|Year : 2013 | Volume
| Issue : 3 | Page : 240-244
Pattern and outcome of patients discharged from chest ward of a university hospital
Ruchi Sachdeva1, Sandeep Sachdeva2, Krishan B Gupta1
1 Department of TB and Respiratory Diseases, PGIMS, Rohtak, India
2 Department of Community Medicine, PGIMS, Rohtak, India
|Date of Web Publication||5-Jul-2013|
Department of Community Medicine, PGIMS, Rohtak - 124 001
Source of Support: None, Conflict of Interest: None
Aim: To describe morbidity and mortality profile of patients discharged from chest ward of a university hospital. Materials and Methods: Prospectively selected information (age, gender, residence, length of stay, outcome and primary diagnosis) of all consecutive in-patients was recorded for six month reference period. Results: Out of 967 patients, mean age was 50.64 years (±15.71); M:F = 3.5:1; 81.3% were from rural area. Primary diagnosis was tuberculosis/sequel among 528 (54.60%) and non-TB among 439 (45.4%) patients (chronic obstructive pulmonary diseases [COPD] - 20.3%; pneumonia - 15.8%; lung cancer - 5.0%; asthma - 1.6%; bronchiectasis - 0.9%, lung abscess - 0.8%, miscellaneous - 1.0%). Total deaths observed was 142 (14.7%) of all discharges and 54.25% of deaths occurred within 48 hours of admission suggesting criticality/late presentation; time distribution of death was similar considering 8-hourly period of 24-h cycle. Average length of stay for all patients was 6.91 (±5.14) days while it was 7.38 (±4.98) days for discharge live and 4.19 (±5.21) days for expired patients. Conclusion: Study provides a snapshot of patients discharged from chest ward that may aid in decision making, improving quality of care and initiation of educational activities at primary level.
Keywords: Chronic obstructive pulmonary disease, cancer, gender, hospital, lung, mortality, morbidity, respiratory diseases, rural, tuberculosis
|How to cite this article:|
Sachdeva R, Sachdeva S, Gupta KB. Pattern and outcome of patients discharged from chest ward of a university hospital. Med J DY Patil Univ 2013;6:240-4
|How to cite this URL:|
Sachdeva R, Sachdeva S, Gupta KB. Pattern and outcome of patients discharged from chest ward of a university hospital. Med J DY Patil Univ [serial online] 2013 [cited 2019 Mar 25];6:240-4. Available from: http://www.mjdrdypu.org/text.asp?2013/6/3/240/114642
| Introduction|| |
Non-communicable diseases (NCDs) are the leading global causes of death, causing more deaths than all others causes combined and worst affected are low and middle-income countries due to exposure to multiple risk factors. A total of 57 million deaths occurred in the world during 2008 of which 36 million (63%) were due to NCDs, principally cardiovascular diseases, diabetes, cancer and chronic respiratory diseases.  Chronic respiratory diseases not only restrict quality of life but also impose enormous medical, social and economic burden on society. Chronic respiratory diseases account for four million deaths annually while measured in disability adjusted life years (DALYs), it accounted for 4% of global burden and 8.3% of burden of chronic diseases.  Lower respiratory tract infections, chronic obstructive pulmonary disease (COPD), tuberculosis and lung cancer are each among the leading 10 causes of death worldwide. 
In Asian continent, it is often linked to poverty, illiteracy, epidemic of tobacco consumption, exposure to allergens, solid biomass fuel, working/living in congested and poor sanitary conditions, social, geographical issues and economic barriers in seeking appropriate health care. India is currently experiencing double load of disease burden i.e., it has still not been able to overcome communicable diseases substantially yet non-communicable diseases have arrived with both short-and long-term consequences.
Health statistics is an important resource for teaching, training, research, policy making, advocacy, and planning in any country but unfortunately there is limited availability of such data in developing nations. Further, good practice requires that medical professionals are able to introspect and critically reflect upon processes and outcomes of their interventions and review morbidity and mortality within institution for future development. With this background, a prospective descriptive study was undertaken to assess pattern and outcome of patients discharged from Chest/Tuberculosis and Respiratory Diseases ward of a teaching hospital from northern India.
| Materials and Methods|| |
The study was conducted in the publically funded premier tertiary care institution that provides specialist's services to patients belonging to lower/middle socio-economic strata of society primarily with rural but also urban background. It is a teaching and training center for MBBS, BDS, pharmacy, nursing, physiotherapy in addition to post-graduate courses and a government of India recognized institution for reporting in accordance with International Statistical Classification of Diseases (ICD-10 th revision) of WHO. It caters to an avg. daily out-patient (OPD) attendance of 5000 patients and more than 80,000 annual admissions supported by 1750 in-patient beds including 10-bedded intensive care unit (ICU), fully functional casualty, bronchoscopy, CT and MRI facilities etc., Hospital works full strength during 8 am to 4 pm routinely all 6-days a week while rest of the time immediate patient care is managed by residents and consultant are on call-duty. Chest/Tuberculosis and Respiratory Diseases department works in collaboration but independent of department of Internal Medicine and has 49 sanctioned chest beds. It undertakes OPD/emergency in-patient (14 years and above) admission throughout seven-days of the week across the year using protocol-based consultative approach, evaluation and management of patients presenting with respiratory problems.
