threatening conditions in a specialised unit. The objective of this study was to describe the morbidity and mortality patterns as well as outcome of patients admitted in the Paediatric Intensive Care Unit (PICU) of a tertiary care government paediatric hospital in Nepal. Methods: A cross-sectional study of 652 children admitted to the PICU of Kanti Children’s Hospital was undertaken from 1st January 2018 to 31st December 2018. The data were retrieved retrospectively from the record files of PICU regarding patient’s age, sex, inhabitant, admitting and final diagnosis, length of stay in the ICU and final outcome. Data were entered into MS Excel and analysed using Pearson’s Chi Square Test. Results: Among 652 admitted children between 1 month to 14 years of age, 397 (61%) were males and 255 (39%) females with male to female ratio 1.55:1. Majority 352 (54%) of them were in the age group of one month to 12 months of age. Pneumonia (216, 33.1%) was the major disease seen followed by septicemia (123, 18.9%), bronchiolitis (44, 6.7%), other infectious diseases (38, 5.8%) and so on. Out of total admission, 484 (74.23%) cases improved, 46 (7.05%) left against medical advice (LAMA) and 120 cases died with mortality rate of 18.46%. More than half of the deaths (n = 87/120, 72.5%) were due to infections (Septicemia, acute gastroenteritis, pneumonia and meningitis and other infectious diseases). Conclusions: Pneumonia with respiratory distress was the major cause of PICU admission while fatality was highest for acute leukemia. Therefore it seems justifiable to improve primary and secondary health care facilities for timely and reliable delivery of current standardised therapeutic practice as well as to increase ICU facilities in those areas.


INTRODUCTION
The care of critically ill children remains one of the most demanding and challenging aspects in the field of paediatrics. Paediatric intensive care unit (PICU) aims at promoting early intervention and quality care with an objective of achieving good results and better prognosis. 1 Advances in knowledge and technology of medical science has dramatically improved the prognosis of critically-ill children. Numerous conditions that were previously fatal are now treatable. 2 Though the specialty of paediatric critical care medicine has grown and matured over years in the developed countries, the concept of paediatric critical care is relatively new in Nepal. 3 A growing demand for critical care services has led some of the major teaching hospitals to provide spaces for management of severely ill children, in spite of a lack of trained manpower, adequate infrastructures and appropriate knowledge. 4 Paediatric intensive care admissions vary among different regions in different settings. The profile of children admitted mainly differs from western countries in terms of the demography, spectrum of diseases, incidence and outcomes. 5 Respiratory, neurological and infectious diseases are more common in this part of the globe whereas solid tumours, trauma and neurological infections are more common in western world. 6 There are several reports on the outcome of PICUs from developed countries, but only few reports are available from Nepal. 3,4,7 Therefore we planned to carry out this study at the only central level Government's paediatric hospital with largest critical care unit catering services to the needy children referred from all over the country.
The main objective of the study was to determine the pattern and prevalence of morbidity, temporal distribution, geographical distribution, duration of hospital stay, outcome and mortality pattern among children between one month to 14 years of age admitted in PICU. Results thus obtained would be useful in modifying healthcare strategies if necessary, appropriate resource allocation and formulating appropriate interventions leading to better management and outcome of critically ill children.

