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This prospective cohort study evaluated the associations of day and time of admission to the Intensive Care Unit (ICU) with hospital mortality at a referral hospital in Malawi, a low-income country in sub-Saharan Africa. Patients admitted to the ICU during the day (08:00-16:00) were compared to those admitted at night (16:01-07:59); patients admitted on weekdays (Monday-Friday) were compared to admissions on weekends/holidays. The primary outcome was hospital mortality. Most patients were admitted during daytime (56%) and on weekdays (72%). There was no difference in mortality between night and day admissions (58% vs. 56%, P = 0.8828; hazard ratio [HR] = 1.09, 95% confidence interval [CI = 0.82-1.44, P = 0.5614) or weekend/holiday versus weekday admissions (56% vs. 57%, P = 0.9011; HR = 0.87, 95% CI = 0.62-1.21, P = 0.4133). No interaction between time and day was found. These results may be affected by high overall hospital mortality. [ABSTRACT FROM AUTHOR]

Background: Critical illness disproportionately affects people in low-income countries (LICs). Efforts to improve critical care in LICs must account for differences in demographics and infrastructure compared to high-income settings. Part of this effort includes the development and validation of intensive care unit (ICU) risk stratification models feasible for use in LICs. The purpose of this study was to validate and compare the performance of ICU mortality models developed for use in sub-Saharan Africa. Materials and Methods: This was a prospective, observational cohort study of ICU patients in a referral hospital in Malawi. Models were selected for comparison based on a Medline search for studies which developed ICU mortality models based on cohorts in sub-Saharan Africa. Model discrimination was evaluated using the area under the curve with 95% confidence intervals (CI). Results: During the study, 499 patients were admitted to the study ICU, and after exclusions, there were 319 patients. The cohort was 62% female, with the mean age 31 years (IQR: 23-41), and 74% had surgery preceding ICU admission. Discrimination for hospital mortality ranged from 0.54 (95% CI 0.48, 0.60) for the Universal Vital Assessment (UVA) to 0.72 (95% CI 0.66, 0.78) for the Malawi Intensive care Mortality Evaluation (MIME). After tenfold cross-validation, these results were unchanged. Conclusions: The MIME outperformed other models in this prospective study. Most ICU models developed for LICs had poor to modest discrimination for hospital mortality. Future research may contribute to a better risk stratification model for LICs by refining and enhancing the MIME. [ABSTRACT FROM AUTHOR]

Introduction: Intensive care medicine can contribute to population health in low-income countries by reducing premature mortality related to surgery, trauma, obstetrical and other medical emergencies. Quality improvement is guided by risk stratification models, which are developed primarily within high-income settings. Models validated for use in low-income countries are needed.Methods: This prospective cohort study consisted of 261 patients admitted to the intensive care unit (ICU) of Kamuzu Central Hospital in Malawi, from September 2016 to March 2018. The primary outcome was in-hospital mortality. We performed univariable analyses on putative predictors and included those with a significance of 0.15 in the Malawi Intensive care Mortality risk Evaluation model (MIME). Model discrimination was evaluated using the area under the curve.Results: Males made up 37.9% of the study sample and the mean age was 34.4 years. A majority (73.9%) were admitted to the ICU after a recent surgical procedure, and 59% came directly from the operating theater. In-hospital mortality was 60.5%. The MIME based on age, sex, admitting service, systolic pressure, altered mental status, and fever during the ICU course had a fairly good discrimination, with an AUC of 0.70 (95% CI 0.63-0.76).Conclusions: The MIME has modest ability to predict in-hospital mortality in a Malawian ICU. Multicenter research is needed to validate the MIME and assess its clinical utility. [ABSTRACT FROM AUTHOR]

Background: Anemia is associated with intensive care unit (ICU) outcomes, but data describing this association in sub-Saharan Africa are scarce. Patients in this region are at risk for anemia due to endemic conditions like malaria and because transfusion services are limited.Methods: This was a prospective cohort study of ICU patients at Kamuzu Central Hospital (KCH) in Malawi. Exclusion criteria included age <5 years, pregnancy, ICU readmission, or admission for head injury. Cumulative incidence functions and Fine-Gray competing risk models were used to evaluate hemoglobin (Hgb) at ICU admission and hospital mortality.Results: Of 499 patients admitted to ICU, 359 were included. The median age was 28 years (interquartile ranges (IQRs) 20-40) and 37.5% were men. Median Hgb at ICU admission was 9.9 g/dL (IQR 7.5-11.4 g/dL; range 1.8-18.1 g/dL). There were 61 (19%) patients with Hgb < 7.0 g/dL, 59 (19%) with Hgb 7.0-8.9 g/dL, and 195 (62%) with Hgb ≥ 9.0 g/dL. Hospital mortality was 51%, 59%, and 54%, respectively. In adjusted analyses, anemia was associated with hospital mortality but was not statistically significant.Conclusions: This study provides preliminary evidence that anemia at ICU admission may be an independent predictor of hospital mortality in Malawi. Larger studies are needed to confirm this association. [ABSTRACT FROM AUTHOR]

Background: Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality., Methods: This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality., Results: There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001)., Conclusions: Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.