6th Report of - CRC...Hospital Sultan Ismail Johor Bahru 27. Hospital Ampang Participating sites...

Malaysian Registry of Intensive Care

Report for 2010

Prepared by

Technical Committee of


2 Malaysian Registry of Intensive Care | Report for 2010

May 2011

© Malaysian Registry of Intensive Care

Published by:


Clinical Research Centre

Ministry of Health Malaysia

Disclaimer:

This work may be reproduced in whole or part for study or training purposes, subject to the

inclusion of an acknowledgement of the source.

Suggested citation:

Jenny MG Tong, LL Tai, CC Tan, Ahmad S, CH Lim

Malaysian Registry of Intensive Care 2010 report

Electronic version:

This report can be downloaded at MRIC website: www.mric.org.my

3Malaysian Registry of Intensive Care | Report for 2010

CONTENTS Page

Contents……………………………………………………………………………………. 3

Report Summary…………………………………………………………………………... 4

Acknowledgement………………………………………………………………………… 5

Foreword…………………………………………………………………………………… 6

MRIC Technical Committee 2009………………………………………………………. 7

Participating Hospitals…………………………………………………………………… 8

Categories of ICU …………………………………………………………………………. 9

Site Investigators and Source Data Providers 2009…..………………………………… 10

Abbreviations……………………………………………………………………………… 13

List of Tables………………………………………………………………………………. 14

List of Figures……………………………………………………………………………… 15

Introduction……………………………………………………………………………….. 16

Results

Section A General Information…………………………………………………… 19

Section B Patient Characteristics………………………………………………… 25

Section C Interventions…………………………………………………………… 45

Section D Complications…………………………………………………………. 55

Section E Mortality Outcomes…………………………………………………... 65

Section F Special report on Dengue infection in ICU 2010................................. 73

Section G Special report on H1N1 infection in ICU 2009 and 2010................... 79

Summary…………………………………………………………………………………… 83

References…………………………………………………………………………………… 85


REPORT SUMMARY

This is the report on all intensive care admissions to the 37 participating centres from 1st January to 31st December 2010. The following are the main findings: 1. The total number of ICU beds in the 36 MOH participating units was 439 with an average

bed occupancy rate of 91%.

2. The number of cases analysed was 26,977, an increase of 27% over the previous year.

3. The overall reporting rate over the past few years had been fairly constant at 88%. 4. The percentage of patients denied admission due to the unavailability of ICU beds had

declined from 53.4% to 36.5% in the last five years. 5. The average age of the patients, excluding those below 18 years, was 49.4 years.

6. The average duration of ICU and hospital stay were 4.7 and 14.6 days respectively. 7. In MOH hospitals, 63% of ICU admissions were non-operative patients.

8. Direct admissions to ICU from the emergency department had increased from 9% in 2004 to 24% in 2010.

9. 63% of ICU admissions had one or more organ failure within 24 hours of ICU admission. 10. Head injury, sepsis and dengue infection were the three most common diagnoses leading

to ICU admission in MOH hospitals. Over the past 8 years, head injury and sepsis remained the two most common diagnoses. In 2010, dengue infection overtook community acquired pneumonia as the 3rd most common diagnosis leading to ICU admission. The in-hospital mortality rates for this group of patients were 27.4%, 59.3% and 8.6% respectively.

11. The average SAPS II score was 35.1, which carries a predicted in-hospital mortality of

27.0%. 12. In MOH hospitals, 71.6% of patients received invasive ventilation with an average duration

of 4.1 days. 13. The percentage of patients who received non-invasive ventilation increased from 6.5% in

2003 to 14.3% in 2010. 14. The incidence of VAP decreased by more than half, from 28.0 to 10.1 per 1000 ventilator

days, in the last eight years. 15. The crude in-ICU and in-hospital mortality rates were 20.9% and 28.1% respectively. 16. The mean standardised mortality ratio was 0.80 (95% C.I. 0.54 – 1.14).


ACKNOWLEDGEMENT The Malaysian Registry of Intensive Care would like to thank the following: Sister Lim Siew Kim, MRIC Project Manager All site investigators and source data providers The heads of Department of Anaesthesia and Intensive Care of participating ICUs Staff of the participating ICUs Quality of Health Care Unit, Medical Development Division, Ministry of Health Clinical Research Centre, Ministry of Health All who have contributed in one way or another to MRIC


FOREWORD I am honoured to be given the opportunity to write the foreword for this 2010 report which will be

my last as the national advisor for the Anaesthetic and Intensive Care Services in Ministry of

Health. Having been with NAICU and subsequently MRIC for almost a decade, it is with great

pride and satisfaction that I pen this parting note. It is no small feat to maintain a registry and

produce high quality annual reports for an uninterrupted period of eight years. As a fraternity, we

are incredibly proud of this achievement.

The anaesthetic discipline has benefited greatly from the findings generated from the data in the

registry. We are able to benchmark our performance, identify shortcomings and introduce changes

in clinical practice. The ventilator care bundle introduced in 2007 had made a positive impact on

patient care by reducing the rate of ventilator-associated pneumonia in MOH ICUs. Data on ICU

facilities and ICU denial give credence to our request for more ICU beds to be established. It is not

unfair to say that the registry has been a major catalyst in advancing intensive care in Ministry of

Health and to a certain extent the entire nation.

Whilst the registry has covered almost all the ICUs in Ministry of Health, it has not been well

received by the private and university hospitals. Since the participation of Sime Darby Medical

Centre in 2006, there has not been a second participating centre outside MOH. This is a major set

back. It is my fervent wish that there would be greater participation from the private and

university sectors. I am hopeful that the scenario will change in the next few years when

accreditation, clinical governance and accountability become more wide spread.

Now it only remains for me to thank each and every one who has contributed in one way or

another to make this registry a success. I am especially thankful to Dr. Jenny Tong, Dr. Tai Li Ling

and Dr. Tan Cheng Cheng for their unwavering support and hard work that has spanned almost a

decade. Their dedication and commitment is unparalleled. I am confident that under their

stewardship while ably assisted by the 'new generation' in Dr. Ahmad Shaltut, Dr. Lim Chew Har

and Dr. As Niza, MRIC is in good hands and that it will continue to scale greater heights.

Dr. Ng Siew Hian

National Advisor

Anaesthetic and Intensive Care Services

Ministry of Health


TECHNICAL COMMITTEE

MALAYSIAN REGISTRY OF INTENSIVE CARE 2010

Advisors Dr. Hjh Kalsom Maskon Deputy Director (Quality of Health Care Unit) Medical Development Division, Ministry of Health Dr. Ng Siew Hian Consultant Anaesthesiologist and Head Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur

Principal Investigator Dr. Jenny Tong May Geok Consultant Anaesthesiologist and Head Department of Anaesthesia and Intensive Care Hospital Tuanku Ja’afar Seremban

Co-Investigators Dr. Tai Li Ling Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Kuala Lumpur Dr. Tan Cheng Cheng Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Sultanah Aminah Johor Bahru Dr. As-niza Abdul Shukor Consultant Anaesthesiologist and Head Department of Anaesthesia and Intensive Care Hospital Taiping Dr. Ahmad Shaltut Othman Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Sultanah Bahiyah Alor Setar Dr. Lim Chew Har Consultant Intensivist Department of Anaesthesia and Intensive Care Hospital Pulau Pinang

Medical Development Division, Ministry of Health

Dr. Paa Mohamed Nazir Abdul Rahman Senior Principal Assistant Director Dr. Fakhruddin Amran Principal Assistant Director Puan Nor Wati Mohd Nursing Sister


PARTICIPATING HOSPITALS No. Name of hospital Abbreviation

Sites since 2002 1. Hospital Sultanah Bahiyah Alor Setar AS

2. Hospital Pulau Pinang PP

3. Hospital Raja Permaisuri Bainun Ipoh IPH

4. Hospital Kuala Lumpur KL

5. Hospital Selayang SLG

6. Hospital Tengku Ampuan Rahimah Klang KLG

7. Hospital Tuanku Ja’afar Seremban SBN

8. Hospital Melaka MLK

9. Hospital Sultanah Aminah Johor Bahru JB

10. Hospital Tengku Ampuan Afzan Kuantan KTN

11. Hospital Sultanah Nur Zahirah Kuala Terengganu KT

12. Hospital Raja Perempuan Zainab II Kota Bharu KB

13. Hospital Umum Sarawak Kuching KCH

14. Hospital Queen Elizabeth Kota Kinabalu KK

Sites since 2005 15. Hospital Sultan Abdul Halim Sungai Petani SP

16. Hospital Putrajaya PJY

17. Hospital Pakar Sultanah Fatimah Muar MUR

18. Hospital Teluk Intan TI

19. Hospital Taiping TPG

20. Hospital Seberang Jaya SJ

21. Hospital Kajang KJG

22. Hospital Tuanku Fauziah Kangar KGR

Sites since 2006 23. Sime Darby Medical Centre Subang Jaya SDMC

24. Hospital Sultan Haji Ahmad Shah Temerloh TML

25. Hospital Tuanku Ampuan Najihah Kuala Pilah KP

26. Hospital Sri Manjung SMJ

27. Hospital Batu Pahat BP

28. Hospital Tawau TW

29. Hospital Miri MRI

30. Hospital Kulim KLM

31. Hospital Serdang SDG

Sites since 2010

32 Hospital Sibu SB

33 Hospital Duchess of Kent Sandakan DKS

34 Hospital Sultan Ismail Johor Bahru SI

35 Hospital Sungai Buloh SBL

36 Hospital Ampang AMP

37 Hospital Wanita dan Kanak-Kanak Sabah LIK


CATEGORIES OF ICU Based on the number of ICU beds (as of 31st December 2010 for the purpose of MRIC 2010 report) Participating sites with 16 ICU beds or more

1. Hospital Sultanah Bahiyah Alor Setar

2. Hospital Pulau Pinang

3. Hospital Raja Permaisuri Bainun Ipoh

4. Hospital Kuala Lumpur

5. Hospital Selayang

6. Hospital Tengku Ampuan Rahimah Klang

7. Hospital Melaka

8. Hospital Sultanah Aminah Johor Bahru

9. Hospital Sultanah Nur Zahirah Kuala Terengganu

10. Hospital Taiping

11. Hospital Sungai Buloh

Participating sites with 8 – 15 ICU beds

12. Hospital Tuanku Ja’afar Seremban

13. Hospital Tengku Ampuan Afzan Kuantan

14. Hospital Raja Perempuan Zainab II Kota Bharu

15. Hospital Umum Sarawak Kuching

16. Hospital Queen Elizabeth Kota Kinabalu

17. Hospital Putrajaya

18. Hospital Pakar Sultanah Fatimah Muar

19. Hospital Seberang Jaya

20. Hospital Sultan Haji Ahmad Shah Temerloh

21. Hospital Sri Manjung

22. Hospital Batu Pahat

23. Hospital Serdang

24. Hospital Sibu

25. Hospital Duchess of Kent Sandakan

26. Hospital Sultan Ismail Johor Bahru

27. Hospital Ampang

Participating sites with 7 ICU beds or less

28. Hospital Sultan Abdul Halim Sungai Petani

29. Hospital Teluk Intan

30. Hospital Kajang

31. Hospital Tuanku Fauziah Kangar

32. Hospital Tuanku Ampuan Najihah Kuala Pilah

33. Hospital Tawau

34. Hospital Miri

35. Hospital Kulim

36. Hospital Wanita dan Kanak-Kanak Sabah

Private hospital

37. Sime Darby Medical Centre Subang Jaya


LIST OF SITE INVESTIGATORS AND SOURCE DATA COLLECTORS

January – December 2010

No Hospital Site investigator Data collectors

1 Sultanah Bahiyah Alor Setar

Dr Ahmad Shaltut bin Othman

Sr Teoh Shook Lian SN Seniwati @Nurhayati bt Salleh SN Hafisoh bt Ahmad SN Haslina bt Khalid SN Norashikin bt Man

2 Pulau Pinang Dr Lim Chew Har SN Khairulniza bt Razar SN Rosmalizawati bt Ibrahim SN Siti Hazlina bt Bidin SN Rosmawati bt Yusoff

3 Raja Permaisuri Bainun Ipoh

Dr Azlina bt Muhamad SN Khairiah bt Mat Daud (Jan-July 2010) SN Saadiah bt Bidin SN Ng Pek Yoong (June-Dec 2010)

4 Kuala Lumpur Dr Tai Li Ling SN Sakulawati bt Said SN Zainab bt Ali

5 Selayang Dr Laila Kamariah bt Kamalul Baharin

SN Norzaila bte Saad@Hanafi SN Noor Azawati bt Daud SN Maimun bt Ismail

6 Tengku Ampuan Rahimah Klang

Dr Faezah bt Shaari

SN Latifah bt Omar SN Norlaili bt Ismail

7 Tuanku Ja’afar Seremban Dr Jenny Tong May Geok Sr Chew Bee Ngoh SN Farawahida bt Ahmad

8 Melaka Dr Anita bt Alias SN Morni bt Omar

9 Sultanah Aminah Johor Bahru

Dr Tan Cheng Cheng

Sr Marian Sais ak Sipit SN Aishah bt Abu Bakar AMO Mohd Zakuan bin Mohd Nor AMO Hairizam b Zulkhifli AMO Mohd Adib b Jasni AMO Anand a/l Sivasamy

10 Tengku Ampuan Afzan Kuantan

Dr Rusnah bt Ab. Rahman

Sr Nurhaini bt Kassim SN Aminah bte Abd Hamid SN Salina bt Sulaiman

11 Sultanah Nur Zahirah Kuala Terengganu

Dr Mohd Ridhwan bin Mohd Nor

SN Zauwiah bt Idris SN Norhayati bt Abd Rahman SN Aslinawati bt Chik

12 Raja Perempuan Zainab II Kota Bharu

Dr Wan Nasrudin bin Wan Ismail

SN Azilah bt Ishak SN Azizum bt Ismail SN Haryati bt Hassan

13 Umum Sarawak Kuching Dr Sanah bt Mokhtar

SN Norelsa bt Daim SN Sabia Lew SN Rosmica Jiton


14 Queen Elizabeth Kota Kinabalu

Dr Khoo Tien Meng SN Jusim Lugu SN Safiah bt Mokhtar SN Conny Chong Chiew Fah

15 Sultan Abdul Halim Sungai Petani

Dr Rafidah bt Kasim Sr Rafizah Md Zuki Sr Puziah bt Yahya SN Halijah bt Kasim SN Hamiza bt Mohd Noor

16 Putrajaya Dr Fauziah bt Yusoff Sr Noorainee bt Romli SN Noryasni bt Mahtrod@Ahmad (Jan-Oct 2010) SN Latifah bt Mohd Korib SN Maznah bt Muhamad

17 Pakar Sultanah Fatimah Muar

Dr Azmin Huda bt Abdul Rahim

SN Ropeah bt Ahmad SN Roslina bt Othman SN Mazlidah bt Osman

18 Teluk Intan Dr Wang Shir Siong

SN Azliza bt Zakaria SN Rohayu Dalila bt Yusof SN Puspavali a/Punusamy AMO Mohd Najib bin Misbah

19 Taiping Dr As-niza bin Abdul Shukor

Sr Norlidah bt Abu Bakar SN Ummi Khadijah bt Bani SN Saleha bt Salleh

20 Seberang Jaya Dr Jusminder bt Abdul Jamal

SN Zuraina bt Muhamad SN Nooraslina bt Othman SN Noorazleena bt Hassim

21 Kajang Dr Wan Hafizah bt Wan Tajul Ariffin

SN Saiza bt Mat Yusof

22 Tuanku Fauziah Kangar Dr Azilah bt Desa SN Zarina Mat Bistaman SN Julaida bt Din SN Zulmirnani bt Ariffin SN Norazlisyan bt Ramli

23 Sime Darby Medical Center Subang jaya

Dr Alan Wong Ket Hiung Ms Navjeet Kaur SN Normazimah bt Mohamad Nazar

24 Sultan Haji Ahmad Shah Temerloh

Dr Rahimah bt Haron Sr Rakiah bt Mohd Noor SN Norliza bt Ismail SN Norsuha bt Mat Amin SN Rohayu bt Yusof

25 Tuanku Ampuan Najihah Kuala Pilah

Dr Zalifah bt Nordin Sr Lee New SN Noorliza bt Othman

26 Sri Manjung Dr Khairudin bin Zainal Abidin

SN Rohani bt Ali SN Hartini bt Abd Rahman

27 Batu Pahat Dr Azizul Hisham bin Bahari

SN Rosmawati bt Saimin SN Rashidah bt Bahari


28 Tawau Dr Kyaw Soe (Jan-Dec

2010) Dr Tun Hla Aung (Aug-Dec 2010)

SN Lilybeth Feliciano Ferez SN Sarwah bt Isa

29 Miri Dr Ooi Shien Lung SN Norida bt Daud (Jan-Jun 2010) SN Noriah bt Ilai SN Zuriha bt Acim

30 Kulim Dr Chua Kok Boon Dr Loh Hoong Heng

Sr Mahani bt Hassan SN Mohana bt Omar SN Bahayah bt Mohamed Bakari SN Che Asmah bt Haji Md Isa

