Clinical Research: Pattern and Severity of Intensive Care Admission in Hong Kong

Pattern and Severity of

Intensive Care Admissions in Hong Kong
M.R. Ferguson and T.E. Oh

ABSTRACT
This study aimed to provide details of patients admitted to the Intensive Care Unit at the Prince of Wales Hospital, and assess
their severity of illness using the APACHE II score. The patients admitted appeared to have higher scores than in other reports.
The pattern of mortality followed the APACHE II scores except for some postoperative patients. Non-surgical cases had higher
APACHE II scores and a higher mortality. Many of these patients had suffered an acute cardio-respiratory arrest.

INTRODUCTION were admitted for cardiovascular failure (19%). This group is

Intensive Care Units cater for critically ill patients of all slightly larger than those with nonoperative respiratory
age groups suffering from varying diseases and multi-system failure (13%), but the difference is not statistically significant.
failure. Better knowledge of the types of patient admissions The biggest number of admissions from the operative group
would help towards improving the quality of care and to was for gastro-intestinal failure (21%). This is not significantly
rationalize the use of expensive resources. The aim of this more than the next highest operative group of admissions,
study is to classify admissions to the Intensive Care Unit and those for respiratory system failure (15%). The results of the
assess the severity of illness using an internationally accepted APACHE II scores are given in Table 2. The average
scoring system (APACHE II). APACHE II score of all admissions is 25.1 (+/- 10.6). The
nonoperative group had a statistically higher APACHE II
METHOD score (31.2 +/-10.5) than the operative group (21.3 +/- 8.6)
All consecutive patients admitted to the Intensive Care (P 0.01). In the operative group, the APACHE II score 20
Unit of the Prince of Wales Hospital from 21st February 1988 24 point subgroup had the most number of patients (26%),
to 30th April 1988 were sub-divided into 5 groups according whereas in the nonoperative group the 35 plus point subgroup
to which of the major organ system failure led to admission had the most patients (39.3%).
gastro-intestinal, renal/metabolic, neurological, cardiovas- ICU ADMISSIONS
cular or respiratory systems. Post-operative patients were Total 157
classified separately from those not undergoing surgery. All
patients had their APACHE II (Acute Physiology And
Chronic Health Evaluation) scores calculated. The APACHE
II score was calculated from the most abnormal results of 12
physiological variables within the first 24 hour period from
admission, plus age and chronic health problems. The
resultant APACHE II scores were then matched for the
mortality observed in the group of patients. Mann Whitney
test was used when comparisons were made of different
patient APACHE II subgroups. Category Chi Square test was
applied to compare numbers in system failure groups.

RESULTS I
CO
During the study period 157 patients were admitted to
the ICU. Details regarding sex and age distribution are given 1
in Table 1. The average age was 54.7 (+/- 20.4) years, with
the median being 58 years. The large standard deviation
reflects the wide age range of patients admitted during the
study (from 2 months to 87 years old). Females were slightly
younger (average 53 years) than males (average 55 years).
Admissions classified under the 5 primary system failure
headings are shown in Fig. 1. Most of the nonoperative group
GIT Ren/met Neuro CVS Resp
Organ System
Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong,
Prince of Wales Hospital, Shatin, NT, Hong Kong HI Nonoperative I I Postoperative
M.R. Ferguson, M.B.,B.S. (Edin.), F.F.A.R.C.S., Lecturer
T.E. Oh, F.F.A.R.C.S., F.F.A.R.A.C.S., Professor and Chairman, and Director of
Intensive Care
Fig. 1 Admissions classified according to the primary
Correspondence to: Prof. T.E. Oh system/organ failure

