The hospital burden of critical illness across global settings: a point-prevalence and cohort study in Malawi, Sri Lanka and Sweden

Abstract

Key PointsQuestion:What is the burden of critical illness in hospitals in different global settings, and where are critically ill patients being cared for?Findings:Among 3652 hospitalized patients in countries of different socio-economic levels (Malawi, Sri Lanka, and Sweden) we found a point-prevalence of critical illness of 12.0% (95% CI, 11.0-13.1), with a hospital mortality of 18.7% (95% CI, 15.3-22.6). The odds ratio of death of critically ill compared to non-critically ill patients was 7.5 (95% CI, 5.4-10.2). Of the critically ill patients 3.9 % (95% CI, 2.4-6.1) were cared for in Intensive Care Units (ICUs).Meaning:Critical illness is common in hospitals and has a high mortality. Ensuring that feasible critical care interventions are implemented throughout hospitals including in general wards where more than nine in ten critically ill patients are cared for, has potential to improve outcomes across all medical specialties.AbstractImportance:Large unmet needs of critical care have been identified globally, but evidence to guide policy priorities is scarce. Available studies into the burden of critical illness have important limitations.Objective:To assess the adult burden of critical illness in hospitals across global settings.Design, Setting, and Participants:This was a prospective, observational, international, hospital-based, point-prevalence and cohort study in Malawi, Sri Lanka, and Sweden. On specific days, all adult in-patients in the eight study hospitals were examined for the presence of critical illness and followed up for hospital mortality.Exposure:Patients with one or more severely deranged vital sign were classified as critically ill.Main Outcomes and Measures:The primary study outcomes were the point-prevalence of critical illness and 30-day in-hospital mortality. In addition, we assessed the proportion of critically ill patients who were cared for in Intensive Care Units (ICU)s, and the association between critical illness and 30-day in-hospital mortality.Results:Among 3652 hospitalized patients in countries of different socio-economic levels we found a point-prevalence of critical illness of 12.0% (95% CI, 11.0-13.1), with a hospital mortality of 18.7% (95% CI, 15.3-22.6). The odds ratio of death of critically ill compared to non-critically ill patients was 7.5 (95% CI, 5.4-10.2). Of the critically ill patients 3.9 % (95% CI, 2.4-6.1) were cared for in ICUs.Conclusions and Relevance:The study has revealed a substantial burden of critical illness in hospitals from different global settings. One in eight hospital in-patients were critically ill, 19% of them died in hospital, and 96% of the critically ill patients were cared for outside ICUs. Implementing feasible, low-cost, critical care in general wards and units throughout hospitals would impact all critically ill patients and has potential to improve outcomes across all acute care specialties.