31 Serdang Dr Rohana bt Mohemad SN Zamzurina bt Yahaya (Jan-Aug 2010) SN Norain bt Saad SN Siti Ainah bt Buang

32 Sibu Dr Huwaida bt Abdul Halim

SN Nadzarizan bt Buang SN Wong Chen Chen SN Yong Suk Moi

33 Duchess of Kent Sandakan

Dr Norhayati bt Mohd Said

SN Norahimah bt Dulraman Sr Martina Gawis

34 Sultan Ismail Johor Bahru Dr Mohd Zaini bin Laman Sr Mariah bt Kassim SN Huzaimah bt Jahir SN Norwati bt Jamiran (Jun-Dec 2010)

35 Sungai Buloh Dr Shanti Ratnam SN Zainidah bt Mat Kasim

36 Ampang Dr Rusnah bt Ab Latif SN Normazlin bt Md Derus SN Amiza Dyana bt Abu Amin SN Siti Baizura bt Che Ahmad

37 Wanita dan Kanak-Kanak Sabah

Dr Oushpal Kaur SN Haineh bt Amin SN Siti Rajiah bt Muslimin


ABBREVIATIONS Adm. Admission AKI Acute kidney injury ALI Acute lung injury AMO Assistant medical officer AOR At own risk APACHE II Acute Physiologic and Chronic Health Evaluation (Version II) ARDS Acute respiratory distress syndrome Creat Creatinine CRRT Continuous renal replacement therapy ED Emergency department ENT Otorhinolaryngology HD Haemodialysis HDU High dependency unit Hosp Hospital Hrs Hours ICU Intensive care unit Int. Intensive MOH Ministry of Health MRIC Malaysian Registry of Intensive Care MV Mechanical ventilation NA Not available NAICU National Audit on Adult Intensive Care Units NIV Non-invasive ventilation NHSN National Healthcare Safety Network NNIS National Nosocomial Infection Surveillance No. Number O&G Obstetrics & Gynaecology PaCO2 Partial pressure of arterial carbon dioxide PaO2 Partial pressure of arterial oxygen Refer. Referred SAPS II Simplified Acute Physiologic Scoring System (Version II) SD Standard deviation SIRS Systemic inflammatory response syndrome SMR Standardised mortality ratio SN Staff nurse SOFA Sequential Organ Failure Assessment Sr Sister SPSS Statistical Package for Social Sciences TWBC Total white blood count VAP Ventilator-associated pneumonia VCB Ventilator care bundle Yrs Years % Percentage


LIST OF TABLES

Page Table 1 ICU beds and ICU bed occupancy rate, by MOH hospitals 2007-2010……………………….. 20 Table 2 ICU admissions, by individual hospital 2005 – 2010…………………………………………… 21 Table 3 Reporting rates, by individual hospital 2007 – 2010……………………………………………. 23 Table 4 Intensive care referrals and refusal of admission, by individual hospital 2006 – 2010……… 24 Table 5 Gender 2005 -2010……………………………………………………………………….................. 26 Table 6 Mean age 2005 -2010……………………………………………………………………………….. 26 Table 7 Ethnic groups 2010…………………………………………………………………………………. 27 Table 8 Length of ICU stay, by individual hospital 2005 – 2010……………………………................... 28 Table 9 Length of hospital stay, by individual hospital 2005 – 2010…………………………………… 29 Table 10 Referring units 2010 ……………………………………………………………………………….. 30 Table 11 Category of patients 2010……………………………………………….…………………………. 31 Table 12 Category of patients in MOH hospitals 2005 -2010…………………………………................... 32 Table 13 Location before ICU admission, by hospitals 2010…………………………………................... 33 Table 14 Location before ICU admission in MOH hospitals 2005 – 2010……………………………….. 33 Table 15 Main organ failure on ICU admission 2010……………………………………………………… 34 Table 16 Number of organ failure(s) on ICU admission 2010…………………………….……………… 36 Table 17 Ten most common diagnoses leading to ICU admission 2010……………………………….… 37 Table 18 Ten most common diagnoses leading to ICU admission using APACHE II diagnostic

category 2010………………………………………………………………………………………..

39 Table 19 Severe sepsis, ARDS and AKI within 24 hours of ICU admission 2010…… 40 Table 20 Severe sepsis, ARDS and AKI within 24 hours of ICU admission, by individual hospital

2010……………………………………………………………………………

41 Table 21 SAPS II score, by individual hospital 2005 – 2010 ……………………………………………… 42 Table 22 SOFA score, by individual hospital 2007 – 2010 ……………………………………................... 43 Table 23 Invasive ventilation, non-invasive ventilation and reintubation 2010 …………….................. 46 Table 24 Duration of invasive ventilation, by individual hospital 2006 – 2010 ………………………… 48 Table 25 Renal replacement therapy and modalities of therapy 2010………………………................... 49 Table 26 Tracheostomy 2010 …………………………………..…………………………………………….. 50 Table 27 Tracheotomy, by individual hospital 2010………………………………………………………. 51 Table 28 Tracheostomy, by individual hospital 2007 -2010………………………………………………. 52 Table 29 Withdrawal /withholding of therapy, by individual hospital 2008 - 2010…………………... 53 Table 30 Incidence of ventilator-associated pneumonia, by individual hospital 2004-2010…………... 56 Table 31 Onset of VAP from initiation of invasive ventilation, by individual hospital 2008 – 2010….. 57 Table 32 Bacteriological cultures in VAP 2010 ……………………………………………………………. 60 Table 33 Bacteriological cultures in VAP 2008 –2010……………………………………………………… 61 Table 34 Unplanned extubation per 100 intubated days, by individual hospital 2004 –2010…………. 62 Table 35 Pressure ulcer, by individual hospital 2008 - 2010………………………………………………. 64 Table 36 Hospital outcome 2010 …………………………………………………………………………….. 66 Table 37 Crude in-ICU and in-hospital mortality rates, by individual hospital 2005 – 2010………….. 67 Table 38 Ten most common diagnoses leading to ICU admission in MOH hospitals and observed

In-hospital mortality2010…………………………………………………………………………..

69 Table 39 Severe sepsis, ARDS and AKI within 24hrs of ICU admission and observed

in-hospital mortality 2010……………………………..……………………………………………

69 Table 40 Standardised mortality ratio, by individual hospital 2005 - 2010…………………………...…. 70 Table 41 General comparison for Dengue and Non-Dengue infection 2010……………………………. 74 Table 42 Dengue infection by hospital and crude in-hospital mortality, 2010………………………….. 76 Table 43 Dengue infection by regions and crude in-hospital mortality, 2010……………...…………… 77 Table 44 Main organ failure and mortality for Dengue and Non-Dengue infection 2010……………... 78 Table 45 Comparison of characteristics and outcomes of patients with Influenza A (H1N1)

infection 2009–2010…………………………………………………………………………...……..

80 Table 46 Influenza A H1N1 infection and crude in-hospital mortality, by hospital 2009 and 2010….. 81


LIST OF FIGURES

Page Figure 1 ICU admissions, by participating centres 2010………………………………. 22 Figure 2 ICU admissions 2003 – 2010……………………………………………………. 22 Figure 3 Age groups 2010 ………………………………………………………………... 26 Figure 4 Ethnic groups 2010 ……………………………………………………………... 27 Figure 5 Referring units 2010 …………………………………………………………… 30 Figure 6 Category of patients 2010 ……………………………………………………… 31 Figure 7 Category of patients 2005 – 2010………………………………………………. 32 Figure 8 Location before ICU admission, by hospitals 2010 ………………………… 33 Figure 9 Location before ICU admission in MOH hospitals 2005 – 2010……………. 34 Figure 10 Main organ failure on ICU admission, by hospitals 2010…………………… 35 Figure 11 Number of organ failure(s) on ICU admission, by hospitals 2010 ………… 36 Figure 12 Ten most common diagnoses leading to ICU admission in MOH hospitals

2010…………………………………………………………………………………

38 Figure 13 Invasive ventilation, by hospitals 2010………………………………………... 46 Figure 14 Non-invasive ventilation, by hospitals 2010………………………………….. 46 Figure 15 Non-invasive ventilation, MOH hospitals 2004 – 2010 …………………....... 47 Figure 16 Re-intubation, MOH hospitals 2004 – 2010……………………........................ 47 Figure 17 Modalities of renal replacement therapy, by hospitals 2010 ……………….. 49 Figure 18 Techniques of tracheostomy, by hospitals 2010 ……………………………... 50 Figure 19 VAP per 1000 ventilator days 2004 - 2010 ……………………………………. 58 Figure 20 VAP per 1000 ventilator days, by individual hospital 2010………………… 58 Figure 21 VCB compliance and VAP 2007 – 2010………………………………………... 59 Figure 22 Bacteriological cultures in VAP 2010 …………………………………………. 61 Figure 23 Unplanned extubation, by individual hospital 2010………………………… 63 Figure 24 Crude in-ICU and in-hospital mortality rates, by individual hospital 2010. 68 Figure 25 Standardised mortality ratio by individual hospital 2010…………………... 71 Figure 26 Age groups and Mortality in Dengue 2010……………………………………. 77


INTRODUCTION The National Audit on Adult Intensive Care Units (NAICU) was established in 2002 as a quality improvement initiative to systematically review the intensive care practices in Malaysia and where possible, to introduce remedial measures to improve outcome. To date, this audit had published seven reports and introduced several quality measures such as ventilator care bundle, central venous care bundle and ICU networking. In 2009, the NAICU was renamed the Malaysian Registry of Intensive Care (MRIC) under the purview of the Clinical Research Centre, Ministry of Health Malaysia. This report is thus the third for MRIC, but eighth in the series. The objectives of this registry are to:

1. Establish a database of patients admitted to the adult ICUs 2. Review the clinical practices of intensive care 3. Determine clinical outcomes 4. Determine the resources and delivery of intensive care service 5. Evaluate the impact of quality improvement measures on patient care 6. Provide comparisons of performance of participating centres against national and

international standards 7. Conduct health care research related to intensive care

In 2010, 6 six new centres (Hospitals Sibu, Duchess of Kent Sandakan, Sultan Ismail Johor Bahru, Sungai Buloh, Ampang and Hospital Wanita & Kanak-Kanak Sabah) were added to the list of 31 participating hospitals in the registry. This report describes the intensive care practices and outcomes in a centre in a private hospital and 36 ICUs in MOH. Data Collection and Verification Data were collected prospectively by trained nurses (source data providers) and specialists (site investigators) based on a written protocol. Data was initially collected on a standard e-case report form for each patient. Since 1st January 2010, data were entered directly in a central depository via a web-based programme by individual centres. All participating centres were to ensure “accuracy and completeness” of their individual databases. Merged data were ‘cleaned’ and verified before being analysed using SPSS version 10.0.1. This report is based on all admissions into the 37 participating ICUs from 1st January to 31st December 2010. Those admitted during this period but were still warded in hospital on 31st


January 2011, were excluded from the analysis. The total number of admissions in 2010 was 28,080 out of which 1103 (3.9%) were re-admissions. For patients with multiple ICU admissions, only the first admission was included in the analysis. Due to missing and inconsistent data, the sum total of some variables shown in the tables may not add up to the actual number of admissions. Data Limitations Limitations to the registry data were mainly related to the data entry and collection process. Some of the participating ICUs experienced rapid turnover of their site investigators and source data providers resulting in under-reporting and data inconsistencies. Format of Report The format of this report follows the patient’s journey in four sections: demographics, interventions, complications and outcomes. Information is reported on a total of 26,977 ICU admissions. In this report, information was provided for individual centres. Wherever appropriate, comparisons were made between three categories of hospitals based on the number of ICU beds. In MOH hospitals, the three categories were centres with more than 16 beds, 8 to 15 beds and those with 7 beds or less. Where relevant, trends of certain variables over the years were reported. In this report, a special mention has been made with regard to the Influenza A (H1N1) and dengue infections in MOH participating centres.


SECTION A:

GENERAL INFORMATION


Table 1: No. of ICU beds and occupancy rate, by MOH hospitals 2007–2010

Hospital

Number of functional ICU beds (as of 31-12-2010)

ICU bed occupancy rate %

2007 2008 2009 2010

AS 9 66.2 80.5 88.6 83.2

PP 22 113.7 94.0 81.3 61.5

IPH 22 71.1 79.1 103.0 104.0

KL 30 112.3 112.7 108.6 109.3

SLG 20 75.7 80.2 72.6 97.7

KLG 22 98.4 100.5 198.7 91.9

SBN 8 111.8 110.4 111.8 114.0

MLK 24 84.7 87.3 84.2 88.1

JB 32 111.5 106.7 108.7

KTN 12 89.5 89.5 102.2 103.0

KT 17 101.3 109.2 115.2 93.9

KB 15 88.5 88.9 86.6 88.5

KCH 9 108.0 96.8 101.5 104.9

KK 9 109.7 125.3 87.3 100.1

SP 7 85.5 90.8 79.3 80.9

PJY 11 108.8 89.2 88.4 89.5

MUR 8 63.5 108.2 72.6 89.6

TI 4 107.0 83.0 86.5 91.0

TPG 18 61.5 83.5 83.6 98.4

SJ 8 76.7 68.7 101.9 90.7

KJG 6 78.4 74.2 75.8 75.6

KGR 5 87.8 79.1 71.8 70.2

TML 10 98.9 133.8 119.0 110.5

KP 4 62.9 57.8 51.0 56.2

SMJ 8 101.3 121.9 71.6 79.0

BP 8 74.5 86.4 77.0 71.4

TW 4 64.2 64.5 45.9 82.5

MRI 6 83.0 87.9 54.5 79.7

KLM 7 98.6 98.2 121.2 99.2

SDG 8 86.1 116.0 102.0 87.4

SB 10 102.6

DKS 8 116.2

SI 12 79.2

SBL 18 118.2

AMP 12 89.0

LIK 6 62.0

Total 439 - - - -

Median - 88.1 89.3 87.0 90.2

The total number of ICU beds in MOH as of 31st December 2010 was 439 with a median bed occupancy rate of 90%.


Table 2: ICU admissions, by individual hospital 2005 – 2010

Hospital

2005 2006 2007 2008 2009 2010

n (%) n (%) n (%) n (%) n (%) n (%)

AS 340 (4.6) 383 (3.8) 418 (3.2) 546 (3.2) 1121 (5.3) 1094 (4.1)

PP 488 (6.5) 535 (5.3) 439 (3.3) 568 (3.3) 505 (2.4) 911 (3.4)

IPH 335 (4.5) 692 (6.8) 723 (5.5) 873 (5.1) 924 (4.3) 1143 (4.2)

KL 1158 (15.5) 942 (9.3) 943 (7.2) 1578 (9.3) 1768 (8.3) 1947 (7.2)

SLG 580 (7.8) 692 (6.8) 738 (5.6) 877 (5.2) 888 (4.2) 1053 (3.9)

KLG 399 (5.3) 491 (3.9) 482 (3.7) 788 (4.6) 1080 (5.1) 1215 (4.5)

SBN 295 (3.9) 292 (2.9) 427 (3.2) 467 (2.7) 510 (2.4) 542 (2.0)

MLK 666 (8.9) 634 (6.3) 1175 (8.9) 1366 (8.0) 1439 (6.8) 1636 (6.1)

JB 920 (12.3) 1018 (10.1) 1074 (8.2) 1106 (6.5) 1245 (5.9) 1443 (5.3)

KTN 478 (6.4) 432 (4.3) 513 (3.9) 563 (3.3) 613 (2.9) 744 (2.8)

KT 361 (4.8) 417 (4.1) 270 (2.1) 601 (3.5) 824 (3.9) 1087 (4.0)

KB 469 (6.3) 442 (4.4) 725 (5.5) 847 (5.0) 803 (3.8) 826 (3.1)

KCH 528 (7.1) 594 (5.9) 461 (3.5) 464 (2.7) 461 (2.2) 512 (1.9)

KK 455 (6.1) 454 (4.5) 517 (3.9) 687 (4.0) 319 (1.5) 808 (3.0)

SP - 202 (2.0) 119 (0.9) 183 (1.1) 261 (1.2) 207 (0.8)

PJY - 234 (2.3) NA 351 (2.1) 397 (1.9) 523 (1.9)

MUR - 328 (3.2) 611 (4.6) 869 (5.1) 774 (3.6) 759 (2.8)

TI - 318 (3.1) 253 (1.9) 281 (1.7) 262 (1.2) 276 (1.0)

TPG - 259 (2.0) 684 (5.2) 412 (2.4) 867 (4.1) 834 (3.1)

SJ - 412 (4.1) 59 (0.4) 504 (3.0) 599 (2.8) 590 (2.2)

KJG - 228 (2.3) 146 (1.1) 142 (0.8) 265 (1.2) 323 (1.2)

