Outcome of Care Provided in Neonatal Surgery Intensive Care Unit of a Public Sector Tertiary Care Teaching Hospital of India.

AIMS: There is limited literature on the outcome of care in intensive care units (ICUs), especially when it comes to neonatal surgical units. Hence, this study was aimed to observe the outcome of care provided in the neonatal surgery ICU (NSICU) at an apex tertiary care teaching institute of North India.
METHODS: A descriptive, observational study was carried out through retrospective medical record analysis of all the patients admitted in NSICU from January to June 2011.
RESULTS: In NSICU, from January to June 2011, 85 patients were admitted. More than two-third (69.9%) patients were admitted through the emergency department. Of the total admitted patients, 69.9% were male. Mean and median age of the admitted patients were 6.31 and 2 days (range 0-153 days), respectively. The most common diagnosis was esophageal atresia with tracheoesophageal fistula (36.1%). Within a day of admission at NSICU, 88% patients underwent surgical intervention. Of the total admitted patients, 56.6% required mechanical ventilation with 3.57 days (range 0-31 days) of mean duration of mechanical ventilation. Reintubation rate (within 48 h of extubation) was observed to be 15.7%, and 27.7% (23) of the patients required vasopressor support during their NSICU stay. Patients who developed postoperative complications were 34.25%, with the most common being wound infection/discharge/dehiscence. Two patients were readmitted within 72 h of their discharge/transfer out from the NSICU.
CONCLUSION: NSICU survival rate was 85.5% and net death rate was observed to be 14.5%. Sepsis was the major reason for mortality in NSICU. Copyright:

INTRODUCTION

Pediatric intensive care is an essential component in the postoperative management of children undergoing complex surgical procedures.[1] The progressive development of neonatal intensive care has led to dramatic improvements in the survival and outcome of small premature infants and those with congenital malformations. Antenatal diagnosis of congenital malformations has had a major impact on pediatric surgical practice.[2] In 1975, the first neonatal surgical intensive care unit (NSICU), in India, was established at the AIIMS, New Delhi.[3] There is a national need for specialist neonatal surgical units given the changes in their workload and their requirements in terms of medical and nursing staff, equipment, and transport of sick neonates.[2] The concentration of neonatal surgery into specialist pediatric surgical units has been associated with marked fall in mortality and morbidity of the surgical neonate. The increasingly complex demands of caring for the sick, frequently premature neonate necessitates close collaboration between pediatric surgeons, neonatologists, and other specialists.

There are various indices which can be used to study the outcome of care being rendered to ascertain the quality of health care. Patients, doctors, hospital administrators, insurers, and governmental regulatory agencies often differ in the value they place on any particular outcome of illness.[4] There are many important outcomes in critical care, including mortality and length of stay (LOS). However, outcome parameters such as quality-of-life outcome after ICU discharge (including functional and psychosocial recovery) and cost are also receiving research attention.[5] Predominantly studied outcome measures include mortality, morbidity, resource use, and patient-centered outcomes (which incorporate patient preferences for their care and for their own functional status). In the future, audit of both, medical and surgical neonates, is likely to assume greater importance in evaluating standards of neonatal care.[6]

The provision of intensive care in a resource-constraint setting raises difficult moral and ethical questions. In high-income countries, care of the critically ill comprises a large proportion of health-care spending; however, in low-income countries, little infrastructure exists to provide critical care. It establishes disparities of a global “10/90 gap:” 10% of worldwide expenditure on health research and development is devoted to the problems that primarily affect the poorest 90% of the world's population.[7] Apposite criteria already exists for monitoring the standard of neonatal intensive care.[8] Therefore, this study was conducted to ascertain the outcome of care being rendered in the NSICU of a leading tertiary care apex institute located in the Northern part of India.

METHODS

A descriptive and observational study was carried out in the NSICU of a leading tertiary care apex teaching institution located in North India. It was inducted from October 2011 to September 2012 after obtaining clearance from the Institute Ethics Committee. The outcome of the care rendered in the NSICU was studied by retrospective analysis of medical records of all the admitted patients over a period of 6 months (January 2011 to June 2011). Medical records of the admitted patients were studied to arrive at the outcome. The outcome parameters were selected through review of literature and are given in consequent table [Table 1]. Data collected were analyzed using Microsoft Excel 2010.

