in the past two decades , there has been tremendous growth of intensive care medicine in india . however , there are scant data on the organizational aspects , case mix and practice patterns in indian intensive care units ( icus ) .
most of the available information comes from either single - center studies or studies in specific groups of patients or conditions .
it is essential to have data from several indian icus to reflect the vast and diverse spectrum of critical care illness , services , and practices .
such information may be useful to identify deficiencies in the organization of care and to identify targets for education , clinical improvement , and research .
the data would provide baseline estimates of disease prevalence , severity of illness and mortality , essential for designing research studies .
this multicenter study was planned to gather such information about icus all over india . in order to enable participation from a large number of icus throughout the country
, we used a point prevalence design , obtaining data on four different days over a 1-year period .
this was a multicenter , observational , point prevalence study , performed on four separate days .
all patients present in the icu on july 14 , 2010 , october 13 , 2010 , january 12 , 2011 and april 13 , 2011 were included in the study .
these days were the second wednesdays in the 1 month of each quarter and were representative of the major seasons .
data were recorded for all patients present in the icu during the 24 h starting 08.00 am on the study day to 08.00 am next day .
the first time an icu joined the study , data about the icu was recorded .
a closed icu was defined as one in which final orders for the patient were written by the icu team ; an open icu was defined as one in which care of the patient was directed by non - icu doctor teams , and orders could be written by non - icu team doctors .
a center was considered adequately equipped if all the following facilities were available either in the icu or in the hospital : renal replacement therapy ( rrt ) , computerized tomography scan , microbiology , biochemistry and hematology laboratories , echocardiography and cardiac catheterization laboratory .
facilities available in the intensive care unit and hospital in 120 centres intensive care unit characteristics data collected for each patient included the following : 
 primary reasons for icu admission , source of admission , demographics , patient characteristics and comorbidities as listed in tables 3 and 4 .
admission was defined as surgical if the patient was admitted to the icu from the operation theatre or recovery room .
elective surgery was defined as a surgical procedure which was planned more than 24 h prior to icu admission .
emergency surgery was defined as a surgical procedure before icu admission which was planned < 24 h in advance .
the primary reason for icu admission was the single most applicable diagnostic category based on the acute physiology and chronic health evaluation ( apache ) iii classificationage , physiological parameters , and comorbidities used to calculate the apache ii score and sequential organ failure assessment ( sofa ) score .
physiological variables were the worst recorded values during the 24-h study period . when data for any parameter required calculation of the apache ii and sofa score was missing , that parameter was assumed to be normal .
a sofa score of 3 or 4 for any individual organ was used to identify organ failureinterventions are listed in table 5presence of infection ( suspected or proven infection at icu admission or during the 24-h study period ) ; severe sepsis or septic shock ( svspss ) at any time during the patient 's icu stay ; suspected or proven tropical infections ( malaria , dengue , leptospirosis , scrub typhus ) ; microrganisms , and antibiotic therapy .
primary reasons for icu admission , source of admission , demographics , patient characteristics and comorbidities as listed in tables 3 and 4 .
admission was defined as surgical if the patient was admitted to the icu from the operation theatre or recovery room .
elective surgery was defined as a surgical procedure which was planned more than 24 h prior to icu admission .
emergency surgery was defined as a surgical procedure before icu admission which was planned < 24 h in advance .
the primary reason for icu admission was the single most applicable diagnostic category based on the acute physiology and chronic health evaluation ( apache ) iii classification age , physiological parameters , and comorbidities used to calculate the apache ii score and sequential organ failure assessment ( sofa ) score .
when data for any parameter required calculation of the apache ii and sofa score was missing , that parameter was assumed to be normal .
a sofa score of 3 or 4 for any individual organ was used to identify organ failure interventions are listed in table 5 presence of infection ( suspected or proven infection at icu admission or during the 24-h study period ) ; severe sepsis or septic shock ( svspss ) at any time during the patient 's icu stay ; suspected or proven tropical infections ( malaria , dengue , leptospirosis , scrub typhus ) ; microrganisms , and antibiotic therapy .
primary reason for intensive care unit admission patient demographics , intensive care units admission characteristics and severity of illness * survival status at icu discharge was recorded within 30 days from the day of the study .
patients discharged alive from icu were followed up till hospital discharge , or 30 days from the day of the study , whichever was earlier . for patients dying in the icu , investigators were asked to record whether any form of limitation of treatment occurred .
terminal discharges ( tds ) from icu to a location outside the hospital , either on family or patient request , as well as those documented as left against medical advice , were also recorded .
