| Abstract|| |
Background: Low and middle-income countries like Nigeria face many challenges in emergency medical care owing to poor treatment facilities and inadequately trained personnel. Most Nigerians live in rural areas. The disease and death burdens in accident and emergency departments in this setting have not been closely studied. Aim: To determine the basic demographics, disease burden, and outcomes for accident and emergency admissions. Settings and Design: This retrospective study was carried out on patients admitted to an accident and emergency department. Materials and Methods: A retrospective review of medical admissions to the accident and emergency wards of the Federal Medical Centre, Ido-Ekiti, Ekiti State, southwest Nigeria, between January 2010 and December 2012. Statistical analysis used: The data were analyzed using SPSS Version 16 software. The results were presented in descriptive and tabular forms. Result: In all, 2922 patients were admitted during the study period (age range, 11-100 years; mean, 51.89 ± 20.11 years). There were 1679 (57.5%) males and 1243 (42.5%) females, with a ratio of 1.4:1. Young adults (aged 40 years and under) formed the highest age group (46.8%). The number of patients admitted for non-communicable diseases were high (1989 patients: 68.07%). Among non-communicable diseases, cardiovascular disorders were the most frequent (797; 27.28%). The most common cause of deaths was cardiovascular disease (33.5%). Conclusion: Young adults and males were the groups most commonly admitted. Non-communicable diseases were more frequent than communicable diseases. The proportion of patients discharged against medical advice and fatalities requires urgent attention.
Keywords: Emergency, medicine, Nigeria, patient outcome, rural community
|How to cite this article:|
Ogunmola OJ, Olamoyegun MA. Patterns and outcomes of medical admissions in the accident and emergency department of a tertiary health center in a rural community of Ekiti, Nigeria. J Emerg Trauma Shock 2014;7:261-7
|How to cite this URL:|
Ogunmola OJ, Olamoyegun MA. Patterns and outcomes of medical admissions in the accident and emergency department of a tertiary health center in a rural community of Ekiti, Nigeria. J Emerg Trauma Shock [serial online] 2014 [cited 2020 Apr 1];7:261-7. Available from: http://www.onlinejets.org/text.asp?2014/7/4/261/142744
| Introduction|| |
Accident and emergency (A&E) services are one of the mainstays in the survival of acute patients. Between 1993 and 2006, hospital admissions from the emergency department (ED) grew by 50% (from 11.5 million to 17.3 million) in the United States.  In some parts of Europe, A&E accounts for 70% of all hospital admissions.  In Nigeria, A&E is the predominant route of admission into medical wards. Low and middle-income countries like Nigeria face many challenges in emergency medical care owing to poor treatment facilities and lack of adequately trained personnel.  As in other developing countries, the majority of Nigerians live in rural areas.  The burden of disease and death at A&E departments in this setting has not been comprehensively investigated. The promotion of health services by the World Bank includes a minimum of six cost-effective interventions, including non-specialized interventions for emergencies.  To the best of the authors' knowledge, there is a paucity of data on the patterns of morbidity and mortality for patients in A&E departments in rural Nigeria. However, such information is important considering the objective of the World Health Organization (WHO) in constantly evaluating available health services as an integral part of managing health-care delivery.  Such hospital-based data may assist in assessing patterns of morbidity, thereby helping health planners in prioritizing their work. Having such data could enhance the responsiveness of the health system towards meeting patient expectations, leading to improved use of services and better outcomes. 