METHODS
This cross sectional study was conducted in the PICU of Kanti Children's Hospital (KCH), the largest tertiary care Government paediatric hospital in Nepal. Being the only tertiary care Government paediatric hospital in the country, the twelve bedded PICU with two extra isolation beds operates at full capacity all the time.
Record files of all the paediatric patients, aged one month to 14 years, admitted in PICU of KCH over a period of one year (1 st January 2018 to 31 st December 2018) were reviewed retrospectively out of which 652 admitted children's record were found to have complete data set and hence were included for analysis. Variables recorded were patient's age, gender, date of entry into and exit from PICU, duration of stay, diagnosis at admission and exit from PICU as well as final outcome. Diagnosis was classified as per international classification of disease. "Other Infectious Diseases" included tropical diseases like, tuberculosis, enteric fever, scrub typhus, pertusis like illness, chicken pox, kala-azar, tetanus, brucellosis and Croup. Address of the patient was categorised into district and provinces. Data were entered into MS Excel and exported to SPSS version 20.0 for analysis. Descriptive statistics were computed for all study variables with mean standard deviation and median used as measures of central tendency. Comparisons of proportions were performed using Pearson chisquare test with a p value of < 0.05 considered as significant. The odds of a particular disease was calculated with respect to remaining all other diseases. The study was conducted after taking an Ethical approval from Intuitional Review Committee of Kanti Children's Hospital with ref no: 339/075-076. Formula used for calculating hospital statistics are as follows. 8,9 Length of stay = Total inpatient -days stay / Total Number of discharges and deaths Mean cases per month = Total number of cases admitted during study period / 12 Bed occupancy rate= Number of inpatients-days x 100 / No of inpatients-bed available x 365 Bed turn-over rate = Number of discharges (including deaths) in a given time period / Number of beds available during that time period.
Case fatality rate = Number of deaths by particular disease x 100 / Number of cases of that particular disease registered in the same year.

RESULTS
During one year of study period, a total of 652 patients were admitted in PICU (mean 54.3 cases/ month). The bed occupancy rate was 85.18% per year with the turnover rate of 50.33. Among the study population, 397 (61%) were males and 255 (39%) females, with a M:F ratio of 1.55:1. Age on admission ranged from one month to 14 years with a mean of 34.18 ± 45.48 months and median of nine months. Table 1 shows demographic distribution of the study population.
Pneumonia (33.1%) was the major disease seen in our PICU followed by sepsis (18.9%) and bronchiolitis (6.7%). Various diseases encountered in PICU are as listed in Table 2. Diseases like bronchial asthma, rheumatic heart disease (RHD), PSGN, Bartter syndrome, renal tubular acidosis, SLE, liver cirrhosis, anaemia with complications, diabetes mellitus and complications etc were included in miscellaneous group.
System wise evaluation showed respiratory system (n = 178, 27.3%) and infectious group (n = 157, 24.1%) at the top of the list followed by neurological cases (n = 68, 10.4%). Around 67 (10.3%) cases had involvement of more than two systems. Figure 1 shows system wise distribution of cases in PICU. Almost one fifth (n = 141, 21.62%) of the cases were having underlying comorbid conditions mainly congenital heart diseases (CHD) (n = 68), Down's phenotype with complications (n = 23) and global developmental delay (GDD) (n=13). Besides, cerebral palsy (CP), failure to thrive (FTT), protein energy malnutrition (PEM), acute Leukemia and paediatric surgical problems like CDH, HD, gastroschiasis, etc were less common co-morbid association. Around 13 cases were found to be readmitted during the study period.
The main reason for PICU admission was respiratory distress including ARDS (n = 401, 61.50%) with underlying respiratory, cardiac and metabolic diseases. Around 40 (6.13%) patients were admitted because of shock, majority of which was septic shock 28 (4.29%). Other causes included status epilepticus with altered mental status and poor GCS, 35 (5.36%) mainly with the diagnoses of meningitis, meningoencephalitis and hepatic

