Profile and outcomes of critically ill children in a lower middle-income country

Epidemiological trends of febrile infants presenting to the Paediatric Emergency department, in a tertiary care hospital, Karachi, Pakistan: a retrospective review

BACKGROUND

Understanding the epidemiological patterns of febrile infants can offer valuable insights for optimising management strategies and developing quality improvement initiatives, aiming to improve healthcare delivery in high-volume, low-resource emergency departments (EDs).

OBJECTIVES

To characterise the epidemiology of febrile infants presenting to the paediatric ED of a tertiary care hospital.

METHODS

A retrospective chart review of medical records was performed for febrile infants ≤1 year old, at paediatric ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan (1 January 2020-31 December 2020).

RESULTS

There were a total of 2311 patients in the study, with a male-to-female ratio of 1.4:1. The mean age of presentation was 4.9±2.7 months. Cough (n=1002, 43.2%) was the most frequent presenting symptom. The most common provisional ED diagnosis in ≤1 month of age was sepsis (n=98, 51%), bronchopneumonia (n=138, 28.6%) in 1.1-3 and 3.1-6 months (n=176, 36.45%); and upper respiratory tract illness (n=206, 47.4%) in 6.1-12 months of age. Age was significantly associated with provisional ED diagnosis and outcomes (p<0.001). Of 175 ED admissions (n=47, 26.8%), patients were discharged with a hospital diagnosis of bronchopneumonia and (n=27, 15.4) of sepsis. The infant mortality rate was 3/1000 live births.

CONCLUSIONS

This study is the first of its kind to explore the epidemiology of febrile infants in Pakistan, highlighting the burden and severity of respiratory illnesses and sepsis. It underscores the challenges of resource-limited settings, failing to meet the need for admission of febrile infants presenting to ED, IHHN. Moreover, it has highlighted the necessity to optimise the existing triage systems to effectively allocate resources and manage high patient volumes in low-resource EDs.

The spectrum of acute illness and mortality of children and adolescents presenting to emergency services in Sanghar district hospital, Pakistan: a prospective cohort study

OBJECTIVE

To describe presenting diagnoses and rates and causes of death by age category and sex among children with acute illness brought to a district headquarter hospital in Pakistan.

DESIGN

Prospective cohort study.

SETTING

Sanghar district headquarter hospital, Sindh, Pakistan between December 2019 and April 2020 and August 2020 and December 2020.

PARTICIPANTS

3850 children 0-14 years presenting with acute illness to the emergency and outpatient departments and 1286 children admitted to the inpatient department.

OUTCOME MEASURES

The primary outcome was Global Burden of Disease diagnosis category. Secondary outcomes were 28-day mortality rate, cause of death and healthcare delays, defined as delay in care-seeking, delay in reaching the healthcare facility and delay in appropriate treatment.

RESULTS

Communicable diseases were the most common presenting diagnoses among outpatients and among inpatients aged 1 month to 9 years. Non-communicable diseases and nutritional disorders were more common with increasing age. Few children presented with injuries. Newborn period (age <28 days) was associated with increased odds of death (OR 4.34 [95% CI 2.38 to 8.18], p<0.001, reference age 28 days-14 years) and there was no significant difference in odds of death between female vs male children (OR 1.12, 95% CI 0.6 to 2.04, p=0.72). 47 children died in the hospital (3.6%) and three (0.2%) died within 28 days of admission. Most children who died were <28 days old (n=32/50, 64%); leading diagnoses included neonatal sepsis/meningitis (n=13/50, 26%), neonatal encephalopathy (n=7/50, 14%) and lower respiratory tract infections (n=6/50, 12%). Delays in care-seeking (n=15) and in receiving appropriate treatment (n=12) were common.

CONCLUSION

This study adds to sparse literature surrounding the epidemiology of disease and hospital outcomes for children with acute illness seeking healthcare in rural Pakistan and, in particular, among children aged 5-14 years. Further studies should include public and private hospitals within a single region to comprehensively describe patterns of care-seeking and interfacility transfer in district health systems.

Emergency Department as the Entry Point to Inpatient Care: A Nationwide, Population-Based Study in South Korea, 2016-2018

(1) Background: The emergency department provides lifesaving treatment and has become an entry point to hospital admission. The purpose of our study was to describe the characteristics and outcomes of patients who were admitted through the emergency department to the intensive care unit or general ward. (2) Methods: We performed a retrospective, cross-sectional, descriptive analysis using the National Emergency Department Information System, analyzing patient data including disease category, diagnosis, and mortality from 1 January 2016, to 31 December 2018. (3) Results: During the study period, about 13.6% were admitted through the emergency department. Of these, the overall in-hospital mortality was 4.6%. The frequent disease class for the intensive care unit admissions was the cardiovascular system, and the classes for the general ward admissions were as follows: injury and toxicology, digestive system, and respiratory system. Cardiovascular system-related emergencies were the predominant cause of death among patients admitted to the intensive care unit; however, oncologic complications were the leading cause of death in the general ward. (4) Conclusions: Emergency departments are incrementally utilized as the entry point for hospital admission. Health care providers need to understand emergency department admission epidemiology and prepare for managing patients with certain common diagnoses.