KGR - 211 (2.1) 238 (1.8) 268 (1.6) 302 (1.4) 294 (1.1)

SDMC - - 1842 (12.2) 1900 (10.0) 2085 (9.8) 1578 (5.8)

TML - - 382 (2.9) 429 (2.5) 607 (2.9) 624 (2.3)

KP - - 140 (1.1) 193 (1.1) 165 (0.8) 234 (0.9)

SMJ - - 226 (1.70 347 (2.0) 336 (1.6) 314 (1.2)

BP - - 266 (2.0) 342 (2.0) 397 (1.9) 409 (1.5)

TW - - 256 (1.9) 316 (1.9) 215 (1.0) 238 (0.9)

MRI - - 180 (1.4) 267 (1.6) 212 (1.00 302 (1.1)

KLM - - 298 (2.3) 316 (1.9) 343 (1.6) 474 (1.8)

SDG - - 385 (2.9) 456 (2.7) 679 (3.2) 824 (3.1)

SB - - - - - 471 (1.7)

DKS - - - - - 246 (0.9)

SI - - - - - 568 (2.1)

SBL - - - - - 1234 (4.6)

AMP - - - - - 534 (2.0)

LIK - - - - - 160 (0.6)

Total 7472 (100) 10110 (100) 14990 (100) 18907 (100) 21266 (100) 26977 (100)


The number of admissions has increased over the years. The increase from 2009 to 2010 was about 27%. This was attributed to the addition of 66 beds in the 6 new centres and to the opening up of an additional 43 beds in the existing centres. The re-admission rate within the first 48 hours of ICU discharge was 2.1%. The percentage of admissions from the three categories of ICUs was as follows: more than 16 beds (50.4%), 8 to 15 beds (34.4%), 7 or less beds (9.3%) and private hospital (5.9%). Figure 1: ICU admissions, by participating centres 2010

Figure 2: ICU admissions, 2003 - 2010

0

5000

10000

15000

20000

25000

30000

2003 2004 2005 2006 2007 2008 2009 2010

Year

No.

of a

dmis

sio

Cohort of first 14 ICUs

All participating ICUs


Table 3: Reporting rates, by individual hospital 2007 – 2010

Hospital 2007 %

2008 %

2009 %

2010 %

AS 86.7 91.3 93 92.2

PP 93.2 97.4 93 87.4

IPH 97.1 96.3 96 96.3

KL 98.4 98.9 95 94.8

SLG 99.2 99.7 84 94.8

KLG 99.4 90.9 92 91.1

SBN 97.7 99.6 97 96.4

MLK 99.9 99.3 92 94.8

JB 99.5 99.8 97 97.4

KTN 99.4 99.6 96 94.8

KT 49.6 98.2 90 96.1

KB 100.0 99.3 94 95.7

KCH 93.0 93.0 89 87.5

KK 75.2 90.3 60 89.4

SP 29.2 53.4 50 38.5

PJY 0 80.9 87 96.5

MUR 74.3 82.6 80 63.0

TI 87.6 102.2 97 92.0

TPG 99.9 46.6 95 95.5

SJ 20.1 99.0 96 95.2

KJG 54.0 57.7 87 81.4

KGR 82.2 91.8 94 97.0

TML 95.7 95.8 86 87.4

KP 89.4 98.0 98 98.3

SMJ 92.5 89.2 100 95.4

BP 90.9 97.2 90 95.1

TW 90.3 100.0 93 78.3

MRI 82.9 68.5 65 94.1

KLM 98.1 101.3 97 95.2

SDG 97.5 98.9 94 66.7

SB - - - 74.8

DKS - - - 54.8

SI - - - 92.4

SBL - - - 92.5

AMP - - - 95.5

LIK - - - 27.2

Total 82.4 89.9 89.0 87.7

The reporting rate is calculated by comparing the number of ICU admissions reported to the MRIC and to the national census (collected by the Anaesthetic programme head). The total number reported to the MRIC was slightly less than that of the national census, as patients who were still in hospital on 31st January 2011 were excluded from the analysis. The average reporting rate was 88%. Hospital SP and LIK had low reporting rates of 38% and 27% respectively.


Table 4: Intensive care referrals and refusal of admission, by individual hospital 2006 - 2010

Hosp

2006 2007 2008 2009 2010

No. refer. for int. care

% denied adm.


% denied adm.


% denied adm.


% denied adm.


% denied adm.

AS - - 429 76.2 227 23.4 358 19.0 - -

PP 1054 78.1 1299 81.8 1478 84.3 1407 82.3 1292 83.3

IPH 351 94.3 635 77.2 633 79.5 612 82.5 1275 69.3

KL 2294 38.4 2327 36.2 2512 34.4 2230 31.0 2218 34.6

SLG 185 45.9 79 16.5 440 40.0 345 33.6 151 40.4

KLG 876 74.5 1490 82.3 1657 73.0 2072 64.2 2155 56.7

SBN 1330 66.0 1558 62.6 1770 65.5 1863 63.3 1862 59.3

MLK 879 52.2 1085 43.2 940 62.1 981 56.0 1035 70.3

JB 2066 57.2 2101 48.6 1638 49.0 1111 50.1 2065 50.4

KTN 447 36.9 811 33.3 768 28.3 755 20.4 1092 29.1

KT 476 29.2 160 20.6 385 26.8 105 30.5 264 20.1

KB 720 57.9 953 68.1 1067 67.1 1219 66.1 1399 63.3

KCH 315 30.5 569 51.5 580 61.4 486 58.4 326 61.4

KK 249 48.6 299 60.9 294 60.9 378 7.9 992 13.2

SP - - 95 60.9 137 42.3 48 18.8 - -

PJY - - - - 212 - - - - -

MUR - - 575 18.1 542 32.1 - - 619 15.8

TI - - 211 9.5 52 5.8 - - 186 21.0

TPG 488 62.9 685 5.7 499 15.4 1186 11.6 902 2.0

SJ - - 226 1.3 222 21.6 660 15.0 758 23.5

KJG - - 9 22.2 - - - - 170 5.3

KGR - - 84 19.1 335 20.3 165 22.4 230 21.7

TML - - 416 22.1 303 44.6 68 35.3 800 35.3

KP - - 225 26.7 334 39.2 346 48.6 372 33.3

SMJ - - 192 35.4 236 26.7 174 17.8 203 16.3

BP - - 310 14.8 346 4.3 442 7.0 382 8.6

TW - - 248 0.0 326 - - - 250 0.0

MRI - - 116 25.0 168 14.5 126 29.4 141 16.3

KLM - - 289 17.7 291 12.7 302 10.6 411 2.9

SDG - - 162 27.8 299 43.1 698 30.8 581 21.5

SB - - - - - - - - - -

DKS - - - - - - - - 130 38.5

SI - - - - - - - - 478 35.6

SBL - - - - - - - - 119 40.3

AMP - - - - - - - - - -

LIK - - - - - - - - - -

Total 12280 53.4 17638 47.9 18689 48.3 18365 40.0 22861 36.5

The percentage of patients who were refused admission due to unavailability of ICU beds in 2010 was 36.5%, a significant improvement from 53.4% in 2006. However, 9 centres (PP, IPH, KLG, SBN, MLK, JB, KB, KCH) had high refusal rates of more than 50%.


SECTION B:

PATIENT CHARACTERISTICS


Table 5: Gender 2005 – 2010

Gender 2005

n (%) 2006 n (%)

2007 n (%)

2008 n (%)

2009 n (%)

2010 n (%)

Male 4406 (59.0) 5821 (57.6) 7654 (58.2) 11081 (58.7) 12489 (58.7) 16040 (59.6)

Female 3066 (41.0) 4289 (41.0) 5492 (41.8) 7811 (41.3) 8768 (41.3) 10875 (40.4)

The ratio of male to female patients (60:40) remained fairly consistent over the years.

Table 6: Mean age (years) 2005 - 2010

Age 2005 2006 2007 2008 2009 2010

All ages, Mean + SD yrs

42.3 ± 21.0

43.3 ± 20.8

45.0 ± 21.0

46.5 ± 20.9

46.5 ± 20.9

45.6 ± 20.6

Age ≥ 18 years Mean + SD yrs

-

-

-

50.3 ± 18.2

50.3 ± 18.1

49.4 ± 18.1

The average age for all age groups was 45.6 + 20.6 years (median 47.0 years). For adult patients with age exceeding 18 years, the average age was 49.4 + 18.1 years (median 50.3 years). The average age of patients admitted to ICUs had remained fairly the same over the last 4 years.

Figure 3: Age groups, 2010

Geriatric patients (age more than 65 years) and paediatric patients (age less than 12 years) accounted for 20.6% and 3.5% of total admissions respectively.


Table 7: Ethnic groups 2010 Ethnic group n %

Malay 15009 55.6

Chinese 5231 19.4

Indian 2903 10.8

Foreigner 1569 5.8

Bumiputra Sabah/Sarawak 1598 5.9

Other Malaysian 445 1.7

Orang Asli 155 0.6

Unknown 10 .0

Total 26920 100.0

Figure 4: Ethnic groups 2010

The distribution of patients admitted to ICU reflected the distribution of the ethnic groups of the general population in Malaysia.


Table 8: Length of ICU stay, by individual hospital 2005 – 2010

Hospital

Mean (Median), days

2005 2006 2007 2008 2009 2010 AS 4.0 4.3 4.3 (2.4) 4.3 (2.4) 3.9 (2.2) 4.1 (2.2)

PP 5.5 4.5 5.2 (2.2) 4.6 (2.0) 5.4 (2.5) 5.6 (2.8)

IPH 5.8 5.1 5.4 (2.7) 5.1 (2.7) 5.1 (2.8) 5.0 (2.6)

KL 4.7 5.2 5.1 (2.9) 4.9 (2.4) 4.9 (2.8) 4.7 (2.5)

SLG 5.1 4.6 4.5 (2.6) 4.4 (2.7) 4.4 (2.7) 4.4 (2.1)

KLG 5.3 4.9 4.4 (1.9) 4.8 (2.7) 4.9 (2.7) 4.9 (2.7)

SBN 4.8 5.4 4.8 (3.0) 5.9 (3.0) 5.3 (2.9) 5.1 (2.8)

MLK 2.8 2.8 3.7 (1.9) 4.0 (2.0) 4.3 (2.1) 4.1 (2.1)

JB 5.9 4.8 4.9 (2.5) 4.9 (3.8) 4.5 (2.4) 5.0 (2.8)

KTN 3.9 4.2 4.2 (2.3) 4.8 (2.5) 4.7 (2.9) 4.4 (2.5)

KT 3.9 3.5 4.3 (2.3) 4.2 (2.6) 4.3 (2.7) 4.5 (2.5)

KB 4.6 4.5 4.8 (2.5) 4.5 (2.5) 4.4 (2.3) 4.8 (2.0)

KCH 3.4 3.3 4.7 (2.3) 5.5 (2.6) 5.4 (2.7) 5.0 (2.7)

KK 4.7 5.0 4.6 (2.3) 4.6 (2.0) 5.4 (2.9) 6.2 (3.2)

SP - 5.1 6.4 (4.1) 7.3 (4.8) 3.9 (2.4) 4.6 (3.2)

PJY - - - 4.5 (1.9) 4.4 (1.9) 3.6 (1.7)

MUR - 5.7 5.1 (2.8) 4.4 (3.0) 4.4 (2.0) 3.5 (1.8)

TI - 3.9 4.4 (2.5) 3.7 (2.4) 3.5 (2.1) 4.2 (1.8)

TPG - 4.3 4.8 (2.5) 4.5 (2.8) 5.4 (2.7) 7.4 (3.5)

SJ - 4.6 5.9 (1.9) 5.5 (2.5) 4.3 (2.6) 4.3 (2.3)

KJG - 4.5 4.4 (2.7) 4.6 (2.5) 4.9 (2.6) 3.8 (2.1)

KGR - 3.5 5.2 (2.1) 5.2 (2.8) 4.0 (2.7) 4.2 (2.2)

SDMC - - 2.5 (1.2) 2.5 (1.4) 2.3 (1.2) 2.5 (1.3)

TML - - 4.4 (2.2) 4.8 (2.7) 5.0 (2.8) 4.9 (2.8)

KP - - 5.4 (2.2) 4.2 (2.4) 4.9 (2.4) 3.5 (2.0)

SMJ - - 6.4 (2.5) 4.9 (2.7) 5.3 (3.0) 4.4 (2.2)

BP - - 5.5 (2.7) 5.6 (3.2) 4.3 (2.5) 4.8 (2.7)

TW - - 4.0 (2.3) 4.4 (2.0) 4.2 (2.2) 4.1 (2.3)

MRI - - 5.5 (3.1) 4.8 (2.8) 6.2 (3.0) 5.4 (2.8)

KLM - - 3.5 (2.2) 3.6 (2.4) 4.2 (2.6) 3.9 (2.3)

SDG - - 4.6 (2.10 4.5 (2.3) 4.3 (2.1) 4.3 (2.1)

SB - - - - - 5.3 (2.9)

DKS - - - - - 6.8 (3.2)

SI - - - - - 5.2 (2.3)

SBL - - - - - 5.7 (2.8)

AMP - - - - - 5.3 (2.9)

LIK - - - - - 2.4 (1.5)

Total 4.6 4.5 4.7 (2.4) 4.7 (2.6) 4.4 (2.3) 4.7 (2.4) The average length of ICU stay was 4.7 days while the median length of stay was 2.4 days. Hospital LIK recorded the shortest average length of stay (2.4 days) while Hospital TPG recorded the longest stay of 7.4 days.


Table 9: Length of hospital stay, by individual hospital 2005 – 2010

Hospital

Mean (Median), days

2005 2006 2007 2008 2009 2010 AS 14.9 14.8 14.2 (9.7) 15.5 (9.3) 12.6 (7.9) 13.4 (8.3)

PP 22.1 20.3 21.7 (14.0) 21.4 (13.7) 20.4 (11.5) 21.1 (12.0)

IPH 19.0 16.6 15.4 (10.6) 17.0 (10.6) 14.5 (10.0) 14.6 (9.4)

KL 18.7 19.6 19.7 (12.4) 20.1 (11.4) 18.5 (10.8) 17.8 (10.3)

SLG 17.6 17.1 17.2 (10.7) 16.9 (11.1) 17.1 (10.2) 15.3 (9.8)

KLG 17.0 15.9 15.7 (10.8) 18.8 (11.3) 15.5 (10.8) 14.1 (9.6)

SBN 15.8 17.1 16.6 (11.1) 20.4 (12.4) 16.0 (10.8) 16.7 (10.1)

MLK 14.0 12.5 13.6 (9.7) 14.6 (10.0) 13.6 (8.9) 13.6 (8.3) JB 17.9 15.7 16.2 (11.3) 16.1 (10.4) 14.9 (10.0) 14.2 (9.8)

KTN 16.5 16.0 17.5 (12.1) 18.5 (12.4) 15.3 (10.9) 14.9 (10.0)

KT 14.4 16.1 15.2 (9.0) 16.7 (11.9) 13.2 (8.7) 12.7 (8.9)

KB 15.7 16.1 16.4 (10.7) 16.0 (10.9) 17.2 (10.7) 16.6 (10.1)

KCH 17.4 17.7 20.4 (13.1) 21.2 (14.1) 19.8 (12.8) 19.6 (12.8)

KK 22.8 23.3 29.5(19.0) 26.2 (15.2) 23.2 (14.9) 21.0 (13.2)

SP - 14.0 11.4 (7.6) 14.4 (9.6) 10.5 (7.9) 12.8 (8.3)

PJY - - - 13.8 (7.9) 13.5 (8.3) 11.7 (8.1)

MUR - 17.9 15.7 (10.5) 17.6 (10.3) 15.8(10.2) 13.3 (8.3)

TI - 12.3 10.8 (8.03) 11.7 (8.5) 11.6 (7.6) 12.4 (8.0)

TPG - 15.6 12.0 (8.3) 11.6 (7.9) 12.5 (8.3) 14.3 (8.7)

SJ - 10.7 14.5 (8.4) 12.9 (9.1) 11.0 (8.7) 11.4 (8.4)

KJG - 13.3 13.9 (10.3) 12.6 (9.8) 13.8 (9.2) 12.2 (7.6)

KGR - 14.5 18.1 (10.4) 15.6 (10.7) 16.3 (10.7) 12.7 (8.1)

SDMC - - 12.1 (5.7) 11.8 (5.9) 8.4 (5.1) 7.3 (5.1)

TML - - 13.9 (9.8) 15.5 (11.2) 14.0(10.4) 13.8 (9.0)

KP - - 13.8 (7.6) 11.3 (8.6) 12.9 (8.6) 12.1 (6.0)

SMJ - - 13.5 (9.0) 10.6 (6.8) 11.4(7.9) 12.5 (8.0)

BP - - 13.0 (7.7) 14.8 (9.9) 12.0 (8.4) 13.1 (8.3)

TW - - 12.4 (8.9) 15.8 (9.7) 13.3 (7.9) 14.1 (9.0)

MRI - - 15.2 (10.3) 14.6 (10.0) 15.1 (9.9) 16.6 (10.6)

KLM - - 11.4 (7.2) 10.3 (7.7) 10.8 (7.8) 10.6 (7.4)

SDG - - 16.6 (10.4) 17.1 (9.6) 15.8 (9.3) 14.6 (8.8)

SB - - - - - 15.4 (9.0)

DKS - - - - - 15.8 (9.0)

SI - - - - - 16.6 (10.9)

SBL - - - - - 17.1 (9.8)

AMP - - - - - 15.6 (9.0)

LIK - - - - - 11.8 (8.1)

Total 17.6 16.4 16.3 (10.5) 15.9 (10.3) 14.4 (9.0) 14.6 (9.0)

The average length of hospital stay was 14.6 days with a median of 9 days. Hospital PP and KK reported average lengths of hospital stay that exceeded 20 days.


