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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 221-225

Mortality pattern in surgical wards and autopsy rate at a university teaching hospital in South-West Nigeria


1 Department of Surgery, Ekiti State University, Ado-Ekiti, Nigeria
2 Department of Surgery, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
3 Department of Anatomic Pathology, Ekiti State University, Ado-Ekiti, Nigeria

Date of Submission02-Sep-2019
Date of Decision21-Feb-2020
Date of Acceptance11-Mar-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Dr. Moruf Babatunde Yusuf
Department of Surgery, Ekiti State University, Ado-Ekiti
Nigeria
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DOI: 10.4103/smj.smj_43_19

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  Abstract 


Background: Patients coming to the hospital hope on getting well or cured of their ailment, but this hope goes unrealized, sometimes leading to their death. Objectives: We looked at the pattern and causes of death at adult surgical wards and autopsy rates in our facility. Materials and Methods: Retrospective descriptive study of the mortalities in adult surgical wards at Ekiti State University Teaching Hospital, Ado-Ekiti, in South-Western Nigeria, over a period of 5 years, July 2011–June 2016. Results: Two thousand one hundred and thirty-eight patients were managed in the adult surgical wards, and there were 89 (4.16%) cases of death during the study with 51 case notes available for the analysis. Twenty-eight males and 23 females with a male: female of 1.2:1. Age ranges from 18 to 93 years, with a mean of 57.14 ± 20.42 years. The highest mortalities were recorded in general surgical unit (25, [49.0%]) with a mortality rate of 3% and highest in patients with neoplastic diseases (24, [47.1%]), followed by trauma (17, [33.3%]). Overwhelming sepsis (14, [27.5%]) and hypovolemic shock (10, [19.6%]) were the leading immediate causes of death. Only 4 had autopsy done with autopsy rate of 7.8%. Conclusion: Neoplasm and trauma are the leading underlying causes of death. Strategies geared toward early detection and treatment of neoplasms, as well as prevention and prompt care of trauma patients, are advocated. Autopsy rate is low in our center.

Keywords: Autopsy rate, mortality, surgical wards


How to cite this article:
Yusuf MB, Ogundipe KO, Olaogun JG, Kadiri IA, Popoola SO, Ajibola DB, Omonisi AE, Ogunlusi JD. Mortality pattern in surgical wards and autopsy rate at a university teaching hospital in South-West Nigeria. Sahel Med J 2020;23:221-5

How to cite this URL:
Yusuf MB, Ogundipe KO, Olaogun JG, Kadiri IA, Popoola SO, Ajibola DB, Omonisi AE, Ogunlusi JD. Mortality pattern in surgical wards and autopsy rate at a university teaching hospital in South-West Nigeria. Sahel Med J [serial online] 2020 [cited 2021 Mar 4];23:221-5. Available from: https://www.smjonline.org/text.asp?2020/23/4/221/310023




  Introduction Top


A patient coming to the hospital hopes on getting well or cured of his or her ailment, but this hope goes unrealized sometimes. Much more devastated are the close relatives of the patients who suffer the untimely and painful loss of loved ones. Although death is a necessary end of individuals, the doctors have a responsibility toward reducing the mortality of patients to the barest minimum.[1]

In-hospital death is conventionally defined as deaths occurring within 30 days after admission or surgery.[2] This definition does not take into consideration deaths that occur beyond 30 days of admission, and this constitutes an underestimation of in-hospital deaths.

Death could occur preoperatively, intraoperatively, and even postoperatively; the causes of which are myriad. A study by at the Olabisi Onabanjo Teaching Hospital Sagamu, Ogun State, Nigeria, puts the causes of death as follows: trauma (38.8%), cancers (29.4%), infections/inflammatory (9.4%), and other causes (22.4%).[3]

While the timing of surgical intervention is paramount, other factors such as the disease process itself, late presentation, presence of comorbidities, or lack of funds to provide the necessary care of the patients could contribute to mortality. Although modern technologies have increased our diagnostic abilities, autopsy is still regarded as the gold standard against which clinical impressions are validated.[4]

Death in hospital is often a reflection of the quality of care. Information about the pattern and causes of death is an important set of health information needed for deciding on possible intervention strategies.[1] There are many local and international reports on in-hospital surgical mortality;[5],[6],[7] however, there is none from our center. The aim of this study is to document the pattern and causes of deaths and autopsy rates in the surgical wards in our teaching hospital.


