Ikenna Stanley Ilo^1,3, Doris Ifeyinwa Ilo¹*, Isaac Sunday Chukwu², Onyinye Nathan Mbawike⁴, Victor Obidike Adindu¹, Chukwuebuka Somto Aneke¹, Godwin Onyemachi Alaede^1
1 Department of Anaesthesia, Federal Medical Centre Umuahia, Nigeria
² Department of Surgery, Federal Medical Centre Umuahia, Nigeria
³ Gregory University Uturu, Abia State, Nigeria
⁴ Alex Ekwueme Teaching Hospital Abakaliki, Ebonyi State, Nigeria

Corresponding author: Doris Ifeyinwa Ilo

DOI: https://doi.org/10.55320/mjz.53.3.1089

Keywords: Intensive Care Units; Critical Care; Hospitalization; Neurosurgery; General Surgery; Trauma; Resource-Limited Settings; Nigeria.

Background: Intensive care unit (ICU) admission patterns reflect the burden of critical illness and guide resource allocation. Data from tertiary centres in Nigeria remain limited, particularly in the South-East.

Objectives: This study described the demographic profile, specialty referral patterns, diagnostic distribution, temporal trends, outcomes, and ICU length of stay at Federal Medical Centre, Umuahia, over five years.

Methods: A retrospective review of all ICU admissions from January 2020 to December 2024 was conducted. Data on demographics, referring specialty, primary diagnosis, annual volumes, outcomes, and length of stay were analysed descriptively.

Results: A total of 778 patients met inclusion criteria. The mean age was 39.0 ± 23.7 years, with males predominating (56.7%). Age distribution was as follows: 0–17 years, 21.2% (n = 165); 18–39 years, 31.1% (n = 242); 40–59 years, 23.1% (n = 180); and ≥60 years, 24.6% (n = 191). Adults (≥18 years) comprised 78.8% of admissions overall. Annual admissions increased from 85 in 2020 to 308 in 2023, then declined to 119 in 2024.

Neurosurgery was the leading specialty (29.9%; 95% CI: 26.8–33.3), followed by general surgery (19.2%) and internal medicine (15.0%). Severe traumatic brain injury was the most frequent diagnosis (10.29%), followed by sepsis (9.90%) and cerebrovascular accident (6.04%). Neurological/neurosurgical conditions accounted for 30.33% (n = 236) of admissions.

Overall ICU mortality was 45.1% (n = 351), with survival in 54.9% (n = 427). Mortality was higher among paediatric patients (49.7%) than adults (43.9%). ICU stay was right-skewed (Shapiro–Wilk p<0.05), median 5.0 days (IQR: 3.0–11.0), mean 8.8 ± 10.7 days, maximum 48 days.

Conclusion: ICU admissions were dominated by young adult males, surgical referrals, and neurotrauma. Mortality remained high, especially in paediatrics, with variable but typically short ICU stays, underscoring the need for strengthened critical care capacity.

Intensive care units (ICUs) provide advanced monitoring and life-sustaining interventions for critically ill patients and constitute an essential component of tertiary hospital care.^[1] Globally, ICU utilisation reflects the burden of critical illness across specialties, the referral practices of institutions, and the availability of critical care resources. Whilst high-income countries maintain between 5 and 30 ICU beds per 100,000 population, resource-limited settings in sub-Saharan Africa operate with as few as 0.1 to 2.5 beds per 100,000 people, resulting in marked disparities in access to critical care.^[2] This infrastructural deficit is particularly pronounced in Nigeria, where a national survey of ICU services across 30 units identified low bed capacity, deficits in haemodynamic monitoring equipment, and an acute shortage of trained intensivists as recurring challenges across both public and private facilities.^[3] Prior to the COVID-19 pandemic, Nigeria had an estimated 350 ICU beds serving a population exceeding 200 million — equivalent to fewer than two beds per million people — underscoring the severity of this capacity gap.^[4]