Table 1

Outcome parameters studied in neonatal surgery intensive care unit

Demographic and general profile of patients

Morbidity

Length of stay

ICU

Hospital

Diagnosis

Postoperative intervention/complication

Vasopressor support

Oxygen administration

Ventilator days

Unplanned reintubation within 48 h

ICU readmission within 72 h

Mortality

Hospital

ICU

ICU: Intensive care unit

RESULTS

NSICU is an independent physical entity, however, co-located within the pediatric surgery ward, controlled and managed by the Department of Pediatric Surgery (teaching department). There is a separate neonatal ICU within the hospital which takes care of the preterm babies. Pediatric surgery works as a single team under Head of the Department. It has the capacity to admit ten patients (bassinets with infant warmers and incubators) and is an open type of ICU with rights of admission reserved with the treating surgeon.

There is no designated full-time faculty in-charge/head of the NSICU, and every day, a faculty is available in NSICU, who is responsible for administrative and clinical decision making; however, he/she has got other assigned responsibilities of the Department as well. Senior Residents (pursuing MCh Paediatric Surgery) are posted on a rotational basis for a period of 1 month and are physically available round the clock in NSICU. Patients are admitted by Senior Residents on duty in consultation with Faculty on call for that particular day. One dedicated Assistant Nursing Superintendent is posted for NSICU, who looks after the Nursing administrative work of the NSICU. There are a total of 20 nursing staff (Grade I and II nursing sisters) posted in NSICU. They are responsible for day-to-day nursing care of the admitted neonates. An Operation Theater Assistant (OTA) is available only during the daytime for management of the equipment within the NSICU. One Hospital Attendant and Sanitary Attendant are posted in each shift in NSICU. Multidisciplinary professional needs for patient care are met through super specialty and support departments available in-house. There are no dedicated physiotherapist, dietician, radiology technician, etc., for NSICU but are available in-house. NSICU has got state of the art incubators, ventilators, sophisticated multiparameter monitors, etc.

Patients admitted in NSICU were mainly from northern states of India, i.e., Delhi, Haryana, and Uttar Pradesh. In NSICU, over a period of 6 months, a total of 85 patients were admitted, of which 65 (78.3%) were referred. Medical records of only 84 patients were available for the study. Patients were transferred in mainly-from the emergency department (69.9%), outpatient department (13.3%), neonatal ICU (12%), etc., of the hospital. Majority (approx. 85%) of the patients were outborn and very few were inborn. Of the total admissions, 69.9% (58) were male and rest of them were female (30.1% [25]). Mean and median age of the patients admitted to NSICU were 6.31 days and 2 days (range 0–153 days), respectively. Majority (80.7%) of the patients at the time of admission were in their early neonatal period [Figure 1].

Figure 1

Age distribution of patients

Birth history of admitted patients was also analyzed, and it was found that 78.3% (65) were delivered at term, 20.5% (17) were delivered preterm, and only one patient was delivered postterm. Majority of the patients, i.e., 89.2% (74) had an institutional delivery, while rest (10.8%) were home delivered. History of the patients revealed that 62.7% (52) had normal vaginal delivery and 36.1% were delivered through lower segment cesarean section, of which 16.67% (5) of the patients were delivered through the emergency lower segment cesarean section. Only one patient was delivered through assisted breech delivery.

Patients admitted at NSICU presented most commonly with esophageal atresia along with tracheoesophageal fistula (36.1%), anorectal malformation (9.6%), lumbosacral meningomyelocele (8.4%), posterior urethral valve (4.8%), diaphragmatic hernia (4.8%), etc., [Table 2]. Almost one-third of the patients (29.8%) reported with multiple anomalies, 23.8% presented with double anomalies, whereas rest had single anomaly (46.4%) [Table 3].

