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Abstract
Objective To determine the clinical profile and outcome of critically ill children presenting to a paediatric ED in a lower middle-income country.
Methods We performed a retrospective analysis of children (<14 years) presenting to the ED of the National Institute of Child Health, Karachi, between January and December 2014 who were assigned to acuity 1 (requiring immediate life-saving interventions) according to the Emergency Severity Index. Data included demographic variables, presenting complaints, interventions and outcomes in the ED.
Results There were 172 162 visits during the year. Of these, 13 551 (8%) were level 1. 64% of level 1 patients were transported to the ED without ambulance service. Neonates (0–28 days) constituted 48% of level 1 children; their most frequent presenting complaints were respiratory symptoms, followed by fever and reluctance to feed. Above the neonatal age group, the most common presenting complaints were gastrointestinal symptoms (with signs of hypoperfusion), followed by seizures, reluctance to feed and respiratory symptoms. 64% of children of >28 days presenting were malnourished. Interventions included cardiopulmonary resuscitation, application of bubble continuous positive airway pressure and endotracheal intubation. Overall mortality was 13%; 63% of all deaths were in the neonatal age group.
Conclusion Children with the highest triage acuity represent 8% of all visits to a paediatric ED. In this group, neonates account for nearly half of all the children, and more than half of all the deaths among critically ill children came in ED. A large proportion of high-acuity children are malnourished.
- paediatric resuscitation
- emergency department
- death/mortality
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Key messages
What is already known on this subject
Emergency care is not well established in Pakistan and other lower middle-income countries. As opposed to high-income countries, low-income and middle-income countries have high rates of severe illnesses and mortality in children. Knowledge of the acuity, causes and possible contributors to paediatric emergencies will be important for developing structure in the emergency healthcare system.
What this study adds
In this retrospective review from a paediatric ED in Pakistan, 8% of children presented in the highest triage acuity, with an overall mortality of 13% in the ED. Neonates constituted nearly half of this high-acuity group and accounted for 63% of all deaths. A large portion of the children were also malnourished.
Introduction
Paediatric emergency medicine is still in its beginning in many regions of the world, although it is a mature discipline in developed regions.1 Data from low-income and middle-income countries on paediatric emergencies are limited. The World Bank designates Pakistan as a lower middle-income country.
Data regarding the epidemiology of children attending emergency rooms requiring resuscitation are virtually non-existent in Pakistan. However a few studies from Pakistan do describe the burden of seriously ill and injured children. The Children’s Hospital in Islamabad admitted 192 children over 3 months with serious injuries.2 Another study in Karachi observed that 1320 injured children were transported over a 3-year period to hospitals by the main provider of emergency medical transport.3 Similarly a study from Lahore reported 346 cases of acute poisoning out of 37 000 paediatric emergency room attendances in a 5-year period.4
To formulate appropriate strategies for the management of acutely ill children brought to emergency services, adequate information about the spectrum of various diseases or conditions and their presentations is needed. Although over the years the general trends of paediatric morbidity have been reported,5 not much published information is available about the pattern of emergencies and utilisation of emergency services in Pakistan. Most of the published data are from the developed countries.6–8
The paediatric emergency service at the National Institute of Child Health (NICH), Karachi, Pakistan, has witnessed a threefold increase in patients’ visits in the last 3 years (Emergency Department of National Institute of Child Health, Karachi, 2013-2016, unpublished data). The objective of this study is to define the profile and outcomes of critically ill patients who required immediate life-saving interventions presenting to one of the largest paediatric EDs in our country.
Materials and methods
Study design
This study was performed as a retrospective analysis of all children presenting to our paediatric ED and who were triaged as level 1 according to Emergency Severity Index (ESI) between January and December 2014 for 1 year. Level 1 patient are those who require immediate life-saving interventions, such as immediate significant fluid resuscitation, bag mask ventilation, cardiopulmonary resuscitation (CPR), blood administration, control of major bleeding, need of inotropic support, defibrillation and endotracheal intubation or immediate requirement of non-invasive nasal bubble continuous positive airway pressure (CPAP).
The study was approved by the ethical and review committee of NICH with a waiver of the requirement for informed consent.
Study setting
The study was conducted in the paediatric ED of the NICH, Karachi, which has an annual census of around 172 162 (average monthly was 14 346) visits in 2014 and is the hub of residency training programme for general paediatrics. Repeat visits were not excluded and there may be multiple visits in ED by a single patient during that year due to lack of access to quality primary care in late evenings and nights. This institute is a multidisciplinary teaching and referral hospital. Its paediatric ED is one of the largest in the country with 55 beds. Patient age ranges from neonates on the first day of life up to the age of 14 years. The ED receives support from a non-governmental organisation (NGO), ‘ChildLife Foundation’. It is the first public-sector ED in the country with a well-established triage system to prioritise patients by acuity. ESI acuity is assigned by registered nurses after initial assessment and vitals before registration.