Within this constrained environment, surgical specialties — particularly neurosurgery, trauma, and general surgery — have emerged as major drivers of ICU demand in Nigerian tertiary hospitals, reflecting the high burden of road traffic injuries, traumatic brain injury, and acute abdominal emergencies.^{[5] [6]} Medical specialties, including internal medicine and infectious diseases, also contribute substantially, given the coexisting burden of communicable and non-communicable diseases.^[7] Understanding the specialty-specific distribution of ICU admissions is therefore critical for evidence-based resource allocation, workforce planning, and the prioritisation of critical care infrastructure in settings where resources must be rationed.^[8]

Published data on ICU admission patterns in Nigeria remain sparse and are largely concentrated in a small number of centres in the South-West and South-East geopolitical zones, including reports from Jos, Enugu, Calabar, and Lagos.^{[5] [6]} Federal Medical Centre (FMC) Umuahia, the sole federal tertiary hospital in Abia State and a major referral centre for the South-East zone, has not previously been the subject of a systematic critical care audit. This knowledge gap limits the ability of hospital administrators and health policymakers to make evidence-informed decisions regarding ICU capacity and specialty prioritisation at this institution. This study therefore aimed to describe the demographic profile, specialty distribution, diagnostic case mix, temporal trends, outcomes, and ICU length of stay at FMC Umuahia over a five-year period, and to identify the specialties contributing the greatest burden of ICU utilization.

Study Design and Setting

This was a retrospective descriptive study of ICU admissions at Federal Medical Centre (FMC), Umuahia, Abia State, Nigeria, conducted over five years from 1 January 2020 to 31 December 2024.

FMC Umuahia is a tertiary referral hospital serving Abia State and neighbouring states in South-East Nigeria. The ICU is a multidisciplinary unit managing critically ill medical, surgical, obstetric, paediatric, and trauma patients. During the study period, the unit comprised 8 beds and operated as an open-type unit, equipped with 6 ventilators, 1 dialysis machine, and 8 multiparameter monitors. Staffing included anaesthesiologists, resident doctors, critical care nurses, and allied health professionals, with five nurses on day shift and three on night shift. Admission was prioritised for patients requiring mechanical ventilatory support, invasive haemodynamic monitoring, post-operative stabilisation, or management of life-threatening emergencies; when demand exceeded capacity, clinician-led triage based on clinical urgency and anticipated benefit guided allocation. Formal severity-of-illness scoring was not consistently applied due to resource constraints. Bed occupancy ranged from 2 to 7 of the 8 available beds throughout the study period.

Study Population

The study population comprised all patients admitted to the ICU during the study period.

Inclusion Criteria

All patients admitted between 1 January 2020 and 31 December 2024 with complete records on age, sex, admitting specialty, primary diagnosis, and outcome.

Exclusion Criteria

Records with incomplete or missing data on one or more key study variables (n = 98) and repeat ICU admission episodes classified as readmissions (n = 8) were excluded.

A total of 884 ICU admissions were identified. Of these, 106 records were excluded — 98 due to incomplete data and 8 repeat admission episodes classified as readmissions — leaving 778 admissions for final analysis. Outcome by referring specialty, mechanical ventilation rates, and organ support utilisation were not consistently documented and were therefore excluded from analysis.

Variable Definitions

Age at admission was categorised into four non-overlapping groups: paediatric patients (0–17 years), young adults (18–39 years), middle-aged adults (40–59 years), and older adults (≥60 years). Patients were also classified into paediatric (<18 years) and adult (≥18 years) groups for outcome summaries. Variables extracted included age, sex, mortality, length of stay, admitting specialty, primary diagnosis, and year of admission. Low-frequency specialties were grouped as "Others."

Data Collection

Data were retrieved from ICU admission registers, patient case records, discharge summaries, and hospital databases using a structured extraction form, cross-checked by trained investigators for completeness and consistency.

Statistical Analysis

Data were analysed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Categorical variables were summarised as frequencies and percentages; continuous variables as means ± standard deviations or medians. Normality was assessed using the Shapiro–Wilk test; length of stay was right-skewed (median reported) whilst age was normally distributed. Temporal trends were examined descriptively by calendar year from 2020 to 2024; no formal statistical test for trend was performed. Ninety-five percent confidence intervals for specialty-specific proportions (Table 3) were calculated using the Wilson score method, which was preferred over the uncorrected Wald interval given the small counts recorded for several specialties (e.g., mental health and family medicine, n = 1 each).