Table 2

Surgical diagnosis of the admitted patients

Diagnosis	n
Esophageal atresia (28)
Pure	5
Esophageal atresia plus tracheaesophageal fistula	20
H-type	2
Short esophagus	1
Spinal dyscrasia (9)
Lumbosacral meningomyelocele	6
With rupture	1
Hemivertebrae	2
Patent ductus arteriosus	8
Duodenal atresia	6
Atrial septal defect	6
Anorectal malformations (6)
Male	1
Female	5
Intestinal malrotation	4
Meconium peritonitis	3
Hirschsprung’s disease (colonic aganglionosis)	3
Posterior urethral valve	4
Congenital diaphragmatic hernia	4
Eventration of the diaphragm	2
Ileal atresia, exomphalos major, gastroschisis, radial ray effect, congenital heart disease, bilateral HDUN	2 patients of each morbidity
Inguinal hernia, epispadias, duplication cyst, pantaloon hernia, midgut volvulus, common cloaca, ventricular septal defect, laryngotracheal cleft, Ebstein anomaly, ventricular hemorrhage with hydrocephalus, incomplete twining, renal tumor, pulmonary hypoplasia, and Down’s syndrome	Single patient of each morbidity

HDUN: Hydroureteronephrosis

Table 3

Number of anomalies in the admitted patients

Anomalies	Number of patients (%)
Single anomaly/morbidity	39 (46.4)
Double anomaly	20 (23.8)
Multiple anomalies	25 (29.8)
Total	84 (100)

Of the total admitted patients, 74 (88%) patients underwent surgical procedures, of which almost all the patients (99%) underwent surgical procedure/intervention within 24 h of admission. Of the ten patients who could not be operated upon, four patients left the hospital against medical advice, three patients succumbed to the disease condition (too sick to be operated upon), whereas remaining (three) were discharged. Following the surgical procedure, 34.25% (25) developed postoperative complications with the most common being wound infection/discharge/dehiscence. A little more than quarter (27.7%) of the patients required vasopressor support during their NSICU stay.

More than half of the patients, i.e., 56.6% (47) required mechanical ventilation. A total of 296 days of mechanical ventilation was provided to patients admitted in the NSICU with 3.57 days (range 0–31 days) of mean mechanical ventilation. Median length of mechanical ventilation required by NSICU patients was 2 days. Mean and median length of mechanical ventilation were longer in patients who expired (7.3 days) than those who survived (4 days). Out of the total patients requiring mechanical ventilation, 15.7% (13) were reintubated within 48 h of extubation (either due to unplanned extubation or failed extubation). Two patients were readmitted within 72 h of their discharge/transfer out from the NSICU.

Mean and median hospital length of stay (LOS) of patient who received NSICU care was 16.41 days and 11 days (range – 1–101 days), respectively. Mean and median NSICU LOS of the admitted patient was 13.78 days and 10 days (range 1–68 days), respectively. It was observed that hospital LOS of patients who received NSICU care decreased with increase in age. Mean length of NSICU stay among male and female patients was almost similar but median LOS was higher among females. Mean and median hospital as well as NSICU LOS was more in patients who survived compared to those who died [Table 4]. Bed occupancy rate of NSICU was calculated to be 72.5%.

Table 4

Morbidity parameters among patients admitted in the neonatal surgery intensive care unit

Variable	n	Age		Hospital LOS		NSICU LOS		Ventilator days
		Mean	Median	Mean	Median	Mean	Median	Mean	Median
	83	6.3	2.0	16.4	11	13.8	10	3.6	2
Age group
0-<1 day	11			19.1	14	10.3	7	4.0	1
1-<7 days	56			16.8	11	14.9	11	4.3	2
7-28 days	15			13.5	7	12.6	7	0.7	0
>28 days	1			7.0	7	7.0	7	0.0	0
Gender
Male	58	7.9	2.0	17.6	11	14.1	8.5	3.7	1
Female	25	2.6	2.0	13.6	11	13.0	11	3.3	2
Region wise
Delhi	21	3.3	2.0	23.2	14	15.3	10	4.0	2
Uttar Pradesh	20	7.8	3.5	12.7	9.5	12.2	8.5	4.0	0
Haryana	29	3.3	1.0	13.9	11	13.5	11	3.2	2
Bihar	3	9.3	3.0	25.7	31	25.7	31	2.0	0
Status at discharge from ICU
Discharged	58	5.2	3.0	18.0	11	15.0	10.5	2.8	1
Expired	13	2.1	1.0	13.1	8	13.1	8	7.3	6
Shifted to ward	7	27.7	3.0	14.1	10	10.3	11	4.7	0
LAMA	4	4.0	4.0	6.0	4	6.0	4	0.0	0
Shifted to NICU	1	0.0	0.0	26.0	26	7.0	7	3.0	3

