Predictors and outcome of time to presentation among critically ill paediatric patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania.

BACKGROUND: Mortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown. In this study delay was defined as presentation to the emergency department of tertially hospital i.e. Muhimbili National Hospital, more than 48 h from the onset of the index illness. METHODOLOGY: This was a prospective cohort study of critically ill children aged 28 days to 14 years attending emergency department at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was the association of delay with mortality and secondary outcomes were predictors of delay among critically ill paediatric patients. Logistic regression and relative risk were calculated to measure the strength of the predictor and the relationship between delay and mortality respectively. RESULTS: We enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR = 9-60] months and 63.9% were males. The median time to Emergency Department arrival was 3 days [IQR = 1-5] and more than half (56.6%) of critically ill children presented to Emergency Department in > 48 h whereby being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.4(95% CI 1.4-4.0) and 1.8(95% CI 1.1-2.8) times increased odds of presenting late to the Emergency Department respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR = 1.3, CI: 0.9-1.9). Majority died > 24 h of Emergency Department arrival (P-value = 0.021). CONCLUSION: The risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill pediatric patients to identify preventable delays in care.

Predictors and outcome of cardiac arrest in paediatric patients presenting to emergency medicine department of tertiary hospitals in Tanzania.

BACKGROUND: The survival of children who suffer cardiac arrest is poor. This study aimed to determine the predictors and outcome of cardiac arrest in paediatric patients presenting to an emergency department of a tertiary hospital in Tanzania. METHODOLOGY: This was a prospective cohort study of paediatric patients > 1 month to ≤ 14 years presenting to Emergency Medicine Department of Muhimbili National Hospital (EMD) in Tanzania from September 2019 to January 2020 and triaged as Emergency and Priority. We enrolled consecutive patients during study periods where patients' demographic and clinical presentation, emergency interventions and outcome were recorded. Logistic regression analysis was performed to identify the predictors of cardiac arrest. RESULTS: We enrolled 481 patients, 294 (61.1%) were males, and the median age was 2 years [IQR 1-5 years]. Among studied patients, 38 (7.9%) developed cardiac arrest in the EMD, of whom 84.2% were ≤ 5 years. Referred patients were over-represented among those who had an arrest (84.2%). The majority 33 (86.8%) of those who developed cardiac arrest died. Compromised circulation on primary survey (OR 5.9 (95% CI 2.1-16.6)), bradycardia for age on arrival (OR 20.0 (CI 1.6-249.3)), hyperkalemia (OR 8.2 (95% CI 1.4-47.7)), elevated lactate levels > 2 mmol/L (OR 5.2 (95% CI 1.4-19.7)), oxygen therapy requirement (OR 5.9 (95% CI 1.3-26.1)) and intubation within the EMD (OR 4.8 (95% CI 1.3-17.6)) were independent predictors of cardiac arrest. CONCLUSION: Thirty-eight children developed cardiac arrest in the EMD, with a very high mortality. Those who arrested were more likely to present with signs of hypoxia, shock and acidosis, which suggest they were at later stage in their illness. Outcomes can be improved by strengthening the pre-referral care and providing timely critical management to prevent cardiac arrest.

Feasibility and yield of HIV screening among adult trauma patients presenting to an urban emergency department of a tertiary referral hospital in Tanzania.