Ethical Considerations

Ethical approval was obtained from the Health Research Ethics Committee of FMC Umuahia (Protocol No. FMC/QEH/G.596/Vol.10/927). Informed consent was waived given the retrospective design. All data were anonymised in compliance with the Declaration of Helsinki. This study was reported in accordance with the STROBE guidelines.

A total of 884 ICU admissions were identified during the study period; 106 records were excluded (98 due to incomplete data, 8 repeat admission episodes classified as readmissions), leaving 778 admissions for final analysis. The mean age was 39.0 ± 23.7 years. By age group, patients aged 0–17 years accounted for 21.2% (n = 165), 18–39 years for 31.1% (n = 242), 40–59 years for 23.1% (n = 180), and ≥60 years for 24.6% (n = 191). Male patients predominated (56.7%; n = 441). Adults (≥18 years) constituted 78.8% (n = 613) of admissions, whilst paediatric patients (<18 years) accounted for 21.2% (n = 165). The overall ICU mortality rate was 45.1% (n = 351), with 427 patients (54.9%) surviving to discharge. Mortality was higher among paediatric patients (49.7%) than adults (43.9%). ICU length of stay was right-skewed (Shapiro–Wilk p<0.05); median 5.0 days (IQR: 3.0–11.0), mean 8.8 ± 10.7 days, maximum 48 days. These findings are summarised in Table 1.

Table 1: Demographic Characteristics, Outcomes, and Length of Stay (n = 778)

Annual admissions increased from 85 in 2020 to a peak of 308 in 2023, before declining to 119 in 2024. Neurosurgery was the leading referring specialty (233 admissions; 29.9%), rising from 20 cases in 2020 to a peak of 89 in 2023. General surgery was second (149 cases; 19.2%), followed by internal medicine (117; 15.0%), obstetrics and gynaecology (96; 12.3%), and paediatrics (88; 11.3%). Remaining specialties each contributed smaller proportions, including urology (3.2%), oral and maxillofacial surgery (2.3%), and paediatric surgery (2.2%). Annual trends by specialty are presented in Table 2.

Table 2: Annual trends in admissions by specialty from 2020 to 2024.

Neurosurgery accounted for the highest proportion of ICU admissions (29.9%; 95% CI: 26.8–33.3), followed by general surgery (19.2%; 95% CI: 16.5–22.1) and internal medicine (15.0%; 95% CI: 12.7–17.7). Obstetrics and gynaecology contributed 12.3% (95% CI: 10.2–14.8) and paediatrics 11.3% (95% CI: 9.3–13.7). Urology (3.2%), oral and maxillofacial surgery (2.3%), paediatric surgery (2.2%), orthopaedics (1.4%), and cardiothoracic unit (1.2%) contributed smaller proportions. Ear, nose and throat (ENT) represented 1.0%, whilst plastic surgery, mental health, and family medicine each contributed less than 1%. Overall, surgical specialties constituted the majority of ICU admissions. Specialty utilisation data are presented in Table 3.

Table 3: Specialty-Based Utilization of the Intensive Care Unit Among Admitted Patients (n = 778)

Severe traumatic brain injury (STBI) was the most frequent diagnosis (80 cases; 10.29%), followed by sepsis (77; 9.90%), cerebrovascular accident (47; 6.04%), and intracranial tumour (36; 4.63%). Perforated peptic ulcer disease accounted for 30 admissions (3.86%), cervical spine injury and peritonitis each for 29 (3.73%), intestinal obstruction for 26 (3.34%), and antepartum haemorrhage for 24 (3.08%). The remaining 400 patients (51.40%) were distributed across 38 diagnostic categories, each contributing fewer than 3.0% of admissions, detailed in the footnote to Table 4. Neurological and neurosurgical conditions collectively — comprising STBI, CVA, intracranial tumour, cervical spine injury, acute subdural haematoma, hydrocephalus, intraventricular haemorrhage, and cerebral abscess — constituted the largest diagnostic cluster, accounting for 236 admissions (30.33%).

