Making recording and analysis of chief complaint a priority for global emergency care research in low-income countries

Essential human and material resources for emergency care in the district hospitals of Burundi

Introduction

Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery.

Methods

In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p<0.05 considered significant.

Results

Forty of 45 district hospitals completed the survey, of which 35 were rural (matching national demographics). The majority of district hospitals (21/40) had ready access to ≥4/5 critical drugs while few (5/40) were equipped with ≥4/5 key material. One quarter had 24/7 physician coverage and X-ray available. Only 3 had continuous access to ultrasound studies despite most district hospitals having ultrasound machines. Trained emergency room staff were almost totally absent from the field, with only 6 nurses, 4 generalists, and 1 specialist reported across 9 sites. Even a single EM-trained staff member was significantly correlated with being better equipped for emergencies (p<0.01).

Conclusion

Burundi needs a strategic investment in emergency preparedness and care. Policy initiatives and technology purchases have demonstrated reasonable penetration down to the district hospital level, however, trained personnel are essential to develop sustainable emergency capacity.

AI-based approach for transcribing and classifying unstructured emergency call data: A methodological proposal

Emergency care-sensitive conditions (ECSCs) require rapid identification and treatment and are responsible for over half of all deaths worldwide. Prehospital emergency care (PEC) can provide rapid treatment and access to definitive care for many ECSCs and can reduce mortality in several different settings. The objective of this study is to propose a method for using artificial intelligence (AI) and machine learning (ML) to transcribe audio, extract, and classify unstructured emergency call data in the Serviço de Atendimento Móvel de Urgência (SAMU) system in southern Brazil. The study used all "1-9-2" calls received in 2019 by the SAMU Novo Norte Emergency Regulation Center (ERC) call center in Maringá, in the Brazilian state of Paraná. The calls were processed through a pipeline using machine learning algorithms, including Automatic Speech Recognition (ASR) models for transcription of audio calls in Portuguese, and a Natural Language Understanding (NLU) classification model. The pipeline was trained and validated using a dataset of labeled calls, which were manually classified by medical students using LabelStudio. The results showed that the AI model was able to accurately transcribe the audio with a Word Error Rate of 42.12% using Wav2Vec 2.0 for ASR transcription of audio calls in Portuguese. Additionally, the NLU classification model had an accuracy of 73.9% in classifying the calls into different categories in a validation subset. The study found that using AI to categorize emergency calls in low- and middle-income countries is largely unexplored, and the applicability of conventional open-source ML models trained on English language datasets is unclear for non-English speaking countries. The study concludes that AI can be used to transcribe audio and extract and classify unstructured emergency call data in an emergency system in southern Brazil as an initial step towards developing a decision-making support tool.

White Paper on Early Critical Care Services in Low Resource Settings

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS.

LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities.

Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient—these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel.

Currently, a single “best” care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy.

Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country’s current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum.

Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement.

Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient’s geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Multicultural presentation of chest pain at an emergency department in Australia

OBJECTIVE

To investigate differences in presenting patient characteristics, investigation, management and related outcomes between culturally and linguistically diverse (CALD) and non-CALD chest pain (CP) patients presenting to the ED.

METHODS

A cohort study of 258 patients was enrolled on presentation to Liverpool Hospital ED with a complaint of CP over a 2-week period. Main outcomes included frequency and timeliness of diagnostic and radiological investigations, medication administered and ED length of stay. Administrative and clinical data were extracted and linked from Cerner EMR FirstNet®, PowerChart® and paper records.

RESULTS

There were 155 (60%) CALD and 103 (40%) non-CALD patients. CALD patients were older by 10 years (95% CI 4, 15; P < 0.0001). There were no significant differences in the number of pathology and imaging investigations carried out in each group, and similarly there were no significant differences in the number of patients administered analgesia or cardiac-specific medications. Neither group differed in their ED length of stay (median 280 vs 259.5 min; P = 0.79) or hospital admission rate (median 56% vs 55%, P = 0.8).

CONCLUSION

Both CALD and non-CALD ED CP patients had similar test ordering, medication administration and clinical outcomes, but this was in the context of CALD patients being 10 years older together with a small study sample size. A larger cohort, matched for age, would provide further insights into potentially important differences.

Calibrating a chief complaint list for low resource settings: a methodologic case study

BACKGROUND

The chief or presenting complaint is the reason for seeking health care, often in the patient's own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Our group worked with colleagues from the African Federation of Emergency Medicine building on the existing literature to create a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. An ideal list for any setting is one that strikes a balance between ease of use and length, while covering the vast majority of diseases with enough detail to permit epidemiologic surveillance and make informed decisions about resource needs.

METHODS

This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list.

