Inpatient care activities: admissionsBed capacity (Hospital and Health Centres)

With opening of the new 6 beds neonatal unit in January 2009, the Hospital bed capacity has increased to 482 in the main Hospital and 24 beds in each of the three Health Centres. The total bed capacity of the Hospital complex is therefore 554. For statistic purposes however, the Hospital bed capacity is considered to be respectively of 476 and 548 beds until the end of the FY on the 30/06/09.

Patients with severe medical and surgical conditions are admitted and treated as inpatient, both in the Hospital and in the three Peripheral Health Centres. Patients that require Hospital treatment are referred to the Hospital from the Health Centres through the Hospital ambulance services.

Admissions – Hospital and Health Centres

The total number of admissions to the Hospital has increased by 7% from 41,486 FY 2007/08 to 44,283 this FY. About 75% of all these admissions are children less than 6 years and mothers with reproductive health problems, who are the most vulnerable groups in the community. Children alone account for over 56% of admissions. The Hospital is therefore in compliance with its mission, which targets the most vulnerable people in the society.

Table 25   Endoscopy and physiotherapy services, FY 2001/02 to 2007/08

Service 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Endoscopy    528    438    385    633    904    720    722
Physiotherapy 1,121 1,153 1,063 1,139 1,356 1,384 1,298

Trend of admissions in the Hospital

 

The number of Hospital admissions continued to increase every year. The number of Hospital admissions has increased 9 times since 1988 and it has almost trebled since the time of the Ebola outbreak of 2000.

The average number of new patients admitted per day into the Hospital wards this FY 2008/09 were 120 new patients per day. With bed occupancy rate of 131.42% and average length of stay of 5.94 days, the total bed days in 2008/2009 were 262,867.

 

Trend of admissions over 20 years

The increase in the number of inpatients has been very sharp after the Ebola crisis and has continued to do so up to now. This could be due to the way the Hospital handled the Ebola epidemic, following which the Hospital reviewed its policy and hence improved the quality of care in general terms, subsequently attracting more patients to the facility as the community developed more trust in the Hospital.

Admissions in the Health Centres

 

There has been a general decrease in the number of admissions in the Health Centres, especially to Opit HC, which recorded a decrease of up to -1,303 patients compared to last year. A total of 9,533 patients were admitted to the three health centres compared to 10,069 patients FY 2007/08.

Amuru, however, admitted 4,033 patients compared to 3,302 last year; Opit admitted only 2,452 this year compared to 3,755 last FY while a total of 3,048 patients were admitted to Pabo HC compared to 3,012 patients last year. The patients admitted to the Health Centres accounted for about 21% of all the admissions. Strengthening the Health Centres would possibly decongest the Hospital as services will be taken nearer to the rural population therefore improving access to the services.

 

There was a marked decrease in the number of admissions in Opit Health Centre, which recorded a 35% decrease in the number patients admitted. This was possibly due to the large number of people who left the camp and returned to their original home, and may also be due to the functionalities of two nearby Health Centres which were being run by an NGO.

 

Leading causes of admission to the Hospital

 

Admission among children

Malaria was the commonest cause of admission among patients less than 6 years, contributing to 45% of all the admissions in FY 2008/09; followed by pneumonia, anaemia, diarrhoea, malnutrition and septicaemia.

Leading causes of admissions in children ward, FY 2008/09

N. Diagnosis (multiple diagnoses allowed) Number Percentage
1 Malaria  15,711 45%
2 Pneumonia  3,843 11%
3 Anaemia  2,748       7.8%
4 Acute respiratory tract infection  2,703       7.7%
5 Acute diarrhoea  2,661       7.6%
6 Septicaemia  1,284       3.6%
7 Malnutrition  1,110       3.1%
8 Injuries      436       1.2%
9 AIDS      335       0.9%
10 Skin diseases      317       0.9%
11 Dysentery      211       0.6%
12 TB      171       0.4%
13 Burkitt lymphomas      157       0.4%
14 Meningitis      130       0.3%
15 Hernia      105       0.3%
16 Urinary tract infection        94       0.2%
17 Cardiovascular diseases        82       0.2%
18 Congenital malformation        78       0.2%
19 Genital urinary diseases, non infective        77       0.2%
20 Poisoning        60       0.1%
21 Others  2,556 7.3%
  Total 34,869 100%

Admissions among adults

The most common diseases causing admission in adults (including children of 6 years and over) in this FY were malaria, injuries, HIV/AIDS, TB and pneumonia; this is when complications of pregnancy are excluded.