Table 4: Distribution of Major ICU Diagnoses (n = 778)

Footnote: “Others” (n = 400; 51.4%) comprised 38 distinct diagnoses, each <3% of admissions. The most frequent were postoperative monitoring (22), hydrocephalus (21), exploratory laparotomy (18), postpartum haemorrhage (18), acute subdural haematoma (15), intra-abdominal tumour (14), pulmonary embolism (14), eclampsia (12), aspiration pneumonitis (10), and spine fracture (10), with the remaining 28 conditions occurring in ≤9 cases each.

The mean age of 39.0 ± 23.7 years recorded in this study is consistent with findings from comparable Nigerian centres. A five-year review at the University of Nigeria Teaching Hospital (UNTH), Enugu, reported a mean age of 38.2 ± 18.2 years among 766 ICU admissions,^[5] whilst a recent study at the University of Port Harcourt Teaching Hospital reported a higher mean age of 48.6 ± 15.2 years, reflecting a predominantly medical admission profile.^[9] A similar young adult predominance was reported at Lagos University Teaching Hospital (LUTH), where patients in the young and middle-age groups constituted 66.9% of all ICU admissions.^[10] The relatively young age distribution observed — with young adults (18–39 years) constituting the largest single band at 31.1%, followed by those aged ≥60 years (24.6%), 40–59 years (23.1%), and children under 18 years (21.2%) — mirrors the demographic structure of the Nigerian population and the disproportionate burden of trauma and acute surgical illness borne by economically active age groups.

This contrasts sharply with high-income country ICU populations, where elderly patients predominate. In Western settings, patients aged 80 years and above now constitute a significant and growing proportion of ICU admissions,^[11] reflecting ageing populations and the rising burden of chronic non-communicable diseases. A large Ugandan study similarly noted that ICU populations in low-income settings tend to be considerably younger than those in high-income countries,^[12] affirming that the age profile observed in the present study is characteristic of sub-Saharan African critical care practice.

The male predominance (56.7%) is consistent with other Nigerian reports. The UNTH Enugu study recorded 65.4% male patients,^[5] whilst an 18-year review at the University of Abuja Teaching Hospital found a slight female majority of 51.1% among 2,078 admissions,^[13] which may be attributable to the predominance of medical and obstetric cases at that centre. The male preponderance observed in this study is consistent with the high burden of road traffic crashes and traumatic brain injury in Nigeria, conditions that disproportionately affect working-age males; however, as mechanism-of-injury data were not systematically collected, a direct causal attribution cannot be made. International data confirm that men are more frequently admitted post-operatively and are more likely to require emergent surgery and mechanical ventilation,^[14] a pattern consistent with the surgical and trauma-dominant case mix of this study. The overall ICU mortality rate of 45.1% is consistent with figures reported from comparable Nigerian tertiary centres, including UNTH Enugu (44.8%)^[5] and ESUT-TH Enugu (38.2%–46.7%).^[6] The higher mortality observed among paediatric patients (49.7%) compared with adult patients (43.9%) may reflect greater severity of illness at the point of referral, limited paediatric-specific critical care resources, and the predominance of high-acuity conditions within this age group.^[7] The median ICU length of stay of 5.0 days (IQR: 3.0–11.0 days) is comparable to figures reported from similar Nigerian centres.^[8]

The progressive increase in annual admissions from 85 in 2020 to a peak of 308 in 2023, followed by a decline to 119 in 2024, is likely multifactorial. Possible contributing factors include progressive expansion of unit capacity, recovery of care-seeking behaviour following pandemic-related disruptions, and variations in referral patterns over the study period; however, the retrospective design of this study precludes definitive attribution of these temporal trends to any single cause. The low admission figures recorded in 2020 are consistent with pandemic-related reductions in elective and emergency care-seeking behaviour documented across sub-Saharan Africa during that period. The ESUT-TH Enugu study reported its highest ICU mortality rate in 2020 at 46.7%,^[6] suggesting that pandemic pressures may have been associated with reduced admission volumes and adverse outcomes during that year. In Nigeria, the limited pre-existing ICU infrastructure — estimated at approximately 350 ICU beds nationally for a population exceeding 200 million prior to the pandemic — rendered the health system particularly vulnerable to COVID-19-related critical care demand.^[15]