nonsurvivors were patients who died in the icu as well as those who were tds within 30 days from the day of the study .
secondary outcomes were as follows : hospital mortality , defined as a composite of those who died in the hospital and tds from the icu within 30 days from the day of the study , and icu and hospital lengths of stay , till 30 days from the study day .
the standardized mortality ratio ( smr ) using the hospital mortality and that predicted by apache ii was calculated for those patients who were admitted to the icu within 24 h of the study day . for calculation of icu and hospital length of stay , missing data
analysis was confined to data from adult patients ( > 16 years of age ) .
continuous variables were compared with the use of the student 's t - test , analysis of variance , mann - whitney test or the kruskal - wallis test .
multivariate binary logistic regression analysis was performed to determine the independent predictors of icu mortality .
a stepwise forward conditional multivariate analysis was performed with icu characteristics , patient factors , and interventions found to be statistically significant in the univariate analyses .
analysis was confined to data from adult patients ( > 16 years of age ) .
continuous variables were compared with the use of the student 's t - test , analysis of variance , mann - whitney test or the kruskal - wallis test .
multivariate binary logistic regression analysis was performed to determine the independent predictors of icu mortality .
a stepwise forward conditional multivariate analysis was performed with icu characteristics , patient factors , and interventions found to be statistically significant in the univariate analyses .
analysis was confined to data from adult patients ( > 16 years of age ) .
continuous variables were compared with the use of the student 's t - test , analysis of variance , mann - whitney test or the kruskal - wallis test .
multivariate binary logistic regression analysis was performed to determine the independent predictors of icu mortality .
a stepwise forward conditional multivariate analysis was performed with icu characteristics , patient factors , and interventions found to be statistically significant in the univariate analyses .
data analysis was done for adult patients ( n = 4038 ) from 120 icus . details of participation are provided in the supplementary tables 14 .
about 81 centers ( 67.5% ) were considered adequately equipped , whereas 29 ( 32.5% ) were categorized as  not adequately equipped . 
patients in medical icus had significantly higher severity of illness and mortality compared to patients in other types of icus .
more than half the number of participating icus had a patient - nurse ratio of two or less patients per nurse .
the primary apache iii diagnostic categories are summarized in table 3 , and patient demographics , severity of illness , and outcomes are detailed in table 4 .
almost 546 patients died in the icu , and 183 patients were tds from the icu .
the hospital mortality was 21.7% and included 694 patients who died in hospital and 183 tds .
median length of icu stay was 6 ( interquartile range [ iqr ] 3 - 13 ) days , with significantly longer stays in nonsurvivors than in icu survivors [ table 2 ] .
figures 1 and 2 show the distribution of apache ii scores and number of organ failures with the associated mortality .
almost 53.6% patients did not have any organ failure on the study day ; mortality was 8.3% in these patients .
distribution of acute physiology and chronic health evaluation ii scores ( number of patients in vertical bars on the y1 axis ) and mortality rate ( solid line on the y2 axis ) distribution of organ failures ( number of patients in vertical bars on the y1 axis ) and mortality rate ( solid line on the y2 axis ) a subset of 1718 patients were admitted within 24 h of a study day , of which 1627 patients could have an apache ii diagnostic category assigned to enable calculation of the predicted mortality . of these
, 428 patients were predicted to die in hospital , whereas the observed hospital mortality was 286 .
apache ii over predicted mortality at scores above 19 , as seen in figure 3 .
observed mortality ( solid line ) versus acute physiology and chronic health evaluation ii predicted mortality ( dashed line ) on the y2 axis in 1627 patients .
horizontal bars denote number of patients ( y1 axis ) mortality was higher in inadequately equipped icus compared to well - equipped icus ( 27.8% vs. 20.8% , p < 0.001 ) , despite similar apache ii scores .
medical admissions accounted for 77.1% of admissions ; they had a higher severity of illness than surgical admissions and a significantly higher mortality .
similarly , mortality was significantly higher for admissions after emergency surgery than elective surgery [ table 3 ] .
almost 124 patients were admitted after poisoning or drug overdose , including 72 organophosphorus or organochlorine poisoning , 5 snake bites and 21 unknown toxins .
a sub - group of 1144 patients ( 28.3% ) had svspss during the icu stay , with mortality of 34.0% .
about 12.2% patients developed an infection during their icu stay and 1455 patients had a suspected or confirmed infection during the 24-h study period .
microbiological cultures and other tests for microbial identification were obtained in 2039 patients , and positive results were obtained in 35.9% .