Data Collection and Study Variable
Considering feasibility and resources constraints it was envisaged to collect selected information prospectively for all consecutive in-patients for six months i.e., from 1 st January to 30 th June, 2011 admitted to chest ward. The patients admitted on the last day of reference period were followed up to their discharge status. The study variables included primary diagnosis, month, date and time of admission, age, sex, residence, discharge outcome, date and time of discharge including death. Some of the patients presented with multiple health problems, however only the primary diagnosis responsible for current hospital admission were considered in the present study. There was no repeat admission noticed during reference period.
Data collection was carried using structured proforma and analysis carried out using SPSS software (ver. 16) by calculating descriptive statistics and Chi-square test which was considered significant at P < 0.05.
| Results|| |
A total of 967 consecutive in-patients were recorded during 6-months reference period and primary diagnosis is shown in [Table 1] with tuberculosis/sequel among 528 (54.60%) and non-TB among 439 (45.4%) patients [COPD - 196 (20.3%); pneumonia - 153 (15.8%); lung cancer - 48 (5.0%); asthma - 14 (1.6%); bronchiectasis - 9 (0.9%), lung abscess - 8 (0.8%), miscellaneous - 10 (1.0%)].
|Table 1: Primary diagnosis of chest patients recorded for 6-month reference period|
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Overall mean age of patients was 50.64 (±15.71) years; TB patients (45.94 ± 16.1) were comparatively younger than non-TB patients (56.30 ± 13.11). M:F ratio was 3.5; 81.3% patients were from rural native place and nearly 69.1% were from districts outside the location of study hospital. Time of admission was 9.0% (12 am to 8 am), 59.3% (8 am to 4 pm) and 31.7% during 4 pm to 12 midnight [Table 2].
|Table 2: Characteristics of chest patients according to selected variables|
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Total deaths recorded was 142 (14.7%) of all discharges during the reference period; causes of mortality being tuberculosis in 81 (57.04%) patients and 61 (42.95%) for non-TB causes [COPD (21.83%) and pneumonia (9.15%) etc]; case-fatality was observed to be 15.34% (81/528) for TB patients and 13.89% (61/439) amongst non-TB patients (P > 0.05). Further, it was noticed that 54.25% of deaths occurred within 48 hours of admission while time distribution of death was similar considering 8-hourly period of 24-hour cycle: 33.8% during 12 am to 8 am, 33.8% (8 am to 4 pm) and 32.2% (4 pm to 12 midnight).
A statistically significant association (P < 0.05) was noted for mortality with month and time of hospital admission only. Jan month recorded highest proportion (25.35%) of deaths followed by June (19.71%) and March (16.9%) respectively; maximum deaths was observed for those admissions which occurred during 4 pm-12 midnight (52.81%) followed by 8 am-4 pm (35.21%). No statistically significant association of age, sex, residence or diagnosis was noticed among expired patients. Average length of stay (ALOS) for all patients was 6.91 (±5.14) days; similar for TB and non-TB patients; while it was 7.38 (±4.98) days for live and 4.19 (±5.21) days for expired patients.
| Discussion|| |
A study was undertaken to describe profile of patients discharged from Chest/Tuberculosis and Respiratory Diseases ward of a teaching hospital from north India, first of its kind study in this region of the country. Epidemiologically, episode of hospitalization is considered as a tip of ice-berg phenomenon in the natural history of disease that arises due to emergency/severity of disease/delay in seeking appropriate health care at the right time; diagnostic dilemmas or social reasons. But hospitalization in such critical situation results in reduction of morbidity, mortality and thereby improves quality of life. One of the limitations of the present study is that hospital admissions encompasses various decision factors including volume-load, patient condition(s), health seeking behavior, resources, number, skills and competence of health personnel, non-availability of information on co-morbidity (especially HIV etc.) and therefore results cannot be generalized. However keeping patient at the center of all decision matrixes study reflects a snapshot of clinical scenario with major load of chest ward quite understandably still being borne by communicable disease [tuberculosis/sequel (54.60%)] followed by COPD (20.3%), pneumonia (15.8%), lung cancer (5.0%), asthma (1.6%) etc.
Tuberculosis (TB) has brought untold miseries to generation and even today when new modalities for diagnosis and treatment of TB on domiciliary basis (DOTS) have made the disease curable, people continue to suffer and die from the disease more so in developing countries especially India. Country detected maximum number (1.98 million) of incident TB cases in the world accounting for one-fifth of global TB burden; out of total mortality load of communicable diseases, 17.6% of deaths occurred due to TB.  There is scope of observing the trend/pattern over-time with simultaneous urgent need for evaluation and critical appraisal of implementation of Revised National Tuberculosis Control Program (RNTCP) in catchment districts as system fatigue, complacency and declining motivation among human resource involved with TB control is being observed extensively.