RESULTS

Overall, 3537 patients' chief complaints were reviewed, of which 640 were identified as 'potential mismatches.' When considering the 191 confirmed mismatches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. "Pain" was used 2076 times for 58.7% of all patients. A combination of user feedback and expert-panel modified Delphi analysis of mismatched complaints and clustered complaints resulted in several substantial changes to the pilot symptom list.

CONCLUSIONS

This study presented a systematic methodology for calibrating a chief complaint list for the local context. Our revised list removed/reworded symptoms that frequently clustered together or were misinterpreted by health professionals. Recommendations for additions, modifications, and/or deletions from the pilot chief complaint list we believe will improve the functionality of the list in low resource environments.

Disagreements between emergency patients and physicians regarding chief complaint - Patient factors and prognostic implications

INTRODUCTION

The predictive power of chief complaints reported at presentation to the emergency department (ED) is well known. However, there is a lack of research on the coherence of patient versus physician reported chief complaints. The aim of this study was to determine the rate of disagreement between patients and physicians regarding chief complaint and its significance for the prediction of the outcomes number of resources used during ED work-up, hospitalisation, ICU admission, in-hospital mortality and hospital length of stay.

METHODS

In this secondary analysis of a study conducted over a time course of 9 weeks, consecutive emergency patients and their physicians were independently asked to report the chief complaint upon presentation. The two reports were assessed for pair-wise agreement.

RESULTS

Of 6722 emergency patients (mean age 53.3, 46.8% female), the median number of symptoms reported by patients was two and one reported by physicians. The rate of disagreement on chief complaints was 32.6%. Disagreement was associated with a higher number of resources (β = 0.24; CI, 0.18, 0.31, P <.001) and hospitalisation (OR = 1.31; CI, 1.16, 1.48, P <.001), using multivariable analyses. Patient factors associated with disagreement were age (OR = 1.01; CI, 1.01, 1.01, P <.001), number of patient reported symptoms (OR = 1.27; CI, 1.23, 1.32, P <.001) and male gender (OR = 1.12; 1.01, 1.25, P =.0285).

CONCLUSION

Disagreement on chief complaint between patient and physician may be an early marker for a complex work-up, requiring more resources and hospitalisations. The relevance of this finding is the newly identified signal of chief complaint replacement. It is easy to identify and should generate attention, as it affects a certain phenotype (older male patients with higher numbers of complaints).

Healthcare in transition in the Republic of Armenia: the evolution of emergency medical systems and directions forward

Armenia, an ex-Soviet Republic in transition since independence in 1991, has made remarkable strides in development. The crisis of prioritization that has plagued many post-Soviet republics in transition has meant differential growth in varied sectors in Armenia. Emergency systems is one of the sectors which is neglected in the current drive to modernize. The legacy of the Soviet Semashko system has left a void in specialized care including emergency care. This manuscript is a descriptive overview of the current state of emergency care in Armenia using in-depth key informant interviews and review of published and unpublished internal United States Agency for International Development (USAID) and Ministry of Health (MOH) documents as well as data from the Yerevan Municipal Ambulance Service and international agencies. The Republic of Artsakh is briefly discussed.

The development of emergency care systems is an extremely efficient way to provide care across many different conditions in many age groups. Conditions such as traumatic injuries, heart attacks, cardiac arrest, stroke, and respiratory failure are very time-dependent. Armenia has a decent emergency infrastructure in place and has the benefit of an educated and skilled physician workforce. The missing piece of the puzzle appears to be investment in graduate and post-graduate education in emergency care and development of hospital-based emergency care for stabilization of stroke, myocardial infarction, trauma, and sepsis as well as other acute conditions.

Defining High-risk Emergency Chief Complaints: Data-driven Triage for Low- and Middle-income Countries

OBJECTIVES

Emergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints (CCs) are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether CCs independently predict emergency unit patient outcomes.

METHODS

Patient data collected in a Ugandan emergency unit between 2009 and 2018 were randomized into validation and derivation data sets. A recursive partitioning algorithm stratified CCs by 3-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, CCs were categorized as "high-risk" (>2× baseline mortality), "medium-risk" (between 2 and 0.5× baseline mortality), and "low-risk" (<0.5× baseline mortality). Risk categories were then included in a logistic regression model to determine if CCs independently predicted 3-day mortality.

RESULTS

Overall, the derivation data set included 21,953 individuals with 7,313 in the validation data set. In total, 43 complaints were categorized, and 12 CCs were identified as high-risk. When controlled for triage data including age, sex, HIV status, vital signs, level of consciousness, and number of complaints, high-risk CCs significantly increased 3-day mortality odds ratio (OR = 2.39, 95% confidence interval [CI] = 1.95 to 2.93, p < 0.001) while low-risk CCs significantly decreased 3-day mortality odds (OR = 0.16, 95% CI = 0.09 to 0.29, p < 0.001).