BACKGROUND: The World Health Organization and Tanzanian National Guidelines for HIV and AIDS management, recommends provider initiated testing and counseling for HIV at any point of health care contact. In Tanzania, over 45% of people living with HIV are unaware of their HIV positive status. We determine the feasibility and yield of HIV screening among otherwise healthy adult trauma patients presenting to the first full-capacity Emergency Department in Tanzania. METHODS: This was a prospective cohort study of consecutive adult trauma patients presenting to Emergency Medicine Department at Muhimbili National Hospital (EMD-MNH) in Dar es Salaam, from March 2017 to September 2017. Eligible patients provided informed consent, pre and post-test counseling was done. Structured case report forms were completed, documenting demographics, acceptance of testing, results and readiness to receive results. Outcomes were the proportion of patients accepting testing, proportion of positive tests, readiness of the patient to receive the results, and proportion of patients who had an HIV test ordered as part of care. RESULTS: We screened 2848 trauma patients, and enrolled 326 (11.5%) eligible patients. Median age was 33 (IQR 25-42 years), and 248 (76.0%) of participants were male. Of those enrolled, 250 (76.7%) patients accepted testing for HIV, and among them 247 (98.8%) were ready to receive their test results. Of those tested, 14 (5.6%) were found to be HIV positive and 12 were ready to receive results. Two months post hospital discharge 6 (50%), of those who were informed of positive results had visited Care and Treatment Clinics (CTC) for HIV treatment. Three additional patients had not yet attended and three could not be reached. The treating ED physician tested none of the enrolled patients for HIV as part of their regular treatment. CONCLUSIONS: In our cohort of adult trauma patients presenting to ED, routine HIV screening for unrelated reason, was feasible and acceptable. The yield is sufficient to warrant an on-going program and superior to having physicians choose which patients to test. Future studies should focus on factors affecting the linkage to CTC among HIV positive patients identified at the ED.

Performance characteristics of a local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania.

BACKGROUND: A number of region-specific validated triage systems exist; however very little is known about their performance in resource limited settings. We compare the local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania. METHODOLOGY: Prospective descriptive study of consecutive under-fives seen at Muhimbili National Hospital (MNH), ED between November 2017 to April 2018. Patients were triaged according to Local Triage System (LTS), and the information collected were used to assign acuities in the other triage scales: Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), Manchester Triage Scale (MTS) and South African Triage Scale (SATS). Patients were then followed up to determine disposition and 24 h outcome. Sensitivity, specificity, positive and negative predictive values for admission and mortality were then calculated. RESULTS: A total of 384 paediatric patients were enrolled, their median age was 17 months (IQR 7-36 months). Using LTS, 67(17.4%) patients were triaged in level one, 291(75.8%) level 2 and 26 (6.8%) in level 3 categories. Overall admission rate was 59.6% and at 24 h there were five deaths (1.3%). Using Level 1 in LTS, and Levels 1 and 2 in other systems, sensitivity and specificity for admission for all triage scales ranged between 27.1-28.4% and 95.4-98% respectively, (PPV 90.3-95.3%, NPV 47.1-47.4%). Sensitivity for mortality was 80% for LTS, and 100% for the other scales, while specificity was low, yielding a PPV for all scales between 6.9 and 8%. CONCLUSION: All triage scales showed poor ability to predict need for admission, however all triage scales except LTS predicted mortality. The test characteristics for the other scales were similar. Future studies should focus on determining the reliability and validity of each of these triage tools in our setting.

Respiratory compromise in children presenting to an urban emergency department of a tertiary hospital in Tanzania: a descriptive cohort study.

BACKGROUND: Respiratory compromise is the leading cause of cardiac arrest and death among paediatric patients. Emergency medicine is a new field in low-income countries (LICs); the presentation, treatment and outcomes of paediatric patients with respiratory compromise is not well studied. We describe the clinical epidemiology, management and outcomes of paediatric patients with respiratory compromise presenting to the first full-capacity Emergency Department in Tanzania. METHODS: This was a prospective cohort study of paediatric patients (< 18 years) with respiratory compromise (respiratory distress, respiratory failure or respiratory arrest) presenting to the Emergency Medicine Department of Muhimibili National Hospital (EMD-MNH) in Dar es Salaam, from July-November 2017. A standardized case report form was used to record demographics, presenting clinical characteristics, management and outcomes. Primary outcomes were hospital mortality and secondary outcomes were EMD mortality, 24-h mortality, incidence of cardiac arrest in the EMD, length of stay, ICU admission, and risk factors for mortality. RESULTS: We enrolled 165 children; their median age was 12 months [IQR: 4-36 months], and 90 (54.4%) were male. At presentation 92 (55.8%) children were in respiratory failure. Oxygen therapy was initiated for 143 (86.7%) children, among which 21 (14.7%) were intubated. The most common aetiologies were pneumonia followed by congenital heart disease and sepsis. The majority 147 (89.1%) of children were admitted to the hospital, with 20 (12%) going to ICU. Four (2%) children were discharged from EMD and 14 (8.5%) died in the EMD. In the EMD, 18 children developed cardiac arrest, with two surviving to hospital discharge. Overall 51 (30.9%) children died; 84% of deaths were in children under five years. Risk of mortality was increased in children presenting with decreased consciousness (RR = 2.2 (1.4-3.4)), hypoxia RR = 2.6 (1.6-4.4)) or bradypnoea (RR = 3.9 (2.9-5.0)), and those who received CPR (RR = 3.7 (2.7-5.2)) and intubation (RR = 3.1 (2.1-4.5)). CONCLUSIONS: In this EMD of a LICs, respiratory compromise in children carries high mortality, with children of young age being the most vulnerable. Many children arrived in respiratory failure and few children received ICU care. Outcomes can be improved by earlier recognition to prevent cardiac arrest, and more intensive treatment, including ICU and assisted ventilation.

