An audit of admissions and mortality of orthopedic indoor patients in a tertiary care hospital of India

Abstract

Introduction

Mortality in orthopaedics is different in underdeveloped, developing and developed countries depending on the health, orthopaedic and trauma care services, education status and social awareness. Analysis of mortality and causes of death is an important step to identify the risk factor. Such study is invaluable for epidemiological monitoring and health care planning.

Methods

Between September 2015 to August 2018 demographic data, timing and primary diagnosis of both mortality and admission were collected retrospectively in a leading tertiary care hospital in the city of Mumbai, India.

Results

Total admissions of 10,937 in the 3-year period with increased average monthly admission in the month of June, July and August. Trauma to be most common cause of admission and death and Road traffic accident to be the most common cause of trauma followed by slip and fall. The death rate was 0.55 per 100 admissions per year. In males most common age group was 18–60 years and in females above 60 years of age.

Conclusion

There is a link of increased admission rate in the monsoon months (rainy season) in India and road traffic accident and slip and fall. So accident prevention and health care planning and management of trauma victim, improvement of quality of life of general population will reduce trauma and related complications.

1. Introduction

India is the second largest populated country in the world after China.1, 2 Mortality data of polytrauma patients from different parts around the globe has been well mentioned in the general surgery literature³ and scoring system such as Injury Severity score is used for assessment.⁴ Mortality in orthopedics is different in underdeveloped, developing and developed countries and depends on the health, orthopedic and trauma care services and facilities, education status and social awareness of the general population of the country.5, 6, 7 Analysis of mortality and causes of death is an important step to identify the risk factor of death following orthopedic trauma and orthopedic diseases. Also demographic pattern of admission in government health care facilities, primary causes (ex. road traffic accident) is an indirect indicator of the overall aspects of development such as life expectancy, health awareness, road safety etc. Indoor patient’s mortality is an indicator of the quality of health service provided by the country.⁸ Audit of admissions and deaths of a tertiary care hospital is useful for the comparison of the quality of health care with other hospitals. It is useful for epidemiological monitoring, planning and the other aspects to be addressed for the prevention and improvement of heath care to be provided to the patients. Recent studies are required for such comparisons and analysis. To the best of our knowledge few recent studies are available based on admission and mortality patterns related to orthopedic trauma in India.

Aim of the study is to analyze the various factors associated with mortality among the indoor patients of orthopedic department. This study will also help to formulate further guidelines for prevention of mortality of orthopedics cases in India. The study is carried out in one of the largest trauma care center and tertiary care hospital in India and the findings will help in extrapolating the various factors associated with admission and mortality and will form the basis of more such studies in the future.

2. Methods

Between September 2015 to August 2018 we studied retrospectively the patients admitted in orthopedics wards of a leading tertiary care teaching hospital and one of the largest trauma care center in India.

The patients admitted in the orthopedic wards of the hospital in the above mentioned time period were included in the study. The exclusion from the study sample were the patients with musculo-skeletal trauma along with other organ-system injury such as head injury, chest injury, gastrointestinal tract injury admitted and died in the intensive care unit (ICU) and patients who were admitted in orthopedic ward but took discharge against medical advices.

Sampling method used was “consecutive sampling-a type of nonprobability sampling”.

Demographic details of admissions, timing, primary diagnosis were obtained from the admission records of the hospital. The details of death that occurred during that period were obtained from the mortality register in the respective orthopedic wards and other details such as co-morbidities were recorded from the deceased patient’s files after permission from the hospital authority with the help of medical records department (MRD) of the hospital.

The number of admissions and death were divided into 2 groups (male, female) and distributed on monthly basis over the 3-year period. Then the average number of admission and death of each month were calculated.

The primary diagnosis of admitted patients of each month were divided into trauma, infection, degenerative diseases, congenital and developmental disorders and tumors. Trauma patients were divided into closed fractures, open fractures and crush injury (including traumatic amputation of limbs). Closed trauma included patients with closed fractures of the extremities, pelvic-acetabular and spinal trauma. Infection included infection of joints (septic arthritis), osteomyelitis, Koch’s spine and postoperative infection patients with primary fixation done outside. Degenerative diseases included degenerative spine such as PIVD, spondylosis and spondylolisthesis and joint diseases such as avascular necrosis of hip, osteoarthritis who required joint replacement surgery, these patients were admitted for planned surgery (except cauda equine) with optimization of the medical comorbidities (if present). Congenital and developmental disorders were mainly patients of the pediatric age group with congenital bony and soft tissue anomalies such as cerebral palsy, DDH and developmental disorders such as perthes and other deformities. Tumor admission in the study hospital strictly restricted to benign musculoskeletal tumors only as malignant bony and soft tissue tumors (both primary and metastatic) were referred to specialized cancer hospital and research center in the city.

Data Analysis and Interpretation: Data was entered into Microsoft Excel (Windows 7; Version 2007) and analyses were done using the Statistical Product and Service Solutions (SPSS) for Windows software (version 22.0; SPSS Inc, Chicago). Descriptive statistics such as mean and standard deviation (SD) for continuous variables, frequencies and percentages were calculated for categorical Variables were determined. Bar charts and Pie charts were used for visual representation of the analyzed data. Level of significance was set at 0.05.

3. Results

The total admission in the period of study was 10,937 (4531 females) and male and female ratio was 1.4:1. Maximum admissions were seen in the months of June, July and August (Fig. 1).

Fig. 1.

Distribution of average monthly admission.

Among the male patients admitted 58.6% were between the age group of 18–60 years and among female patient’s maximum number of patients (61.1%) were above 60 years of age but only 35.1% of the male patients admitted were above 60 years of age (Table 2).

Table 2.