Table 10: Referring units 2010

Referring units

Hospitals Beds ≥ 16

n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Medicine 6313 (46.5) 4100 (44.3) 1131 (45.2) 551 (34.9) 12095 (44.9)

General Surgery 2983 (22.0) 2593 (28.0) 734 (29.4) 88 (5.6) 6398 (23.8)

Orthopaedic Surgery 949 (7.0) 811 (8.8) 153 (6.1) 173 (11.0 2086 (7.7)

O&G 679 (5.0) 552 (6.0) 360 (14.4) 12 (0.8) 1603 (6.0)

Vascular Surgery 210 (1.5) 11 (0.1) - 22 (1.4) 243 (0.9)

Paediatric Surgery 37 (0.3) 63 (0.7) 19 (0.8) 9 (0.6) 128 (0.5)

Neurosurgery 1099 (8.1) 384 (4.1) - 203 (12.9) 1686 (6.3)

Plastic surgery 111 (0.8) 17 (0.2) - 5 (0.3) 133 (0.5)

ENT 276 (2.0) 178 (1.9) 19 (0.8) 28 (1.8) 501 (1.9)

Ophthalmology 17 (0.1) 9 (0.1) 3 (0.1) - 29 (0.1)

Urology 139 (1.0) 37 (0.4) - 46 (2.9) 222 (0.8)

Dental Surgery 91 (0.7) 49 (0.5) 8 (0.3) 3 (0.2) 151 (0.6)

Paediatric Medical 156 (1.1) 292 (3.2) 70 (2.8) 26 (1.6) 544 (2.0)

Cardiology 29 (0.2) 7 (0.1) 1 (0.0) 132 (8.4) 169 (0.6)

Haematology 10 (0.1) 93 (1.0) - 18 (1.1) 121 (0.4)

Nephrology 188 (1.4) 50 (0.5) - 59 (3.7) 297 (1.1)

Neurology 108 (0.8) 4 (0.0) - 192 (12.2) 304 (1.1)

Cardiothoracic Surgery 3 (0.0) 2 (0.0) - 7 (0.4) 12 (0.0)

Others 180 (1.3) 10 (0.1) 2 (0.1) 3 (0.2) 195 (0.7)

Total 13578 (100.0) 9262 (100.0) 2500 (100.0) 1577 (100.0) 26917 (100.0)

Figure 5: Referring units 2010

The proportion of patients admitted from the medical-based disciplines had steadily increased from 29.5% in 2003 to 46.4% in 2009 and 50.2% in 2010.


Table 11: Category of patients 2010


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Non-operative 8503 (62.6) 5868 (63.3) 1569 (62.7) 1116 (70.8) 17056 (63.4)

Elective operative 1443 (10.6) 1146 (12.4) 278 (11.1) 392 (24.9) 3259 (12.1)

Emergency operative 3630 (26.7) 2249 (24.3) 657 (26.2) 69 (4.4) 6605 (24.5)

Total 13576 (100) 9263 (100) 2504 (100) 1577 (100) 26920 (100)

Non-operative: Refers to patients in whom no surgery was done out within 7 days before ICU admission or during the first 24 hours after ICU admission

Operative-elective: Refers to patients in whom surgery was done within 7 days before ICU admission or during the first 24 hours after ICU admission on a scheduled basis

Operative-emergency: Refers to patients in whom surgery was done within 7 days before ICU admission or during the first 24 hours after ICU admission on an unscheduled basis

Figure 6: Category of patients 2010

The categories of patients did not differ much between ICUs in MOH hospitals. However, the proportion of emergency operative patients in the private hospital was significantly less compared to MOH hospitals.


Table 12: Category of patients in MOH hospitals 2005 - 2010

Category of patients 2005 (%)

2006 (%)

2007 (%)

2008 (%)

2009 (%)

2010 (%)

Non-operative 48.4 49.0 55.8 59.2 61.6 62.9

Elective operative 16.5 15.9 13.2 14.3 12.8 11.3

Emergency operative 35.1 35.1 31.0 26.5 25.4 25.8

Figure 7: Category of patients 2005 – 2010

There was a steady increase in non-operative patients over the past 6 years with a 15% increase from 2005 to 2010. Correspondingly, the percentage of elective operative and emergency operative patients decreased by 5% and 9% respectively from 2005 to 2010.


Table 13: Location before ICU admission, by hospitals 2010

Location


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Ward 5103 (37.6) 3891 (42.0) 1000 (40.0) 308 (19.5) 10302 (38.2)

OT 4099 (30.2) 2642 (28.5) 678 (27.1) 389 (24.7) 7808 (29.0)

A&E 3123 (23.0) 1942 (20.9) 597 (23.9) 773 (49.0) 6435 (23.9)

Other critical area 668 (4.9) 239 (2.6) 87 (3.5) 8 (0.5) 1002 (3.7)

Other location 87 (0.6) 46 (0.5) 22 (0.9) 76 (4.8) 231 (0.9)

Other hospital 506 (3.7) 511 (5.5) 119 (4.8) 24 (1.5) 1160 (4.3)

Total 13586 (100.0) 9271 (100.0) 2503 (100.0) 1578 (100.0) 26938 (100.0)

Location before ICU admission: Refers to the area/location patient was being managed just before being admitted into ICU

Figure 8: Location before ICU admission, by hospitals 2010

Table 14: Location before ICU admission in MOH hospitals 2005 - 2010

Location 2005 (%)

2006 (%)

2007 (%)

2008 (%)

2009 (%)

2010 (%)

Ward 32.5 32.8 37.2 34.5 37.5 38.2

Operation theatre 45.4 40.6 35.7 36.2 31.5 29.0

Emergency department 9.3 12.6 13.2 16.7 20.5 23.9

Other critical areas 9.6 9.0 7.3 6.5 4.4 3.7

Other locations 0.4 0.5 0.4 0.6 0.7 0.9

Other hospitals 2.8 4.5 6.1 5.6 5.5 4.3


Figure 9: Location before ICU admission in MOH hospitals 2005 - 2010 The percentage of admissions from the

emergency department

had increased significantly

more than two-fold over the last 6 years;

admissions from the

operating theatre and other critical areas had decreased by 16% and 6%

respectively. The recent trend is more consistent with the practices in developed countries. Table 15: Main organ failure on ICU admission 2010

Main organ failure


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Without organ failure 3912 (33.3) 2817 (36.7) 618 (30.7) 1143 (81.4) 8490 (37.2)

Cardiovascular 3330 (28.4) 1504 (19.6) 425 (21.1) 7 (0.5) 5266 (23.1)

Respiratory 1554 (13.2) 1637 (21.3) 523 (26.0) 27 (1.9) 3741 (16.4)

Neurological 1486 (12.7) 780 (10.2) 260 (12.9) 57 (4.1) 2583 (11.3)

Renal 753 (6.4) 495 (6.5) 120 (6.0)) 80 (5.7) 1448 (6.3)

Haematological 598 (5.1) 362 (4.7) 47 (2.3) 81 (5.8) 1088 (4.8)

Hepatic 98 (0.8) 77 (1.0) 17(0.8) 10 (0.7) 202 (0.9)

Total 11731 (100) 7672 (100) 2010 (100) 1405 (100) 22818 (100)

The definition of organ failure is based on the Sequential Organ Failure Assessment (SOFA) [1] Main organ failure: Refers to the main or most important organ failure within 24 hours of ICU admission and management.

Figure 10: Main organ failure on ICU admission, by hospitals 2010


In 2010, about a third of admissions to MOH ICUs did not have any organ failure in comparison to the private hospital where two-thirds of admissions were without any organ failure. In MOH ICUs, cardiovascular failure (37%) was the most common organ failure during the first 24 hours of ICU admission, followed by respiratory (26%), neurological (18%).%), renal (10%), haematological (7%) and hepatic (2%). This is in contrast to 2003, where respiratory failure (57%) was the most common organ failure followed by cardiovascular failure (19%).


Table 16: Number of organ failure(s) on ICU admission 2010

Main organ failure


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Without 4015 (34.2) 2874 (37.5) 632 (31.4) 1149 (81.8) 8670 (38.0)

Single 3637 (31.0) 2266 (29.5) 557 (27.7) 221 (15.7) 6681 (29.3)

Two 2554 (21.8) 1456 (19.0) 466 (23.2) 23 (1.6) 4499 (19.7)

Three 1143 (9.7) 757 (9.9) 252 (12.5) 8 (0.6) 2160 (9.5)

Four 327 (2.8) 257 (3.3) 84 (4.2) 3 ( 0.2) 671 (2.9)

Five 52 (0.4) 56 (0.7) 18 (0.9) 1 (0.1) 127 (0.6)

Six 3 (0.0) 6 (0.1) 1 (0.0) 0 (0.0) 10 (0.0)

Total 11731 (100) 7672 (100) 2010 (100) 1405 (100) 22818 (100)

Figure 11: Number of organ failure(s) on ICU admission by hospitals 2010

In 2010, 38% of patients admitted to ICUs were without any organ failure, while 29% had single organ failure. In keeping with current practice, increasing numbers of MOH ICUs function as combined intensive/high dependency care units. This could be one of the reasons for the high proportion of patients admitted without any organ failure.


Table 17: Ten most common diagnoses leading to ICU admission 2010

Diagnosis Number Percentage Hospitals with ICU beds ≥ 16 Head Injury 1511 11.1

Sepsis 1152 8.5

Dengue 1096 8.1

Community acquired pneumonia 726 5.3

Bronchial asthma 404 3.0

Chronic lower respiratory disease 378 2.8

Gastrointestinal perforation (including anastomotic leak) 347 2.6

Non-cardiogenic pulmonary oedema 338 2.5

Infection/gangrene of limb (including osteomyelitis, necrotizing fascitis) 313 2.3

Intraabdominal injury 292 2.1

Hospitals with ICU beds 8-15 Sepsis 684 7.4

Head injury 614 6.6

Community-acquired pneumonia 574 6.2

Dengue 466 5.0

Bronchial asthma 332 3.6



Intra-abdominal injury 230 2.5

Infection / gangrene of limb (including osteomyelitis, necrotizing fascitis) 227 2.4

Gastrointestinal bleeding 217 2.3

Hospitals with ICU beds < 7 Sepsis 201 8.0

Head injury 189 7.5


Other obstetric conditions 121 4.8


Pregnancy induced hypertension/ Eclampsia 82 3.3

Dengue 81 3.2


Non-cardiogenic pulmonary oedema 72 2.9

Congestive heart failure 61 2.4

Private Hospital Cerebrovascular disease 152 9.6

Dengue 107 6.8

Gastrointestinal bleeding 99 6.3

Other CNS condition 75 4.8

Epilepsy 63 4.0

Ischaemic heart disease/ acute coronary syndrome 62 3.9

Other disorders of the musculoskeletal system 55 3.5

Other renal / genito-urinary conditions 47 3.0


Other abdominal/ pelvic conditions 41 2.6


Figure 12: Ten most common diagnoses leading to ICU admission in MOH hospitals 2010

Head injury, sepsis and dengue infection were the three most common diagnoses leading to ICU admission in MOH hospitals. Over the past 8 years, head injury and sepsis remained the two most common diagnoses. In 2010, dengue infection replaced community-acquired pneumonia as the 3rd most common diagnosis leading to ICU admission.


Table 18: Ten most common diagnoses leading to ICU admission using APACHE II diagnostic category 2010

Diagnosis Number Percentage Hospitals with ICU beds ≥ 16

Non-operative: Sepsis 1644 12.1

Non-operative: Respiratory infection 1273 9.4

Non-operative: Respiratory system as principal reason for admission 829 6.1

Operative: Respiratory system as principal reason for admission 642 4.7

Non-operative: Cardiovascular system as principal reason for admission 638 4.7

Non-operative: Multiple trauma 583 4.3

Non-operative: Haemorrhagic shock/hypovolaemia 582 4.3

Operative: Cardiovascular system as principal reason for admission 519 3.8

Non-operative: Head trauma 496 3.6

Operative: Gastrointestinal perforation / obstruction 459 3.4

Hospitals with ICU beds 8-15





Non-operative: Metabolic/ renal system as principal reason for admission 461 5.0

Operative: Respiratory insufficiency after surgery 440 4.7




Non-operative: Asthma/allergy 292 3.1

Hospitals with ICU beds < 7 Non-operative: Respiratory system as principal reason for admission 245 9.8




Non-operative: Head trauma 116 4.6

Non-operative: Hypertension 100 4.0

Non-operative: COPD 100 4.0


Non-operative: Metabolic/ renal system as principal reason for admission 94 3.7

Operative: Haemorrhagic shock 89 3.5

Private Hospital Non-operative: Metabolic/ renal system as principal reason for admission 211 13.4

Non-operative: Neurologic system as principal reason for admission 176 11.2




Non-operative: Gastrointestinal system as principal reason for admission 86 5.4

Operative: Neurologic system as principal reason for admission 68 4.3

Non-operative: Seizure disorder 68 4.3

Non-operative: Gastrointestinal bleeding 67 4.2

Non-operative: Coronary artery disease 64 4.1


Table 19: Severe sepsis, ARDS and AKI within 24hrs of ICU admission 2010


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Severe sepsis* 3016 (22.2) 1778 (19.2) 472 (18.8) 20 (1.3) 5286 (19.6)

ARDS# 1640 (12.1) 1031 (11.1) 272 (10.9) 11 (0.7) 2954 (11.0)

AKI^ 2039 (15.0) 1079 (11.6) 225 (9.0) 6 (0.4) 3349 (12.4)

* Sepsis refers to documented infection with 2 out of 4 SIRS criteria:

1) Temperature >38.3 or < than 36°C 2) TWBC of > 12000 or < 4000 3) Heart rate > 90/min 4) Respiration rate > 20 breath / minute or PaCO2 < 32mmHg

Severe sepsis is sepsis with one of the following organ dysfunctions:

(1) Hypotension: Systolic blood pressure < 90 mmHg or mean arterial pressure < 70 mm Hg (2) PaO2/FIO2 ≤ 300 mmHg. (3) Acute decrease in platelet count to < 100 000 u/L (4) Acute increase in total bilirubin to > 70 umol/L (5) Acute increase in serum creatinine to >170umol/L or urine output < 0.5 mL/kg/hour for > 2 hours (6) Serum lactate >4 mmol/l

# ARDS refer to severe form of ALI with a PaO2/FIO2 ratio ≤ 200 mm Hg with diffuse radiologic infiltrates which is not predominantly due to heart failure ^AKI : Serum creat x 2 baseline or urine output < 0.5 ml/kg/hr x 12 hours


Table 20: Severe sepsis, ARDS and AKI within 24hrs of ICU admission, by individual hospital 2010

Hospital Severe sepsis

n (%) ARDS n (%)

AKI n (%)

AS 350 (32.0) 292 (26.7) 208 (19.0)

PP 254 (27.9) 86 (9.4) 230 (25.2)

IPH 97 (8.5) 183 (16.0) 61 (5.3)

KL 488 (25.1) 444 (22.8) 471 (24.2)

SLG 13 (1.2) 2 (0.2) 12 (1.1)

KLG 182 (15.0) 72 (5.9) 82 (6.7)

SBN 182 (33.6) 81 (15.0) 68 ( 12.6)

MLK 350 (21.5) 24 (1.5) 360 (22.1)

JB 406 (28.1) 156 (10.8) 260 (18.0)

KTN 99 (13.3) 45 (6.1) 39 (5.2)

KT 222 (20.4) 9 (0.8) 82 (7.6)

KB 95 (11.5) 19 (2.3) 37 (4.5)

KCH 53 (10.4) 25 (4.9) 52 (10.2)

KK 168 (20.8) 277 (34.3) 106 (13.1)

SP 51 (24.8) 57 (27.7) 37 (18.0)

PJY 37 (7.1) 45 (8.6) 50 (9.6)

MUR 143 (18.9) 24 (3.2) 34 (4.5)

TI 82 (29.8) 91 (33.0) 48 (17.4)

TPG 541 (65.0) 217 (26.1) 175 (21.0)

SJ 213 (36.1) 50 (8.5) 97 (16.4)

KJG 57 (17.6) 6 (1.9) 15 (4.6)

KGR 23 (7.9) 0 (0.0) 5 (1.7)

SDMC 20 (1.3) 11 (0.7) 6 (0.4)

TML 99 (15.9) 41 (6.6) 45 (7.2)

KP 60 (25.6) 19 (8.1) 40 (17.1)

SMJ 34 (10.8) 24 (7.7) 30 (9.6)

BP 124 (30.3) 76 (18.6) 126 (30.9)

TW 37 (15.5) 52 (21.8) 36 (15.1)

MRI 22 (7.3) 14 (4.6) 1 (0.3)

KLM 139 (29.3) 32 (6.8) 43 (9.1)

SDG 73 (8.9) 89 (10.8) 82 (10.0)

SB 102 (21.7) 66 (14.0) 125 (26.6)

DKS 73 (29.8) 44 (18.0) 42 (17.1)

SI 139 (24.6) 61 (10.7) 77 (13.6)

SBL 113 (9.2) 155 (12.6) 98 (8.0)

AMP 144 (27.0) 64 (12.0) 69 (13.0)

LIK 1 (0.6) 1 (0.6) 0 (0.0)

Total 5286 (19.6) 2954 (11.0) 3349 (12.4)

During the first 24 hours of ICU admission, 19.6%, 11% and 12% of patients had severe sepsis, acute respiratory distress syndrome and acute kidney injury respectively.