It is noted that according to Global Adult Tobacco Survey, more than one-third (35%) of adults in India use tobacco in some form or the other.  Based on these, there are 274.9 million tobacco users with 163.7 million users of only smokeless tobacco, 68.9 million only smokers and 42.3 million users of both smoking and smokeless tobacco in the country with mean age at initiation being 17.8 years. The survey also reported that 52% [rural (58%) to urban (39%)] of adults were exposed to second-hand-smoke (SHS) at home. According to Census 2011, two-third of households in country are using firewood/crop residue, cow dung cake/coal etc., in their kitchen. The tobacco epidemic worldwide and particularly in developing country along with extensive use of bio-fuel is now presenting itself with its adverse consequences in community and at health facilities. Tobacco is a risk factor for 6 out of the 8 leading causes of death and nearly 800,000-900,000 people die every year in India due to diseases related to tobacco use.  This observation is further substantiated, as COPD accounted for second most common reason for respiratory morbidity and mortality in the present study. The politics of legislation related to tobacco control enactment has been won but still other challenges remain. As tobacco consumption is related to access, lifestyle and human behavior, the need of the hour is to ensure effective implementation of tobacco control legislation at ground level.
A study carried out among 912 patients in chest ward of Congo hospital also observed high load of tuberculosis patients (52.08%) followed by other infection (13.48%), asthma (5.15%) and tumors (1.53%) etc., with overall mortality of 13.48%.  In contrast, a study conducted in a medical-ward of university hospital in Saudi Arabia to assess pattern of respiratory diseases showed maximum case of bronchial asthma (38.6%), followed by COPD (17.2%), pneumonia (11.5%), lung cancer (8.4%) and TB (7.2%),  while another OPD-based study at respiratory tertiary institute at Kolkata (India) showed asthma (26.54%) had highest prevalence followed by COPD (12.18%), TB (7.26%) and other infective problems (7.16%) etc. 
As for socio-demographic characteristics, male outnumbered female by 3.5 times in present study in accordance with global literature, M:F ratio ranging between 1.7 and 3.5.  Mean age of patients in present study was 50.64 (±15.71) years which is similar to study carried out to assess hospitalization due to respiratory conditions in Africa (49 ± 13.5 years; 47.8 ± 19.6), with major burden due to tuberculosis (60.0%), reflecting similar socio-economic and disease structure. , Over the years, there is increased global tendency of declining length of stay for hospitalized patients thereby improving patient's quality-of-life, early return to routine lifestyle and eventually benefiting family and health system. The present study recorded 6.91 (±5.14) days while the avg. length of stay for 'all' in-patients reported by this hospital was 5.61 days during 2011.
Globally, a seasonality pattern has been noticed in presentation of respiratory diseases. An OPD-based study (2002-2008) reported similar trend of seasonal variation among chest symptomatic and TB patients at a referral center in neighboring state (Delhi) with highest presentation and detection of cases during months of Apr-June.  Our study also reflected similar picture with higher proportion of TB-related admission during Apr-June (56.4%) in comparison to Jan-Mar (43.6%) (not shown in table). A study on incidence of TB in New York City (1990-2007) noted a cyclical pattern of detection every 12 months and of the 34,004 TB cases included, 21.9% were in the fall (September-November), 24.7% in winter (December-February), 27.3% in spring (March-May) and 26.1% in the summer (June-August). The proportion of cases was lowest in fall (P < 0.0001) and highest in the spring (P < 0.0002).  Further, higher proportion of mortality was observed in present study during extreme weather conditions of winter (Jan) followed by summer (June) but it would be premature to comment on this dimension with this limited period of study data and size. Studies undertaken in referral hospitals of Brazil, Botswana and Saudi Arabia showed proportion of tuberculosis mortality as 16.2%, 15.7% and 18.0%, respectively, similar to as observed in present (15.34%) study. ,,
India is second most populous country in the globe next only to China therefore large people in absolute numbers get reflected either with positive health or present as patients in health facilities. For frail patients, hospital becomes site for therapeutic care and/or a place to die. With such a large volume and turn-over of patients, quality-of-care appears to be low on scrutinizing high proportion of mortality. But as more than half (54.25%) of deaths occurred within 48 hours of admission, it is suggestive of patient-related factors i.e., criticality of disease condition or late presentation.
Majority of Indian population resides in rural (69.0%) areas with difficult access to competent health personnel thus resulting in under-reporting of death without any proper diagnosis. This study throws light on this dimension and may aid in decision making, planning health services, mobilization of resources, initiation and promotion of educational activities at primary level. On the corollary for strengthening quality of health care and reduction in mortality there is need for expansion of critical care (ICU) beds, induction of human resource, inter-alia strengthening health provider and patient communication with additional scope for improving system efficiency.
| Acknowledgment|| |
Vice-chancellor, Director and Department of TB and Respiratory Diseases, PGIMS, Rohtak-124001, India.
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[Table 1], [Table 2]