The aim of the present study was to provide a comprehensive report on the patterns and outcomes of diseases seen in A&E in a hospital located in the rural setting of Ekiti State, Nigeria.
| Materials and Methods|| |
This study was a retrospective analysis conducted on patients admitted to the A&E department of the Federal Medical Centre, Ido-Ekiti, Ekiti State, southwest Nigeria. The A&E (adult only) has a contiguous layout with medical and surgical care provided in one area, divided into male and female wards. In this hospital, every patient treated is admitted for observation as a rule. This may eventually lead to discharge of the patient within 24 hours, or transfer to the ward or refer to other centers as appropriate after 24 hours. The general outpatient department receives patients not requiring emergency treatment. This hospital is a tertiary health center, serving as a referral center for Ekiti and neighboring states. The institution also operates an internship and postgraduate training in internal medicine. During the study period, the department of internal medicine had 11 consultant specialists, who were responsible for all medical A&E cases. The specialist team included three cardiologists, one nephrologist, two endocrinologists, two gastroenterologists, one clinical pharmacologist; and visiting chest physician, neurologist, and nephrologist. This retrospective review included patients admitted to the A&E department for whom information was complete (96%) and who met the clinical and laboratory diagnostic criteria. The population studied consisted of patients who were registered and seen in the A&E department. The analysis included all patients admitted from January 2010 to December 2012. Case notes from medical record department and nurses' report books were used for the analysis.
All the diagnoses were based on the final ones made by the supervising consultants. Owing to the high expense, echocardiography was performed on only 204 (59.5%) cardiac disease patients during the period 2011-12; it was not available in 2010. However, the Framingham clinical diagnostic criteria, which have been widely used and validated, were applied to all the heart failure patients included in the present study.  Only 11 stroke patients (3.9%) underwent cranial computerized tomography scans owing to non-availability or non-affordability. The diagnosis of stroke was conducted using the WHO criteria, which have been shown to have high sensitivity among Nigerians in determining the pathological type of stroke. 
We designed a data extraction form and entered each patient's data into it using the case notes and other relevant sources. This was later cross-checked for accuracy. The collected data included age, gender, cause of admission, and clinical cause of death (if appropriate). The diagnosed conditions were categorized into body systems using the WHO International Classification of Diseases, 10th Revision (ICD-10), version 2010 guidelines.  The outcome of the admitted cases was categorized as follows: Discharged, died, referred, and discharged against medical advice (DAMA).
We obtained approval from the ethics and research committee of our institution. The data were analyzed using the Statistical Package for the Social Science (SPSS), version 16 software (SPSS Inc., Chicago, IL, USA). The results are presented in descriptive and tabular forms.
| Results|| |
During the 3-year study period, 2922 medical patients were admitted into the A&E department. These accounted for 57.3% of all A&E admissions (the remaining 42.7% were surgical patients). There were 1679 (57.5%) male patients and 1243 female patients (42.5%); the male-to-female ratio was thus approximately 1.4:1. The age range of the patients was 11-100 years, with a mean of 51.89 ± 20.11 years. The age range for male patients was 13-100 years, with a mean of 53.05 ± 20.17 years. The female age range was 11-100 years with a mean of 50.32 ± 19.91. [Table 1] shows the frequency of admissions during the period under review. The number of male admissions during the entire period was high. [Table 2] shows the age and gender distribution of the patients. With 2385 patients (46.8%), young adults accounted for the highest number of admissions followed by elderly patients (1370; 26.9%). The lowest number was among middle-aged patients (1344; 26.3%).
|Table 1: Admissions to the accident and emergency department between January 2010 and December 2012|
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|Table 2: Age and sex distribution of admissions to the accident and emergency department between January 2010 and December 2012|
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In terms of disease burden, as evident in [Table 3], the most frequent cause of A&E admission was non-communicable diseases (1989 patients; 68.07%), of which cardiovascular disorders ranked first (797; 27.28%). The leading cause of admission was heart failure with 329 patients (41.3%). The outcomes of the patients following admission are shown in [Table 4]: 2601 patients (89.01%) were discharged; there were 88 DAMA patients (3.01%); 66 (2.26%) were referred to other appropriate centers; and 167 (5.72%) died following admission. Among the deaths, there were 88 males (52.7%) and 79 females (47.3%). The commonest cause of death was non-communicable diseases, which accounted for 131 (78.44%) fatalities; among these [Table 5], stroke accounted for the greatest number with 33 patients (19.8%). Severe sepsis topped the list of communicable disease fatalities with 16 patients (9.6%).
