International Journal of Surgery 8 (2010) 381e383

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International Journal of Surgery

journal homepage: www.theijs.com

Mortality pattern in the surgical wards: A ve year review at Federal Medical

Centre, Owerri, Nigeria
Anelechi B. Chukuezi*, a, Jones N. Nwosu
Department of Otolaryngology, Imo State University Teaching Hospital, P.M.B 8, Orlu Imo State, Nigeria

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To identify deaths in the surgical wards, elicit the cause of death and suggest changes that will
Received 1 April 2010 ensure improved surgical care of patients and outcome.
Received in revised form Study design: Retrospective.
27 April 2010
Methods: Records collected from the theatre operation registers, ward registers and case notes of all
Accepted 18 May 2010
patients who were admitted into the surgical wards Federal Medical Centre, Owerri whether elective or
Available online 9 June 2010
emergency from January 1997 to December 2001 were reviewed. Data extracted included date of
admission, age, sex, educational status, residence; surgical diagnosis and clinical cause of death Data
Keywords:
Mortality
obtained were analyzed and presented in tabular and descriptive forms.
Surgical wards Results: There were 4583 surgical admissions in all the surgical wards of which males were 2751 and
Pattern females 1832. During this period there were 419 deaths with an overall death per admission crude
Review mortality rate of 9.14%. The leading causes of death were acute abdomen (22.20%), RTA with head injury
(18.14%) and malignances (14.56%). Of the 419 deaths males were 305 (72.79%) and females 114 (27.21%)
in a ratio of 2.68:1.
Conclusion: Aggressive enlightenment and healthcare campaigns, health education, improvement of
healthcare facilities and accessibility to healthcare facilities are highlighted. Structured study in the
management of surgical cases is emphasized.
2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction there is a dearth of information concerning this in the West Africa

Surgery is performed in every community: wealthy and poor,
rural and urban. Although surgical care can prevent loss of life or
limb, it is also associated with a considerable risk of complications
and death.1 Surgical care is an integral part of healthcare
throughout the world, with an estimated 234 million operations
performed annually.2 Mortality is an inevitable complication of
surgery. Among the sick, mortality could be due to medical or
surgical reasons; medical or surgical errors; delay in treatment and
error in judgment; limited hospital resources and poor infrastruc-
tures on the ground. Audit of pattern of mortality entails
a systematic, critical analysis of the quality of care, including the
procedures used for diagnosis and treatment, the use of resources,
and the resulting outcome and quality of life for the patient. The
quality of care could be improved through audit or surveillance.
Studies from various parts of the world on surgical mortality3e9
deal with surgical audit from different perspectives. However,
* Corresponding author. Tel.: 234 8033410504.
E-mail address: fortbarn@yahoo.com (A.B. Chukuezi).
a
Former Consultant ENT Surgeon, Federal Medical Centre, Owerri, Nigeria.
sub-region. This study which is a review of mortality pattern in the
surgical wards is intended to bridge this gap whether an operation
has taken place or not within the period under study, elicit the
possible causes of death and consider trends that will improve the
mortality rate which can be implemented. The study was done to
elucidate the spectrum of surgical admissions in a tertiary hospital
in eastern Nigeria. It is a retrospective study to determine in-
hospital mortality rate.
2. Materials and methods
Records collected from the theatre operation registers, ward
registers and case notes of all patients who were admitted into the
surgical wards whether elective or emergency of Federal Medical
Centre, Owerri from January 1997 to December 2001 were
reviewed. Data extracted included demographics, date of admis-
sion, age, sex, educational status, residence, surgical diagnosis and
clinical cause of death. All deaths in the surgical wards whether an
operation has taken place or not were included in the study.
Surgical deaths in the A&E or other location in the hospital that
have not been formally admitted into the wards were excluded in

1743-9191/$ e see front matter 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2010.05.010
382 A.B. Chukuezi, J.N. Nwosu / International Journal of Surgery 8 (2010) 381e383

Table 1 Table 3
Sex distribution of patients. Residence of mortalities.

Sex Frequency Percentage (%) Year Urban dwellers Rural dwellers

Male 305 72.79 1997 21 40
Female 114 27.21 1998 22 44
1999 28 65
Total 419 100.00
2000 36 60
2001 21 82

Total 128 (30.55%) 291(69.45%)

the study. The data obtained were analyzed using SPSS version 11
software and presented in tabular and descriptive forms.
Table 4
3. Results Educational status.