Disaster preparedness and response capacity of regional hospitals in Tanzania: a descriptive cross-sectional study.

BACKGROUND: Tanzania has witnessed several disasters in the past decade, which resulted in substantial mortality, long-term morbidity, and significant socio-economic losses. Health care facilities and personnel are critical to disaster response. We assessed the current state of disaster preparedness and response capacity among Tanzanian regional hospitals. METHODS: This descriptive cross-sectional survey was conducted in all Tanzanian regional hospitals between May 2012 and December 2012. Data were prospectively collected using a structured questionnaire based on the World Health Organization National Health Sector Emergency Preparedness and Response Tool. Trained medical doctors conducted structured interviews and direct observations in each hospital. RESULTS: We surveyed 25 regional hospitals (100% capture) in mainland Tanzania, in which interviews were conducted with 13-hospital doctors incharge, 9 matrons and 4 heads of casualty. All the hospitals were found to have inadequate numbers of all cadres of health care providers to support effective disaster response. 92% of hospitals reported experiencing a disaster in the past 5 years; with the top three being large motor vehicle accidents 22 (87%), floods 7 (26%) and infectious disease outbreaks 6 (22%). Fifteen hospitals (60%) had a disaster committee, but only five (20%) had a disaster plan. No hospital had all components of surge capacity. Although all had electricity and back-up generators, only 3 (12%) had a back-up communication system. CONCLUSION: This nationwide survey found that hospital disaster preparedness is at an early stage of development in Tanzania, and important opportunities exist to better prepare regional hospitals to respond to disasters.

Trauma burden in Tanzania: a one-day survey of all district and regional public hospitals.

BACKGROUND: Trauma contributes significantly to the burden of disease and mortality throughout the world, but particularly in developing countries. In Tanzania, there is an enormous research gap on trauma; the limited data available reflects realities in cities and areas with moderately- to highly-resourced treatment centers. Our aim was to provide a description of the injury epidemiology across all of Tanzania. Our data will serve as a basis for future larger studies. METHODS: This is a subgroup analysis of a cross-sectional, prospective study of the clinical epidemiology of patients presenting at all public district and regional hospitals in Tanzania. The study was conducted between May 2012 and December 2012. A team of emergency doctors used a purpose-designed data collection sheet to gather the demographic and clinical information of all patients presenting during the day-site visit to each hospital. Descriptive statistics, including means, standard deviations, medians, and ranges are reported. RESULTS: A total of 5227 patients were seen in 24-h period in 105 (100% response rate) district (or designated district) and regional hospitals in mainland Tanzania. Of these patients, 508 (9.7%) presented with trauma-related complaints. Among patients with trauma-related complaints, 286 (56.3%) were male, and the overall median age of 30 (interquartile range of 22-35) years. Road traffic crash was the most common mechanism of injury, accounting for 227 (44.7%) complaints. Open wounds and bone fractures were the two most frequent diagnoses, with a combined 300 (59%) cases. Most of the patients - 325 (64%) - were discharged, 11 (2.2%) went to operating theatres and 4 (0.8%) of patients died while receiving care at the acute intake areas. CONCLUSIONS: Trauma-related complaints constitute a substantial burden among patients seeking care in acute intake areas of hospitals across Tanzania. There is a need to develop, implement and study systems that can support the improvement of trauma care and optimize outcomes of trauma patients.

