Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department.

BACKGROUND: Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation. METHOD: This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined. RESULTS: The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%. CONCLUSION: DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.

Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan.

BACKGROUND: Nearly 90% of out-of-hospital cardiac arrest (OHCA) patients are witnessed, yet only 2.3% received bystander cardiopulmonary resuscitation (CPR) in Pakistan. This study aimed to determine retention of knowledge and skills of Hands-Only CPR among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan. METHODS: Pre and post-tests were conducted among CPR training participants from diverse non-health-related backgrounds from July 2018 to October 2019. Participants were tested for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after training (re-test). All the participants received CPR training through video and scenario-based demonstration using manikins. Post-training CPR skills of the participants were assessed using a pre-defined performance checklist. The facilitator read out numerous case scenarios to the participants, such as drowning, poisoning, and road traffic injuries, etc., and then asked them to perform the critical steps of CPR identified in the scenario on manikins. The primary outcome was the mean difference in the knowledge score and skills of the participants related to the recognition of OHCA and initiation of CPR. RESULTS: The pre and post-tests were completed by 652 participants, whereas the retention test after 6 months was completed by 322 participants. The mean knowledge score related to the recognition of OHCA, and initiation of CPR improved significantly (p < 0.001) from pre-test [47.8/100, Standard Deviation (SD) ±13.4] to post-test (70.2/100, SD ±12.1). Mean CPR knowledge after 6 months (retention) reduced slightly from (70.2/100, ±12.1) to (66.5/100, ±10.8). CPR skill retention for various components (check for scene safety, check for response, check for breathing and correct placement of the heel of hands) deteriorated significantly (p < 0.001) from 77.9% in the post-test to 72.8% in re-test. Participants performed slightly better on achieving an adequate rate of chest compressions from 73.1% in post-test to 76.7% in re-test (p 0.27). CONCLUSION: Community members with non-health backgrounds can learn and retain CPR skills, allowing them to be effective bystander CPR providers in OHCA situations. We recommend mass population training in Pakistan for CPR to increase survival from OHCA.

Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study.

BACKGROUND: T-CPR has been shown to increase bystander CPR rates dramatically and is associated with improved patient survival. OBJECTIVE: To evaluate the acceptability of T-CPR by the bystanders and identify baseline quality measures of T-CPR in Karachi, Pakistan. METHODS: A cross-sectional study was conducted from January to December 2018 at the Aman foundation command and control center. Data was collected from audiotaped phone calls of patients who required assistance from the Aman ambulance and on whom the EMS telecommunicator recognized the need for CPR and provided instructions. Information was recorded using a structured questionnaire on demographics, the status of the patient, and different time variables involved in CPR performance. A One-way ANOVA was used to compare different time variables with recommended AHA guidelines. P-value ≤ 0.05 was considered significant. RESULTS: There were 481 audiotaped calls in which CPR instruction was given, listened to, and recorded data. Out of which in 459(95.4%) of cases CPR was attempted Majority of the patients were males (n = 278; 57.8%) and most had witnessed cardiac arrest (n = 470; 97.7%) at home (n = 430; 89.3%). The mean time to recognize the need for CPR by an EMS telecommunicator was 4:59 ± 1:59(min), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.). CONCLUSION: Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.

Burden of out-of-hospital cardiac arrest in Karachi, Pakistan: Estimation through the capture-recapture method.

OBJECTIVE: To assess the application of capture-recapture method as a potential strategy to estimate the incidence of out-of-hospital cardiac arrest. METHODS: This cross-sectional study was carried out from January to April 2013 in Karachi and comprised three public general hospitals, one public cardiac hospital, one private general hospital and two ambulance services. Two-sample capture-recapture method was used: first capture was through cardiac arrest data from two major emergency medical services and second capture was from the five teaching hospitals. Records from the hospitals and ambulance services were compared on 7 variables; name, age, gender, date and time of arrest, cause of arrest and destination hospital. Matched and unmatched cases were used in the equation to estimate the incidence of out-of-hospital cardiac arrest. RESULTS: Of the 630 out-of-hospital cardiac arrest cases reported, 191(30.3%) related to the emergency medical services records and 439(69.7%) to hospital records. The capture-recapture identified only 9(1.4%) matched cases even with the least restrictive criteria and estimated the annual out-of-hospital cardiac arrest incidence as 166/100,000 population (95% confidence interval: 142.9 to 189.6). CONCLUSIONS: Capture-recapture method could be a potential alternative for providing population level data in the absence of organised health information systems.