CONCLUSIONS

High-risk CCs were identified and found to predict increased 3-day mortality independent of vital signs and other data available at triage. This list can be used to expand local triage systems and inform emergency training programs. The methodology can be reproduced in other LMIC settings to reflect their local disease patterns.

Pediatric Patients in a Local Nepali Emergency Department: Presenting Complaints, Triage and Post-Discharge Mortality

Background. In low-income countries, pediatric emergency care is largely underdeveloped although child mortality in emergency care is more than twice that of adults, and mortality after discharge is high. Aim. We aimed at describing characteristics, triage categories, and post-discharge mortality in a pediatric emergency population in Nepal. Methods. We prospectively assessed characteristics and triage categories of pediatric patients who entered the emergency department (ED) in a local hospital. Patient households were followed-up by telephone interviews at 90 days. Results. The majority of pediatric emergency patients presented with injuries and infections (~40% each). Girls attended ED less frequent than boys. High triage priority categories (orange and red) were strong indicators for intensive care need and for mortality after discharge. Conclusion. The study supports the use and development of a pediatric triage systems in a low-resource general ED setting. We identify a need for interventions that can reduce mortality after pediatric emergency care. Interventions to reduce pediatric emergency disease burden in this setting should emphasize prevention and effective treatment of infections and injuries.

Generating contextual embeddings for emergency department chief complaints

Objective

We learn contextual embeddings for emergency department (ED) chief complaints using Bidirectional Encoder Representations from Transformers (BERT), a state-of-the-art language model, to derive a compact and computationally useful representation for free-text chief complaints.

Materials and methods

Retrospective data on 2.1 million adult and pediatric ED visits was obtained from a large healthcare system covering the period of March 2013 to July 2019. A total of 355 497 (16.4%) visits from 65 737 (8.9%) patients were removed for absence of either a structured or unstructured chief complaint. To ensure adequate training set size, chief complaint labels that comprised less than 0.01%, or 1 in 10 000, of all visits were excluded. The cutoff threshold was incremented on a log scale to create seven datasets of decreasing sparsity. The classification task was to predict the provider-assigned label from the free-text chief complaint using BERT, with Long Short-Term Memory (LSTM) and Embeddings from Language Models (ELMo) as baselines. Performance was measured as the Top-k accuracy from k = 1:5 on a hold-out test set comprising 5% of the samples. The embedding for each free-text chief complaint was extracted as the final 768-dimensional layer of the BERT model and visualized using t-distributed stochastic neighbor embedding (t-SNE).

Results

The models achieved increasing performance with datasets of decreasing sparsity, with BERT outperforming both LSTM and ELMo. The BERT model yielded Top-1 accuracies of 0.65 and 0.69, Top-3 accuracies of 0.87 and 0.90, and Top-5 accuracies of 0.92 and 0.94 on datasets comprised of 434 and 188 labels, respectively. Visualization using t-SNE mapped the learned embeddings in a clinically meaningful way, with related concepts embedded close to each other and broader types of chief complaints clustered together.

Discussion

Despite the inherent noise in the chief complaint label space, the model was able to learn a rich representation of chief complaints and generate reasonable predictions of their labels. The learned embeddings accurately predict provider-assigned chief complaint labels and map semantically similar chief complaints to nearby points in vector space.

Conclusion

Such a model may be used to automatically map free-text chief complaints to structured fields and to assist the development of a standardized, data-driven ontology of chief complaints for healthcare institutions.

Developing a research question: A research primer for low- and middle-income countries

As demand for emergency care (EC) systems in low- and middle-income countries (LMICs) grows, there is an urgent need to expand the evidence base for clinical and systems interventions in resource limited EC settings. Clinicians are well placed to identify, define and address unanswered research questions using both quantitative and qualitative approaches. This paper summarises established research priorities for global EC and provides a step-wise approach to developing a research question.

Research priorities for global EC broadly fall into two categories: systems-based research and research with a clinical care focus. Systems research is integral to understanding the essential components of safe and effective EC delivery, while clinical research aims to answer questions related to particular disease states, presentations or population groups.

Developing a specific research question requires an enquiring, questioning and critical approach to EC delivery. In quantitative research, use of the PECO formula (Population, Exposure, Comparator, Outcome) can help frame a research question. Qualitative research, which aims to understand, explore and examine, often requires application of a theoretical framework. Writing a brief purpose statement can be a helpful tool to clarify the objectives of a qualitative study.

This paper includes lists of tips, pitfalls and resources to assist EC clinical researchers in developing research questions. Application of these tools and frameworks will assist EC clinicians in resource limited settings to perform impactful research and improve outcomes for patients with acute illness and injury.