|Table 4: Outcome of admissions to the accident and emergency department between January 2010 and December 2012|
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|Table 5: Clinical causes of deaths in the accident and emergency department between January 2010 and December 2012|
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| Discussion|| |
Healthcare in developing countries has not traditionally focused on emergency medical treatment. Fortunately, global health experts are beginning to take a more comprehensive view of health, including providing emergency medical care, than was previously the case.  In Nigeria, most people live in rural areas. The pattern and outcome of A&E admissions in tertiary health centers in rural Nigeria have not been investigated in detail. In this study, we found that over half of the A&E patients in the study area were male. This was consistent throughout the study period and among all age groups (young, middle-aged, and elderly adults). This finding may be related to the demographics in Ekiti State. Males were found predominant in the census figures for both 1991 and 2006 (the most recent censuses).  In addition, men are usually the main source of family income. Therefore, there is a likely tendency to take care of the main provider on priority. Similarly, one study conducted in Ogun State University Teaching Hospital, Sagamu, southwest Nigeria revealed that most women tend to be admitted to hospital once complications have set in.  It is common knowledge among medical experts in Nigeria that women often seek treatment from spiritual healers before seeking hospital treatment. This phenomenon may affect the number of women admitted to hospital. It is also possible that males have better health-seeking behavior than females in the population of Nigeria. The finding of male preponderance with hospital admissions has been documented in a number of studies in both rural and urban centers of Nigeria as well as some other countries around the world. ,,,,,
About half of the A&E patients in the present study were young adults, and there were about equal proportions of middle-aged and elderly patients. The predominance of young adults in A&E admissions may be related to several factors. First, parental care of the young is particularly strong (partly motivated by the parents in old age wishing to be cared for by their children) in the study area, and that may have influenced the findings. Second, the most common disease burden by systemic classification in this study was communicable diseases (CDs); these diseases (HIV/AIDS, malaria, pulmonary tuberculosis, sepsis, and gastroenteritis) are commonly found in young adults rather than other age groups. Last, the relatively reduced life expectancy in the developing world may also affect the number of elderly patients seen among A&E admissions. The age distribution observed in A&E admissions in this study is similar to that reported for urban centers in Nigeria and elsewhere. ,
In the present study, non-communicable diseases (NCDs) were frequently diagnosed compared to CDs. This finding is in contrast to the traditional observation of CD preponderance in developing countries. A lack of awareness and inadequate treatment of traditional risk factors for cardiovascular disease (CVDs) may explain this observation. Furthermore, the increasing adoption of a westernized lifestyle may also have contributed to the finding. In addition, improved personal hygiene and environmental sanitation have taken place in most states in southwest Nigeria, which may have contributed to the reduced frequency of CDs. Another contributing factor may have been the widespread awareness and administration of vaccines. The trend from CDs to NCDs has been reported for the disease burden in urban A&E admissions in Nigeria.  Recent studies on admissions to medical wards have shown similar findings in Spain,  Federal Medical Centre, Asaba, Nigeria,  University of Nigeria Teaching Hospital, Enugu, Nigeria,  and primary health care in rural South Africa. 
In the present study, the commonest NCD was CVD, with heart failure accounting for the most cases. The high prevalence of cardiovascular risk factors, medical ignorance, and poor access to health services and treatment may explain this finding. Many of the patients in the outpatient clinic suffered from arterial hypertension and diabetes mellitus, which may suggest high prevalence in the community. A recent WHO report  indicates that CVD is a leading contributor to the global disease burden.
By systemic classification, infectious diseases were the commonest disease type in the present study. In decreasing order, malaria, sepsis, gastroenteritis, and HIV/AIDS were the leading infectious diseases among A&E admissions. This finding reveals the enormous challenge for developing countries in light of their recent rise in chronic NCDs. Malaria is the leading infectious disease as a result of the environmental conditions that favor malarial infestation. The lack of potable water and safe refuse-disposal methods increases the frequency of gastroenteritis. The use of over-the-counter medication to treat common infections and late presentation may contribute to the high frequency of sepsis. Stigma and discrimination remain high and continue to be a barrier for accessing services related to HIV/AIDS.  The patterns observed in the present study with regard to CDs are similar to those reported in an urban area of Nigeria. 