DISCUSSION
Caring for critically ill children is a challenge in developing countries, where necessary equipment is scarce and trained manpower is limited. 10 Due to the scarcity of published data of PICU profile within Nepal, adequate comparison of relative incidence and outcome is not possible within the country.
In this study, 652 cases were admitted with an average of 54.3 cases / month and bed occupancy rate of 85.18%, which was much higher than that was seen in Patan Academy of Health Sciences (PAHS) (n = 126) and B.P Koirala Institute of Health Sciences (BPKIHS) (n = 230). 4,7  We observed a wide spectrum of cases covering almost all the systems like respiratory (n = 178, 27.3%), infections (n = 157, 24.1%), neurology (n = 68, 10.4%), cardiorespiratory (n = 57, 8.7%) Cardiac (n = 24, 3.7%) and hemato-oncology (n = 44, 6.7%). Pneumonia (33.01%) was the major disease requiring PICU admission as was reported in other earlier studies. 5,7,10 This may be attributed to the fact that pneumonia is one of the leading causes of paediatric morbidity and mortality in South East Asia. 12 In our study 161 children (24.69%) were admitted for infectious diseases, significant number of which were due to sepsis (n = 123, 18.9%). This may be due to the fact that infectious diseases still contribute to a vast majority of illnesses in our part of the world. 13 In contrast to our finding, GBS, RHD and post infectious glomerulonephritis were more prevalent in Ethiopia. 11 This shows that paediatric intensive care admissions vary among different regions in different settings and one should be aware of the prevalent conditions to develop the facilities and prepare relevant treatment plan.
The study revealed that around 1.9% (n = 13) of the patients discharged to the paediatric ward were readmitted to the PICU. Early discharge of less severe PICU patients to provide PICU beds for more severe critically ill patients can be a reasonable explanation for this. Establishment of a paediatric intermediate care unit as a step down unit will not only offer better care to such patients but also avail more vacant beds in the PICU.
Respiratory distress (61.5%) was the major reason for PICU admission in our study, which is in accordance to the study done by Khanal  country reported respiratory distress / failure as their primary cause for admission. 3 But in PAHS Basnet S et al. reported shock (45%), particularly septic shock (30%) as the main reason for PICU admission which was the second common cause in our study. 4 The discrepancy in these findings may be just because of the differences in the morbidity patterns of the study population. Neurological causes like status epilepticus and poor GCS were other common reasons requiring PICU admission in our study as has been reported in earlier study. 3,4 Among the total study population, 484 (74.23%) patients improved and were transferred to ward or discharged to home. Several previous studies showed nearly similar pattern of improvement ranging between 68% to 77%. 7,10,14 Two (0.3%) cases were referred to other centre for not having cardio-thoracic and neurosurgical facility in our centre and 46 (7.05%) cases went on LAMA. Most of these patients left the hospital either due to financial constraints or parents' perception that the child won't survive from current illness which is in accordance with various other published studies. 7,15 Mortality rate in our study was 18.5%. This rate may be considered acceptable, as mortality rates between 12.6% -19% have been reported from PICUs in other parts of the world. 2,7,10,14 However, a higher mortality rate was reported in another study within the country. 4 This could be attributed to the fact that there is an inverse relationship between patient volume and outcomes in the setting of the PICU. PICUs with greater volumes had reductions in both PICU mortality risk and PICU length of stay. 16 Factors contributing to high morbidity and mortality in ICUs are poor healthcare system, length of illness, delayed presentation, history of treatment before PICU admission, level of clinical instability while being treated and severity of disease when the patients presented to the hospital. 14,17 Though age related mortality in our PICU was highest (47.5%) for the age group of less than one year and more male patients died as compared to female (74 vs 46), age and sex did not show any statistically significant difference between survivor and non-survivor. Contrary to our findings, patients within the age group of one to five years were having highest mortality in AIIMS (32.1%) and BPKIHS (7.8%). 5,7 This could be because infants were the major contributor for PICU admission in our hospital. The average LOS in our unit was 5.72 ± 5.78 days and median of four days regardless of outcome whereas mean of 6.2 ± 5.3 days and median of four days was seen at PAHS. 4 As in Egypt (78.4%) majority of the children in our study (78.06%) remained in PICU for less than seven days. 14  Our study incorporated a variety of patients with different illnesses reflecting the wider service facility of central PICU. Despite this and large sample size, our study was limited by the fact that it was a single centric study, the result of which may not be generalised to the population of various areas where resources are more limited. Also, being a retrospective study, data collected were incomplete in terms of use of mechanical ventilation which couldn't be analysed. A wider study needs to be conducted that encompasses the outcome of mechanical ventilations as well.

CONCLUSIONS
Pneumonia with respiratory distress was the major cause of admission in PICU, followed by sepsis, bronchiolitis and other infectious diseases. Case fatality was highest for acute leukemia. Almost one fifth of the patients had some form of comorbidity. The results of this study confirm that the mortality rate was positively correlated with association of co-morbidities, LOS and younger age.