overall , 1077 organisms were identified : 68.9% gram - negative organisms , 15.9% gram - positive organisms , 7.5% fungi , 2.4% mycobacteria , 1.7% viruses , and 1.1% malarial parasites .
various interventions in the icu are detailed in table 5 . on the study day , 5342 antibiotics were given to 72.4% patients , while 4.7% patients received antimalarials .
about 60.7% of 2583 patients who did not have a suspected or confirmed infection on the study day received antibiotics , whereas 6.7% of the 1455 patients with a suspected or confirmed infection on the study day did not receive antibiotics . about 56.0% of medical patients and
72.3% of surgical patients received antibiotics without having a suspected or confirmed infection on that day . in patients receiving antimicrobials ,
patients receiving invasive mechanical ventilation ( mv ) , vasopressors or inotropes ( vis ) , and rrt had significantly higher mortality than those who did not ( 35.6% vs. 11.1% , p < 0.001 ; 36.1% vs. 12.9% , p < 0.001 ; and 31.5% vs. 16.2% , p < 0.001 , respectively ) . in 898 patients receiving vis , arterial and central venous catheters
were inserted in 46.7% and 71.4% patients , respectively , and cardiac output and lactate levels were measured in 10.9% and 18.8% patients , respectively .
normal saline was the preferred fluid in more than 86% of the 1085 patients that received a fluid bolus .
the results of the multivariate analysis of organizational and patient characteristics , severity of illness , and need for interventions are summarized in table 6 .
the apache ii and sofa scores , public hospital icus , medical icus , inadequately equipped icus , medical admission , self - paying patient , the presence of svspss shock , acute respiratory failure ( pao2 /fio2 ratio < 300 ) or cancer , and the need for a fluid bolus and mv were independent predictors of mortality .
patients had moderate severity of illness , as evidenced by an apache ii and sofa scores of 17.4  9.2 and 3.8  3.6 , respectively .
this widespread practice of tds is contrary to that reported in one single center study and one study of end - of - life care practices in four hospitals in mumbai .
it suggests that end - of - life care in indian icus may be suboptimal and is probably related to the unresolved legal status of withholding and withdrawal of life - sustaining treatments in critically ill patients in india .
it may also perhaps reflect a small proportion of cases in which the patients or families wishes to have a peaceful death at home were respected .
we assumed that all tds from the icu eventually died and included these in the icu mortality .
admittedly , while a small proportion of tds may have survived , merely counting the number of patients who died in icu would underestimate the number of nonsurvivors .
the low smr observed in a subset of patients in this study must be interpreted with caution .
it may reflect the quality of care , but could also be due the visibly poor calibration of apache ii .
variables such as the glasgow coma scale may have been inaccurately recorded in sedated patients , with resultant erroneously high apache ii scores .
our mortality in patients with apache ii scores above 19 and in patients with 3 or more organ failures was lower than that predicted by apache ii or that observed by vincent et al . in their study of the sofa score .
a formal evaluation of apache ii as well as other scoring systems is necessary to determine the scoring system that works best in our circumstances .
our overall icu mortality rate of 18.1% was higher than the 16.2% rate observed in the intensive care over nations ( icon ) audit .
our icu mortality of 34.0% from svspss was similar to the 36.7% mortality in a multicenter study of 150 icus from 16 asian countries .
however , it was higher than that reported in the impress study ( 28.4% globally and 30.8% for asia ) and in the icon study ( 258% ) . in mechanically ventilated patients , mortality of 33.8% in our study was more than the 28% mortality reported in the third international survey on mv .
thus , improvements are required in the organization and delivery of critical care in indian icus .
it is essential to increase health insurance plans and government schemes to reduce the economic burden on individuals and families .
absence of adequate facilities in the hospital may lead to inadequate or delayed care or may necessitate transport that may increase the risk of complications , with consequent increase in mortality .
a study by parikh and karnad in a large public hospital icu in mumbai had an observed mortality of 36% , smr of 1.67 and lower intensity of interventions .
this could represent either variations in case mix and clinical practice or could reflect inadequate facilities as well as patients inability to afford expensive interventions .
perhaps , greater spending to attain higher levels of care in terms of equipment , drugs , interventions , staffing , and organization may lead to better outcomes with greater cost - effectiveness . a more detailed analysis that includes costs and the participation of more public hospital icus is essential to answer these questions .
the presence of a training program in critical care medicine was not associated with improved outcome on multivariate analysis .
