The Unmet Critical Care Burden at a Central Hospital in a Resource-Limited Setting: A Point Prevalence Study

Abstract

Introduction: The unmet burden of critical illness in low-resource settings is unknown. The Modified Early Warning Score (MEWS) is a validated tool that quantifies patient risk for critical illness and higher level of care. This study evaluates the burden of critical illness outside of the ICU using MEWS and predictors of mortality among adult inpatients at a central hospital in Malawi, where ICU capacity is limited.

Methods: We conducted a prospective cohort study among adult inpatients (≥ 13 years) across medical, surgical, and obstetrics-gynecology wards. MEWS was used to assess critical illness based on respiratory and heart rates, temperature, systolic blood pressure, and mental status. Data were collected over three days in 2024, with follow-ups on Day 7 and Day 30. Statistical analyses included chi-squared, Mann-Whitney, and logistic regression.

Results: Among 315 patients, 62.9% were female, median age was 33 (24-48) years, and 17.5% met critical illness criteria outside of an ICU setting. Critically ill patients had significantly higher inhospital mortality (18.2% vs. 5.4% and p = 0.001) and 30-day mortality (20% vs. 7.3% and p = 0.004). Increasing MEWS strongly predicted mortality (OR = 1.38, 95% CI [1.15, 1.65], and p = 0.001). MEWS is the strongest predictor of critical illness in surgical patients, with the highest mortality increase compared to medicine patients who had similar mortality between both groups.

Conclusion: There is a high-unmet burden of critical illness outside of the ICU in our setting, with a resulting high mortality. MEWS effectively stratifies patient risk, particularly in surgical patients. Early identification and intervention and increasing critical care capacity are imperative.