Critically Ill Children in a Swiss Pediatric Emergency Department With an Interdisciplinary Approach: A Prospective Cohort Study

Objective: Delivery of prompt and adequate care for critically ill and injured children presenting to the pediatric emergency department (PED) is paramount for optimal outcomes. Knowledge of the local epidemiology, patient profile, and presentation modes are key for organizational planning, staff education strategy, and optimal care in a PED. Our aim was to analyze the profile of critically ill and injured children admitted to a tertiary, non-academic Swiss PED, to investigate potential risk factors associated with admission to the pediatric intensive care unit (PICU), and the outcomes mortality and PICU admission. Methods: Prospective cohort study of critically ill and injured children presenting to the PED over a two-year period (2018-2019). Inclusion criteria were Australasian triage scale category (ATS) 1, trauma team activation (TTA), medical emergency response (MER) activation, additional critical care consult, and transfer to an outside hospital. Results: Of 42,579 visits during the two-year period, 347 presentations matched the inclusion criteria (0.81%). Leading presentations were central nervous system (CNS) disorders (26.2%), trauma (25.1%), and respiratory emergencies (24.2%). 288 out of 347 cases (83%) arrived during the day or evening with an even distribution over the days of the week. 128 out of 347 (37%) arrived unexpectedly as walk-ins. 233 (67.15%) were ATS category 1. 51% of the cohort was admitted to PICU. Australasian triage scale category 1 was significantly more common in this group (p = 0.0001). Infants with respiratory disease had an increased risk of PICU transfer compared to other age groups (OR 4.18 [95%CI 2.46, 7.09] p = 0.0001), and this age group presented mainly as walk-in (p = 0.0001). Pediatric intensive care unit admissions had a longer hospital stay (4 [2, 8] days vs. 2 [1, 4] days, p = 0.0001) compared to other patients. 0.045% of all PED patients had to be transferred out. Three deaths (0.86%) occurred in the PED, 10 patients died in the PICU (2.9%). Conclusions: High acuity presentations in the PED were rare, more likely to be young with CNS disorders, trauma and respiratory diseases. A significant proportion were unexpected walk-in presentations, mainly during day and evening shifts. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED.

Pediatric emergency care in a low-income country: Characteristics and outcomes of presentations to a tertiary-care emergency department in Mozambique

Background

An effective pediatric emergency care (PEC) system is key to reduce pediatric mortality in low-income countries. While data on pediatric emergencies from these countries can drive the development and adjustment of such a system, they are very scant, especially from Africa. We aimed to describe the characteristics and outcomes of presentations to a tertiary-care Pediatric Emergency Department (PED) in Mozambique.

Methods

We retrospectively reviewed PED presentations to the "Hospital Central da Beira" between April 2017 and March 2018. Multivariable logistic regression was used to identify predictors of hospitalization and death.

Results

We retrieved 24,844 presentations. The median age was 3 years (IQR 1-7 years), and 92% lived in the urban area. Complaints were injury-related in 33% of cases and medical in 67%. Data on presenting complaints (retrieved from hospital paper-based registries) were available for 14,204 (57.2%) records. Of these, respiratory diseases (29.3%), fever (26.7%), and gastrointestinal disorders (14.2%) were the most common. Overall, 4,997 (20.1%) encounters resulted in hospitalization. Mortality in the PED was 1.6% (62% ≤4 hours from arrival) and was the highest in neonates (16%; 89% ≤4 hours from arrival). A younger age, especially younger than 28 days, living in the extra-urban area and being referred to the PED by a health care provider were all significantly associated with both hospitalization and death in the PED at the multivariable analysis.

Conclusions

Injuries were a common presentation to a referral PED in Mozambique. Hospitalization rate and mortality in the PED were high, with neonates being the most vulnerable. Optimization of data registration will be key to obtain more accurate data to learn from and guide the development of PEC in Mozambique. Our data can help build an effective PEC system tailored to the local needs.

Disease Spectrum and Frequency of Illness in Pediatric Emergency: A Retrospective Analysis From Karachi, Pakistan

Background: The National Institute of Child Health (NICH) is the largest tertiary care pediatric hospital operating in Karachi, Pakistan. Its emergency department (ED) is always occupied. However, the spectrum of illness in patients presenting to this ED has not been investigated in depth to identify the most common presentations and to develop effective management for treating patients. Methods: This retrospective study included all children visiting the pediatric ED of the NICH from January 2017 through December 2017. Newborns to children 14 years of age were included, for a total cohort of 188,803 patients. Sociodemographic data and clinical information were extracted from the medical record. Univariate analysis was performed to determine the frequency and percentage for all the variables. Results: The cohort consisted of 9% (n=16,952) neonates (0 to 1 month) and 91% (n=171,351) older children (>1 month to 14 years). Among the neonates, 36.6% presented as triage level 1. Sepsis was diagnosed in 23.8% of neonates, low birth weight/preterm in 18.4%, and respiratory distress/pneumonia in 15.2%. In infants and older children, diagnoses related to the respiratory system (37.3%), gastrointestinal system (16.4%), and multisystem involvement (15.9%) were the most common. During the evening shifts, 38.1% of patients were seen, and on weekends, 51.6% of patients were seen. Sunday was the busiest day in the ED. Conclusion: The tertiary care pediatric EDs in Pakistan have witnessed an increasing number of critical emergencies over time. Respiratory and gastrointestinal emergencies form the majority of the ED burden. A surge of patients is seen on the weekends and during the evening shifts. The spectrum of illnesses should be investigated via prospective, longitudinal studies in other pediatric EDs in Pakistan to understand the trends and to provide the foundation for developing nationwide recommendations for improving pediatric emergency care.