a majority of the programs were of 1-year duration , and there have been variations in the intensity and quality of training between the accredited icus .
the content and structure of the program , as well as the accreditation process , may need to be reviewed .
we defined a closed icu as one where the final orders were written by the intensive care team .
this includes the completely closed model , the semi - closed , transitional , or mandatory consult model or the high - intensity multidisciplinary care models .
studies of the impact of high - intensity models on outcome have shown mixed results , with several studies showing improved mortality and better resource utilization , some showing no effect and one showing higher mortality . however , we were unable to demonstrate that closed units were associated with lower mortality , and this study was not designed to detect other benefits of a closed icu model .
this study confirms that gram - negative infections are predominant in india ( 69% ) , as opposed to gram - positive infections in western countries .
while antibiotics were given in 60.7% of noninfected patients , some patients may have been completing their course of antibiotics , and a proportion of noninfected surgical patients may have received antibiotics as perioperative prophylaxis . nevertheless , these data suggest that infection control practices and antibiotic stewardship need to be strengthened in indian icus . in patients receiving vis ,
insertion of arterial catheters , cardiac output monitoring and estimation of lactate levels were infrequently performed , perhaps because monitoring was not either available or was not utilized .
arguably better - performing icus that were motivated and willing to share data contributed to the study , while icus with poor performance did not .
only 11% of icus and 10% patients were from the public sector , but this may represent the general distribution of icus between the private and public sectors in india . source data verification was not performed .
we assumed that the investigators correctly applied the definitions and diagnostic criteria for sepsis and other conditions such as malaria , dengue fever , etc .
, some data were incomplete , especially for the length of icu stay and hospital stay .
however , there was no systematic exclusion of data , and the information obtained would still remain valuable .
we were unable to obtain data on physician staffing patterns , protocols and night - time coverage by intensivists .
the strengths of this study include a large number of icus and patients from all regions of the country and from different types of icus .
data from this study can be used to determine the prevalence of different conditions in indian icus , as well as to determine the baseline mortality rates in important subgroups of patients , e.g. , 34.0% in patients with svspss , 33.8% and 36.1% in patients requiring mv and vis , respectively .
we did not estimate the smr from the apache ii score for all patients as we calculated the score on the study day , and not in the first 24 h of icu admission .
however , we did estimate the smr for those patients whose apache scores were calculated within 24 h of icu admission .
we only analyzed data from adult patients as there were only 171 children in the database .
this multicenter , point - prevalence study of 4038 adult patients from 120 icus is a snapshot of intensive care in india .
highlights include a moderate severity of illness with relatively high mortality in patients with severe sepsis and septic shock , patients on vasopressors or inotropes or receiving mechanical ventilation .
antibiotics are often given in noninfected patients , monitoring practices in seriously ill patients can be improved .
self - paying patients , public hospitals icus , and inadequately equipped icus are independently associated with a worse outcome .
terminal discharge from the icu is widely practiced and legal , social , and other issues related to end - of - life care need to be resolved .
 aims : to obtain information on organizational aspects , case mix and practices in indian intensive care units ( icus).patients and methods : an observational , 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 icus . 
 icu and patient characteristics , and interventions were recorded for 24 h of the study day , and outcomes till 30 days after the study day . 
 data were analyzed for 4038 adult patients from 120 icus.results:on the study day , mean age , acute physiology and chronic health evaluation ( apache ii ) and sequential organ failure assessment ( sofa ) scores were 54.1  17.1 years , 17.4  9.2 and 3.8  3.6 , respectively . 
 about 46.4% patients had 1 organ failure . 
 nearly , 37% and 22.2% patients received mechanical ventilation ( mv ) and vasopressors or inotropes , respectively . 
 nearly , 12.2% patients developed an infection in the icu . 
 about 28.3% patients had severe sepsis or septic shock ( svspss ) during their icu stay . 
 about 60.7% patients without infection received antibiotics . 
 there were 546 deaths and 183 terminal discharges ( tds ) from icu ( including left against medical advice or discharged on request ) , with icu mortality 729/4038 ( 18.1% ) . in 1627 
 patients admitted within 24 h of the study day , the standardized mortality ratio was 0.67 . 
 the apache ii and sofa scores , public hospital icus , medical icus , inadequately equipped icus , medical admission , self - paying patient , presence of svspss , acute respiratory failure or cancer , need for a fluid bolus , and mv were independent predictors of mortality.conclusions:the high proportion of tds and the association of public hospitals , self - paying patients , and inadequately equipped hospitals with mortality has important implications for critical care in india . 