 

Leading causes of admissions in adults including children > 6 years, FY 20087/09

 

N. Diagnosis (multiple diagnoses allowed) Number Percentage
1 Deliveries  4,611 25.7%
2 Malaria  2,566 14.3%
3 Injuries  1,669  9.3%
4 AIDS     988  5.5%
5 TB     811  4.5%
6 Abortions     715  3.9%
7 Pneumonia     673  3.7%
8 Anaemia     546  3.0%
9 Cardiac diseases     361  2.0%
10 Hypertension     361  2.0%
11 Hernia     309  1.7%
12 GE, non infective     301  1.6%
13 Liver diseases     283  1.5%
14 Diarrhoea     252  1.4%
15 UTI     250  1.3%
16 Meningitis     230  1.2%
17 Septicaemia     194  1.0%
18 RTI     179  0.9%
19 Musculoskeletal/Connective tissue diseases     175  0.8%
20 Asthma     136  0.7%
21 Others  2,300 12.8%
  Total 17,910 100%

 

Most cases of malaria are being treated more effectively as outpatients, due the introduction of the more effective ACT based combination therapy more than a year ago in the country. The commonest causes of injuries were road traffic accidents, which have become more common due to the increased number of vehicles and motorcycle taxis locally referred to as ‘boda-boda’. HIV/AIDS cases are being diagnosed more easily due to the more liberal testing policy of routine testing and counselling being encouraged.

Monthly rates of admissions to the Hospital

The rate of admission of children shows seasonal variation as previously seen for OPD attendance in the YCC. The lowest admission is realized during the dry months of December to early March when the incidence of malaria, the major cause of illness in children, is low due to the dry environmental condition unfavourable for breeding of mosquitoes. On average a total of 1,573 children are admitted to the Hospital every month, which is about 50 children every day. Adult admissions dip slightly in December, which is the festive season, but are generally almost stable throughout the year.

On average, the rate of monthly admission to the Hospital is 1,573 children and 1,322 adults. This is a total of about 100 admissions in the Hospital on a daily basis, more than ½ being in the children wards.

 

December, January, and February are the months with the lowest number of admissions to the Hospital in FY 2008/09, as it had been so in the past years.

 

Average length of stay (ALOS) & bed occupancy rates (BOR) in the Hospital

 

The Hospital average length of stay in FY 2008/09 was 6.56 days, down by 8% from 7.14 days in the last FY 2007/08; bed occupancy rate was 131.27%, up by 1% from last FY 2007/08, which was at 130.12%.

The average length of stay varies by ward, with maternity having the lowest ALOS of 3.88 days, down from 4.65 days of last FY; surgery has the highest ALOS of 12.4 days but has also dropped from 13.8 days of last year. This is because of the different case mix treated in the various wards. War, trauma and other trauma related conditions treated in the surgical wards tend to take longer to recuperate, while most of the cases treated in the maternity ward tend to recover more quickly.

 

Hospital average lenght of stay and bed occupancy rates, FY 2008/09

Ward Bed Capacity Admissions Bed State ALOS BOR
Paediatrics 166 18,881 109,791  5.81 181.20%
Medicine 115  5,075  39,039  7.69  93.01%
Surgery 134  4,390  54,381 12.40 111.19%
Maternity  61  6,404  24,859  3.88 111.65%
Total/Average 476 34,750 228,070  6.56 131.27%

 

The average length of stay in each ward over the last seven years has shown downward trends. The ALOS is generally higher in the surgical wards due to high number of injuries involving bones, which tend to take long to heal. However, a reduction in the ALOS is noticed most in the surgical wards, due to less war trauma being seen in the last two years. The yearly increment in the number of deliveries in the Hospital is largely responsible for the continuous reduction in the ALOS seen in the maternity ward.

 

Inpatient mortality rate in the Hospital

The number of deaths in the Hospital in FY 2008/09 was 1,406, making the Hospital mortality rate 4.0%. Mortality rates in the Hospital have remained fairly stable in the last six years, ranging between 4% and 5%. This is in spite of the increasing numbers of serious patients being treated in the wards.