Table 21: SAPS II [2] score, by individual hospital 2005 - 2010

Hospital SAPS II score (mean)

2005 2007 2008 2009 2010

AS 32.4 40.4 42.2 47.2 42.4

PP 33.5 33.4 36.2 37.8 34.9

IPH 27.0 31.5 31.0 32.9 33.7

KL 37.2 39.1 37.5 38.3 34.5

SLG 34.2 40.2 39.5 38.2 33.2

KLG 35.7 31.9 35.0 34.3 34.5

SBN 37.9 43.3 42.4 39.1 38.0

MLK 34.1 34.4 35.3 36.6 31.9

JB 39.1 38.6 37.5 39.0 38.2

KTN 38.8 36.3 36.6 35.9 33.4

KT 42.7 39.8 37.6 36.0 36.2

KB 34.4 32.8 29.7 25.4 30.0

KCH 32.6 32.0 33.3 33.9 32.4

KK 30.3 32.8 34.7 34.0 37.4

SP - 44.2 43.8 38.1 41.0

PJY - # 33.5 30.8 29.6

MUR - 32.5 30.3 31.2 32.1

TI - 49.2 43.6 43.3 42.6

TPG - 43.5 45.6 42.0 43.5

SJ - 35.8 39.6 42.6 40.6

KJG - 43.6 35.4 35.5 34.9

KGR - 35.3 35.0 34.5 36.3

SDMC - - 21.0 19.7 18.3

TML - 37.1 36.6 40.6 38.3

KP - 47.9 43.0 43.3 43.0

SMJ - 39.2 37.1 39.9 39.6

BP - 40.8 43.5 45.4 41.0

TW - 43.2 46.6 52.9 51.4

MRI - 35.2 34.2 37.5 33.5

KLM - 40.7 41.0 40.6 41.0

SDG - 35.4 34.2 33.7 35.5

SB - - - - 39.6

DKS - - - - 51.0

SI - - - - 40.1

SBL - - - - 33.2

AMP - - - - 45.9

LIK - - - - 17.0

Total 35.5 37.2 37.7 35.8 35.1

The average SAPS II score remained the same over the years. The average SAPS II score in MOH hospitals for 2010 was 35.1; which carries a predicted in-hospital mortality of 27.0%.[3]


Table 22: Sequential Organ Failure Assessment (SOFA) [1] by individual hospital 2007 - 2010

Hospital SOFA score

Mean (Median) 2007 2008 2009 2010

AS 6.8 (6) 7.3 (7) 7.9 (7) 8.0 (8)

PP 6.9 (6) 6.6 (6) 7.1 (7) 6.3 (6)

IPH 5.3 (5) 4.8 (4) 5.9 (5) 5.9 (5)

KL 7.1 (7) 6.6 (6) 6.7 (6) 6.4 (6)

SLG 7.6 (7) 7.6 (7) 7.1 (6) 6.3 (5)

KLG 6.1 (6) 6.6 (6) 6.5 (6) 6.6 (6)

SBN 7.2 (7) 7.3 (7) 7.1 (7) 6.9 (6)

MLK 5.2 (4) 5.5 (5) 6.1 (6) 5.6 (5)

JB 7.5 (7) 7.2 (7) 7.3 (7) 7.4 (7)

KTN 6.4 (6) 6.6 (6) 6.3 (6) 5.7 (5)

KT 5.7 (5) 6.3 (6) 5.9 (5) 6.0 (6)

KB 4.8 (3) 3.9 (3) 3.6 (2) 4.7 (3)

KCH 5.4 (5) 5.6 (5) 5.9 (5) 5.6 (4)

KK 4.5 (4) 4.9 (4) 5.5 (5) 6.0 (5)

SP 7.6 (8) 7.1 (7) 5.3 (4) 6.8 (6)

PJY - 5.2 (4) 4.4 (3) 4.2 (3)

MUR 6.2 (5) 5.7 (5) 5.3 (5) 5.1 (4)

TI 8.7 (8.5) 7.4 (7) 7.4 (7) 8.0 (8)

TPG 7.9 (7) 8.0 (8) 7.7 (8) 8.2 (8)

SJ 5.4 (4) 6.5 (6) 7.3 (7) 6.3 (6)

KJG 7.4 (7) 6.6 (6) 5.7 (5) 6.0 (5)

KGR 6.0 (5) 6.3 (6) 6.0 (6) 5.9 (5)

SDMC 1.8 (1) 2.0 (1) 1.6 (0) 1.3 (0)

TML 5.9 (5) 6.0 (5) 6.8 (6) 6.4 (6)

KP 8.3 (8) 7.7 (7) 7.7 (7) 7.6 (7)

SMJ 7.4 (7) 7.0 (7) 8.3 (8) 7.3 (7)

BP 6.8 (7) 7.0 (6) 6.7 (6) 6.7 (6)

TW 7.5 (7) 8.2 (8) 9.0 (9) 8.8 (9)

MRI 6.0 (6) 6.4 (6) 6.2 (6) 5.2 (4)

KLM 7.4 (7) 7.4 (7) 7.3 (7) 8.4 (8)

SDG 6.2 (6) 6.1 (6) 5.7 (5) 6.3 (5)

SB - - - 7.8 (7)

DKS - - - 9.2 (9)

SI - - - 6.6 (6)

SBL - - - 6.6 (7)

AMP - - - 8.6 (9)

LIK - - - 1.3 (0)

Overall 6.5 (6) 5.9 (5) 6.0 (5) 6.2 (5)

The average SOFA score in 2010 was 6.2. H TW had the highest score of 8.8 while H LIK and SDMC had the lowest score of 1.3.


SECTION C:

INTERVENTIONS


Table 23: Invasive ventilation, non-invasive ventilation and reintubation 2010


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Invasive ventilation

10358 (76.2) 7069 (76.1) 1819 (72.5) 76 (4.8) 19322 (71.6)

Non invasive

ventilation 2285 (16.8) 1234 (13.3) 320 (12.8) 16 (1.0) 3855 (14.3)

Reintubation

773 (7.5) 425 (6.0) 134 (7.4) 5 (6.6) 1337 (6.9)

Non-invasive ventilation : Refers to the continuous use of a non-invasive ventilator for > 1 hour during ICU stay Reintubation: Refers to re-intubation after intended or accidental extubation Figure 13: Invasive ventilation, by hospitals 2010

72% of ICU admissions to MOH hospitals received invasive ventilation, which was similar to the previous years. In contrast, a vast majority of patients (95%) in the private hospital were not mechanically ventilated. Figure 14: Non-invasive ventilation, by hospitals 2010


Figure 15: Non-invasive ventilation, MOH hospitals 2004 – 2010

The percentage of patients receiving non-invasive ventilation in MOH ICUs had increased by almost four fold from 3.7% in 2004 to 14.3% in 2010. Figure 16: Re-intubation, MOH hospitals 2004 – 2010

The re-intubation rate was 6.9% and had decreased slightly over the years.


Table 24: Duration of invasive mechanical ventilation, by individual hospital 2006 - 2010

Hospital Mean + SD days

2006 2007 2008 2009 2010

AS 3.9 + 6.0 3.9 + 5.1 3.6 + 4.5 3.4. + 6.1 3.2 + 4.5

PP 5.0 + 7.0 5.8 + 7.6 4.2 + 6.9 5.0 + 8.6 4.8 + 7.6

IPH 5.6 + 7.0 5.5 + 7.9 4.7 + 6.9 4.6 + 6.2 4.3 + 5.9

KL 4.8 + 7.3 4.6 + 6.1 3.7 + 6.6 3.8 + 6.4 3.7 + 6.4

SLG 4.5 + 6.4 4.2 + 5.6 4.1 + 5.6 4.3 + 5.4 4.1 + 6.4

KLG 4.9 + 6.9 4.7 +7.8 4.7 + 8.6 4.7 + 7.3 4.1 + 5.3

SBN 5.4 + 7.1 4.7 + 5.5 5.3 + 10.5 4.7 + 6.8 4.4 + 6.9

MLK 3.0 + 3.8 4.2 + 5.2 4.1 + 5.3 4.6 + 6.7 4.2 + 5.2

JB 4.9 + 6.2 5.1 +6.6 4.6 + 7.2 4.2 + 6.5 4.2 + 5.7

KTN 4.3 + 5.9 3.9 +5.0 3.8 + 6.5 3.3 + 4.5 2.9 + 3.8

KT 3.6 + 5.2 3.9 + 5.0 3.6 + 5.1 4.2 + 6.7 3.6 + 4.3

KB 4.2 + 6.3 4.0 + 6.0 3.3 + 5.2 3.5 + 5.5 3.6 + 6.0

KCH 3.3 + 4.9 4.8 + 7.5 4.9 + 7.9 4.6 + 6.7 4.1 + 6.2

KK 4.9 + 6.0 4.0 + 5.4 4.7 + 9.5 4.9 + 6.1 4.7 + 7.1

SP 6.0 +7.0 6.0 + 7.7 6.5 + 6.8 3.5 + 3.3 3.6 + 4.0

PJY 5.8 + 8.3 - 3.8 + 5.7 4.1 + 6.3 3.0 + 5.7

MUR 7.0 + 9.5 5.8 + 7.7 5.6 + 10.2 4.5 + 6.4 2.9 + 4.0

TI 3.9 + 7.7 4.1 + 7.2 3.7 + 6.3 3.5 + 5.7 3.0 + 8.0

TPG 4.4 + 6.3 4.7 + 7.0 4.1 + 5.2 5.3 + 7.6 7.0 + 10.1

SJ 4.7 + 6.1 5.7 + 12.0 4.9 + 7.4 4.1 + 5.6 3.7 + 4.8

KJG 4.0 + 5.2 3.7 + 4.8 3.3 + 4.5 5.3 + 7.3 3.6 + 4.4

KGR 3.0 + 3.4 4.4 + 7.3 4.0 + 7.8 3.4 + 4.3 3.1 + 4.7

SDMC - - 4.1 + 5.3 3.8 + 4.5 4.2 + 5.4

TML - 4.1 + 6.5 4.4 + 5.6 4.4 + 6.0 4.5 + 6.3

KP - 5.2 + 10.0 3.9 + 5.5 4.1 + 5.9 2.6 + 3.5

SMJ - 5.9 + 7.8 5.0 + 6.5 4.9 + 7.5 3.9 + 6.0

BP - 6.4 + 8.7 5.5 + 8.7 4.7 + 6.4 4.5 + 7.0

TW - 4.4 + 7.3 4.3 + 6.0 4.5 + 9.5 3.1 + 3.7

MRI - 5.8 + 7.2 4.6 + 5.5 6.1 + 7.7 4.7 + 5.7

KLM - 2.9 + 3.5 2.7 + 3.3 3.4 + 5.5 3.2 + 3.8

SDG - 4.2 + 6.3 4.7 + 7.5 4.1 + 6.1 3.2 + 4.8

SB - - - - 4.6 + 7.3

DKS - - - - 5.8 + 8.5

SI - - - - 4.3 + 6.5

SBL - - - - 5.8 + 6.6

AMP - - - - 3.8 + 5.5

LIK - - - - 1.4 + 1.7

Total 4.5 + 6.4 4.6 + 6.6 4.2 + 6.9 4.3 + 6.5 4.1 + 6.1 The average duration of invasive ventilation was 4.1 days and it has decreased slightly over the years. Hospital LIK had the shortest average duration of invasive ventilation at 1.9 day while Hospital TPG had the longest at 7.0 days.


Table 25: Renal replacement therapy and modalities of therapy 2010


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Renal replacement therapy

1631 (12.0)

1130 (12.2)

225 (9.0)

10 (0.6)

2996 (11.1)

Modalities of therapy

Intermittent haemodialysis

1185 (64.5)

814 (67.9)

179 (72.8)

6 (54.5)

2184 (66.3)

Continuous renal replacement therapy

596 (32.4)

292 (24.4)

4 (1.6)

4 (36.4)

896 (27.2)

Peritoneal dialysis

56 (3.1)

92 (7.7)

63 (25.6)

1 (9.1)

212 (6.5)

Total 1837 (100.0) 1198 (100.0) 246 (100.0) 11 (100.0) 3292 (100.0)

Figure 17: Modalities of renal replacement therapy, by hospitals 2010

In MOH ICUs, 11.7% of admissions received renal replacement therapy in 2010. Intermittent haemodialysis remained the most common modality of renal replacement therapy performed in all the ICUs. When comparing the other modalities of therapy, continuous renal replacement therapy was more common in ICUs with 8 beds or more while peritoneal dialysis was more common in ICUs with less than 8 beds.


Table 26: Tracheostomy 2010


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Tracheostomy

1558 (69.4)

557 (24.8)

127 (5.7)

2 (0.1)

2244 (100.0)

Tracheotomy technique

Surgical

79.3 (50.9)

449 (80.6)

125 (98.4)

2 (100.0)

1369 (61.0)

Percutaneous

765 (49.1)

108 (19.4)

2 (1.6)

-

875 (39.0)

Tracheostomy: Refers to the procedure done during ICU stay Figure 18: Techniques of tracheostomy, by hospitals 2010


Table 27: Tracheostomy, by individual hospital 2010

Hospital

Tracheostomy performed

n

Tracheostomy in relation to days of ventilation

mean (median)

Type of tracheostomy Surgical

n (%) Percutaneous

n (%) AS 105 6.1 (5.4) 60 (57.1) 45 (42.9)

PP 135 6.4 (5.3) 50 (37.0) 85 (63.0)

IPH 153 7.1 (5.4) 147 (96.1) 6 (3.9)

KL 142 7.8 (6.5) 31 (21.8) 111 (78.2)

SLG 66 9.5 (8.3) 58 (87.9) 8 (12.1)

KLG 110 7.2 (5.9) 86 (78.2) 24 (21.8)

SBN 59 8.4 (7.3) 59 (100.0) 0 (0.0)

MLK 105 9.3 (8.2) 105 (100.0) 0 (0.0)

JB 325 4.4 (3.7) 72 (22.2) 253 (77.8)

KTN 40 6.3 (5.3) 38 (95.0) 2 (5.0)

KT 60 9.5 (7.5) 13 (21.7) 47 (78.3)

KB 14 17.7 (18.0) 12 (85.7) 2 (14.3)

KCH 47 7.7 (5.3) 39 (83.0) 8 (17.0)

KK 58 8.4 (6.4) 44 (75.9) 14 (24.1)

SP 8 7.8 (7.4) 8 (100.0) 0 (0.0)

PJY 11 12.5 (13.3) 11 (100.0) 0 (0.0)

MUR 26 6.7 (6.6) 25 (96.2) 1 (3.8)

TI 8 9.7 (7.3) 8 (100) 0 (0.0)

TPG 145 8.7 (6.8) 144 (99.3) 1 (0.7)

SJ 60 5.8 (4.5) 55 (91.7) 5 (8.3)

KJG 26 6.3 (4.1) 26 (100.0) 0 (0.0)

KGR 11 7.2 (4.3) 11 (100.0) 0 (0.0)

SDMC 2 7.6 (7.6) 2 (100.0) 0 (0.0)

TML 45 8.4 (7.9) 45 (100.0) 0 (0.0)

KP 7 7.5 (6.3) 7 (100.0) 0 (0.0)

SMJ 9 7.5 (7.1) 3 (33.3) 6 (66.7)

BP 46 7.5 (7.9) 46 (100.0) 0 (0.0)

TW 10 6.3 (4.0) 10 (100.0) 0 (0.0)

MRI 10 8.3 (9.1) 8 (80.0) 2 (20.0)

KLM 47 5.3 (5.3) 47 (100.0) 0 (0.0)

SDG 44 7.6 (6.2) 25 (56.8) 19 (43.2)

SB 22 9.3 (7.0) 18 (81.8) 4 (18.2)

DKS 13 11.8 (8.5) 6 (46.2) 7 (53.8)

SI 30 12.0 (8.5) 22 (73.3) 8 (26.7)

SBL 212 7.8 (6.8) 27 (12.7) 185 (87.3)

AMP 33 7.0 (4.7) 1 (3.0) 32 (97.0)

LIK 0 0.0 (0.0) 0 (0.0) 0 (0.0)

Total 2244 (100.0) 7.3 (6.0) 1369 (61.0) 875 (39.0) Among invasively ventilated patients, 11.6% had tracheostomies performed. The median time from initiation of invasive ventilation to tracheostomy was 6.0 days. Hospital JB had the shortest interval of 4.4 days while Hospital KB had the longest interval of 17.7 days.