Presenting complaints and mortality in a cohort of 22 000 adult emergency patients at a local hospital in Nepal

Background

There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal.

Methods

Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days.

Results

In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%).

Conclusions

Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed.

CCMapper: An adaptive NLP-based free-text chief complaint mapping algorithm

OBJECTIVE

Chief complaint (CC) is among the earliest health information recorded at the beginning of a patient's visit to an emergency department (ED). We propose a heuristic methodology for automatically mapping the free-text data into a structured list of CCs.

METHODS

A comprehensive structured list categorizing CCs was developed by experienced Emergency Medicine (EM) physicians. Using this list, we developed a natural language processing-based algorithm, referred to as Chief Complaint Mapper (CCMapper), for automatically mapping a CC into the most appropriate category (ies). We trained and validated CCMapper using free-text CC data from the Mayo Clinic ED in Rochester, MN. We developed a consensus-based validation approach to handle both indifferences and disagreements between the two EM physicians who manually mapped a random sample of free-text CCs into categories within the structured list.

RESULTS

The kappa statistic demonstrated a high level of agreement (κ = 0.958) between the two physicians with less than 2% human error. CCMapper achieved a total sensitivity of 94.2% with a specificity of 99.8% and F-score of 94.7% on the validation set. The sensitivity of CCMapper when mapping free-text data with multiple CCs was 82.3% with a specificity of 99.1% and total F-score of 82.3%.

CONCLUSION

Due to its simplicity, high performance, and capability of incorporating new free-text CC data, CCMapper can be readily adopted by other EDs to support clinical decision making. CCMapper can facilitate the development of predictive models for the type and timing of important events in ED (e.g., ICU admission).

Emergency care surveillance and emergency care registries in low-income and middle-income countries: conceptual challenges and future directions for research

Despite the fact that the 15 leading causes of global deaths and disability-adjusted life years are from conditions amenable to emergency care, and that this burden is highest in low-income and middle-income countries (LMICs), there is a paucity of research on LMIC emergency care to guide policy making, resource allocation and service provision. A literature review of the 550 articles on LMIC emergency care published in the 10-year period from 2007 to 2016 yielded 106 articles for LMIC emergency care surveillance and registry research. Few articles were from established longitudinal surveillance or registries and primarily composed of short-term data collection. Using these articles, a working group was convened by the US National Institutes of Health Fogarty International Center to discuss challenges and potential solutions for established systems to better understand global emergency care in LMICs. The working group focused on potential uses for emergency care surveillance and registry data to improve the quality of services provided to patients. Challenges included a lack of dedicated resources for such research in LMIC settings as well as over-reliance on facility-based data collection without known correlation to the overall burden of emergency conditions in the broader community. The group outlined potential solutions including incorporating data from sources beyond traditional health records, use of standard clinical forms that embed data needed for research and policy making and structured population-based research to establish clear linkages between what is seen in emergency units and the wider community. The group then identified current gaps in LMIC emergency care surveillance and registry research to form a research agenda for the future.

Patient Characteristics from an Emergency Care Center in Rural Western Kenya

BACKGROUND

Emergency care is a neglected area of focus in many low- and middle-income countries. There is a paucity of research on types and frequencies of acute illnesses and injuries in low-resource settings.

OBJECTIVE

The primary objective of this study was to describe the demographic characteristics and emergency conditions of patients that presented to a new emergency care center (ECC) at Sagam Community Hospital in Luanda, Kenya.

METHODS

Patient demographic characteristics, modes of arrival, chief symptoms, triage priorities, self-reported human immunodeficiency virus status, tests performed, interventions, discharge diagnoses, and dispositions were collected for all patients that presented to the Sagam Community Hospital ECC.

RESULTS

Between October 1, 2016 and September 30, 2017, 14,518 patients presented to the ECC. The most common mode of arrival to Sagam Community Hospital was by foot (n = 12,605 [86.8%]). There were 8931 (61.5%) female patients and 5571 (38.4%) male patients. Of the total visits, 12,668 (87.3%) were triaged Priority III (lowest priority), 1239 (8.5%) were Priority II, and 293 (2.0%) were Priority I (highest priority). The most common chief symptoms were headache (n = 3923 [15.2%]), hotness of body or chills (n = 2877 [8.8%]), and cough (n = 1827 [5.5%]). The three most common discharge diagnoses were malaria (n = 3692 [18.9%]), acute upper respiratory infection (n = 1242 [6.3%]), and gastritis/duodenitis (n = 1210 [6.2%]).

CONCLUSIONS

Although opening an ECC in rural Kenya attracted patients in need of care, access was limited primarily to those that could arrive on foot. ECCs in rural sub-Saharan Africa have the potential to provide quality care and support attainment of Sustainable Development Goals.

Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan

Background

There is little data describing pediatric emergencies in resource-poor countries, such as Pakistan. We studied the demographics, management, and outcomes of patients presenting to the highest-volume, public, pediatric emergency department (ED) in Karachi, Pakistan.

Methods

In this prospective, observational study, we approached all patients presenting to the 50-bed ED during 28 12-h study periods over four consecutive weeks (July 2013). Participants’ chief complaints and medical care were documented. Patients were followed-up at 48-h and 14-days via telephone.

Results

Of 3115 participants, 1846 were triaged to the outpatient department and 1269 to the ED. Patients triaged to the ED had a median age of 2.0 years (IQR 0.5–4.0); 30% were neonates (< 28 days). Top chief complaints were fever (45.5%), diarrhea/vomiting (32.3%), respiratory (23.1%), abdominal (7.5%), and otolaryngological problems (5.8%). Temperature, pulse and respiratory rate, and blood glucose were documented for 66, 42, and 1.5% of patients, respectively. Interventions included medications (92%), IV fluids (83%), oxygen (35%), and advanced airway management (5%). Forty-five percent of patients were admitted; 11 % left against medical advice. Outcome data was available at time of ED disposition, 48-h, and 14 days for 83, 62, and 54% of patients, respectively. Of participants followed-up, 4.3% died in the ED, 11.5% within 48 h, and 19.6% within 14 days.

Conclusions

This first epidemiological study at Pakistan’s largest pediatric ED reveals dramatically high mortality, particularly among neonates. Future research in developing countries should focus on characterizing reasons for high mortality through pre-ED arrival tracking, ED care quality assessment, and post-ED follow-up.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0175-4) contains supplementary material, which is available to authorized users.

Clinical Characteristics of the 2013 Haiyan Typhoon Victims Presenting to the Belgian First Aid and Support Team

OBJECTIVE

In 2013, the Philippines was struck by typhoon Haiyan, which damaged local hospitals and disrupted health care. The Belgian First Aid and Support Team erected a field hospital and water purification unit in Palo. This study aims to describe the diagnoses encountered and treatment provided.

METHODS

In this cross-sectional study, medical records of 1267 field hospital patients were reviewed for gender, age, complaints, diagnoses, and management and referral information.

RESULTS

Almost 28% of the patients suffered from injury, but most presented with nonsurgical diseases (64%), particularly of respiratory (31%), dermatological (11%), and digestive (8%) origin. Only 53% presented with disaster-related pathology, and 59% showed signs of infection. Patients needed wound care (47%), pain relief (33%), or antibiotics (29%); 9% needed procedures, 8% needed fluid therapy, and 5% needed psychological support. Children under 5 years of age were more at risk for infections (OR, 18.8; CI, 10.6-33.3) and injuries (OR, 10.3; CI, 6.3-16.8). Males were more prone to injuries than females (OR, 2.1; CI, 1.6-2.6).

CONCLUSIONS

One week after the acute phase of a typhoon, respiratory, dermatological, and digestive problems emerge to the prejudice of trauma. Only 53% of patients presented with disaster-related conditions. Young children are more at risk for injury and infectious diseases. These trends should be anticipated when composing Emergency Medical Teams and medical resources to be sent to disaster sites. (Disaster Med Public Health Preparedness. 2019;13:265-278).

Derivation and validation of a chief complaint shortlist for unscheduled acute and emergency care in Uganda

OBJECTIVES

Derive and validate a shortlist of chief complaints to describe unscheduled acute and emergency care in Uganda.

SETTING

A single, private, not-for profit hospital in rural, southwestern Uganda.

PARTICIPANTS

From 2009 to 2015, 26 996 patient visits produced 42 566 total chief complaints for the derivation dataset, and from 2015 to 2017, 10 068 visits produced 20 165 total chief complaints for the validation dataset.

METHODS

A retrospective review of an emergency centre quality assurance database was performed. Data were abstracted, cleaned and refined using language processing in Stata to produce a longlist of chief complaints, which was collapsed via a consensus process to produce a shortlist and turned into a web-based tool. This tool was used by two local Ugandan emergency care practitioners to categorise complaints from a second longlist produced from a separate validation dataset from the same study site. Their agreement on grouping was analysed using Cohen's kappa to determine inter-rater reliability. The chief complaints describing 80% of patient visits from automated and consensus shortlists were combined to form a candidate chief complaint shortlist.