273
 Journal of the Hong Kong Medical Association Vol. 40, No. 4, 1988

ments, age and chronic health status (1). Higher scores

Male Female indicate greater severity of illness and are associated with an
increased mortality in hospital. The APACHE II score is an
Number (%) 99 (63%) 58 (37%)
index of risk on a population basis. While it is not expected to
Average Age 55 53 provide an accurate death prognosis in individuals, it may
contribute to decision making. This system has been
Length of stay 4.24 5.61 validated in hospitals in the U.S., U.K. and Australasia (2, 3).
The Prince of Wales Hospital is a 1,400 bed teaching
APACHE II 24 26 hospital of the Chinese University of Hong Kong with a 12 bed
ICU. The ICU caters for both medical and surgical patients
Mortality 33.3% 32.8% Paediatric patients (except neonates) and acute coronary can
patients requiring ventilatory support are also admitted. It is
Table 1 Details of admissions to ICU managed by the Department of Anaesthesia and Intensive
Care under the directorship of the Professor and Chairman of
APACHE II Score Nonoperative Postoperative Department. Patients are admitted after assessment by the
Subgroups Admissions (%) Admissions (%) senior ICU doctor following requests by the referring
clinicians.
0-4 0(0) 4 (4.2) The average age of ICU patients admitted in this study is
54.7 years, without a preponderance of patients over 65 years.
5-9 2 (3.3) 4 (4.2) Mortality relates more to severity of illness (Fig. 2) rather than
age per se (Table 3). Our policy of not denying intensive care
014 3 (4.9) 15 (15.6)
treatment to elderly patients because of age alone appears to
15-19 5 (8.2) 14 (14.6) be supported (4). The average APACHE II score in this study
is 25.1. This is higher than those reported for the USA (16.5)
20 24 4 (6.6) 25 (26.0) and France (16.1) (2). It suggests that, for our group of patients
at least, our ICU in Hong Kong admits considerably sicker
25-29 12 (19.7) 18 (18.8) patients. It may also indicate as well that Hong Kong doctors
are much more reluctant to deny treatment to anyone
30-34 11 (18.0) 11 (11.4) regardless of presentation or severity of disease. For example,
we often receive requests, even demands, to admit and
35+ 24 (39.3) 5 (5.2) aggressively treat patients with manifestly hopeless con-
Mean APACHE ditions, such as and especially, 80 plus year olds with multi-
31.2 (SD 8.6) 21.3 (SD 10.5) organ failure following cardiac arrest (vide infra). Some of
II score
these patients with extremely poor prognoses might not have
Table 2 APACHE II scores of ICU admissions
APACHE & MORTALITY
The mortality rate for each APACHE II score subgroup
is shown in Fig. 2 for both operative and nonoperative groups. (PWH)
Mortality increases with increasing APACHE II scores
except for 18 postoperative patients with an APACHE II
score between 25 and 29 points. The overall mortality for the
157 patients studied was 33.12%, with a similar mortality rate
for both sexes. This can be regarded as a predictable rate for
the high average APACHE II score in our patients.
Observations on the actual and predicted mortality is under
present investigation.

DISCUSSION
With the advances in medicine over the past two decades, S 60
medical treatment is now complex. Treatment is now
undertaken for critically ill patients and those in advanced i
stages of diseases. The development of Intensive Care
medicine has facilitated the management of these patients.
Unstable and critically ill patients are now managed in an ICU
where trained medical and nursing expertise are centralised.
In order to improve upon the quality of care and to rationalize
delivery of expensive services, knowledge of disease patterns
and outcome of intensive care treatment is important. Such
information, together with ethical and financial considera- 00 00 00
tions, help to concentrate expensive resources on those
patients with potentially recoverable diseases. This study 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35 +
provides information on the types of patients admitted to an Apache II Score
ICU in Hong Kong, together with the severity of their illness
and the outcome in the Unit. To our knowledge, such a study ^H Nonoperative I 1 Postoperative
pertinent to Hong Kong has not been previously reported.
APACHE II is a severity of disease classification using a Fig. 2 APACHE II points score subgroups and their
point score based upon values of 12 physiological measure- corresponding mortality rate.