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures.

BACKGROUND: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. METHODS: From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. RESULTS: Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. CONCLUSIONS: Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country. METHODS: We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a structured questionnaire. All patients ≥18 years of age, presenting with OHCA of cardiac origin, were included. Patients with do-not-resuscitate status or referred from other hospitals were excluded. Our primary outcome was survival of OHCA patients at the end of ED stay. RESULTS: During the three month period, data was obtained from 310 OHCA patients. The overall survival to ED discharge was 1.6 % which decreased to 0 % at 2-months after discharge. More than half (58.3 %) of these OHCA patients were brought to the hospital in a non-EMS (emergency medical service) vehicle i.e. public or private transportation. Patients utilizing non-EMS transportation reached the hospital earlier with a median time of 23 min compared to patients utilizing any type of ambulances which had a delay of 7 min hospital reaching time (median time 30 min). However, patients utilizing ambulances with life-support facilities, as compared to all other types of pre-hospital transportation, had the shortest time to first life-support intervention (15 min). Most of the patients (92.9 %) had a witnessed cardiac arrest out of which only a small percentage (2.3 %) received bystander CPR (cardio pulmonary resuscitation). Median time from arrest to receiving first CPR was 20 min. Only 1 % of patients were found to have a shockable rhythm on first assessment. CONCLUSION: This study showed that the overall survival of OHCA is null in this population. Lack of bystander CPR and weaker emergency medical services (EMS) leading to a delay in receiving life-support interventions were some of the important observations. Poor survival emphasizes the need to standardize EMS systems, initiate public awareness programs and strengthen links in the chain of survival.

Can trained field community workers identify stroke using a stroke symptom questionnaire as well as neurologists? Adaptation and validation of a community worker administered stroke symptom questionnaire in a peri-urban Pakistani community.

BACKGROUND: Stroke is a leading cause of morbidity and mortality worldwide. There is a paucity of data from South Asia where stroke is highly prevalent. Validated tools administrable by community health workers (CHWs) are required to identify stroke in the community in a resource-strapped region such as this. METHODS: The study was conducted in a transitional slum in Karachi, Pakistan. Questionnaire to Verify Stroke-Free Status (QVSFS) was adapted and translated into Urdu. Two CHWs, trained by a neurologist, selected 322 community-dwelling subjects using purposive sampling. Each CHW collected data independently, which was validated by a vascular neurologist who directly examined each participant. To assess the effect of audit and feedback, data from the final 10% of the subjects were collected after a second training session for the CHWs. Sensitivity, specificity, and Cohen kappa were determined for the CHW-administered questionnaire against neurovascular assessment. RESULTS: Mean age of participants was 56.5 years with 71% of participants being women. The sensitivity and specificity of the questionnaire of detecting stroke was 77.1% (confidence interval [CI], 64.1-86.9) and 85.8% (CI, 83.5-87.5), respectively. The chance-corrected agreement using the Cohen kappa statistic was .51 (CI, .38-.60). Kappa ranged from .37 to .58 for each of the 7 stroke symptoms. Hemianesthesia (72.9%) and hemiplegia (64.6%) were the most sensitive symptoms. The performance and agreement improved from moderate to substantial after audit and feedback. CONCLUSIONS: We found a reasonable sensitivity and specificity and moderate agreement between CHW-administered QVSFS and assessment by a vascular neurologist.

Differences in risk-adjusted outcome of road traffic injuries in urban tertiary care centers of Pakistan.