Table 28: Tracheostomy, by individual hospital 2007 – 2010

Hospital

Total tracheostomy (% percutaneous tracheostomy) n (%)

2007 2008 2009 2010 AS 48 (24.0) 64 (48.4) 125 (41.6) 105 (42.9)

PP 61 (40.3) 99 (35.4) 86 (29.1) 135 (63.0)

IPH 84 (57.1) 117 (23.9) 124 (12.9) 153 (3.9)

KL 116 (67.2) 133 (72.9) 104 (79.8) 142 (78.2)

SLG 75 (10.5) 84 (8.3) 58 (6.9) 66 (8.0)

KLG 35 (5.7) 88 (4.5) 117 (1.7) 110 (21.8)

SBN 58 (0.0) 57 (0.0) 58 (0.0) 59 (0.0)

MLK 91 (4.4) 124 (2.4) 134 (0.0) 105 (0.0)

JB 292 (86.7) 242 (83.9) 225 (83.6) 325 (77.8)

KTN 44 (34.1) 53 (13.2) 50 (8.0) 40 (5.0)

KT 24 (45.8) 64 (73.4) 53 (67.9) 60 (78.3)

KB 21 (38.1) 21 (4.8) 12 (8.3) 14 (14.3)

KCH 53 (53.7) 49 (8.2) 23 (13.0) 47 (17.0)

KK 55 (0.0) 55 (1.8) 28 (0.0) 58 (24.1)

SP 13 (0.0) 23 (0.0) 26 (3.8) 8 (0.0)

PJY - 5 (0.0) 10 (0.0) 11 (0.0)

MUR 25 (40.0) 34 (55.9) 26 (0.0) 26 (3.8)

TI 25 (72.0) 16 (62.5) 12 (83.3) 8 (0.0)

TPG 118 (0.0) 53 (0.0) 140 (0.0) 145 (0.7)

SJ 3 (0.0) 44 (2.3) 56 (0.0) 60 (8.3)

KJG 15 (6.7) 19 (0.0) 25 (0.0) 26 (0.0)

KGR 37 (0.0) 20 (0.0) 33 (15.2) 11 (0.0)

SDMC - 15 (33.3) 9 (44.4) 2 (0.0)

TML 35 (0.0) 29 (0.0) 40 (0.0) 45 (0.0)

KP 10 (0.0) 10 (0.0) 18 (0.0) 7 (0.0)

SMJ 11 (18.2) 8 (12.5) 19 (57.9) 9 (66.7)

BP 26 (3.8) 46 (2.2) 39 (0.0) 46 (0.0)

TW 12 (0.0) 11 (9.1) 13 (15.4) 10 (0.0)

MRI 32 (18.2) 23 (4.3) 29 (0.0) 10 (20.0)

KLM 26 (0.0) 34 (0.0) 34 (0.0) 47 (0.0)

SDG 27 (69.0) 39 (41.0) 51 (64.7) 44 (43.2)

SB - - - 22 (18.2)

DKS - - - 13 (53.8)

SI - - - 30 (26.7)

SBL - - - 212 (87.3)

AMP - - - 33 (97.0)

LIK - - - 0 (0.0)

Total 1472 (37.3) 1671 (31.1) 1821 (28.4) 2244 (39.0)

The percentage of percutaneous tracheostomies had increased by 11% from the previous year. In 2010, 40% of tracheostomies were performed percutaneously. There were 14 ICUs that had all tracheostomies performed surgically.


Table 29: Withdrawal / withholding therapy, by individual hospital 2008 - 2010

Hospital

Withdrawal / Withholding of therapy n (%)

2008 2009 2010

AS 24 (13.0) 188 (42.5) 181 (54.4)

PP 17 (21.5) 36 (50.0) 44 (41.9)

IPH 1 (0.8) 0 (0.0) 0 (0.0)

KL 131 (51.2) 190 (57.2) 183 (60.6)

SLG 9 (5.2) 5 (2.3) 3 (1.6)

KLG 0 (0.0) 0 (0.0) 25 (11.2)

SBN 4 (3.3) 49 (40.2) 47 (44.8)

MLK 125 (40.5) 22 (6.0) 41 (11.5)

JB 155 (61.0) 157 (57.7) 196 (71.5)

KTN 38 (33.3) 16 (12.9) 16 (11.5)

KT 45 (45.5) 31 (15.0) 102 (46.2)

KB 58 (37.7) 9 (6.1) 24 (15.1)

KCH 11 (12.1) 2 (2.3) 19 (23.5)

KK 0 (0.0) 3 (4.2) 27 (14.6)

SP NA 61 (78.2) 14 (21.9)

PJY 29 (34.5) 1 (1.3) 1 (1.0)

MUR 1 (0.7) 0 (0.0) 4 ( 3.1)

TI 16 (23.9) 13 (17.3) 6 (10.3)

TPG 64 (42.4) 75 (23.7) 79 (25.8)

SJ 1 (0.9) 13 (7.8) 68 (58.1)

KJG 0 (0.0) 11 (20.8) 2 ( 4.7)

KGR NA 25 (61.0) 60 (95.2)

SDMC 3 (2.8) 2 (2.4) 0 (0.0)

TML 0 (0.0) 8 (6.2) 8 ( 5.3)

KP 0 (0.0) 2 (3.8) 19 (19.4)

SMJ 0 (0.0) 1 (0.7) 42 (50.0)

BP 9 (10.6) 17 (16.0) 10 (13.0)

TW 2 (2.4) 5 (10.9) 2 (4.2)

MRI 0 (0.0) 2 (4.1) 0 (0.0)

KLM 18 (23.1) 23 (22.3) 69 (53.1)

SDG 39 (38.2) 40 (33.3) 127 (89.4)

SB - - 57 (51.8)

DKS - - 3 (2.7)

SI - - 1 (0.7)

SBL - - 82 (42.9)

AMP - - 29 (14.7)

LIK - - 0 (0.0)

Total 918 (24.4) 1007 (21.8) 1591 (29.6) Withdrawal or withholding of therapy: Refers to discontinuation / not initiating any of the following: vasoactive drugs, renal replacement therapy, mechanical ventilation, surgery, cardiopulmonary resuscitation Among deaths in ICU, therapy was withheld or withdrawn in 30% of them. Prendergast et al. [4] reported that in the US between the years of 1987 and 1993, the percentages of deaths in the ICU, following withdrawal or withholding of therapy had increased from 51% to 90%.


SECTION D:

COMPLICATIONS


Table 30: Incidence of ventilator-associated pneumonia, by individual hospital 2004 - 2010

Hospital VAP per 1000 ventilator days

2004 2005 2007 2008 2009 2010 AS - 20.0 3.3 0.68 4.4 9.6 PP 13.2 16.9 18.3 18.6 10.8 12.9 IPH 9.6 8.6 7.4 2.9 22.1 12.3 KL 36.1 19.5 17.9 18.9 12.3 15.2 SLG 52.6 7.7 49.2 32.9 21.4 13.5 KLG 27.6 27.4 12.8 9.5 4.4 3.5 SBN 26.4 9.9 4.9 6.1 7.3 8.7 MLK 11.7 11.0 13.0 11.9 2.8 8.5 JB 17.5 17.5 17.6 13.2 5.5 9.0 KTN 19.1 11.8 2.6 5.4 3.4 3.3 KT 29.7 6.8 6.2 8.2 1.6 8.7 KB 30.8 11.3 9.9 3.5 3.4 4.1 KCH 11.7 26.4 13.4 15.2 10.7 5.0 KK - 5.8 0.0 2.1 # 0.4 SP - - 21.8 33.1 39.5 23.4 PJY - - - 16.8 18.3 14.4 MUR - - 8.6 4.0 7.1 4.9 TI - - 24.2 4.7 5.4 8.8 TPG - - 31.0 21.7 28.8 3.0 SJ - - 36.0 58.3 28.4 14.7 KJG - - 12.5 22.8 15.7 10.9 KGR - - 21.6 20.4 6.0 10.8 SDMC - - 11.8 4.4 0.0 3.4 TML - - 2.7 2.9 2.6 4.0 KP - - 17.1 21.2 4.1 2.2 SMJ - - 30.3 25.5 28.7 37.3 BP - - 9.8 3.6 1.6 2.3 TW - - 0.0 0.0 3.2 8.7

MRI - - 9.0 8.8 10.5 2.8

KLM - - 16.3 21.8 18.8 36.7

SDG - - 20.2 11.4 21.7 13.5

SB - - - - - 7.7

DKS - - - - - 7.0

SI - - - - - 11.1

SBL - - - - - 22.7 AMP - - - - - 18.4 LIK - - - - - 0.0

Total 23.1 14.9 15.4 13.5 11.6 10.1 VAP: Defined as nosocomial pneumonia developing in a patient after 48 hours of mechanical ventilation with radiological evidence of new or progressive infiltrates with or without the presence of a positive bacteriological culture


Table 31: Onset of VAP from initiation of invasive ventilation, by individual hospital 2008 - 2010

Hospital Interval from initiation of ventilation to VAP

Mean (range) days 2008 2009 2010

AS - 9.1 (3.2-16.7) 7.6 (0.1-19.4)

PP 8.2 (1.5-33.1) 13.1 (2.5-34.6) 10.0 (1.6-33.1)

IPH 9.1 (1.2-23.5) 5.9 (2.2-15.7) 4.3 (0.1-12.3)

KL 12.2 (1.4-41.7) 9.7 (3.1-31.4) 11.2 (0.5-48.1)

SLG 5.2 (0.18-29.3) 8.0 (2.2-24.7) 11.9 (2.3-36.2)

KLG 8.0 (1.0-27.3) 10.5 (2.8-24.0) 14.0 (3.8-34.5)

SBN 8.4 (1.1-20.4) 9.7 (2.6-25.1) 10.1 (3.0-29.0)

MLK 7.4 (0.3-21.9) 10.7 (3.5-26.5) 7.8 (2.1-20.3)

JB 6.8 (2.1-25.3) 9.4 (2.5-37.0) 8.8 (1.8-32.0)

KTN 9.5 (2.3-19.4) 11.6 (2.423.0) 7.0 (1.8-16.5)

KT 6.5 (1.3-12.8) 10.7 (6.0-18.6) 7.2 (0.5-16.4)

KB 16.7 (5.9-26.2) 12.3 (5.6-19.2) 9.1 (0.5-24.3)

KCH 8.7 (0.1-37.5) 6.5 (2.6-12.4) 11.5 (1.5-43.7)

KK 18.1 (3.7-36.4) - 11.2 (11.2-11.2)

SP 6.9 (0.0-20.3) 7.3 (3.0-26.1) 7.2 (0.1-24.1)

PJY 8.1 (1.4-22.5) 10.7 (3.2-31.0) 9.9 (1.0-42.9)

MUR 15.7 (2.4-40.4) 13.0 (4.1-29.1) 10.3 (4.1-24.4)

TI 6.5 (2.0-15.3) 10.1 (7.4-15.3) 25.0 (2.3-94.1)

TPG 6.5 (0.4-29.1) 8.1 (2.1-38.0) 7.9 (2.2-18.5)

SJ 5.2 (0.1-21.2) 6.5 (2.0-18.7) 6.5 (1.1-21.3)

KJG 5.2 (2.3-7.3) 12.7 (2.2-26.0) 6.4 (1.4-9.0)

KGR 8.4 (0.8-22.1) 8.5 (3.9-13.4) 7.2 (1.4-16.5)

SDMC 8.9 (4.3-13.5) - 2.0 (0.1-4.0)

TML 11.8 (5.5-22.1) 6.9 (4.1-9.4) 10.3 (5.3-18.4)

KP 9.5 (4.1-20.1) 9.7 (5.0-14.4) 6.5 (6.5-6.5)

SMJ 6.4 (0.4-19.3) 6.0 (2.2-17.3) 5.7 (0.1-21.6)

BP 17.0 (12.6-31.0) 9.7 (5.0-14.3) 21.5 (0.7-55.7)

TW - 4.8 (4.7-5.0) 6.1 (2.1-14.1)

MRI 6.2 (2.0-11.0) 15.2 (3.7-44.6) 8.9 (2.5-13.0)

KLM 5.6(1.3-13.4) 7.3 (2.1-30.5) 5.9 (0.2-29.1)

SDG 6.0 (0.35-15.0) 8.5 (2.1-32.0) 6.6 (0.4-14.2)

SB - - 7.8 (2.7-14.9)

DKS - - 7.7 (0.3-15.5)

SI - - 12.8 (2.1-50.1)

SBL - - 9.1 (1.2-34.4)

AMP - - 7.1 (0.4-25.7)

LIK - - -

Total 7.8 (0.2-41.7) 8.7 (2.0-44.6) 8.8 (0.1-94.1)


Figure 19: VAP per 1000 ventilator days 2004 – 2010

Figure 20: VAP per 1000 ventilator days, by individual hospital 2010


Figure 21: VCB compliance and VAP 2007 – 2010

National Healthcare Safety Network (NHSN) report, data summary for 2006 - 2008

Types of ICU

Ventilator utilisation ratio

VAP per 1000 ventilator days

Pooled mean

Percentile

10th 25th 50th 75th 90th

Mixed medical/ surgical > 15 beds

0.29

2.2

0

0

0.7

3.0

5.8

Mixed medical/ surgical < 15 beds

0.37

1.9

0

0.4

1.3

3.0

4.2

Neurosurgical 0.36 5.3 0 2.6 4.0 5.6 8.2

Surgical 0.39 4.9 0 1.8 3.8 6.5 9.9

Trauma 0.57 8.1 0 2.1 5.2 10.0 16.1

The incidence of VAP had decreased by more than half from 28.0 in 2003 to 10.1 per 1000 ventilator days in 2010. The introduction of the ventilator care bundle in 2007 had contributed to this decrease as illustrated in Figure 20. The mean rate of VAP (10.1 per 1000 ventilator days) in our ICUs was higher when benchmarked with that of US National Healthcare Safety Network (NHSN) [5]; formerly known as National Nosocomial Infection Surveillance system (NNIS) as shown in the table above. The definition for VAP by NHSN has a more stringent inclusion criterion (resulting in fewer cases being defined as VAP) compared to ours. However, the rate of VAP in our ICUs compared favourably with the pooled VAP rate of 13.6 per 1000 ventilator days as reported by Rosenthal et. al.[6] in ICUs in 25 countries in Latin America, Asia, Africa and Europe using the definition of VAP by NHSN.


Ventilator usage is a significant risk factor for developing VAP and the exposure to this risk is measured by ventilator utilisation ratio, which is calculated by dividing the number of ventilator days to number of patient days. Ventilator utilisation ratio in our ICUs was 0.72, which is two times higher than the ICUs in US. The onset of VAP was 8.8 days from the initiation of invasive ventilation. Onset of VAP in all centres exceeded 5 days of ventilation, indicating that most VAPs in MOH ICUs were of late onset Table 32: Bacteriological cultures in VAP 2010

Organisms


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Total n (%)

Acinetobacter spp.

MRO

Non-MRO

233 (44.8)

189 (81.1)

44 (18.9)

81 (40.1)

53 (65.4)

28 (34.6)

36 (41.9)

25 (69.4)

11 (30.6)

350 (44.8)

267 (76.3)

83 (23.7)

Pseudomonas spp.

MRO

Non-MRO

84 (17.0)

24 (28.6)

60 (71.4)

37 (18.3)

18 (48.6)

19 (51.4)

14 (16.3)

2 (14.3)

12 (85.7)

135 (17.3)

44 (32.6)

91 (67.4)

Klebsiella spp.