NSICU: Neonatal Surgery Intensive Care Unit, LOS: Length of stay, LAMA: Left against medical advice, NICU: Neonatal Intensive Care Unit

Out of 83 patients, 13 patients (15.7%) died before getting discharged/transferred out from NSICU. NSICU survival rate was 85.5% and net death rate was observed to be 14.5%. None of the patients died out of the NSICU before getting discharged from the hospital. All the deaths have been observed in early neonatal period (age group of 1 to <7 days). Majority of death took place among males (61.5%) and more than half of the deaths, i.e., 53.8% (7) were observed on the day of admission itself [Figure 2]. Among the deaths observed, esophageal atresia with tracheoesophageal fistula (5 patients, i.e., 38%) was the most common diagnosis, followed by exomphalos major (2 patients), Anorectal malformations (ARM) (1), pure duodenal atresia (1), posterior urethral valve (1), and gastroschisis (1), etc. Sepsis with septic shock was the reason for mortality in 43% cases.

Figure 2

Death among various age groups of patients admitted in the neonatal surgery in intensive care unit

DISCUSSION

The management of neonatal surgical problems continues to pose considerable challenges, particularly in low-resource settings.[9] The mean and median ages of the patients admitted in the current study were 6.31 days and 2 days (range 0–153 days), respectively; however, mean age of the patients admitted in the neonatal surgical center of a developed country was 19 days (median 9 days with range of 0–141 days).[10] The difference may be because of the dissimilar morbidity pattern.

Majority of the patients in NSICU were transferred in from the emergency department (69.9%) and only few were admitted from the outpatient department (13.3%) and in neonatal ICU were 12%. Contrastingly, in a study conducted in a developed country, the majority of admissions occurred from a neonatal unit, either external or internal (medical to surgical referral within the same combined unit) and 10% of admissions were directly from the labor ward. This represents the increasing infants born following prenatal diagnosis of an abnormality surgery.[10] The difference in most common route of admission reported primarily reflects on the organization and availability of such specialized services in the overall delivery of health-care services in developed countries.

Patients admitted at NSICU presented most commonly with esophageal atresia with tracheoesophageal fistula followed by lumbosacral meningomyelocele, etc. Similarly, a study done in Africa showed that neonates most commonly presented with anorectal malformations, esophageal atresia/tracheoesophageal fistula, congenital diaphragmatic hernia, Hirschsprung disease, jejunal/ileal atresia, and incarcerated inguinal hernia/inguinal hernia.[9] However, the most common diagnosis with which the patient is admitted in the UK is necrotizing enterocolitis (NEC)/isolated perforation, conditions usually occurring in preterm babies. This highlights the importance of neonatal surgery in the management of conditions complicating prematurity and low birth weight. These patients require the involvement of a neonatal medical team as well as neonatal surgical care.[10] It is pertinent to mention that there is a separate medical neonatal ICU within the institute under study, and all the NEC patients are being managed there. Furthermore, the difference is probably because of the antenatal diagnosis and termination of a fetus with detectable anomalies in developed countries.