RESULTS

Automated data cleaning and refining recognised 95.8% of all complaints and produced a longlist of 555 chief complaints. The consensus process yielded a shortlist of 83 grouped chief complaints. The second validation dataset was reduced in Stata to a longlist of 451 complaints. Using the shortlist tool to categorise complaints produced 71.5% agreement, yielding a kappa of 0.70 showing substantial inter-rater reliability. Only one complaint did not fit into the shortlist and required a free-text amendment. The two shortlists were identical for the most common 14 complaints and combined to form a candidate list of 24 complaints that could characterise over 80% of all emergency centre chief complaints.

CONCLUSIONS

Shortlists of chief complaints can be generated to improve standardisation of data entry, facilitate research efforts and be employed for paper chart usage.

Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals without appointments: an observational study

BACKGROUND

Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals.

METHODS

Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission.

RESULTS

This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever.

CONCLUSIONS

While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission.

Patient characteristics of the Accident and Emergency Department of Kenyatta National Hospital, Nairobi, Kenya: a cross-sectional, prospective analysis

BACKGROUND

Resource-limited settings are increasingly experiencing a 'triple burden' of disease, composed of trauma, non-communicable diseases (NCDs) and known communicable disease patterns. However, the epidemiology of acute and emergency care is not well characterised and this limits efforts to further develop emergency care capacity.

OBJECTIVE

To define the burden of disease by describing the patient population presenting to the Accident and Emergency Department (A&E) at Kenyatta National Hospital (KNH) in Kenya.

METHODS

We completed a prospective descriptive assessment of patients in KNH's A&E obtained via systematic sampling over 3 months. Research assistants collected data directly from patients and their charts. Chief complaint and diagnosis codes were grouped for analysis. Patient demographic characteristics were described using the mean and SD for age and n and percentages for categorical variables. International Classification of Disease 10 codes were categorised by 2013 Global Burden of Disease Study methods.

RESULTS

Data were collected prospectively on 402 patients with an average age of 36 years (SD 19), and of whom, 50% were female. Patients were most likely to arrive by taxi or bus (39%), walking (28%) or ambulance (17%). Thirty-five per cent of patients were diagnosed with NCDs, 24% with injuries and 16% with communicable diseases, maternal and neonatal conditions. Overall, head injury was the single most common final diagnosis and occurred in 32 (8%) patients. The most common patient-reported mechanism for head injury was road traffic accident (39%).

CONCLUSION

This study estimates the characteristics of the A&E population at a tertiary centre in Kenya and highlights the triple burden of disease. Our findings emphasise the need for further development of emergency care resources and training to better address patient needs in resource-limited settings, such as KNH.

The State of Emergency Medical Services (EMS) Systems in Africa

Introduction

Little is known about the existence, distribution, and characteristics of Emergency Medical Services (EMS) systems in Africa, or the corresponding epidemiology of prehospital illness and injury.

Methods

A survey was conducted between 2013 and 2014 by distributing a detailed EMS system questionnaire to experts in paper and electronic versions. The questionnaire ascertained EMS systems’ jurisdiction, operations, finance, clinical care, resources, and regulatory environment. The discovery of respondents with requisite expertise occurred in multiple phases, including snowball sampling, a review of published scientific literature, and a rigorous search of the Internet.

Results

The survey response rate was 46%, and data represented 49 of 54 (91%) African countries. Twenty-five EMS systems were identified and distributed among 16 countries (30% of African countries). There was no evidence of EMS systems in 33 (61%) countries. A total of 98,574,731 (8.7%) of the African population were serviced by at least one EMS system in 2012. The leading causes of EMS transport were (in order of decreasing frequency): injury, obstetric, respiratory, cardiovascular, and gastrointestinal complaints. Nineteen percent of African countries had government-financed EMS systems and 26% had a toll-free public access telephone number. Basic emergency medical technicians (EMTs) and Basic Life Support (BLS)-equipped ambulances were the most common cadre of provider and ambulance level, respectively (84% each).

Conclusion

Emergency Medical Services systems exist in one-third of African countries. Injury and obstetric complaints are the leading African prehospital conditions. Only a minority (<9.0%) of Africans have coverage by an EMS system. Most systems were predominantly BLS, government operated, and fee-for-service.

Mould-MillmanNK, DixonJM, SefaN, YanceyA, HollongBG, HagahmedM, GindeAA, WallisLA. The state of Emergency Medical Services (EMS) systems in Africa. Prehosp Disaster Med. 2017;32(3):273–283.

A refugee camp in the centre of Europe: clinical characteristics of asylum seekers arriving in Brussels

BACKGROUND

In the summer of 2015, the exodus of Syrian war refugees and saturation of refugee camps in neighbouring countries led to the influx of asylum-seekers in European countries, including Belgium. This study aims to describe the demographic and clinical characteristics of asylum seekers who arrived in a huddled refugee camp, in the centre of a well-developed country with all medical facilities.