The low frequency of rheumatology and dermatology cases observed in the present study was probably due to the lack of specialists in those fields in the study hospital; patients with those conditions were therefore not referred to the Federal Medical Centre. Unlike in many parts of the world, poisoning was found to be uncommon in this study. , That may be related to the strong religious faith of Nigerians, whose beliefs are firmly against suicide.
Our findings are in contrast to those reported for an urban center in Nigeria, where the frequency of poisoning was higher.  The low level of industrialization in the rural setting reduces the exposure to chemicals and poisons and contributes to the low incidence of accidental or intentional poisoning. The frequency of snake poisoning reported at the urban center was notably lower than in our study.  This clearly reflects the reduced exposure to snakes in the urban environment and the common type of occupation there (mainly office jobs) compared with rural areas (mainly farming).
In the present study, the outcome following admission was impressive in terms of the number of patients that were successfully treated and discharged. The reasons for referral to this center varied: There were low numbers of referrals in some areas owing to a lack of specialists, such as in dermatology, rheumatology, and advanced cardiology. Other reasons for low numbers of referrals included deficient facilities or skills in treating some conditions. Patients could also request referral to this center because of proximity to a particular caregiver or treatment sponsor. Some DAMA patients lacked the funds to continue with the required treatment. Other DAMA patients acted as they did owing to falsely perceived slow recovery and the desire to obtain better treatment elsewhere. When certain diagnoses are made, such as with cancer or AIDS, some patients lose all hope and prefer to die at home and leave their few resources to their children after death. Some DAMA patients obtain treatment from alternative medical practitioners or spiritual practitioners. This may often occur if a patient is dissatisfied with the pace of recovery, believes that they have a spiritual illness, is diagnosed with a rare condition or is terminally ill.
The most common cause of death in this study was NCD, with CVD accounting for the highest number of fatalities and stroke topping the list. The preponderance of CVD deaths may be related to the poor control and high prevalence of CVD risk factors. In addition, the clustering of risk factors, late presentation or referral, financial constraints, failure to accept treatment owing to medical ignorance, and incorrect interventions before presentation may all have contributed to the number of CVD fatalities. Similar findings to those recorded in this study have been documented for urban populations in Nigeria,  other African countries, and developed nations. , The high stroke mortality may reflect the poor state of hypertension control, which is known to be the most common etiological factor in stroke. , In addition, the lack of access to early computerized tomography scan and fibrinolytic agents as well as failure in early recognition, may all have contributed to the high stroke mortality.
Among CDs observed in this study, sepsis was the leading cause of mortality. This finding contrasts with that in an urban study conducted in the Port Harcourt Teaching Hospital, Nigeria, where HIV/AIDS was the commonest cause of death.  Self-medication, the use of non-standard medicines purchased from drug peddlers, and delay in presentation for infections may account for this finding.
The limitations of the present study are those inherent to retrospective studies, such as incomplete data, lack of some essential information, deficient medical record keeping, and underreporting of cases. There is the further limitation of possible diagnostic errors in the study patients owing to a lack of diagnostic standards and absence of post mortem evidence.
In conclusion, this study found a higher proportion of males among A&E admissions in Ekiti State. About half of those cases were young adults. NCDs, especially CVD, were the most frequent cause of admission. The major cause of death was CVD, mainly stroke. Among CDs, the leading cause of death was severe sepsis. The proportion of fatalities and the number of DAMA patients indicate that improvements need to be made, particularly in the area of early presentation, health education, and improving the financing of healthcare services.
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Dr. Olarinde Jeffrey Ogunmola
Department of Internal Medicine, Cardiac Care Centre, Federal Medical Centre, Ido-Ekiti, Ekiti
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]