  Materials and Methods Top


This was a retrospective descriptive study of the mortalities in adult surgical wards, excluding high-density unit, at Ekiti State University Teaching Hospital, Ado-Ekiti, in South-Western Nigeria, over a period of 5 years, between July 2011 and June 2016. Patients for general surgery, neurosurgery, orthopedic surgery, plastic surgery, and urology care are admitted into the surgical wards.

Admission and discharge registers of the wards were used to extract information on the total number of admissions and their distribution during the study period. All the recorded mortalities in adult surgical wards were included in this study. The names and hospital numbers of the recorded mortalities were used to retrieve case notes of patients from the hospital medical record and information department. The following information were extracted from the case notes Sociodemographic information, diagnosis, interval between admission and surgical intervention, interval between surgery and death or interval between admission and death (if not operated upon) and clinical cause of death. Autopsy record was looked into at the Anatomic Pathology department and surgical patients that had autopsy done during the study period were extracted. Patients whose case notes were not available were excluded from further analysis. For the purpose of this study, in-hospital death is death that occurred during admission irrespective of the duration of the admission.

An approval for the study, with protocol number EKSUTH/A67/2019/02/009 and dated February 28, 2019 was obtained from the ethics and research committee of our institution.

Data analysis

Data were analyzed using the Statistical Package for the Social Sciences version 16 (SPSS Inc., Chicago, IL, USA), and results were presented in tables and charts.


  Results Top


During the study period, 2138 patients were managed in the adult surgical wards and 89 deaths were recorded in the registers with crude mortality rate of 4.2%. Only 51 (57.3%) of the case notes were available for review. Twenty-eight of the deaths were male (54.9%) and 23 were female (45.1%) with a male: female of 1.2:1. Age ranges were 18–93 years with mean, standard deviation (SD) of 57.14 (20.42) years. Interval between admission and death was 1–150 days with a mean (SD) of 18.22 (24.05) days. Thirty-three (64.7%) of the deaths occurred among patients 50 years and above. The general surgical unit had the highest mortality (25, 49.0%) with a mortality rate of 3%, while neurosurgical unit had the least mortality (5, 9.8%) with a mortality rate of 2.8% during the study period [Table 1].
Table 1: Distribution of mortality in the surgical units

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[Table 2] shows that neoplasm caused most deaths (24, 47.1%) in the disease category, and [Table 3] shows the distribution of the primary disease. Twenty (83.3%) of the deaths from neoplasm occurred among patients 50 years and above. Twenty-six (50.98%) of the patients had surgery done before death, 3 (11.5%) were intraoperative deaths, with general surgical cases accounted for the highest (14, 53.7%), while neurosurgical cases accounted for the least (1, 3.8%), [Table 4]. The interval between admission and surgery was 1–35 days (day of admission to 35 days) with a mean (SD) of 5.92 (8.69) days. Interval between surgery and death was 0–146 days (day of surgery to 146 days) with a mean (SD) of 12.65 (28.78) days. [Figure 1] showed immediate causes of death consequent on the underlying disease. Overwhelming sepsis (14, 27.5%) and hypovolaemic shock (10, 19.6) were the leading immediate causes of death, while severe anemia with sepsis (1, 2.0%) and uremic encephalopathy (1, 2.0%) were the least immediate causes of death. Four of the dead had autopsy done on them, giving an autopsy rate of 7.8%.
Figure 1: Clinical conditions that preceded death of the patients

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Table 2: Distribution of mortalities among category of diseases

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Table 3: Distribution of the primary disease

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Table 4: Distribution of surgical procedures (n=26)

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  Discussion Top


Surgical care is an integral part of healthcare throughout the world, with an estimated 234 million operations performed annually, it could prevent loss of life or limb and is also associated with a considerable risk of complications and death.[6] In-hospital mortality has also been proposed as an indicator of health-care quality. It is useful for epidemiological monitoring, health planning, and improves the quality of health-care services in a nation.[8]

This study looked at the pattern of deaths in the adult surgical ward at our center. Only 57.3% of the case notes were available for review, and this is similar to the finding in Ayoade et al. study at Sagamu, Nigeria.[3] This is a reflection of poor record keeping in our setting and many other parts of the country and a major bane of retrospective studies. Less dependence on manual coding and the use of digital system for information storage will alleviate this ugly trend and make the system more effective and efficient.

