Pattern of admission and outcome of patients admitted to dedicated trauma intensive care unit (ticu), emergency department, teaching hospital, north-eastern malaysia

Original article Pattern of admission and outcome of patients admitted to dedicated trauma intensive care unit (ticu), emergency department, teaching hospital, north-eastern malaysia Wong Choc Ky1, Mohd Hashairi Fauzi2, Nik Hisamuddin Nik Ab Rahman3, Abu Yazid Md Noh4, Tuan Hairulnizam Tuan Kamauzaman5, Kamarul Aryffin Baharuddin6, Nik Abdullah Nik Mohamad7, Shamsul Kamalrujan Hassan8, Wan Nazaruddin Wan Hassan9, Saedah Ali10. Abstract


Introduction
Trauma is a major health problem and a leading cause of mortality and morbidity among adults in the world 1,2 . In Malaysia, the number of road traffic accidents (RTA) was 521, 466 in 2016, a steady increase from 489, 606 in 2015 3 . This rising trend becomes a huge burden to our healthcare system especially Emergency Medical Service across the country. Hence the establishment of dedicated TICUplays a pivotal role to improve the quality of care and outcome in trauma management.
Trauma management in ED required high level of care especially for the multi-system injuries patient. The succesful of trauma management is depend on interdisciplinary involvement, adequate structure and staffing level 4 . However with the 'busy' ED its very difficult to perform at your best. According to the Malaysian National Audit Depatment 2018, ED in Malaysia were understaffed, overcrowded, underfunded and do not have enough equipment to provide proper levels of care 5 . In addition,the report also stated the patient have to stay longer in ED because of the 'access block' including critical ill patient. Moreover, many studies have shown that increasing boarding time is associated with worst outcomes for patient requiring ICU-level of care 6,7 .
In 2015, the Hospital USM Management created dedicated TICU, an ICU under ED flagship and comanagedwith Anaesthesiologyand Intensive Care Department .The aim is to improve critical care delivery in ED and fasten the admission to ICU care. To our knowledge, this is the first model in Malaysia. Thus, the objective of this study is to explore the demographic patterns, severity of injury and clinical assesment trauma patients admitted to TICUand secondly to explore the association between outcome variables.

Materials and methods
This retrospective observational study was conducted between Jun 2016 till May 2018 in Trauma Intensive Care Unit (ICU), Emergency Department, Hospital Universiti Sains Malaysia (HUSM). All trauma patients admitted to TICU through Emergency Department, Hospital USM as inclusion criteria. The new TICU was established in 2015 with 5 bedded capacity. It was managed by by highly qualified and experienced physicians (senior consultants and specialists) both from Anesthesiology & ICU and Emergency Department along with well-trained critical care nurses and allied health professionals.

Data Collection
Data was collected from the patient's folders who were admitted to Trauma ICU from June 2016 till May 2018 using the data collection form. The proforma was aimed at: i. Patient particulars: gender, age, race ii. Injury: mechanism of injury, causes iii. Clinical details: pulse rate, respiratory rate, blood pressure, GCS score, RTS score, APACHE score iv. Hospital outcome: blood transfusion, length of ICU stay, intubation, mechanical ventilation, mortality, trauma related complications

Statistical Analysis
Statistical analysis was performed using IBM SPSS for Windows, version 23.0 (SPSS Inc. Chicago, IL, USA). Demographic data was reported as the mean and standard deviation (SD) as appropriate. A p value of < 0.05 was considered statistically significant. The predictors or demographic factors that affect the outcome of the patient were expressed in simple and multiple logistic regression. Adjusted odds ratio (adj OR) and 95% confidence intervals (CI) were reported, and p < 0.05 was considered statistically significant.

Ethical Consideration
This study received ethical board approval from the Human Research Ethics Committee of Universiti Sains Malaysia (USM/JEPeM/17120722). The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a prior approval by the human research committees. No written consent is needed in this study.