Between January 1997 and December 2001 there were 4583
surgical admissions in all the surgical wards of the Federal Medical
Centre, Owerri of which males were 2751 and females 1832. During
this period there were 419 deaths with an overall death per
admission crude mortality rate of 9.14%. Of the 419 deaths males
were 305 (72.79%) and females 114 (27.21%) in a ratio of 2.68:1
(Table 1). Table 2 shows the age distribution. Majority of mortalities
271 (64.44%) were below 50 years. Two hundred and ninety one,
291 (69.45%) of these mortalities, were rural dwellers (Table 3). The
educational status of the mortalities is shown in Table 4. 351
(83.77%) of them had secondary education and below of which
241of them were rural dwellers. 356 (84.96%) of the patients were
offered surgical intervention while 63 (15.04%) had conservative
management (Table 5). Of the 356 that had surgical intervention, 8
(1.91%), died on table due to anaesthetic problems. The most
frequent clinical condition of the patients was acute abdomen
(22.20%) followed by RTA with head injury (18.14%) and malignant
conditions (14.56%) of which Ca breast was the most prominent
(Table 6).
4. Discussions
The surgical mortality in our study is 9.14%. This compares
favourably with a similar study by Ihegihu et al.10 of a four year
retrospective study reviewing in-hospital surgical mortality at
Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria who
recorded surgical mortality of 8.3%. In a prospective study of 505
patients aged 65 years or over admitted to a general surgical unit
the overall hospital mortality rate was 14.5% and the post-operative
mortality rate 12.0%. These rates fell to 3.6% and 5.8% respectively
when deaths in non-viable patients were excluded from the anal-
ysis.4 McDonald et al.3 reported mortality rate of 2.3%, approxi-
mately four-fold of the death rate in our study. In a prospective
study the indices are mapped out in advance and audit was done in
stages, monthly and annually before totaling the results. The
progress of the patients is monitored throughout their admission.
The concept of viable and non-viable deaths4 was applied. An audit
of surgical outcome that fails to identify non-viable patients is
Table 2
Age distribution of mortalities.
Type Frequency %
Primary 162 38.66
Secondary 189 45.11
Tertiary 41 9.79
Unknown 27 6.44
Total 419 100
potentially misleading. The study thus proposed a standardized
system of reporting surgical mortality to aid comparison of results
from different units. The key elements of the system were stated as
(a) the separation of the results non-viable and potentially viable
patients; (b) the consideration of both operative and non-operative
mortality; (c) the differentiation between medical and surgical
causes of post-operative mortality. Data presented in such a way
should be of direct relevance to surgeons and physicians who are
seeking ways of improving the services provided to surgical
patients. Comorbidity is an important element that should be
considered in the study. Semmens et al.5 found that 91% of patients
who died in their study had signicant comorbidities that
increased the risk of death. In our study the death pattern cuts
across all age groups showing that age was not a determining
factor. However majority of deaths were below 50 years. The life
expectancy in Nigeria is 47 years. 1.91% of the deaths were due to
anaesthetics error. The three topmost list of clinical conditions
leading to death were acute abdomen (22.20%), RTA with head
injury (18.14%) and malignancies (14.56%). 31.74% of the patients
did not have any form of operative intervention and most of the
patients presented late and were in poor clinical state. Majority of
them (69.45%) came from the rural areas and were responsible for
69.45% of those that had secondary education and below. Poor
education, lack of or delayed access to surgical facility as well as
poverty contributed in more deaths in the surgical wards. This is
not surprising as the range and type of surgery performed on a unit
will tend to affect the number of deaths that are assigned to non-
viable or potentially viable categories. A head injury has been
mentioned as the most common injury condition leading to
death.11 Recognizing the importance of audit, attempts have been
made and suggestions to produce a checklist to reduce morbidity
and mortality9 as well as administrative data for continuous clinical
quality assurance.6 In conclusion the study has highlighted the

Age group Frequency Percentage (%) Table 5

0e10 53 12.65 Type of management.
11e20 50 11.93
21e30 63 15.04 Year Conservative Surgical
31e40 46 10.98 1997 18 59
41e50 58 13.84 1998 24 51
51e60 43 10.26 1999 25 65
61e70 75 17.90 2000 42 69
>70 31 7.40 2001 34 62

Total 419 100.00 Total 133 (31.74%) 286 (68.26%)

 A.B. Chukuezi, J.N. Nwosu / International Journal of Surgery 8 (2010) 381e383 383

Table 6 no doubt that surgeons working in these countries have limita-

Clinical conditions/aetiology of the patients. tions. These limitations are preventable. Aggressive enlighten-
Clinical condition Frequency Percentage ment healthcare campaigns, health education, improvement of
Acute abdomen 95 22.68 poor healthcare facilities, alleviation of poverty as well as
RTA with head injury 76 18.14 improvement on accessibility to healthcare facilities and political
Malignancies 67 15.99 will by government to improve on surgical infrastructure, will
Trauma 58 13.84
help in reduction of in-hospital surgical mortality rate the
Diabetic complications 30 7.15
Burns 27 6.44 hospitals.
Hernia 13 3.10
Septicemia 9 2.15 Conict of interest
Benign PH 8 1.91 There is no conict of interest.
Appendicitis 8 1.91
Cellulitis 5 1.00 Funding
Fistula 4 0.95
There is no conict of interest.
Undescended testis 4 0.95
Coma 2 0.47
Ethical approval
Myositis 2 0.48
Abscess 2 0.48 No ethical approval was given but committee on research gave
Foreign body 2 0.48 approval as it is a retrospective study.
Potts disease 1 0.23
HIV 1 0.23
Typhoid perforation 1 0.23
Orchitis 1 0.23
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