The increasing complexity of the disease conditions and the increased referral of critical cases from other hospitals seems not to have affected the mortality rate negatively this year. The mortality rate in the medical ward is always highest largely due to the numerous AIDS cases admitted at a terminal stage of the disease.

 

Leading causes of deaths in the Hospital

Causes of deaths in children

Malaria, anaemia, pneumonia, malnutrition and septicaemia are the most common causes of death in the children ward. They are also the leading causes of admission in the children ward. diarrhoea, AIDS, neonatal sepsis, meningitis and prematurity are other leading causes of deaths.

 

Frequency as concurrent cause of death in children, FY 2008/09

  Disease condition* N. of deaths
1 Malaria  274
2 Anaemia  218
3 Pneumonia  146
4 Malnutrition  128
5 Septicaemia     97
6 Diarrhoea     88
7 AIDS     64
8 Neonatal sepsis     40
9 Meningitis     34
10 Prematurity     34
11 Lymphomas     30
12 RTI     26
  Total 1,179

 

Causes of deaths in adults

HIV/AIDS and TB remain the two leading causes of death among adults at Lacor Hospital. Meningitis,

pneumonia and injuries as well as cardiac conditions are other major causes of death in the medical wards,

followed by anaemia, malaria and hypertension. Chronic diseases like liver cirrhosis, hypertension and

hepatocellular carcinoma are becoming important causes of death in adults as well.

 

Frequency as concurrent cause of death in adults, FY 2008/09

N. Disease condition* N. of deaths
1 AIDS  236
2 TB  139
3 Meningitis  102
4 Pneumonia      93
5 Liver diseases      72
6 Injuries      68
7 Cardiac diseases      60
8 Anaemia      49
9 Malaria      43
10 Hypertension      33
11 Renal failure      27
12 Diabetes      24
13 Kaposis sarcoma      20
  Total    966

*Some of the deaths were due to more than one disease condition

Case fatality rates in the Hospital

Case fatality in children

Disease conditions with highest case fatality rates in children are pyogenic meningitis (26%), HIV/AIDS (19.1%), Burkitt’s lymphoma (19.4%), malnutrition (11.5%), while those with moderate case fatality rates are anaemia (7.9%), septicaemia (7.5%), pneumonia (3.7%), while injuries carry a case fatality rate of 3.8%.

Respiratory tract infections have the lowest case fatality followed by malaria and diarrhoea. The main reason for the high case fatality rates for meningitis, HIV/AIDS and malnutrition is due to late presentation to the Hospital, often in moribund states or with advanced complications.

 

Case fatality rates of leading causes of admission among children, FY 2008/09

  Disease condition N. of admissions N. of deaths Fatality rates
1 Malaria 15,711 274  1.7%
2 Pneumonia  3,843 146  3.7%
3 Anaemia  2,748 218  7.9%
4 Respiratory tract infection  2,703  26  0.9%
5 Diarrhoea  2,661  88  3.3%
6 Septicaemia  1,284  97  7.5%
7 Malnutrition  1,110 128 11.5%
8 Injuries      436  17  3.8%
9 AIDS      335  64 19.1%
10 TB      171  =
11 Burkitt’s lymphoma      154  30 19.4%
12 Meningitis      130  34 26.1%

 

Case fatality in adults

Disease conditions with the highest case fatality rates in adults are pneumonia (36.9%), HIV/AIDS (29.4%), TB (20.8%) and liver diseases with CFR of 20.9%. Conditions with low case fatality rates are injuries (3.2%), hypertension (5.9%) and malaria with 4.4%.

Those dying from pneumonia and TB may as well have underlying HIV infections though not all of them are usually tested for HIV.