METHODS

Using a descriptive cross-sectional study design, physicians of Médecins du Monde prospectively registered age, gender, origin, medical symptoms and diagnoses of all patients presenting to an erected field hospital in Brussels in September 2015. Diagnoses were post hoc categorised according to the International Classification of Diseases.

RESULTS

Of 4037 patients examined in the field hospital, 3907 were included and analysed for this study. Over 11% of patients suffered from injuries, but these were outnumbered by the proportion of patients with respiratory (36%), dental (9%), skin (9%) and digestive (8%) diagnoses. More than 49% had features of infections at the time of the consultation.

CONCLUSIONS

Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey suffer mostly from respiratory, dental, skin and digestive diseases. Still, one in seven suffers from injury. These findings, consistent with other reports, should be anticipated when composing emergency medical teams and interagency emergency health or similar kits to be used in a field hospital, even in a Western European country.

TRIAL REGISTRATION NUMBER

ISRCTN13523620, Results.

Chief Complaints of Elderly Individuals on Presentation to Emergency Department: A Retrospective Analysis of South Korean National Data 2014

PURPOSE

We aimed to assess the chief complaints (CCs) of elderly individuals on presentation to the emergency department (ED) according to gender, age, and disease-related and injury-related visits.

METHODS

The 2014 registry database of the National Emergency Department Information System in South Korea, which included data on 908,761 ED visits by individuals aged 65 years and over, was reviewed.

RESULTS

We found that 80.7% ED visits were related to disease, whereas the remaining visits were related to injury. The most common CCs presented by elderly male and female individuals with disease-related visits were dyspnea and dizziness, respectively. The 10 most common CCs accounted for 45.5% and 49.2% of the total disease-related visits for male and female individuals, respectively. The most common CC in male and female individuals with injury-related visits was headache and hip pain, respectively. The CC rank showed minimal variance among the different age groups, but a difference was observed between male and female individuals. The most common mechanism of injury in elderly male and female individuals was slipping, wherein females showed a higher occurrence rate than their male counterparts.

CONCLUSIONS

These findings can be used to establish an ED training curriculum for nursing students and ED nurses, particularly for ED triage in the elderly.

Developing metrics for emergency care research in low- and middle-income countries

INTRODUCTION

There is little research on emergency care delivery in low- and middle-income countries (LMICs). To facilitate future research, we aimed to assess the set of key metrics currently used by researchers in these settings and to propose a set of standard metrics to facilitate future research.

METHODS

Systematic literature review of 43,109 published reports on general emergency care from 139 LMICs. Studies describing care for subsets of emergency conditions, subsets of populations, and data aggregated across multiple facilities were excluded. All facility- and patient-level statistics reported in these studies were recorded and the most commonly used metrics were identified.

RESULTS

We identified 195 studies on emergency care delivery in LMICs. There was little uniformity in either patient- or facility-level metrics reported. Patient demographics were inconsistently reported: only 33% noted average age and 63% the gender breakdown. The upper age boundary used for paediatric data varied widely, from 5 to 20 years of age. Emergency centre capacity was reported using a variety of metrics including annual patient volume (n = 175, 90%); bed count (n = 60, 31%), number of rooms (n = 48, 25%); frequently none of these metrics were reported (n = 16, 8%). Many characteristics essential to describe capabilities and performance of emergency care were not reported, including use and type of triage; level of provider training; admission rate; time to evaluation; and length of EC stay.

CONCLUSION

We found considerable heterogeneity in reporting practices for studies of emergency care in LMICs. Standardised metrics could facilitate future analysis and interpretation of such studies, and expand the ability to generalise and compare findings across emergency care settings.

An investigation of the questions posted on medical consultation websites

BACKGROUND

Online medical consultation has recently become a more and more popular alternative venue for healthcare. It allows patients and caregivers to discuss their health problems and symptoms with qualified medical health professionals via the Internet.

OBJECTIVE

This study investigates the questions posted on an asynchronous online medical consultation website, Taiwan eDoctor. Five research themes are explored: (1) length of questions, (2) moment of seeking consultation, (3) strategies of communicating chief complaints, (4) purpose of seeking consultation and (5) identity disclosure.

METHODS

Data collection was conducted by randomly selecting 50 resolved consultation Q&As for each of 24 medical specialties, resulting in a total of 1200 entries in the primary data set. Data analysis was conducted qualitatively and quantitatively.

RESULTS

Average length of questions was 161.21 words. Online medical consultation was sought when healthy, healthy but not robust, when suspicious of illness, when diagnosed as ill and during treatment/recovery. In communicating chief complaints, consultation seekers were engaged in contextual, focal or emotional communication styles. Nine distinct purposes to seek online consultation were identified and can be broadly interpreted as intellectual, social and emotional. The finding also suggests that more than two-third of questions were asked for by the patients themselves.