The burden and management strategies of hypertensive crisis in adult patients presenting to emergency departments of district and regional hospitals in Sub-Saharan Africa.

BACKGROUND: Hypertensive crisis is among the causes of morbidity and mortality in adult patients with hypertension in Sub-Saharan Africa. We aimed to determine the burden, risk factors and describe the management strategies of hypertensive crisis among adult patients seen at emergency departments of district and regional hospitals in Tanzania. METHODS: This was a prospective multicenter longitudinal study which included all 162 district and regional hospitals in Tanzania. It was part of the Tanzania Emergency Care Capacity Survey (TECCS), a large assessment of burden of acute illness and emergency care capacity in Tanzania. Adult patients who presented to emergency departments with blood pressure ≥ 180/110mmHg were enrolled. Demographics, clinical presentation, management, and 24-hours outcomes were recorded using a structured case report form. Descriptive statistics were summarized in frequency and median, while logistic regression was used to evaluate the association between risk factors and presence of hypertensive crisis. RESULTS: We screened 2700 patients and enrolled 169 adults, henceforth proportion of adult patients with hypertensive crisis was 63 per 1000. Median age was 62 years (IQR 50-70 years) and predominantly females, 112 (66.3%). Majority 151(89.3%) were self-referred with two-wheel motorcycle being the commonest 46 (27.2%) mode of arrival to the hospital. Hypertensive emergency was found in over half 96 (56.8%) of the patients with hypertensive crisis, with oral medications administered in more than half of them, 71 (74%) as means to control the high blood pressure, and one-third 33 (34.4%) were discharged home. On multivariate analysis increasing age (AOR 4.53, p < 0.001), use of illicit drug (AOR 4.14, p-0.04) and pre-existing hypertension (AOR 8.1, p < 0.001) were independent risk factors for hypertensive crisis occurrence. CONCLUSION: Hypertensive crisis among adult patients attending district and regional hospitals is common (63 patients per every 1000 patients). Increasing age, use of illicit drug and pre-existing hypertension are independent associated factors for developing hypertensive crisis.

Patterns and Predictors of Timely Presentation and Outcomes of Polytrauma Patients Referred to the Emergency Department of a Tertiary Hospital in Tanzania.

Background: Polytrauma patients require special facilities to care for their injuries. In HICs, these patients are rapidly transferred from the scene or the first-health facility directly to a trauma center. However, in many LMICs, prehospital systems do not exist and there are long delays between arrivals at the first-health facility and the trauma center. We aimed to quantify the delay and determine the predictors of mortality among polytrauma patients. Methodology. We consecutively enrolled adult polytrauma patients (≥18 years) with ISS >15 referred to the Emergency Medicine Department of Muhimbili National Hospital, a major trauma center in Tanzania between August 2019 and January 2020. Based on a pilot study, the arrival of >6 hours after injury was considered a delay. The outcome of interest was factors associated with delayed presentation and the association of timeliness with 7-day mortality. Results: We enrolled 120 (4.5%) referred polytrauma adult patients. The median age was 30 years (IQR 25-39) and the ISS was 29 (IQR 24-34). The majority (85%) were males. While the median time from injury to first-health facility was 40 minutes (IQR 33-50), the median time from injury to arrival at EMD-MNH, was 377 minutes (IQR 314-469). Delayed presentation was noted in more than half (54.2%) of participants, with the odds of dying being 1.4 times higher in the delayed group (95% CI 0.3-5.6). Having a GCS <8 (AOR 16.3 (95% CI 3.1-86.3), hypoxia <92% (AOR 8.3 (95% CI 1.4-50.9), and hypotension <90 mmHg (R 7.3 (95% CI 1.6-33.6) were all independent predictors of mortality. Conclusion: The majority of polytrauma patients arrive at the tertiary facilities delayed for more than 6 hours and a distance of more than 8 km between facilities is associated with delay. Hypotension, hypoxia, and GCS of less than 8 are independent predictors of poor outcome. In the interim, there is a need to expedite the transfer of polytrauma patients to trauma care capable centers.