From this study, more than half of the deaths occurred among patients 50 years and above with crude mortality of 4.2%. The crude mortality rate from our center is comparable to 5.1% reported by Ayoade et al., in Sagamu, Nigeria[3] though, lower than the rates reported in similar studies by Onyemaechi et al., (6.6%) in Markurdi, Nigeria,[7] Biluts et al., (7.0%) in Addis Ababa, Ethiopia[9] and Chukuezi and Nwosu (9.1%) in Owerri, Nigeria.[6] According to O'Leary et al.,[10] when comparing hospital mortalities, we usually ignore important factors such as the nature of the catchment area, the proportion of emergency versus elective admissions, the numbers of complex operations performed, and proportion of inevitable and evitable deaths.[10] These will undoubtedly result in different values from various centers.

Fifty-one percent of the patients had surgical intervention before death; this is lower than 84.96% in the study by Chukuezi and Nwosu[6] though, higher than studies by Onyemaechi et al. (49.7%)[7] and Ayoade et al. (35.3%).[3] The figure in our study could have been that high probably because the severely head-injured patient that could have contributed to the number of nonoperated patients was probably referred. The intraoperative death in our study was 11.5%, higher than 1.91% in Chukuezi 's and Nwosu and 6.7% in Ayoade et al.'s study. This may not be unconnected with the severity of the disease and the complexity of the surgical procedures. However, other factors such as delay in diagnosis and treatment, medical and surgical errors, lack of expertise, and inadequate or limited healthcare have been cited in other studies.[3] The effect of these factors was not evaluated in our study.

In this study, the primary diseases were categorized into infection, trauma, and neoplasm in order of increasing mortality. Whereas reports from other studies, Ayoade et al. Sagamu, Nigeria;[3] Onyemaechi et al., Makurdi, Nigeria[7] and Bindroo and Saraf India[11] showed trauma with head injury as the leading cause of death. Trauma was not the leading cause of death in our center because the severely head-injured patients who could have increased the number of mortalities attributable to trauma were usually referred early. We only have a visiting neurosurgeon in our center that is mostly unavailable during these emergency cases, and some of these patients could have been salvaged by the neurosurgeon when available.

From our study, colorectal cancer is the most common condition followed by breast and prostate cancers as causes of deaths, whereas in the study by Shukla et al. in India,[12] colorectal carcinoma was second to gall bladder cancer as a cause of death among the cancer patients. Sepsis and hypovolemic shock were the leading immediate causes of death in our study. Good monitoring and high index of suspicion are required in the perioperative period to pick early signs and symptoms of these rapidly progressive pathological changes with fatal outcome. Appropriate supportive care is needed to move patients through the acute phase of these conditions.

Studies have emphasized the frequent difference between the clinically apparent cause of death and that suggested at autopsy, and It has been documented that 27% of postmortem diagnoses would have changed management if the problem had been known before death.[13] Less than 10% of the deceased had autopsy done in our study, Stiven et al. reported autopsy rate of 2% at Christchurch hospital, Newzealand.[13] Similar studies[3],[6],[7] did not report the number nor percentage of autopsies done. In a study by Edomwonyi et al.[8] on 45 mortalities among Orthopedic and Trauma admissions, none of the deceased had autopsy done. While there may be seemingly higher autopsy rate in our study comparing to other studies, post mortem examination remains the gold standard of establishing the definitive cause of death.[4] Studies worldwide confirm a significant decline in the frequency of hospital autopsies.[13] Low level of autopsy could be related to hospital policy, attitudes of the treating doctor, cultural, social and religious factors such as relatives are responsible for payment for this procedure, and many people see this as a double loss having lost a loved one; belief about reincarnation with fears that the deceased may return disabled; refusal of the family and religious demands on immediate burial of the dead.[8],[13]

The perception by clinicians that autopsy yields little clinically relevant information concerning patients or patient care in this day of “high tech” medicine has also been stated, and the fear, both real and perceived, that new information could potentially prove disastrous to the physician or hospital in our litigious society has also been suggested as a source of decreased autopsy yield.[13] Edomwonyi et al. suggested that postmortem should be done free of charge and that legislation should be enacted and enforced to address the socio-cultural impediments, noting that these would go a long way to reorientate our people on this important investigative tool.