274
 Clinical Research : Pattern and Severity of Intensive Care Admission in Hong Kong

been referred for admission in other centres. The APACHE

II score for the postoperative patients is also higher at 21.3, Age Group (years) Mortality (%)
confirming the high proportion of complicated major surgery
in our clinical workload. Many overseas ICUs routinely admit 0-5 50
all uncomplicated patients who do not require ventilation (i.e.
"high dependancy" patients) who score fewer APACHE II 6-15 25
points (5). This is not our practice, because of limited 16-40 26
resources, and is reflected in our higher APACHE II scores.
The nonoperative group in this study were critically ill, 41-65 33
with most patients scoring over 25 points. Indeed, most of
these patients fell in the 35 plus point subgroup. Acute cardio- 65 + 35
respiratory decompensation contribute most to this group
(Fig. 1) with most patients having suffered a cardio-respira- Table 3 Mortality in different age groups
tory arrest either in the wards or the Accident and Emergency
Department (66.7% of the 35+ points subgroup). The
mortality rate of such critically ill patients is extremely high
MORTALITY RATES
at 77% (Fig. 3). Overall 33.12%
The mortality rate parallels the points score, similar to
previous reports (6) and substantiates the usefulness of
APACHE II as a broad prognostic scoring system (7). It is 100 r
interesting to note that mortality in the post-operative 25 29
point subgroup is less than the other subgroups with less
points (Fig. 2). Patients who have undergone liver and gastro-
intestinal surgery comprise the majority in this subgroup 80
(83.3%) and the fortunate mortality result may reflect the
considerable experience and surgical expertise in this area in
Hong Kong. Liver and gastro-intestinal surgical patients
clearly make up the largest group of postoperative admissions H 60
when primary systems are considered (Fig. 1). Of the
nonoperative patients, most were admitted for primary
cardiovascular and respiratory diseases, but the spread is
more even (Fig. 1). 40
In conclusion, APACHE II was used to determine the
pattern of Intensive Care admissions in the Prince of Wales
Hospital. The patients studied have a greater severity of
illness compared with published reports of those admitted to 20
overseas ICUs. There is a higher number of liver/gastro-
intestinal surgical admissions, but these have a lower
mortality. The most critically ill nonoperative patients had the
highest APACHE II scores and the highest mortality. Most of O
these patients had suffered cardio-respiratory arrests. More GIT Ren/met Neuro CVS Resp
knowledge is required on these patients and other patients
with poor outcome so that clinicians will be better placed to Organ System
concentrate their expertise on those patients with a more HP Nonoperative [ I Postoperative
favourable prognosis, and to refrain from striving for survival
at all costs, when there is little to no chance of recovery. This Fig. 3 Mortality rates of the five primary system/organ failure
subject, as well as a clinical audit in Intensive Care is under groups
investigation and will be reported in a future communication.

ACKNOWLEDGEMENT
We would like to thank Dr. Tony Gin for his assistance
with the statistical analysis and Ms. Josephine Leung for
secretarial assistance.
REFERENCES
1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of
disease classification system. Crit Care Med 1985; 13:818-829.
2. Knaus WA, LeGall JR, Wanger DP, et al. A comparison of intensive care in the
USA and France. Lancet 1982; ii:642-646.
3. Morgan CJ, Branthwaite MA. Severity scoring in intensive care. Br Med J 1986;
292:1546.
4. Editorial. Intensive care audit. Lancet 1985; ii:1428-1429.
5. Jacobs S, Chang RWS, Lee B. One year's experience with the APACHE II severity
of disease classification in a general intensive care unit. Anaesthesia 1987;
42:738-744.
6. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome
from intensive care in major medical centres. Ann Intern Med 1986; 104:410-418.
7. Bion JF, Edlin SA, Ramsay G, McCabe S, Ledingham I McA. Validation of a
prognostic score in critically ill patients undergoing transport. Br Med J 1985;
291:432-434.

275