Neurosurgery was the leading referring specialty (29.9%), followed by general surgery (19.2%) and internal medicine (15.0%), indicating the predominantly surgical and neurotraumatic character of ICU demand at this centre. This pattern is consistent with other south-eastern Nigerian tertiary hospitals. At UNTH Enugu, neurosurgical patients constituted the largest admission group, accounting for 41.2% of all ICU admissions.^[5] The ESUT-TH Enugu study similarly identified general surgery (19%), obstetrics and gynaecology (18.4%), and neurosurgery (16.8%) as the leading sources,^[6] whilst a review at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, also identified neurosurgery as the dominant referring specialty.^[7] By contrast, a five-year review from Irrua Specialist Teaching Hospital (ISTH), a rural southern Nigerian centre, found general surgery (36.7%) to be the dominant referral source, with neurosurgery contributing only 7.5% of admissions,^[8] reflecting the limited neurosurgical infrastructure at that institution. The high neurosurgical burden at Federal Medical Centre Umuahia is consistent with its role as a referral hub for head injury and intracranial pathology within the subregion. The preponderance of traumatic brain injury in LMICs such as Nigeria has been explicitly recognised within the National Surgical, Obstetrics, Anaesthesia and Nursing Plan (NSOANP), which identifies neurological trauma stabilisation as a priority of intermediate surgical care.^[16] Unlike high-income countries, where specialty-stratified ICUs manage distinct patient populations, most ICUs in sub-Saharan Africa are multipurpose units admitting all age groups and a broad spectrum of pathologies from diverse referral sources,^[17] a structural reality reflected in the wide specialty distribution documented in this study.

Severe traumatic brain injury (STBI) was the leading specific diagnosis (10.29%), followed by sepsis (9.90%), cerebrovascular accident (6.04%), and intracranial tumour (4.63%). Neurological and neurosurgical conditions collectively accounted for 30.33% (n = 236) of all admissions.

This diagnostic predominance of neurotraumatic pathology is consistent with prior Nigerian data. At UNTH Enugu, 70.9% of the 316 neurosurgical admissions were attributable to severe traumatic brain injury,^[5] and the ESUT-TH Enugu study similarly identified traumatic brain injury and cerebrovascular accident as the most frequent specific diagnoses among its ICU cohort.^[6] At the continental level, a large Ugandan study identified sepsis, head injury, and acute lung injury as the dominant ICU admission diagnoses,^[12] a pattern broadly mirroring the present findings. A review at Jos University Teaching Hospital (JUTH) similarly reported polytrauma and postoperative surgical conditions as the dominant drivers of ICU utilisation.^[18]

The sepsis burden (9.90%) in this study, whilst clinically significant, appears lower than figures reported in global audits. A multinational ICU prevalence study found infection present in 54% of ICU patients surveyed across 88 countries in 2017, with sepsis-associated mortality highest in resource-limited settings.^[19] The apparently lower sepsis proportion in the present study may reflect competitive displacement by the high volume of trauma admissions, under-documentation of infectious diagnoses, or differences in case ascertainment, rather than a genuinely reduced infective burden. LMICs bear a disproportionately heavier burden of sepsis and septic shock than high-income countries,^[20] and vigilance for under-reporting of sepsis in resource-limited registries remains warranted.

The proportions of perforated peptic ulcer disease (3.86%), peritonitis (3.73%), and intestinal obstruction (3.34%) reflect the persisting burden of acute abdominal surgical emergencies in this setting. The ISTH Irrua study recorded considerably higher proportions of perforated viscus (17.7%) and bowel obstruction (6.3%) as leading diagnoses,^[8] consistent with the more pronounced general surgical profile of that centre. In high-income countries, the ICU diagnostic mix differs fundamentally, with cardiovascular disease, respiratory failure, and postoperative monitoring following elective surgery constituting a larger share of admissions. Structural differences in ICU resource allocation between countries are substantial; the United States has approximately seven times as many ICU beds per capita as the United Kingdom, resulting in broader admission thresholds and a less critically ill admission profile.^[21] The frequent absence of specialty-trained critical care staff and standardised care protocols in LMICs contributes to inferior outcomes when benchmarked against high-income country standards,^[22] a challenge directly relevant to the Nigerian context.