OBJECTIVE: To assess the differences in road injury survival in three tertiary care hospitals in an urban setting. METHODS: The study was conducted in and comprised all road traffic injury victims presenting to the three state-run tertiary care centres in Karachi from September 2006 to October 2009. Patients' age, gender, mode, and delay in arrival, severity of injury were noted. Data was stratified by hospital of presentation. A logistic regression model was developed and probability of survival was assessed after adjusting for various risk factors, including patient characteristics and injury severity. RESULTS: There were 93,657victims in the study, but complete information was missing in 6,458(6.89%) study subjects, including survival information. Overall, 83,837(89.5%) were males; 64,269(74%) were aged between 16 and 45 years; 84,016(95%) had injury severity score of ?15; and overall survival was 84,141(96.5%). CONCLUSIONS: Significant differences existed in risk-adjusted survival of road injury victims presenting to public hospitals of Karachi. These differences pointed to variations in the process of care, and highlighted opportunities for improvement.

Pakistan's Emergency Medical Services (EMS) system & out-of-hospital-cardiac-arrest (OHCA): A narrative review of an EMS system of a low middle income country in context of OHCA.

Pakistan's Emergency Medical Services (EMS) are a critical component of its healthcare system, providing pre-hospital emergency care across a nation with over 220 million people. This article explores the evolutionary journey of Pakistan's EMS, highlighting both the challenges it faces and the strides it has made, with a specific emphasis on patients experiencing out-of-hospital cardiac arrest (OHCA). To extract relevant information, we searched MEDLINE & Embase data bases using MeSH terms "Emergency Medical Services" OR "EMS" AND "Out-of-Hospital-Cardiac-Arrest" OR "OHCA" AND "Pakistan". In addition, we also retrieved information from the EMS leadership in Pakistan through e-mails. We delve into the significance of key performance indicators for OHCA, advocate for the establishment of OHCA registries to improve patient outcomes, address regional disparities in pre-hospital care, and acknowledge the gradual progress of the EMS system.

Development and pilot implementation of a locally developed Trauma Registry: lessons learnt in a low-income country.

BACKGROUND: Trauma registries (TRs) play an integral role in the assessment of trauma care quality. TRs are still uncommon in developing countries owing to awareness and cost. We present a case study of development and pilot implementation of "Karachi Trauma Registry" (KITR), using existing medical records at a tertiary-care hospital of Karachi, Pakistan to present results of initial data and describe its process of implementation. METHODS: KITR is a locally developed, customized, electronic trauma registry based on open source software designed by local software developers in Karachi. Data for KITR was collected from November 2010 to January 2011. All patients presenting to the Emergency Department (ED) of the Aga Khan University Hospital (AKUH) with a diagnosis of injury as defined in ICD-9 CM were included. There was no direct contact with patients or health care providers for data collection. Basic demographics, injury details, event detail, injury severity and outcome were recorded. Data was entered in the KITR and reports were generated. RESULTS: Complete data of 542 patients were entered and analysed. The mean age of patients was 27 years, and 72.5% were males. About 87% of patients had sustained blunt injury. Falls and motor vehicle crashes were the most common mechanisms of injury. Head and face, followed by the extremities, were the most frequently injured anatomical regions. The mean Injury Severity Score (ISS) was 4.99 and there were 8 deaths. The most common missing variables in the medical records were ethnicity, ED notification prior to transfer, and pre-hospital IV fluids. Average time to review each chart was 14.5 minutes and entry into the electronic registry required 15 minutes. CONCLUSION: Using existing medical records, we were able to enter data on most variables including mechanism of injuries, burden of severe injuries and quality indicators such as length of stay in ED, injury to arrival delay, as well as generate injury severity and survival probability but missed information such as ethnicity, ED notification. To make the data collection process more effective, we propose provider based data collection or making a standardized data collection tool a part of medical records.

Intubation in emergency department of a tertiary care hospital in a low-income country.

OBJECTIVE: To study the indications, method, success rate and complications of intubation at the Emergency Department of a private, tertiary care hospital in Karachi, Pakistan. METHODS: The case series involved 278 patients above 14 years of age who underwent emergency intubation at the Emergency Department of Aga Khan University Hospital, Karachi between 1998 and 2003. Descriptive statistics were used to compare rapid sequence intubation with crash intubation. The level of significance was p<0.05. RESULTS: Of the total 278 intubations performed, 37 (13.3%) had to be left out for incomplete information.The study population remaining for inferential analysis comprised of 241 patients. Of the total 278 patients, 174 (63%) were males. Rapid sequence intubation was the commonest type (n=185, 67%) of intubation and was performed mostly by anaesthetists (n=236, 85%). Cardiogenic pulmonary oedema and head injury were commonly seen in these patients.The success on first attempt of intubation was 98% (n=181) in rapid sequence intubation, and 85% (n=48) in crash intubation. Overall, 15 (5.3%) complications were seen in these intubations. CONCLUSION: Study showed a satisfactory success rate in both rapid sequence and crash intubations.