  Conclusion Top


Neoplasm and trauma constituted more than 80% of the mortality in our study. These noncommunicable diseases that constitute great health challenges in our community deserve attention. Neoplastic diseases require screening for early detection, availability of various methods of treatment, and necessary supportive care. Community, primary care physicians, and oncology teams need to be encouraged and supported to take up this challenge in our locality. Trauma, particularly that occurring from road traffic crash, has become major health problems throughout the world.[14] To stem the tide of death from trauma, preventive measures, prompt response to trauma victims and holistic treatment are needed.

[TAG:2]Limitation [/TAG:2]

The scope of our study is limited by the number of mortalities reviewed; large percentage of the case notes was not available for review and only a few of the cases had autopsy done. Multicenter study or systematic review of mortalities in surgical wards will allow pulling of large number of cases for the analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krishnamurthy VR, Ishwaraprasad GD, Rajanna B, Samudyatha UC, Pruthvik BG. Mortality pattern and trends in surgery wards: A five year retrospective study at a teaching hospital in Hassan district, Karnataka, India. Intl Surg J 2016;3:1125-9.  Back to cited text no. 1
    
2.
Goldacre MJ, Griffith M, Gill L, Mackintosh A. In-hospital deaths as fraction of all deaths within 30 days of hospital admission for surgery: Analysis of routine statistics. BMJ 2002;324:1069-70.  Back to cited text no. 2
    
3.
Ayoade BA, Thanni LO, Shonoiki-Oladipupo O. Mortality pattern in surgical wards of a university teaching hospital in Southwest Nigeria: A review. World J Surg 2013;37:504-9.  Back to cited text no. 3
    
4.
Stothert JC Jr., Gbaanador G. Autopsy in general surgery practice. Am J Surg 1991;162:585-8.  Back to cited text no. 4
    
5.
Hayat W, Fahim F, Cheema MA. Mortality analysis of a surgical unit. Biomedica 2004;20:96-8.  Back to cited text no. 5
    
6.
Chukuezi AB, Nwosu JN. Mortality pattern in the surgical wards: A five year review at Federal Medical Centre, Owerri, Nigeria. Int J Surg 2010;8:381-3.  Back to cited text no. 6
    
7.
Onyemaechi NO, Popoola SO, Schuh A, Iorbo AT, Elachi IC, Oluwadiya KS. Mortality pattern of hospitalized surgical patients in a Nigerian tertiary hospital. Indian J Surg 2015;77:881-5.  Back to cited text no. 7
    
8.
Edomwonyi EO, Enemudo RE, Okafor IA. Pattern of mortalities among orthopaedic and trauma admissions in Irrua. Open J Orthopaed 2015;5:179-85.  Back to cited text no. 8
    
9.
Biluts H, Bekele A, Kottiso B, Enqueselassie F, Munie T. In-patient surgical mortality in Tikur Anbessa hospital: A five-year review. Ethiop Med J 2009;47:135-42.  Back to cited text no. 9
    
10.
O'Leary DP, Hardwick RH, Cosford E, Knox AJ. Does hospital mortality rate reflect quality of care on a surgical unit? Ann R Coll Surg Engl 1997;79:46-8.  Back to cited text no. 10
    
11.
Bindroo S, Saraf R. Surgical mortality audit-lessons learned in a developing nation. Int Surg 2015;100:1026-32.  Back to cited text no. 11
    
12.
Shukla D, Patel VK, Chhari AS, Dubey CS, Garg RK, Singh AP, et al. Epidemiological profile of cancer patients in surgery ward of a tertiary teaching hospital in the Vindhya region with special reference to high proportion of carcinoma gall bladder. Int Surg J 2016;3:2025-33.  Back to cited text no. 12
    
13.
Stiven PN, Frampton CM, Lewis DR. Use of autopsy in general surgery: A comparison of practice and opinion. ANZ J Surg 2007;77:722-6.  Back to cited text no. 13
    
14.
Mock C, Quansah R, Krishnan R, Arreola-Risa C, Rivara F. Strengthening the prevention and care of injuries worldwide. Lancet 2004;363:2172-9.  Back to cited text no. 14
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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