The single-centre retrospective design limits generalisability and introduced dependency on record quality; exclusion of 98 of 884 identified admissions (11.1%) because of incomplete key data may have introduced selection bias. If excluded admissions differed systematically from included admissions in case mix, illness severity, or outcome, estimates of specialty proportions and mortality could have been either overestimated or underestimated; the direction and magnitude of this bias cannot be determined from the available records. Severity-of-illness scoring (APACHE II, SOFA, or qSOFA) was not consistently applied, precluding risk-adjusted outcome comparisons, and denominator data on hospital admissions, surgical volumes, and specialty caseloads were unavailable. Whilst annual admission trends were examined descriptively, formal statistical testing was not performed and observed variations should be interpreted with caution. Outcome data stratified by referring specialty, mechanical ventilation rates, and organ support utilisation were unavailable due to inconsistent documentation; future prospective audits should incorporate standardised data capture tools to address these gaps. Possible misclassification of admitting specialty, COVID-19-related confounding, and absence of data on rejected referrals or delayed admissions represent additional constraints on interpretation.

ICU utilisation at this resource-limited tertiary centre was predominantly driven by neurosurgical and general surgical referrals, with severe traumatic brain injury and sepsis constituting the leading diagnostic categories. These findings reflect the substantial burden of neurotrauma, postoperative care, and acute medical illness on critical care services in this setting. Targeted investment in trauma systems, neurosurgical critical care capacity, and infection management infrastructure remains necessary to strengthen ICU service delivery and inform evidence-based resource allocation at comparable Nigerian tertiary institutions.

What is already known

ICUs in Nigerian tertiary hospitals operate under significant resource constraints, with documented shortages of beds, personnel, and monitoring equipment.

Existing audits from centres in Enugu, Jos, Lagos, and Calabar consistently report high ICU mortality, young adult demographics, and surgical specialty predominance, particularly neurosurgery and general surgery.

Severe traumatic brain injury, sepsis, and cerebrovascular accident are the most frequently reported ICU diagnoses across Nigerian and sub-Saharan African tertiary centres.

What this study adds

This is the first systematic ICU audit from Federal Medical Centre Umuahia, addressing a critical data gap in the South-East geopolitical zone of Nigeria.

Annual admissions increased from 85 in 2020 to a peak of 308 in 2023, providing novel temporal trend data; the observed pattern may reflect changes in unit activity, referral practices and pandemic-related service disruption, though the retrospective design precludes attribution to any single cause.

Neurosurgery was the leading referring specialty (29.9%), a finding consistent with the hospital functioning as an important neurotrauma referral centre and providing institution-specific data for the national evidence base.

Acknowledgement

The authors sincerely appreciate the management and staff of the Intensive Care Unit, Federal Medical Centre Umuahia, for their support and cooperation during data collection. We also acknowledge the contributions of the medical records department for facilitating access to archived patient records used in this study. The authors are grateful to all healthcare personnel whose dedication to patient care made this research possible.

Competing interest

The authors declare no conflicts of interest.

Funding

No specific funding was received for this study.

Author Contributions

DII: Conceptualisation; Methodology; Investigation; Writing – original draft.

ISI: Conceptualisation; Methodology; Data curation; Investigation; Writing – original draft.

ISC: Methodology; Validation; Writing – review and editing.

VOA: Formal analysis; Writing – review and editing.

CSA: Formal analysis; Writing – review and editing.

GOA: Formal analysis; Writing – review and editing.

ONM: Supervision; Validation; Writing – review and editing.

All authors have read and approved the final version of the manuscript for submission.

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Medical Journal of Zambia, Vol 53, 3

The Medical Journal of Zambia, ISSN 0047-651X, is published by the Zambia Medical Association.
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