Distribution of admissions according to age and sex

AGE	MALE	FEMALE	TOTAL
<18 YEARS	401	220	621
18-60 YEARS	3756	1545	5301
>60 YEARS	2249	2766	5015
TOTAL	6406	4531	10,937

The primary diagnosis of 75.5% of the patients admitted was trauma followed by degenerative (spine & joint) diseases (Table 1). RTA was most common cause of trauma for male patients (57.8%) and in female patients the most common cause of trauma was slip and fall (65%) (Table 3).

Table 1.

Distribution of admissions according to primary diagnosis.

	TRAUMA	INFECTION	DEGERATIVE HIP,KNEE, SPINE	CONGENITAL & DEVLOPMENTAL	TUMOUR	TOTAL
MALE	4891	517	872	99	27	6406
FEMALE	3363	302	697	173	9	4531
TOTAL	8254	819	1569	272	36	10,937

Table 3.

Distributions of trauma admissions according to cause of trauma.

TRAUMA	MALE	FEMALE	TOTAL
RTA	2827	833	3660
RAILWAY ACCIDENT	787	235	1022
SLIP AND FALL	1023	2188	3211
PHYSICAL ASSUALT	254	107	361

Total death in the 3 years of study period was 180 with a crude mortality rate of 0.55per 100 admissions per year. Among the deceased patients 100(55.6%) were male and 80(44.4%) were females. Male: Female ratio was 1.25:1. Considering male and female deceased patients together 47.8% were between 18 and 60 years and median age was 53.5 years. 63% of the male patients were between 18 and 60 years of age, and 66.25% of the female patients were above 60 years.

Trauma was the most common primary cause of death (82.2% of total deaths). Closed trauma was the cause of 52.78% of the total deaths followed by open trauma (Fig. 2).

Fig. 2.

Distribution of death according to primary cause.

4. Discussion

In ours study the ratio of male patient admitted was higher than female. In similar study by Orimolade EA et al. in Nigeria there was male predominance⁵ and Nigeria lies below the UN development index than India.⁹ In contrary the study by H. B. Tan done in U.K., a ‘developed nation’ where the ratio of female patients admitted were more than male.⁷

Among the trauma patients the most common cause of trauma was Road traffic accident(RTA). Trauma particularly RTA are one of the major health problem in the world.^10,11 Slip and fall was most common cause of trauma in female. Slip and fall that is fall from the same level of the room is very common in community dweller and is more common above 65 years of age.¹² In India only 14.7% of urban females are working population and rest are involved only in household works¹³ and road traffic accidents in females are less common than men in India.¹⁴ In India 83.4% of road traffic accidents victims are between 18 and 60 years of age.¹⁴ In our study maximum number of male patients admitted were between 18 and 60 years of age and the most common cause was RTA whereas maximum of the female patients admitted were above 60 years of age and the most common cause was slip and fall. Increased incidence of slip and fall is seen in rainy season is due to slippery floors.¹⁵

The average monthly admissions were maximum in the months of June, July and August which are the monsoon months in India¹⁶ and there is increased occurrence of RTA during these months.¹⁷

The crude death rate in our study (0.55%) was less than the death rate of the admitted orthopedic patients in the study by Orimolade EA [ 4] in 2010 in Nigeria (3.47%) and by Bhattacharya et al.⁶ in Boston USA in 2002 (0.92%.) The death rate which is even less than USA may probably due to lack of malignant tumor (both primary and metastatic) cases in our study sample, as the mortality of musculoskeletal malignancy is much higher¹⁸ and malignant tumor formed a significant number of his study sample and deaths in the study by Bhattacharya et al.⁶

In our study the median age of deceased patients was 53.5 years. In similar study by Orimolade EA et al. in Nigeria the median age of deceased patients was 45.7 years,⁵ but the study by H. B. Tan in U.K. the median age was 82.14.⁷ In case of death also there was male predominance alike of the study conducted in a Nigeria which lies below the UN development index than India⁵ but female predominance seen in study conducted in U.K., ‘a developed nation’.⁷

In our study the most common cause of death (52.7%) was closed trauma. 69 patients (38.33% of the total deaths) were above 60 years of age and had either hip fracture or pelvic-acetabular fractures. Elderly patients usually are associated with medical co-morbidities which is the cause of perioperative and postoperative complications including mortality.¹⁹ Bhattacharya et al.⁶ found Hip fracture as one of the critical risk factor of postoperative mortality and also increased age (age greater than 70 years) being the other. Tumors was the most common cause of death in the study by H. B. Tan⁷ in U.K. In the study by Bhattacharya et al.⁶ in U.S.A- trauma, tumor and infections were the leading causes and in the study by Orimolade EA et al. in Nigeria trauma was the most common cause of death.

5. Conclusion

Trauma is the main cause of admission and death in the orthopedic ward and road traffic accident being the most common cause of trauma followed by slip and fall. There is relationship of increased admission rate in the monsoon months with the increase in road traffic accidents and slip and fall during the wet season. The lack of visibility of roads during heavy rain, deterioration of road conditions, can be predicted as the cause. The slippery floors specially in the rainy season can be predicted with the increased incidence of slip and fall. So Accident prevention and health care planning and management of trauma victim, improvement of quality of life of general population will reduce trauma and related complications.

However, this study doesn’t analyze the causes of death of patients taking postmortem report into consideration. Since orthopedic trauma is a medico-legal case in this part of the world²⁰ and postmortem reports are kept confidential so authors didn’t have access to the same. Also this is a single center study and a multi-centric study in the future will give a better analysis along with consideration of the postmortem report certifying the cause of death.

CRediT authorship contribution statement

Subhashis Banerjee: Investigation, Data curation, Writing - review & editing. Abhijit B. Kale: Supervision, Validation.

Declaration of competing interest

No conflict of interest by any of the authors.