CONCLUSION

Through content analysis of questions posted on an online medical consultation website, this study characterises communication patterns during the health information seeking process. These findings can help guide the design of more effective patient-centred online medical consultation services.

Emergency Department of a Rural Hospital in Ecuador

Introduction

There is a paucity of data studying patients and complaints presenting to emergency departments (EDs) in low- and middle-income countries. The town of Pedro Vicente Maldonado (PVM) is located in the northwestern highlands of Ecuador. Hospital PVM (HPVM) is a rural teaching hospital providing family medicine residency training. These physicians provide around-the-clock acute medical care in HPVM’s ED. This study provides a first look at a functioning ED in rural Latin America by reviewing one year of ED visits to HPVM.

Methods

All ED visits between April 14, 2013, and April 13, 2014, were included and analyzed, totaling 1,239 patient visits. Data were collected from their electronic medical record and exported into a de-identified Excel® database where it was sorted and categorized. Variables included age, gender, mode of arrival, insurance type, month and day of the week of the service, chief complaint, laboratory and imaging requests, and disposition. We performed descriptive statistics, and where possible, comparisons using Student’s T or chi-square, as appropriate.

Results

Of the 1239 total ED visits, 48% were males and 52% females; 93% of the visits were ambulatory, and 7% came by ambulance. Sixty-three percent of the patients had social security insurance. The top three chief complaints were abdominal pain (25.5%), fever (15.1%) and trauma (10.8%). Healthcare providers requested labs on 71.3% of patients and imaging on 43.2%. The most frequently requested imaging studies were chest radiograph (14.9%), upper extremity radiograph (9.4%), and electrocardiogram (9.0%). There was no seasonal or day-of-week variability to number of ED patients. The chief complaint of human or animal bite made it more likely the patient would be admitted, and the chief complaint of traumatic injury made it more likely the patient would be transferred.

Conclusion

Analysis of patients presenting to a rural ED in Ecuador contributes to the global study of acute care in the developing world and also provides a self-analysis identifying disease patterns of the area, training topics for residents, areas for introducing protocols, and information to help planning for rural EDs in low- and middle-income countries.

Emergency care in 59 low- and middle-income countries: a systematic review

Objective

To conduct a systematic review of emergency care in low- and middle-income countries (LMICs).

Methods

We searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards.

Findings

We identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2–5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3–8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5–6.3%). The median number of patients was 30 000 per year (IQR: 10 296–60 000), most of whom were young (median age: 35 years; IQR: 6.9–41.0) and male (median: 55.7%; IQR: 50.0–59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care.

Conclusion

Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.

Epidemiology of Shortness of Breath in Prehospital Patients in Andhra Pradesh, India

BACKGROUND

Shortness of breath is a frequent reason for patients to request prehospital emergency medical services and is a symptom of many life-threatening conditions. To date, there is limited information on the epidemiology of, and outcomes of patients seeking emergency medical services for, shortness of breath in India.

OBJECTIVE

This study describes the characteristics and outcomes of patients with a chief complaint of shortness of breath transported by a public ambulance service in the state of Andhra Pradesh, India.

METHODS

This prospective, observational study enrolled patients with a chief complaint of shortness of breath during twenty-eight, 12-h periods. Demographic and clinical data were collected from emergency medical technicians using a standardized questionnaire. Follow-up information was collected at 48-72 h and 30 days.

RESULTS

Six hundred and fifty patients were enrolled during the study period. The majority of patients were male (63%), from rural communities (66%), and of lower socioeconomic status (78%). Prehospital interventions utilized included oxygen (76%), physician consultation (40%), i.v. placement (15%), nebulized medications (13%), cardiopulmonary resuscitation (5%), and bag-mask ventilation (4%). Mortality ratios before hospital arrival, at 48-72 h, and 30 days were 12%, 27%, and 35%, respectively. Forty-six percent of patients were confirmed to have survived to 30 days. Predictors of death before hospital arrival were symptoms of chest pain (16% vs. 12%; p < 0.05) recent symptoms of upper respiratory infection (7.5% vs. 4%; p < 0.05), history of heart disease (14% vs. 7%; p < 0.05), and prehospital hypotension, defined as systolic blood pressure <90 mm Hg (6.3% vs. 3.7%; p < 0.05).

CONCLUSIONS

Among individuals seeking prehospital emergency medical services in India, the chief complaint of shortness of breath is associated with a substantial early and late mortality, which may be in part due to the underutilization of prehospital interventions.

An observational study of adults seeking emergency care in Cambodia

Objective

To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals.

Methods

Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation.

Findings

In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients’ mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired.

Conclusion

In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques.