Research Audit in St.Mary’s Hospital Lacor Gulu Uganda 2017

Original Article Published in the journal Anaesthesia 2017

Intensive care medicine in rural sub-Saharan Africa

M. W. Deunser,1,2 R. M. Towey,3 J. Amito4 and M. Mer2,5
1 Senior Consultant in Intensive Care, Department of Anesthesiology, Peri-operative Medicine and General Intensive
Care Medicine, Salzburg University Hospital and Paracelsus Private Medical University, Salzburg, Austria
2 Global Intensive Care Working Group, European Society of Intensive Care Medicine, Brussels, Belgium
3 Consultant, 4 Anaesthetic Officer, Department of Anaesthetics and Intensive Care, St. Mary’s Hospital Lacor, Gulu,
5 Consultant in Intensive Care, Intensive Care Unit, Charlotte Maxeke Johannesburg Academic Hospital and
University of the Witwatersrand, Johannesburg, South Africa

We undertook an audit in a rural Ugandan hospital that describes the epidemiology and mortality of 5147 patients
admitted to the intensive care unit. The most frequent admission diagnoses were postoperative state (including
following trauma) (2014/5147; 39.1%), medical conditions (709; 13.8%) and traumatic brain injury (629; 12.2%).
Intensive care unit mortality was 27.8%, differing between age groups (p < 0.001). Intensive care unit mortality was
highest for neonatal tetanus (29/37; 78.4%) and lowest for foreign body aspiration (4/204; 2.0%). Intensive care unit
admission following surgery (333/1431; 23.3%), medical conditions (327/1431; 22.9%) and traumatic brain injury
(233/1431; 16.3%) caused the highest number of deaths. Of all deaths in the hospital, (1431/11,357; 12.6%) occurred
in the intensive care unit. Although the proportion of hospitalised patients admitted to the intensive care unit
increased over time, from 0.7% in 2005/6 to 2.8% in 2013/4 (p < 0.001), overall hospital mortality decreased (2005/
6, 4.8%; 2013/14, 4.0%; p < 0.001). The proportion of intensive care patients whose lungs were mechanically
ventilated was 18.7% (961/5147). This subgroup of patients did not change over time (2006, 16%; 2015, 18.4%;
p = 0.12), but their mortality decreased (2006, 59.5%; 2015, 44.3%; p < 0.001).

This study is the first to offer a comprehensive
insight into the epidemiology and outcome of critical
illness in a rural sub-Saharan African setting. As the
ICU is the only facility in the study hospital where
critically ill patients are cared for, and because the
study hospital is the only inpatient facility in the
region, our study population is likely to represent
the true spectrum of critical illness for a large rural
sub-Saharan African region. Furthermore, the virtual
absence of financial barriers preventing patients from
entering the ICU, which may be the case in other
ICUs in low-income countries [1, 2], eliminates an
important selection bias from this study.
In conclusion, our study gives a comprehensive
overview of the epidemiology and outcome of critical
illness in a large sub-Saharan African ICU population.
It represents the first and largest study from a rural
ICU in sub-Saharan Africa, and serves as an important
reference for a region where there is an paucity of
data, offering a greater understanding of the practice
of intensive care in such areas. Although only hypothesis-
generating, these results support the role of
intensive care medicine as a life-saving medical specialty,
even under difficult conditions and with limited
resources, as well as the need to foster and grow such
services in these regions.