A comparison of WHO guidelines issued in 1997 and 2009 for dengue fever - single centre experience.

OBJECTIVE: To compare the original (1997) and revised (2009) versions of World Health Organization guidelines for dengue patients METHODS: Adult patients with a positive dengue Immunoglobulin M serology, and a diagnosis of dengue were included in the study at Aga Khan University Hospital during a three-year period from January 2005 to December 2007. Data related to these dengue patients was collected from their medical records. Guidelines were then applied by the research assistant and correlation among these guidelines was computed. SPSS 19 was used for statistical analysis. RESULTS: A total of 612 patients were found with a diagnosis of dengue, but only 439 (71.73%) had a positive IgM. The median age of these 439 patients was 28 (interquartile range: 18) years and majority of them were males, 295 (67%). According to the 1997 guidelines, 383 (87%) patients were classified as having dengue, while according to the 2009 guidelines, all the 439 (100%) patients were classified with a dengue infection. Under WHO 1997, 21 (5.5%) cases were classified as dengue shock syndrome, while 2009 guidelines labelled 88 (20%) cases as severe dengue. There was a consensus on only 11 severe cases by both the guidelines, showing different results between the two. CONCLUSION: By using 2009 guidelines, a physician would classify more dengue patients as having severe disease.

Trends in mortality related to unintentional poisoning in the South Asian region from 1990 to 2019: analysis of data from the Global Burden of Disease Study.

OBJECTIVE: This study aimed to estimate the burden of unintentional poisoning in South Asian countries from 1999 to 2019. DESIGN: An ecological study conducted at the regional level for South Asian countries, based on data from the Global Burden of Disease Study 2019. SETTING: We extracted unintentional poisoning data from the Global Burden of Disease Study data set from 1990 to 2019 to assess trends in mortality, disability-adjusted life-years (DALYs), years of life lost, years lived with disability (YLDs) and causative agents in South Asian countries (Bangladesh, Bhutan, India, Nepal and Pakistan). OUTCOME MEASURES: We determined the per cent change and 95% CI for the period between 1990 and 2019 by age, gender and country. We also conducted Poisson regression to measure the percentage change in the rate per year. RESULTS: The absolute number of deaths due to unintentional poisoning in South Asia decreased (-32.6%) from 10 558 deaths in 1990 to 7112 deaths in 2019. The age standardised death rate from unintentional poisoning in South Asia has seen a downward trend (-55.88%), declining from 0.87 (0.67-1.01) age-standardised per 100 000 population in 1990 to 0.41 (0.34-0.47) in 2019. Among age groups, under 9 years and 10-19 years have seen downward trends for death and DALYs, accounting for -93.5% and -38.3%, respectively. YLDs have seen an upward trend (5.9%), increasing from 10 461.7 per 100 000 in 1990 to 11 084 per 100 000 in 2019. YLDs in women increased by 7.4%, from 11 558.2 per 100 000 to 12 418.3 per 100 000. The incidence rate ratios (IRRs) adjusted by all age groups and gender for DALYs in all South Asian countries has reduced significantly (IRR 0.97, 95% CI 0.96 to 0.97) from 1990 to 2019. CONCLUSION: This study showed reduction in death and DALYs due to unintentional poisoning in South Asia except YLDs which is showing an increasing trend. Public health systems should continue efforts to minimise and prevent disabilities arising from unintentional poisoning in South Asia.

Clinical utility of routine investigations and risk factors of end-organ damage in asymptomatic severe hypertension.