The department is capable of seeing all type of emergencies in children, including trauma, burns, nephrology, oncology, neonatology, endocrinology and common infectious diseases of all severities. Ninety per cent of clinical staff are trained for basic life support course. The ED contains a resuscitation room for critically ill children, equipped with a crash cart filled with life-saving medicines, cardiac monitors, infusion pumps and a defibrillator. There is also a step-down area and an isolation room for immunocompromised patients, fast track, a procedure room and pharmacy with qualified pharmacists. Consultation is available 24/7 for acute surgical emergencies by an on-call senior resident of surgery. Similarly, consultations for cases of acute kidney injuries, oncological emergencies and endocrine problems are available from senior registrars of the respective subspecialties. Those who require neurosurgical consultation for head injury are referred after stabilisation in our ED to another tertiary care facility.
The ED is staffed by full-time senior registrars who have completed a fellowship of 4 years in general paediatrics, and there are on-call rotating senior residents from the paediatric medicine training programme, paediatric surgery, paediatric intensive care unit, neonatal intensive care unit and paediatric nephrology. Nursing is provided by registered nurses from the government as well as NGO side. X-rays, ultrasounds and MRI are available round the clock.
Patients
We included children with age ranges from first day of life up to the age of 14 years and who were triaged as level 1 by the ESI. Children of more than 14 years and those with triage level other than 1 were excluded.
Data collection and analysis
We used the Health Management Information System (HMIS) for the study, part of a comprehensive National HMIS developed by the Ministry of Health.9 HMIS records the demographic data, date and time of registration, presenting complaints, initial vitals and weight of patients other than level 1 (who gave weights estimated using length-based tape), and immunisation status for each ED visit. HMIS also captures final disposition (discharged, specialty under which they are admitted or expired in ED). CPR, application of bubble CPAP and endotracheal intubations are recorded at the time of final disposition, along with initial diagnosis by the data entry operator 24/7. Mode of transportation of level 1 patients (either by ambulance or without ambulance) is recorded at the time of registration.
Outcomes of interest were total patients seen and the proportion that were of the highest acuity, reason for visit, mode of arrival, major interventions and mortality in the ED. Demographic data, including patient weight and immunisation status, are also reported. Results are reported using descriptive statistics. There were no missing data.
Results
The total visits during the year 2014 were 172 162. Repeat visits were not excluded. Out of these, 8% (n=13 551) were triaged as level 1 or critically ill. Male to female ratio was 1.7:1. The majority (87%) were under the age of 5 years (n=11 851) and nearly half were neonates (48%), followed by infants (22%) and then 1–5 years age group (17%).
The numbers and percentage of different age groups along with their presenting complaints and outcomes (mortality in ED) for each presenting complaint are shown in tables 1 and 2, respectively. The most common presenting complaints among neonates were respiratory symptoms, followed by fever and reluctance to feed with signs of hypoperfusion. Forty-nine per cent of neonates presented were preterm.
Demographics and outcomes of level 1 paediatric patients
Chief complaints by age
Among children of >28 days of life, the most common presenting complaints were (1) gastrointestinal symptoms with signs of hypoperfusion and treated as hypovolemic shock, followed by (2) seizures, then (3) reluctance to feed and lethargy, followed by (4) respiratory symptoms and (5) acute life-threatening events. Sixty-four per cent (64%) (n=4457/7004) of all critically ill children among this age group were malnourished or had failure to thrive (table 2).
Among all critically ill patients, 64% (n=8700) were transported to the ED without ambulance services (table 1).
Outcomes
Overall, the mortality was 13% (n=1707) among critically ill patients (level 1). Mortality was highest in neonates with 1082 deaths (63% of deaths), followed by deaths in infants (18%), then age group of 1–5 years (13%), and then in the 5–14 years age group (6%). Fifty-two per cent of the deaths in neonates were in preterm babies (table 1). Sixty per cent of all deaths occurred in patients who were not transported by ambulance.
The major interventions in these critical patients were CPR in 6% (n=843), endotracheal intubations in 7% (n=933) and non-invasive nasal bubble CPAP in 8% (n=1065). The numbers and percentage of deaths for patients who received each intervention are shown in table 3.