 

Case fatality rates for leading causes of admissions among adults, FY 2008/09

  Disease condition N. of admissions No. of deaths Fatality rates
1 AIDS 1,043 307 29.4%
2 Malaria    655  28  4.3%
3 TB    605 126 20.8%
4 Pneumonia    217  80 36.9%
5 Anaemia    368  60 16.3%
6 Hypertension    239  14  5.9%
7 Liver diseases    148  31 20.9%
8 Injuries    786  25  3.2%
9 Cardiac disease    238  31 13.0%
10 Meningitis    459  73 15.9%
11 Septicaemia    179    21 11.7%

Summary of Hospital mortality by ward, FY 2003/04 to 2008/09

  2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Medicine ward (General Med & TB)
Admissions 5,018 4,818 4,358 4,041 4,153 5,075
Total deaths 472 586 556 537 548 550
Mortality rate 9.41% 12.16% 12.76% 13.28% 13.20% 10.80%
Paediatric ward (Children ward, Nutrition & Isolation)
Admissions 18,361 17,226 16,215 14,437 17,626 18,881
Total deaths 609 688 665 664 719 619
Mortality rate 3.32% 3.99% 4.10% 4.59% 4.07% 3.20%
Surgical ward (Surgery I, II & ICU)
Admissions 3,208 3,247 3,413 4,232 4,130 4,390
Total deaths 110 98 117 172 177 205
Mortality rate 3.43% 3.02% 3.43% 4.06% 4.28% 4.60%
Maternity ward (Obstetric & Gynaecology)
Admissions 3,231 3,247 3,963 4,483 5,508 6,404
Total deaths 24 98 25 12 24 32
Mortality rate 0.74% 3.02% 0.63% 0.26% 0.43% 0.49%
All wards
Admissions 29,818 28,872 27,949 27,193 31,417 34,750
Total deaths 1,215 1,388 1,363 1,384 1,468 1,406
Mortality rate 4.07% 4.81% 4.88% 5.08% 4.60% 4.00%

Other inpatient care activities

Surgical operations

 

The theatres operate everyday for emergency surgical procedures and Mondays to Fridays for elective cases. There are a total of six operation theatres which open twenty four hours a day.

 

The major operations include general surgery, orthopaedic surgery, and obstetrics and gynaecology procedures. There were a total of 5,399 major surgical operations performed in the FY 2008/09, 2,568 of these were performed as Emergency operations. This number excludes the many minor procedures done in minor theatres and side rooms of the surgical and gynaecological/obstetric wards. Like most of the activities the number of surgical operations performed has been increasing annually as shown in the figure below.

 

Maternity services

 

The three Health Centres of Opit, Amuru and Pabo provide basic emergency obstetric care, while the Hospital provides all the comprehensive emergency obstetric care. Antenatal care is provided at the three Health Centres and in the Hospital on a daily basis with exception of week ends.

 

Antenatal care

The total number of antenatal attendance increased from 21,775 last year to 23,351 this year, making a 7%

increment in the ANC service output. There was a significant decrease in the numbers attending ANC at Opit

Health Centre due to the factors mentioned previously.

With opening of the new 6 beds neonatal unit in January 2009, the Hospital bed capacity has increased to 482 in the main Hospital and 24 beds in each of the three Health Centres. The total bed capacity of the Hospital complex is therefore 554. For statistic purposes however, the Hospital bed capacity is considered to be respectively of 476 and 548 beds until the end of the FY on the 30/06/09.

Patients with severe medical and surgical conditions are admitted and treated as inpatient, both in the Hospital and in the three Peripheral Health Centres.

Patients that require Hospital treatment are referred to the Hospital from the Health Centres through the Hospital ambulance services.

Table 21   ANC attendance, FY 2007/08 – 2008/09

  2007/08 2008/09 Difference
Hospital 12,836 13,610  774 (6%)
Amuru  3,231  4,641 1,410 (44%)
Pabo  3,957  3,699  -258 (-7%)
Opit  1,751  1,401     -350 (-20%)
Total 21,775 23,351 1,576 (7%)

 

Deliveries

The total number of deliveries in the Hospital and the Health Centres increased from 4,465 last year to 4,611 this year, up by 146 (3.2%) from last year. It has over doubled in the last five years. This is due partly to the abolition of user fees for all delivery services, and also to improvement in the maternity services both in the Hospital as well as in the Health Centres.

 

Maternal Mortality Ratio, Still Birth Ratio and Caesarean Section RateReduction of maternal mortality and perinatal mortality are major priorities of the Ministry of Health as indicated in its Health Sector Strategic Plan II (HSSP II). The national maternal mortality ratio had stagnated at 560/100,000 live births for a long time, it was only recently that it has reduced to 435/100,000 live births.