ESBL

Non-ESBL

103 (20.9)

67 (65.0)

36 (35.0)

34 (16.8)

17 (50.0)

17 (50.0)

15 (17.4)

6 (40.0)

9 (60)

152 (19.5)

90 (59.2)

62 (40.8)

MRSA 13 (2.7) 6 (3.0) 3 (3.5) 22 (2.8)

MSSA 16 (3.2) 7 (3.5) 1 (1.2) 24 (3.1)

Stenotrophomonas maltophilia 11 (2.2) 8 (4.0) 1 (1.2) 20 (2.6)

Coagulase negative Staphylococcus

7 (1.4) 3 (1.5) 1 (1.2) 11 (1.4)

Other gram negative bacteria 5 (0.1) 5 (2.5) 0 (11.6) 10 (1.3)

Fungal 6 (1.2) 7 (3.5) 6 (7.0) 19 (2.4)

Other bacterial culture 15 (3.0) 14 (6.9) 9 (10.5) 38 (4.9)

Total 493 (63.1) 202 (25.9) 86 (11.0) 781 (100.0)


Table 33: Bacteriological cultures in VAP 2008 – 2010

Organisms

2008 n (%)

2009 n (%)

2010 n (%)

Acinetobacter spp. 219 (27.7) 267 (39.0) 350 (44.8)

Pseudomonas spp. 168 (21.2) 107 (15.6) 135 (17.3)

Klebsiella spp. 127 (16.0) 128 (18.7) 152 (19.5)

MRSA 63 (8.0) 50 (7.3) 22 (2.8)

MSSA 73 (9.2) 39 (5.7) 24 (3.1)

Stenotrophomonas maltophilia 25 (3.2) 20 (2.9) 20 (2.6)

Other gram negative bacteria 16 (2.0) 7 (1.0) 10 (1.3)

Fungi 11 (1.4) 6 (0.9) 19 (2.4)

Coagulase negative Staphylococcus

16 (2.0) - 11 (1.4)

Other bacterial culture 73 (9.2) 60 (8.8) 38 (4.9) Figure 22: Bacteriological cultures in VAP 2010

In 2010, Gram-negative organisms accounted for more than three quarter (85.5%) of the causative organisms in VAP. Over the last 7 years, the most common organisms were Acinetobacter spp., Klebsiella spp. and Pseudomonas spp. The percentage of Acinetobacter spp. had significantly increased over the years. MRSA causing VAP is relatively uncommon and has decreased over the years. 42.6% of the causative organisms in VAP were multi-drug resistant strains.


Table 34: Unplanned extubation per 100 intubated days, by individual hospital 2004 - 2010

Hospital

Unplanned extubation per 100 intubated days

2004 2005 2007 2008 2009 2010 AS 0.3 0.5 0 0.2 0.5 0.4

PP - 0.0 2.3 2.0 0.2 0.3

IPH 0.2 0.3 0.9 2.3 0.9 0.4

KL 0.6 0.5 4.3 4.1 1.4 1.4

SLG 0.4 0.8 4.8 2.7 1.3 0.8

KLG 0.2 0.3 1.0 0.6 0.2 0.3

SBN 1.4 0.3 1.8 1.5 0.7 0.6

MLK 0.8 1.8 5.1 2.9 0.8 0.5

JB 1.1 0.9 6.0 4.8 1.8 0.9

KTN 0.4 0.6 3.4 2.0 0.1 0.6

KT 0.6 0.3 2.5 1.8 0.1 0.6

KB 0.9 0.1 1.5 0.1 0.0 0.2

KCH 0.9 0.7 1.1 0.5 0.1 0.2

KK 1.0 0.3 0.9 0.5 0.1 0.2

SP - - 0 0 0.3 0.4

PJY - - - 0.4 0.0 0.5

MUR - - 1.8 0.3 0.1 0.2

TI - - 4.5 2.0 1.3 0.9

TPG - - 3.4 4.7 0.4 0.4

SJ - - 0 2.2 0.5 0.5

KJG - - 1.6 3.6 0.2 0.7

KGR - - 1.1 0 0.0 0.3

SDMC - - - 0 0.0 0.3

TML - - 0.7 0.9 0.0 0.4

KP - - 3.6 4.3 0.0 0.6

SMJ - - 0 0 0.0 0.2

BP - - 1.5 1.9 0.2 0.2

TW - - 1.2 0.5 0.0 0.2

MRI - - 2.8 0 0.0 0.3

KLM - - 1.2 1.5 0.5 1.0

SDG - - 2.6 1.4 0.4 0.3

SB - - - - - 0.3

DKS - - - - - 0.2

SI - - - - - 0.5

SBL - - - - - 0.2

AMP - - - - - 0.7

LIK - - - - - 0.0

Total 0.7 0.5 2.7 1.9 0.6 0.5


Figure 23: Unplanned extubation, by individual hospital 2010

The rate of unplanned extubation had decreased slightly from 0.6 to 0.5 per 100 intubated days from the previous year.


Table 35: Pressure ulcer, by individual hospital 2008 - 2010

Hospital

Pressure ulcer per 1000 ICU days 2008 2009 2010

AS 0.0 4.6 14.9 PP 9.9 14.0 6.6 IPH 0.4 0.4 9.0 KL 20.9 31.6 8.3 SLG 18.5 15.3 13.5 KLG 0.5 1.3 2.4 SBN 2.2 3.7 2.6 MLK 5.0 7.6 4.5 JB 18.8 13.0 8.2 KTN 2.2 1.4 1.8 KT 0.0 0.3 4.3 KB 2.1 5.1 3.0 KCH 3.1 1.6 10.9 KK 0.3 0.0 5.2 SP 2.2 2.0 3.2 PJY 3.2 0.6 2.2 MUR 2.1 2.9 0.4 TI 3.9 0.0 3.5 TPG 17.3 10.5 9.7 SJ 10.1 6.6 9.1 KJG 4.6 5.4 10.6 KGR 1.4 1.6 4.1 SDMC 0.8 1.0 4.3 TML 0.5 0.0 1.0 KP 2.5 6.2 6.1 SMJ 0.6 1.1 0.0 BP 4.7 3.5 14.7 TW 9.3 9.0 4.1 MRI 29.2 18.3 2.5 KLM 2.7 3.5 8.1 SDG 10.2 7.1 8.7 SB - - 9.2 DKS - - 7.2 SI - - 8.1 SBL - - 5.6 AMP - - 6.0 LIK - - 0.0

Total 7.1 7.7 6.6 Pressure ulcer: A circumscribed area in which cutaneous tissue has been destroyed and there is progressive destruction of underlying tissue caused by interference with circulation and nutrition to the area. Signs include blisters or broken skin or sore formation over pressure areas The incidence of pressure ulcers ranged from 0 to 15 per 1000 ICU days with a mean of 6.6.


SECTION E:

MORTALITY OUTCOMES


Crude mortality rates are convenient measures of outcome. However, they are poor indicators of performance of intensive care as they do not take into account variations in patient characteristics such as case mix and the severity of illness. A better measure of ICU performance is standardised mortality ratio (SMR). SMR is the ratio, comparing the observed to the predicted mortality, using a severity scoring system. SMR stratifies patients according to the severity of illness and is a better indicator of ICU performance within certain limitations. SMR of more than one indicates that the actual number of deaths is more than the predicted number of deaths. SMR of less than one indicates that the number of deaths observed is less than the number of deaths predicted. When interpreting SMR values, one must take into consideration factors which affect the severity scoring system used to predict mortality. These include interval between onset of illness to ICU admission (lead time bias), post-ICU care and small sample size. Lead-time bias refers to the erroneous estimation of risk at the time of admission to the ICU due to the results of therapeutic actions taken previously. Table 36: Hospital outcome 2010

Hospital outcome


n (%) Beds 8 -15

n (%) Beds < 7

n (%) Private n (%)

Total n (%)

Alive

9092 (66.9)

6090 (65.5)

1657 (66.1)

1481 (93.9)

18320 (67.9)

Died

3690 (27.1)

2667 (28.7)

729 (29.1)

63 (4.0)

7149 (26.5)

Discharged with grave prognosis

235 (1.7)

147 (1.6)

42 (1.7)

10 (0.6)

434 (1.6)

Transfer to another hospital

580 (4.3)

390 (4.2)

80 (3.2)

24 (1.5)

1074 (4.0)

Total

13597 (100.0)

9294 (100.0)

2508 (100.0)

1578 (100.0)

26977 (100.0)

The hospital outcome for the three categories of ICUs in MOH hospitals was fairly similar.


Table 37: Crude in-ICU and in-hospital mortality rate, by individual hospital 2005 - 2010

Hospital

Crude in-ICU mortality (in-hospital mortality) % 2005 2006 2007 2008 2009 2010

AS 22.4 (31.7) 18.3 (27.8) 26.6 (35.2) 33.7 (40.3) 39.0 (52.7) 32.1 (43.1) PP 15.8 (26.5) 11.6 (25.6) 13.9 (26.0) 13.9 (28.0) 13.8 (26.6) 12.6 (22.8) IPH 14.7 (23.2) 19.5 (29.1) 14.9 (22.7) 14.3 (22.9) 16.1 (25.7) 21.9 (27.3) KL 20.3 (29.0) 20.6 (33.3) 19.5 (29.8) 16.2 (25.5) 16.1 (28.0) 15.5 (22.0) SLG 25.9 (34.2) 25.5 (34.1) 25.7 (34.1) 19.8 (29.6) 23.6 (30.3) 18.0 (24.5) KLG 21.0 (30.3) 26.9 (35.1) 19.3 (28.8) 20.8 (26.0) 22.4 (30.6) 18.7 (26.3) SBN 25.0 (36.3) 21.6 (28.4) 24.8 (32.1) 25.9 (37.3) 22.9 (34.5) 19.9 (28.8) MLK 22.6 (34.2) 26.0 (35.8) 19.5 (29.5) 22.6 (31.0) 24.6 (32.9) 23.2 (30.8) JB 23.4 (33.5) 23.7 (32.6) 23.2 (32.1) 23.0 (30.8) 21.2 (32.2) 20.3 (27.7) KTN 26.8 (39.1) 26.0 (35.7) 20.5 (30.4) 20.2 (31.6) 20.1 (30.0) 19.4 (28.5) KT 32.7 (42.0) 27.0 (38.1) 23.7 (33.0) 16.5 (24.8) 24.4 (36.6) 21.3 (30.6) KB 21.5 (28.7) 21.6 (24.8) 19.0 (22.9) 18.2 (23.3) 18.3 (24.5) 19.2 (26.8) KCH 15.0 (24.6) 12.8 (20.5) 13.4 (19.1) 19.6 (24.4) 18.7 (23.8) 15.8 (21.1) KK 19.4 (24.1) 16.2 (22.8) 14.5 (24.2) 22.2 (31.5) 19.5 (35.7) 24.6 (33.5) SP - 25.0 (35.5) 49.6 (49.6) 35.0 (38.3) 29.5 (38.7) 33.3 (43.0) PJY - 19.8 (22.0) - 23.9 (26.5) 20.8 (23.1) 19.3 (23.1) MUR - 20.3 (28.4) 20.5 (25.4) 16.1 (26.9) 16.5 (21.9) 18.8 (24.6) TI - 33.5 (45.9) 30.0 (38.3) 23.8 (33.1) 27.0 (41.1) 21.7 (34.1) TPG - 13.5 (32.7) 36.0 (43.1) 36.7 (46.8) 36.2 (49.5) 38.1 (48.4) SJ - 23.9 (28.6) 28.8 (28.8) 21.4 (25.6) 27.8 (42.2) 22.4 (33.6) KJG - 26.1 (35.0) 28.8 (32.9) 23.9 (29.6) 17.9 (31.3) 16.1 (20.7) KGR - 23.0 (34.4) 16.0 (26.5) 26.1 (32.5) 13.6 (23.1) 21.8 (29.6) SDMC - - - 5.6 (7.3) 3.5 (4.1) 4.2 (4.6) TML - - 16.2 (20.7) 19.1 (23.1) 20.0 (28.4) 25.6 (32.5) KP - - 40.7 (45.7) 24.9 (32.6) 32.5 (43.5) 41.9 (46.2) SMJ - - 35.0 (42.9) 31.4 (34.0) 40.4 (46.9) 29.9(39.2) BP - - 33.5 (39.5) 24.9 (36.5) 27.5 (38.8) 18.8 (33.0) TW - - 23.4 (27.0) 26.3 (35.1) 20.0 (29.9) 21.8 (30.3) MRI - - 21.1 (26.1) 27.3 (33.3) 23.7 (30.6) 15.9 (24.2) KLM - - 26.5 (33.9) 24.7 (32.0) 28.5 (35.2) 29.7 (37.6) SDG - - 22.9 (28.3) 22.4 (28.7) 17.5 (24.3) 17.5 (23.5) SB - - - - - 23.4 (28.9) DKS - - - - - 48.0 (59.3) SI - - - - - 26.8 (31.7) SBL - - - - - 16.0 (23.3) AMP - - - - - 37.1 (41.8) LIK - - - - - 1.9 (1.9)

Total 21.8 (31.1) 21.7 (31.0) 22.3 (30.1) 19.9 (27.2) 21.2 (29.7) 20.9 (28.1)


Figure 24: Crude in-ICU and in-hospital mortality rates, by individual hospital 2010

The in-ICU and in-hospital mortality rates in MOH hospitals were 20.9% and 28.1% respectively. These rates had remained almost the same over the last six years.


Table 38: Ten most common diagnoses leading to ICU admission in MOH hospitals and observed in-hospital mortality 2010

Diagnosis

Mortality (%) 2009 2010

Head Injury 27.0 27.4

Sepsis 62.2 59.3

Dengue 10.4 8.6

Community acquired pneumonia 46.3 42.6

Bronchial asthma 10.4 7.8

Chronic lower respiratory disease 32.4 26.2

Gastrointestinal perforation (including anastomotic leak)

36.3 33.8

Infection / gangrene of limb (including osteomyelitis, necrotising fascitis)

39.2 39.1

Non-cardiogenic pulmonary oedema

25.9 29.5

Intra-abdominal injury 22.4 23.8

Patients with sepsis carried a high in-hospital mortality of 59.3%. Mortality for patients with head injury was 27.4%. Bronchial asthma and dengue infection carried in-hospital mortality of 7.8 and 8.6% respectively. Table 39: Severe sepsis, ARDS and AKI within 24hrs of ICU admission and observed in-

hospital mortality 2010

In-hospital Mortality (%)

Severe sepsis 58.6

ARDS 56.6

AKI 58.2

In-hospital mortality rates for patients with severe sepsis, acute respiratory distress syndrome and acute kidney injury within 24 hours of ICU admission were as high as 60%.


Table 40: Standardised mortality ratio, by individual hospital 2005 – 2010

Hospital

Standardised mortality ratio (95% CI)

2005 2007 2008 2009 2010 AS 1.23 0.92 0.94 1.00 0.93 (0.70-1.22)

PP 1.00 0.92 0.88 0.78 0.68 (0.47-0.96)

IPH 1.51 0.89 0.90 0.86 0.82 (0.56-1.12)

KL 0.77 0.82 0.70 0.73 0.62 (0.42-0.90)

SLG 1.58 0.91 0.77 0.84 0.76 (0.52-1.07)

KLG 0.85 1.11 0.80 0.98 0.85 (0.60-1.18)

SBN 0.89 0.69 0.87 0.93 0.74 (0.54-1.03)

MLK 0.96 0.98 0.98 0.91 0.97 (0.71-1.34)

JB 0.87 0.92 0.88 0.87 0.71 (0.51-1.00)

KTN 1.02 0.95 0.94 0.88 0.90 (0.69-1.25)

KT 1.22 0.88 0.74 1.09 0.86 (0.62-1.17)

KB 0.86 0.83 1.01 1.41 1.00 (0.70-1.38)

KCH 0.91 0.70 0.84 0.80 0.63 (0.42-0.92)

KK 0.95 0.83 1.00 1.10 0.83 (0.60-1.13)

SP - 1.12 0.87 1.02 0.97 (0.73-1.26)

PJY - 0.85 0.86 0.83 (0.56-1.17)

MUR - 0.92 1.06 0.81 0.88 (0.63-1.23)

TI - 0.75 0.77 0.91 0.71 (0.51-0.96)

TPG - 1.01 1.00 1.16 1.03 (0.77-1.35)

SJ - 0.90 0.67 0.84 0.76 (0.55-1.03)

KJG - 0.79 0.94 1.00 0.64 (0.42-0.91)

KGR - 0.85 0.90 0.71 0.75 (0.53-1.05)

SDMC - 0.59 0.39 0.36 (0.19-0.75)

TML - 0.62 0.76 0.74 0.86 (0.63-1.16)

KP - 0.95 0.76 0.90 0.90 (0.67-1.17)

SMJ - 1.18 1.00 1.20 0.93 (0.69-1.23)

BP - 1.01 0.93 0.81 0.76 (0.54-1.01)

TW - 0.62 0.78 0.54 0.55 (0.40-0.76)

MRI - 0.83 0.99 0.90 0.69 (0.48-1.00)

KLM - 0.88 0.75 0.86 0.87 (0.65-1.16)

SDG - 0.89 0.96 0.86 0.71 (0.48-0.98)

SB - - - - 0.74 (0.50-1.04)

DKS - - - - 1.04 (0.81-1.31)

SI - - - - 0.72 (0.52-0.99)

SBL - - - - 0.73 (0.51-1.04)

AMP - - - - 0.89 (0.68-1.16)

LIK - - - - 0.14 (0.06-0.35)

Total 1.0 0.89 0.85 0.89

0.80 (0.54-1.14)

The pooled standardised mortality ratio for 2010 was 0.8 (95% C.I. 0.54 – 1.14). It is observed that the SMR has been steadily decreasing over the years. This could reflect improved patient care. However, risk-adjusted severity scoring systems are known to drift in calibration over time and this may result in lower SMR over the years.