Demographic Patterns
A total of 108 patients were recruited in this study, with a mean age of 29.49 (SD= 17.71) years old. The mechanism of injury was mainly attributed to blunt trauma (99.1%) and majority due to road traffic accident (RTA) (92.6%), with the motorcyclist occupied two thirds (62%)of the cases. Glasgow Coma Scale (GCS) of < 8 occupied more than half of the patients (57.8%), moderate GCS of 9-12 was 24.1%, and mild GCS of 13-14 was 23.1%. The Revised Trauma Score (RTS) of > 5.0 occupied 88.9% of patients andscore 2.5-4.9 occupied 11.1%. The Acute Physiology and Chronic Health Evaluation (APACHE) II score of < 25 occupied 92.6% of the patients and score 26-50 occupied 7.4%. (Table 1)

Outcome/ Complications
Seventy-six percent of patients were intubated and 7.4% of them died during TICU stay as shown in Table 1. More than two thirds (70.4%) of patients were admitted to TICU for < 7 days. Mean hospital stay (ICU and ward) was 17.43 (SD= 15.37) days. Most of them received packed cell transfusion (50.9%), followed by fresh frozen plasma (24.1%) and platelet transfusion (20.4%). About two thirds of them developed rhabdomyolysis (61.1%), one third developed sepsis (26.9%) and one fifth developed acute kidney injury (AKI) (16.7%) Table 2 showed GCS score < 4, RTS score < 5.5and APACHE II score >28 were associated with prolonged ICU stay (> 7 days) and increased mortality.   Table 3 showed only length of ICU stay > 7 days (p= 0.021) was significant in predicting intubation and mechanical ventilation in multivariate analysis. In addition, predictors for trauma-related complications showed that prolonged ICU stay (> 7 days) resulted 8.5 times higher odds to get sepsis (p= 0.000) and 7 times higher odds to get AKI (p= 0.015) in trauma patients. Trauma patients who received blood transfusion had association with rhabdomyolysis almost 5 times higher compared to those who didn't receive blood (p= 0.002). (Table 4)

Discussion
Since pandemic COVID-19, daily healthcare system activity had beed affected 8 . Emergency Department had severely overcrowded with COVID-19 patient. However at the same time trauma patient need to be manage accordingly. Thus, by knowing the clinical characteristics & predictors of patient outcome will guidephysician to prioritise the trauma patient management 12 .
Sincehospital USM was the only neurosurgical referral center in North-Eastern Malaysia, more than 50% of road traffic injuries were motorcyclist and most of them suffered head injury. In our study those trauma patient with low RTS (<5.5),low GCS (<4) and high APACHE II (>28) scorewere able to predict mortality and length of ICU stay. Overall maortality rate in our study was 7.4% which is lower than study by Chalya et al 1 (32.7%) and Gunning et al 9 (10%). Varies of mortality rate could be due to severity of injuries and transportation time to tertiary centre 3 .
In addition, patients who stayed more than 7 days in TICU were 4 times more likely of getting intubated and ventilated, 8.5 times to get sepsis and 7 times to get acute kideny injury (AKI) in TICU. This finding was similar with Goins et al 10 study whereby mechanical ventilation was required in 78.5% of the time spent in ICU, and the mean time for those patients in ICU was 60 days. Krasnalhia et al 15 also conclude that almost half of trauma patients had AKI and more than half of them were due to sepsis when stay longer in ICU. In our study, most of our patients received packed cell transfusion (50.9%), followed by 24% given FFP and 20.9% given platelets. As evidenced in multivariate analysis, we found that trauma patients who received blood transfusion were 5 times more likely associated with rhabdomyolysis. However furher study need to confirm this finding because of knowledge gap in this issue.

Limitations
The presents study has several limitations due to small sample size and couldn't be generalize to other trauma centre. Furthermore we only used physiological trauma scoring system in our study rather than anatomical scoring in view of difficulty to get complete data as we were using manual entry patient record. Despite limitations we believed this study provide important finding in managing trauma patient and hope in future we are able to explore the impact of TICU towards patient outcome in Emergency department.

Conclusion
In the midst of pandemic COVID-19 it is important for ED physician to early identify and prioritise high risk trauma patient based on predictors and allows for targeted monitoring and intervention that may improve their outcome.This will lead to optimise resources and lessen healthcare burden in managing trauma patient in ED.

Declaration of conflicting interests
We declare that there were no conflict of interests to the study, authorship and/ or publication of this article.

Author contribution
Study idea and design: (