 

The maternal mortality ratio for Gulu district is still one of the highest in the country, standing at 610/100,000 live births. The next table summarises these indicators in Lacor Hospital for the last 6 years.

Table 22   Maternity services, FY 2002/03 to 2008/09

Services 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Total deliveries 1,625 2,150 2,534 2,913 3,591 4,465 4,611
Deliveries in HCs    323    401    626    730 1,065 1,260 1,178
N. C/Sections    249    221    280    283    382    635  772
C/Section rates 15% 10% 11% 10% 10% 14% 17%
N. Maternal deaths      13     13     13      21      12     16    23
MMR     814    618     513     530     334    360  511
N. live births 1,598 2,104 2,536 2,854 3,538 4,445 4,502
N. still births      66     89      56    112       78      25  167
Still birth rates    41.4  42.3    22.0  38.4    22.0     5.6    37

 

The previous improvement was attributed to the general improvement in the obstetric care in the district as well as the improvement in the referral system, both by Government heath units and NGO run heath units making patients to reach the Hospital more timely to receive more timely interventions. Some of these NGOs have since left the district and the referral system is declining due to lack of proper ambulance services making expectant mothers with complications delay in accessing emergency obstetric care thus increasing the mortality rates. The still birth rates has also gone up to 37/1000 live births, while caesarean section rates have increased to 16.7%, after remaining stable around 10% for the last four years. This might be the consequence of referral already mentioned but also due to many complicated cases being referred to Lacor Hospital rather than to other hospitals.

 

Dental services

 

The number of patients receiving dental treatment dropped significantly this year from 7,605 FY 2007/08 to

6,286 this FY 2008/09. These included conservative dentistry as well as other emergency dental treatment.

 

Laboratory services

 

Clinical/diagnostic laboratory examinations are daily routines in both Lacor Hospital and the three Health Centres. The laboratory tests performed at the Health Centres are basic microscopy and haematological tests, while the types of laboratory investigations performed at the Hospital ranges from the basic microscopy to more complex serological tests, CD4 counts as well as viral load tests. Histopathological specimens are analysed at the pathology section of the laboratory mainly by visiting pathologists who have been constant at the Hospital for the last two years.

The number of laboratory examinations continued to increase with the general increase in the number of patients treated in the Hospital There was a 11.39% increase of laboratory examinations, from 239,315 in FY 2007/08 to 266,592 this FY. The general increase in the case mix and referral requires more laboratory tests, as do the increasing number of patients receiving treatment for HIV/AIDS.

Table 23   Number of laboratory tests performed, FY 2002/03 to 2008/09

FY 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Hospital 176,082 186,574 193,715 199,939 198,655 212,809 233,492
HCs  15,716  13,601  19,953  17,258  27,474  26,506  33,100
Total 191,798 200,175 213,668 217,197 226,129 239,315 266,592

 

Radiological services

 

The department provides both diagnostic and interventional services. The main diagnostic procedures include X-rays and ultrasound examinations.

The total number of radiological examinations increased by 2.6% from 38,374 last year to 39,385 this year FY 2008/09. The X- Ray department receives many direct referrals from neighbouring hospitals for radiological examinations. As shown in the figure below the number of X-rays examinations have been coming down over the last five years while the number of ultrasound scans has been on the rise since FY 2000/01.

Table 24   Radiological examinations performed from FY 2000/01 to 2008/09

Exam 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
X-Rays 24,909 25,533 27,834 31,109 27,300 23,004 20,997 21,821
USS  7,381  8,979 11,283 13,697 14,691 19,214 17,377 17,564
Total 32,290 34,512 39,117 44,034 41,991 42,034 38,374 39,385

 

Endoscopy and physiotherapy services

Endoscopy and physiotherapy are two other specialized services offered by the Hospital. This FY 2007/08, 720 endoscopic examinations were performed and 1,384 physiotherapy sessions were carried out.

Physiotherapy is performed both as outpatients and on admitted patients. This is the same for endoscopy examinations. The general trends for both physiotherapy and endoscopy is on the increase since 2002/03, with a slight reduction in the number of physiotherapy sessions since 2006/07.