In this study, NSICU survival rate was 85.5% and net death rate was observed to be 14.5%. Majority of the deaths on the day of admission could be due to severity of the diagnosis and >50% patients having double/multiple anomalies. All deaths were observed in the early neonatal period, and most of the patients were referred cases from other hospitals. Various studies were carried out among surgical neonates in India; the survival rate has been reported to 60%–70%;[111213] however, in this study, it is found to be nearing 85% which is quite good and reflects on the quality of care being rendered in the health-care facility. Similarly, in the Middle East, South East Asian and African countries or so to say developing countries, the mortality in surgical neonates is observed to be 20%–60%.[9141516] However, neonatal surgical mortality in high-income countries is <5%. In developing countries, the practice of neonatal surgery still faces multiple challenges and problems leading to high morbidity and mortality.

Sepsis with septic shock was the major reason for mortality in NSICU. Nearly all of the patients reporting to the institute under study are not only outborn but also presents late with a stay in other hospitals and are already infected at the time of admission. In addition, the nursing staff and hospital ratio of 1:1 is not being maintained in NSICU under study, which could lead to compromised infection control practices. Nosocomial sepsis is a serious and common problem for neonates who are admitted for the intensive care because it is associated with an increase in mortality, morbidity, and prolonged length of hospital stay. It is, therefore, critically important to look for simple changes in processes of care (reducing barriers to handwashing, developing careful protocols for limiting the duration and contamination of central lines, improving the design of the NICU, and early feedings), which when implemented, can help reduce the risk of nosocomial sepsis and improve outcomes.[17]

NSICU under study had to get over a lot of challenges, both technical and nontechnical when it was being set up. The following are the salient features of our approach which helped it to overcome stumbling blocks successfully. The ICU was placed under the care of the pediatric surgeons directly and not under the pediatricians, neonatologists, or anesthesiologists. Since the patients being nursed in this ICU are the surgical patients, their respective consultants understand the disease process and are in a better position to decide what is best for the patients. In this context, it is imperative to understand that sometimes the management has to be tailored to the disease process. For example, a baby of esophageal atresia who has undergone a primary repair may be fit for weaning from ventilator, but the surgeon may wish to ventilate electively in view of anastomosis being under tension.

The duty doctors belong to the specialty of pediatric surgery, which improves the prognosis of such patients. It would not be an exaggeration to claim that a surgical complication is likely to be picked up earlier if the doctor on duty belongs to the same specialty. The training of nurses working in such ICU has to be specific to the diseases being managed. There is a well-developed system of regular and cyclical training of all nurses posted in the NSICU. An understanding has been made with the hospital administration to avoid shunting or transfer of nurses posted in the NSICU to other patient care areas in the hospital unless there is a very strong reason. This decision is based on the understanding that ICU care is not learned in a day; it needs years of experience, commitment, and dedication. Such a system is also instrumental in effective training of the pediatric surgeons who are exposed to ICU management of the patients after surgery. NSICU is in the process of developing a strong antibiotic policy which is beneficial for the society but does not in any way hamper the required management of the surgical neonates. Quality improvement initiatives are being run to tide over operational issues.

It is pertinent to mention that the NSICU under study is the oldest ICU setting for neonates undergoing surgical intervention and is >40 years. The quantum of services has increased many folds with allotted footprint remaining the same. These parameters do have a bearing on the infection control practices and can affect the delivery of health-care services. In addition, the institute under study is one of the leading apex institutes in the public sector in a developing country; it is overwhelmed by the sheer volume of critical cases being received. Further, the deficiencies in the overall health-care delivery system of India, namely, inequitable distribution and lack of health-care infrastructure, paucity of basic preventive health-care services, diagnostic limitations, the absence of an emergency transport system leading to extended transport times, delayed resuscitation, etc., act as a hindrance in delivering quality health care.

CONCLUSION

Outcome of care observed in this health-care facility is much better than what has been observed in other studies in similar health-care settings; however, it is much more than what has been observed in high-income/developed countries. Majority of the deaths were because of the sepsis, which in turn is because of the exposure of neonate to multiple health-care facilities with weak/lacking infection control practices. There is a scope of improvement in the delivery of health-care services in NSICU, as it has the best of resources when it comes to machinery and equipment as well as qualified and trained workforce, so to say comparable to high-income/developed countries, however, not comparable in terms of number of nursing staff per bed. There is a need to focus on the organizing part of the NSICU and streamlining the process of delivery of health-care services in the NSICU.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.