Interventions and outcomes
Discussion
In this study of a large, single paediatric ED, mortality was 13% in level 1 patients, with 94% of deaths in age group less than 5 years. The highest number of deaths was in neonates, and 52% of neonatal deaths were in preterm babies. The majority of the patients who died in the highest acuity group presented with respiratory symptoms, fever and reluctance to feed, and seizures requiring intensive care setting.
Pakistan is one of the five countries in the world with the highest under 5 mortality largely due to infectious diseases.10–13
Paediatric infection-related ailments were the most common presenting complaints in our study, which is also consistent with literature from elsewhere in Pakistan and other lower middle-income countries.14–16 Armon et al 6 have also observed that fever, respiratory difficulty and diarrhoea were the common presenting complaints in paediatric emergency patients in the UK.
Sixty-four per cent of children of >28 days of life who presented as critically ill (level 1) were malnourished in our study. Malnutrition in children is a global public health problem with wide implications. Malnourished children have increased risk of dying from infectious diseases, and it is estimated that malnutrition is the underlying cause of 45% of global deaths in children below 5 years of age.17 18 Malnutrition increases susceptibility to infections, while infections aggravate malnutrition by decreasing appetite, inducing catabolism and increasing demand for nutrients.19
The WHO conducted a study in 21 hospitals in low-income countries like Bangladesh, Dominican Republic, Ethiopia and Indonesia, and reported that 90% of children had severe forms of common infectious diseases, especially pneumonia, diarrhoea, sepsis, malaria and meningitis, often complicated by chronic malnutrition.10
The majority of our critically ill patients came to the ED without ambulance services and without a medical personnel or a paramedic. Although mortality was similar among those who did and did not use ambulance services, this was not formally studied with consideration of potential confounders. Reasons for preferential utilisation of private transport may include the lack of a well-coordinated nationwide emergency medical service and lack of awareness regarding availability of ambulances.20–22
Unfortunately, 72% of CPR patients who received CPR did not survive. Similarly, 48% of intubated patients died and most of the intubated patients could not get ventilator support due to limitation of resources in our facility. However, critically ill patients in whom application of nasal bubble CPAP was initiated in the ED appeared to have a good survival rate.
Based on our findings, the physicians and management team working in ED developed a series of recommendations (figure 1). The need is high to improve healthcare services at a community level by developing quality primary care access so that there will be optimum antenatal care for pregnant women, early recognition and initial treatment of infectious-related illnesses in children at primary care level, and support for mothers to make food healthier for their children. There is also the need for more tertiary care hospitals for children with optimum resources. Ambulance services should be strengthened as well.
Recommendations by physicians and management team working in ED. NICU, neonatal intensive care unit; PICU, paediatric intensive care unit.
Limitations
This a single-centre study and thus it cannot be assumed that the children in other institutes of the country present with similar complaints and diagnosis. Furthermore, data on diagnostic categories have inherent limitations. The main priority during acute emergency care is to stabilise the patient according to severity of the illnesses rather than reach a diagnosis. We have therefore presented data on the basis of presenting complaints as well as diagnostic categories. These are the data of a single year, and so it is possible that some of the presenting complaints and diagnostic categories will differ due to the effect of seasonal variation on disease pattern in subsequent years.
Conclusion
The children with highest acuity level presenting to a paediatric ED of a lower middle-income country were mostly <5 years of age with infectious-related problems, and the mortality was highest in neonatal and infant age groups. A large number of children were also malnourished. More than half of all high-acuity level were transported to the ED without ambulance services. Our findings suggest that there is a need for improved prevention and treatment at the primary care level.
Operational definitions
Preterm: is defined as baby born alive before 37 weeks of pregnancy are completed.23 Neonate: A newborn infant, or neonate, is a child 28 days of life or younger.24 Infants: >28 days to 12 months of age.
Malnourished child: a child whose weight is below a specified percentage of median weightfor age25 according to Gomez classification. In our study, all malnourished children werethose whose weight for age was <60% of their median weight for age (grade 3 malnutrition). Failure to thrive: in children, it is usually defined in terms of weight, and can be evaluatedeither by a low weight for the child’s age, or by a low rate of increase in the weight.26
References
Footnotes
Contributors MIH and KMK developed the initial draft and analysis plan. MIH and KMK were involved in data analysis and interpretation. MIH and KMK provided critical review of the draft as well as in overall design and implementation of draft. Both authors approved of the final draft.
Competing interests None declared.
Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen detailed information available and are satisfied that the information backs up the case the authors are making.
Provenance and peer review Not commissioned; externally peer reviewed.