Figure 25: Standardised mortality ratio by individual hospital, 2010

D KS

SI

A M P

SB L

LIK

SBSLGSB N

KJG

A SKLG

M LK

JB

M U R

PPKC H

KKKT

TPG

B P

KB

KP

M R I

KL

T M L IPH

SD G

SM J

SP

T I

KLMPJY

KTN

TW

SJ

0

20

40

60

80

100

120

140

160

180

200

0 100 200 300 400 500 600

Expected number of deaths

Stan

dard

ised

Mor

talit

y R

atio

Average 2SD limits 3SD limits

KGR

The above figure shows the funnel plot for standardised mortality rates (SMR) in MOH hospitals. We use 2 standard deviations (SD) from the mean (inner curves) to highlight units that might be different and 3 SD from the mean (outer curves) to highlight units that are different. There are many reasons that could explain statistical outliers, from mere chance, differences in resources or standard of care. There was a wide variation among the performance of the participating units. Units with low SMR (outside 3 SD limits) were KL, JB, PP, KCH, TW and LIK. There were no units outside the 3 SD limits for high SMR.


SECTION F:

SPECIAL REPORT ON DENGUE INFECTION


Report on patients with Dengue infection who were admitted to the intensive care units in the Ministry of Health hospitals in 2010 Dengue infection is endemic in Malaysia and the number of dengue cases rose by 11% from 41,486 in 2009 to 46,171 in 2010. The number of deaths had also increased by 52% from 88 in 2009 to 134 in 2010, resulting in an increase in case fatality rate from 0.21 to 0.29. [7] The number of ICU admissions with dengue infections in 2009 was 636 in the 30 MOH ICUs. The corresponding figure for 2010 was 1386, a significant increase of 118%. When the cases in the 6 new centres were included, the total admissions in 2010 were 1,643. The gender and ethnic distribution was fairly similar to that seen in the general ICU population. Male patients accounted for 57.8% of the admissions. The mean age was 32.0 ± 15.4 years. Thus, patients with dengue infection were younger than the general ICU population. The following is the data analysis carried out on these 1,643 patients. Table 41: General comparison for Dengue and Non-Dengue infection 2010

Dengue Infection n = 1643

Non-Dengue Infection n = 23341

P value

Age, days median (IQR)

28.8 (22.5 – 47.3)

47.8 (29.2 – 62.9)

P < 0.0001

Length of ICU stay, days median (IQR)

1.9 (1.9 – 9.6)

2.6 (1.4 – 6.8)

P < 0.0001

Length of hospital stay, days median (IQR)

5.5 (3.4 – 17.5)

9.9 (5.4 – 19.7)

P < 0.0001

Length of mechanical ventilation, days median (IQR)

3.8 (1.4 – 7.2) 1.9 (0.7 – 5.0) P < 0.0001

Total SAPS II score, mean

19.0 + 14.1 37.3 + 18.9 P < 0.0001

% Invasive mechanical ventilation

18.6 79.7 P < 0.0001

% Co-morbid diseases 18.1 51.1 P < 0.0001

Main organ failure

Without organ failure

32.2 34.4 P = 0.1

Respiratory failure

4.7 18.2 P < 0.0001

Cardiovascular failure

7.1 25.7 P < 0.0001

Neurological failure

0.6 12.5 P < 0.0001

Renal failure

0.9 6.7 P < 0.0001

Hepatic failure

0.4 0.9 P = 0.05

Haematological failure 54.0 1.5 P < 0.0001

SMR (95% CI)

0.75 (0.42-1.20) 0.81 (0.57-1.09)


Patients with dengue infection were younger and fewer had co-morbid diseases. They had shorter in-ICU and in-hospital stays and tended not to be mechanically ventilated. The mean SAPS II score and SMR were lower compared with the rest of the ICU population. Haematological failure was the main organ failure in patients with dengue infection. About one third of the patients with dengue infection had no organ failure while another half had one organ failure.


Table 42: Dengue infection by hospital and crude in-hospital mortality, 2010

Hospital ICU admission n (%)

In-hospital mortality n (%)

MLK 256 (15.6) 18 (7.0) KL 165 (10.0) 5 (3.0) KLG 164 (10.0) 16 (9.8) SBL 164 (10.0) 11 (6.7) SLG 98 (6.0) 5 (3.0) SDG 97 (5.9) 15 ( (15.5) JB 84 (5.1) 7 (8.3) IPH 78 (4.7) 6 (7.7) PP 56 (3.4) 2 (3.6)

KJG 53 (3.2) 5 (9.4)

MUR 52 (3.2) 0 (0)

TML 47 (2.9) 3 (6.4)

SB 38 (2.3) 10 (26.3)

AMP 36 (2.2) 1 (2.8)

KB 36 (2.2) 11 (30.6)

SBN 34 (2.1) 5 (14.7)

KTN 25 (1.5) 2 (8.0)

KCH 22 (1.3) 8 (36.4)

KK 17 (1.0) 4 (23.5)

SMJ 17 (1.0) 1 (5.9)

BP 16 (1.0) 2 (12.5)

SI 15 (0.9) 2 (13.3)

KT 13 (0.8) 0 (0)

AS 10 (0.6) 0 (0)

PJY 10 (0.6) 1 (10.0)

TPG 8 (0.5) 2 (25.0)

MRI 7 (0.4) 1 (14.3)

KLM 6 (0.4) 1 (16.7)

SP 6 (0.4) 2 (33.3)

KP 3 (0.2) 2 (66.7)

DKS 3 (0.2) 1 (33.3)

TI 2 (0.1) 0 (0)

TW 2 (0.1) 1 (50.0)

KGR 1 (0.1) 0 (0.0)

LIK 1 (0.1) 0 (0.0)

Total 1643 (100.0) 150 (9.1) The average in-hospital mortality for this group of patients was 9.1%.


Table 43: Dengue infection by regions and crude in-hospital mortality, 2010

Hospital Admissions n (%)

In-hospital mortality n (%)

Central region (KL, SLG, KLG, PJY, KJG, SDG, SBL, AMP)

787 (48.0) 59 (7.5)

Northern region (AS, PP, IPH, SP, TPG, SJ, TI, KGR, SMJ, KLM)

185 (14) 14 (7.6)

Southern region (SBN, MLK, JB, KP, BP, SI)

460 (28.0) 36 (7.8)

East coast region (KTN, KT, KB, TML)

121 (7.4) 16 (13.2)

East Malaysia (KCH, KK, TW, MRI, SB, DKS, LIK)

90 (5.5) 25 (27.8)

Total

1643 (100.0) 150 (9.1)

Figure 26: Age groups and Mortality in Dengue 2010

Patients aged more than 70 years had the highest crude mortality of 33%.


Table 44: Main organ failure and Mortality for Dengue and Non-Dengue infection 2010

Crude mortality %

Dengue Infection

Non-Dengue Infection

Without organ failure

1.4 10.3

Respiratory failure

34.4 22.3

Cardiovascular failure

42.4 43.3

Neurological failure

62.5 14.4

Renal failure

0.0 6.7

Hepatic failure

0.0 1.3

Haematological failure

8.3 1.8

This table shows a comparison of mortality between patients with dengue and non-dengue infection in terms of organ failure. Patients with dengue infection associated with neurological failure as the main organ failure had an exceptionally high mortality of 60%. However, the number of patients in this group was only 8.


SECTION G:

SPECIAL REPORT ON INFLUENZA A (H1N1)


Report on patients with Influenza A (H1N1) infection admitted to the MOH ICUs 2009 - 2010

This is an audit of patients with influenza A (H1N1) infection admitted to MOH ICUs during the 2009 pandemic and in 2010. The diagnosis of influenza A (H1N1) infection was based on clinical findings confirmed by positive respiratory tract specimen for influenza A (H1N1) using RT-PCR test. The audit for 2009 was carried out from 15th July to 14th December 2009 (5 months). For 2010, the audit covered all admissions from 1st January 2010 to 31st December 2010 (12 months).

Table 45: Comparison of characteristics and outcomes of patients with Influenza (H1N1) infection 2009 and 2010

2009 2010

Study period 15/7/2009 – 14/12/2009 1/1/2010 - 31/12/2010

Duration of study, days 153 365

No. of patients 351 127

Female sex no./total no. (%) 181/351 (51.6) 70/127 (55.1)

Children (< 18 years) no./total no. (%) 49/351 (14.0) 16/127 (12.6)

Age, yr mean + SD median (IQR)

37.8 + 19.1 38 (25 - 53)

35.5 + 16.7 34 (25-47)

SAPS II score mean + SD 34.7 + 7.8 27.5 +13.1

SOFA score on Day 1 ICU mean + SD 7.2 + 4.8 5.4 + 4.0

Co-morbidities no./total no. (%) 169/327 (51.7) 51/127 (40.2)

Chronic lung disease no./total no. (%) 43/326 (13.2) 17/127 (13.4)

Diabetes mellitus no./total no. (%) 81/327 (24.8) 24/127 (18.9)

Hypertension no./total no. (%) 89/327 (27.2) 25/127 (19.7)

Invasive ventilation no./total no. (%) 256/345 (74.2) 82/127 (64.6)

Non-invasive ventilation no./total no. (%) 113/332 (34.0) 40/127 (31.5)

Renal replacement therapy no./total no. (%) 49/316 (15.5) 14/127 (11.0)

Duration of invasive ventilation, days median (IQR) 4.8 (1.6 -9.3) 5.2 (2.6-9.5)

Duration ICU stay, days median (IQR) 5.8 (2.2 – 10.9) 4.0 (1.9-9.4)

Duration hospital stay, days median (IQR) 10.1 (4.5 – 19.2) 9.1 (5.1-17.1)

Time from hospitalisation to ICU admission, days median (IQR) 0.3 (0.0 – 1.8) 0.3 (0.0-1.2)

Time from hospitalisation to death, days median (IQR) 5.0 (1.6 -10.6) 6.2 (3.4-19.3)

Standardised mortality ratio 1.12 0.86 (95 % CI 0.58-1.25)


Table 46: Influenza A H1N1 infection and crude in-hospital mortality, by hospital 2009 and 2010

Hospital n (%) 2009 2010

KL 40 (11.4) 4 (3.1) MLK 37 (10.5) 11 (8.7) JB 34 (9.7) 11 (8.7) SBL 19 (5.4) 14 (11.0) SJ 16 (4.6) 1 (0.8) SBN 15 (4.3) 2 (1.6) SLG 13 (3.7) 3 (2.4) KT 12 (3.4) 4 (3.1) TPG 12 (3.4) 0 (0.0) KCH 11 (3.1) 0 (0.0) KTN 10 (2.8) 14 (11.0) KLM 9 (2.6) 2 (1.6) SDG 9 (2.6) 0 (0.0) PP 8 (2.3) 18 (14.2) SP 8 (2.3) 1 (0.8) TML 8 (2.3) 1 (0.8) SI 8 (2.3) 7 (5.5) KLG 8 (2.3) 4 (3.1) LIK 7 (2.0) 1 (0.8) SB 7 (2.0) 3 (2.4) PJY 7 (2.0) 2 (1.6) MUR 6 (1.7) 0 (0.0) BP 6 (1.7) 1 (0.8) AS 6 (1.7) 0 (0.0) AMP 6 (1.7) 1 (0.8) IPH 5 (1.4) 1 (0.8) TW 4 (1.1) 0 (0.0) KP 4 (1.1) 0 (0.0) KB 3 (0.9) 12 (9.4) SMJ 3 (0.9) 2 (1.6) MRI 2 (0.6) 0 (0.0) KGR 2 (0.6) 0 (0.0) KK 1 (0.3) 0 (0.0) KJG 1(0.3) 6 (4.7) DKS 0 (0.0) 1 (0.8) Lahad Datu 1 (0.3) - Keningau 1 (0.3) - Bintulu 1 (0.3) - Kemaman 1(0.3) - Total 351 (100.0) 127 (100)

A total of 351 patients were admitted to the 40 MOH ICUs (including Lahad Datu, Keningau, Bintulu and Kemaman which are not in the MRIC) from 15th July 2009 to 14th December 2009. In 2010, there were a total of 127 patients admitted to the 36 MOH ICUs. This was about one third of the caseload for the five months in 2009.


In 2010 cohort, there were slightly more female patients (55.1 vs 51.6%). The mean age was lower (36 vs 38 yr in 2009). Patients in 2010 cohort had lower SAPS and SOFA scores (27.5 vs 34.7 and 5.4 vs 7.2) indicating that they had less severe illness. They had less co-morbidities (40 vs 52%), received less mechanical ventilation (64.6 vs 74.2%) and renal replacement therapy (11.0 vs 15.5%). This population had shorter in-ICU and in-hospital stay (4.0 vs 5.8 and 9.1 vs 10.1). They also had significantly lower crude in-hospital mortality rates (20.5% vs 38.5%) and a lower SMR (0.86 vs 1.12).


SUMMARY 1. The total number of ICU beds in the 37 participating units was 439.

2. The number of cases analysed for year 2010 was 26,977, an increase of 27% over the previous year.

3. The overall reporting rate had been fairly constant at 88%.

4. The average age of patients excluding those below 18 years was 49.4 years.

5. In MOH hospitals, foreigners constituted 6% of all ICU admissions.

6. The average lengths of ICU and hospital stays were 4.7 and 14.6 days respectively.

7. In MOH hospitals, 63% of admissions were non-operative patients, an increase of 15% in the last six years.

8. Direct admission to ICU from the emergency department had increased from 9% in 2004 to

24% in 2010.

9. Inter-hospital ICU admissions increased from 2.8% to 4.3% in the last six years. 10. 63% of admissions had one or more organ failure within 24 hours of ICU admission. 11. Cardiovascular failure (37%) was the most common among those with organ failure

followed by respiratory failure (26%) and neurological failure (18%). 12. Head injury, sepsis and dengue infection were the three most common diagnoses leading

to ICU admission, in MOH hospitals for 2010. The in-hospital mortality for this group of patients was 27.4%, 59.3% and 8.6% respectively.

13. The average SAPS II score was 35.1, which carries a predicted risk of in-hospital mortality

of 27.0%. 14. In MOH hospitals, 71.6% of patients received invasive ventilation with an average duration

of 4.1 days. 4.8% of ICU admissions in the private hospital were mechanically ventilated with average duration of 4.2 days.

15. The percentage of patients who received non-invasive ventilation increased from 6.5% in

2003 to 14.3% in 2010.

16. In MOH hospitals, 12% of ICU admissions had renal replacement therapy, with intermittent haemodialysis being the most common modality of therapy.

17. Among patients who were invasively ventilated, 29% of them had tracheostomy

performed, with the average time from initiation of ventilation to tracheostomy being 6.0 days.

18. Among those who died in ICU, decisions to withdraw or withhold therapy were made in 30% of them.

19. The incidence of VAP had decreased by more than half from 28.0 to 10.1 per 1000 ventilator

days over the last eight years.


20. The majority (85%) of the organisms causing VAP were Gram-negative. Acinetobacter spp., Pseudomonas spp. and Klebsiella spp. remained the 3 most common organisms causing VAP over the last 7 years in MOH ICUs. 43% of organisms causing VAP were multi-drug resistant.

21. The crude in-ICU and in-hospital mortality rates were 20.9% and 28.1% respectively. 22. The mean standardised mortality ratio was 0.80 (95% CI 0.54 – 1.14).


REFERENCES

1. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996;22:707-710

2. Le Gall JR, Lemeshow S, Saulnier F. A New Simplified Acute Physiology Score (SAPS II) based on a European/North American Multi-centre Study JAMA 1993;270(24):2957-2963

3. Tai LL et al . Validation and recustomisation of Simplified Acute Physiologic score II (SAPS II) in patients in Malaysian ICU. Poster presentation at the 13th Western Pacific Association of Critical Care Medicine Conference, Seoul 2004

4. Prendergast TJ, Claessens MT, Luce JM: A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 1998, 158:1163-1167.

5. Edwards JR, Peterson KD, Mu Y et al. National Healthcare Safety Network (NHSN) report, data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009; 37:783-805

6. Rosenthal VD, Maki DG, S Jamulitrat et. al. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009. Am J Infection Control 2009; 38: 95-106

7 Situasi Semasa Demam Denggi Dan Chikungunya Di Malaysia Bagi Minggu 52/2010 (26 Dis 2010 hingga 01 Jan 2011). http://www.moh.gov.my

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