The hospital burden of critical illness across global settings: a point-prevalence and cohort study in Malawi, Sri Lanka and Sweden.

Key Points Question: What is the burden of critical illness in hospitals in different global settings, and where are critically ill patients being cared for? Findings: Among 3652 hospitalized patients in countries of different socio-economic levels we found a point-prevalence of critical illness of 12% with a hospital mortality of 19%. Of the critically ill patients 96% were cared for in general wards. Meaning: Critical illness is common in hospitals and has a high mortality. Ensuring that feasible adequate critical care interventions are implemented throughout hospitals could impact a large number of high-risk patients and has potential to improve outcomes across all medical specialties. Abstract Importance: The burden of critical illness may have been underestimated and there is little data showing where critically ill patients receive care. Objective: To assess the adult burden of critical illness in hospitals across different global settings. Design, Setting, and Participants: This was a prospective, observational, hospital-based, point-prevalence and cohort study in Malawi, Sri Lanka and Sweden. On specific days, all adult in-patients in the eight study hospitals were examined by the study team for the presence of critical illness and followed up for hospital mortality. Exposure: Patients with at least one severely deranged vital sign were classified as critically ill. Main Outcomes and Measures: The primary study outcomes were the presence of critical illness and 30-day hospital mortality. In addition, we determined where in the hospitals the critically ill patients were being cared for and the association between critical illness and 30-day hospital mortality. Results: Among 3652 hospitalized patients in countries of different socio-economic levels we found a point-prevalence of critical illness of 12.0% (95% CI, 11.0-13.1), with a hospital mortality of 18.7% (95% CI, 15.3-22.6). The crude odds ratio of death of critically ill compared to non-critically ill patients was 7.5 (95% CI, 5.4-10.2). Of the critically ill patients 96.1% (95% CI, 93.9-97.6) were cared for in the general wards outside Intensive Care Units (ICUs). Conclusions and Relevance: The study has revealed a substantial burden of critical illness in hospitals from different global settings. One in eight hospital in-patients was critically ill, 19% of the critically ill died in hospital, and 96% of the critically ill patients were cared for outside of ICUs. Implementing fundamental low-cost critical care in units and general wards throughout hospitals could impact a large number of high-risk patients and has the potential to improve outcomes across all acute care specialties. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was supported by the Centre for Clinical Research Sormland, Uppsala University, Sweden, Regional Research Council Mid Sweden, Swedish Research Council, the Association of Anaesthetists of Great Britain and Ireland, Travel Grants from Swedish Society of Medicine and Karolinska Institutet, Martin Rinds Stiftelse, Life Support Foundation and Laerdal Foundation. The funders had no role in study design, data collection and analysis, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committees in all study settings gave ethical approval for this work. Malawi: College of Medicine Reserach and Ethics Committee (P.08/16/2007); Sri Lanka: Ethics Review Committee, Faculty of Medicine, University of Kelaniya (P/111/04/2018) and Ethics Review Committee, Faculty of Medicine, University of Jaffna (J/ERC/19/102/NDR/0205); Sweden: Ethical Review Board Stockholm (2017-1907-31-1). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Due to the sensitive nature of the information about severely unwell patients, and the requirements of the College of Medicine Research and Ethics Committee, data from the study are not publicly available. Data can be requested by contacting the corresponding author carl.schell@ki.se including a reasonable motivation for the request for the data and a study plan.