Asymptomatic severe hypertension is defined as systolic blood pressure of ≥ 180 mmHg or diastolic blood pressure of ≥ 120 mmHg without signs and symptoms of end-organ damage or dysfunction. Literature shows that around 5% of the patients with severe asymptomatic hypertension had acute hypertension-related end-organ damage. This study aimed to determine the clinical utility of routine investigations and risk factors of end-organ damage in patients presented to the emergency department with  asymptomatic severe hypertension. This single-center, cross-sectional study was conducted at the emergency department of the Aga Khan University Hospital, Karachi, Pakistan, from January 2018 to December 2020. All adult patients (age ≥ 18 years) presented to the emergency department with a systolic blood pressure of ≥ 180 or diastolic blood pressure of ≥ 120 mmHg without any signs and symptoms of end-organ damage (e.g., chest pain, unilateral limb or facial weakness, or hemiplegia, altered mental status, shortness of breath, decreased urine output, and sudden-onset of severe headache) were included. Routine investigations were analyzed to detect end-organ damage, including complete blood count, basic metabolic panel, urine detailed report, electrocardiogram, and troponin-I. Multivariable binary logistic regression was applied to identify the risk factors of end-organ damage considering the significant p value of ≤ 0.05. A total of 180 patients were presented to the emergency department with asymptomatic severe hypertension during the study period. Among the total patients, 60 patients (33.3%) had abnormal investigation findings; out of them, new-onset end-organ damage was diagnosed in 15 patients (8.3%). The most common end-organ damage was the kidney (73.3%) followed by the heart (26.6%). The multivariable binary logistic regression showed that age of more than 60 years, past medical history of diabetes, ischemic heart disease, and cerebrovascular accident were significantly associated with a higher risk of end-organ damage (p < 0.05). The study identified a higher prevalence of abnormal routine investigations and acute end-organ damage in emergency department patients with asymptomatic severe hypertension compared to high-income countries and suggested a lower threshold for end-organ damage screening in these patients. The current recommendations of foregoing further workup in patients with asymptomatic severe hypertension may need modification for emergency departments in low-middle-income countries if similar associations are replicated in other settings.

Follow-up household assessment for child unintentional injuries two years after the intervention: A community-based study from Karachi, Pakistan.

BACKGROUND: Unintentional childhood injuries are a growing public health concern, and the home is the most common location for non-fatal injuries in children less than 5 years of age. This study describes the long-term effects of two injury prevention educational interventions for caregivers-an educational pamphlet and an in-home tutorial guide-by comparing the change in the prevalence of home injury hazards before and after the interventions. METHODS: This was a pre- (June and July 2010) and post-study with short-term follow-up (November-December 2010) and long-term follow-up (November 2012- January 2013). Neighborhood one included households that received only educational pamphlets after completing a baseline assessment; neighborhood two included households that received an in-home tutorial guide after completing the baseline assessment and receiving the educational pamphlet. The main outcome of this study was the reduction in home injury hazards for children under 5 years of age. RESULTS: A total of 312 households participated in the long-term phase to compare the effect of the interventions. Between the short-term to long-term follow-up, injury hazards significantly reduced in neighborhood two compared to neighborhood one. These included fall hazards (walker use) (IRR 0.24 [95% CI 0.08-0.71]), drowning hazards (open bucket of water in the courtyard and uncovered water pool) (IRR 0.45 [95% CI 0.85-0.98] and IRR 0.46 [95% CI 0.76-0.94]), burn hazards (iron, water heater within reach of child) (IRR 0.56 [95% CI 0.33-0.78] and IRR 0.58 [95% CI 0.32-0.91]), poisoning hazards (shampoo/soap and medicine within reach of child) (IRR 0.53 [95% CI 0.44-0.77] and IRR 0.7 [95% CI 0.44-0.98]) and breakable objects within reach of child (IRR 0.62 [95% CI: 0.39-0.99]). CONCLUSION: An injury prevention tutorial to caretakers of children supplemented with pamphlets could significantly decrease the incidence of falls, drowning, burns, poisoning, and cut injury hazards for children under 5 years of age in their homes in a low-resource setting. This intervention has the potential to be integrated in existing public health programs, such as Lady Health Visitors (LHVs), to disseminate injury prevention information in routine home health visits.

A successful model of Road Traffic Injury surveillance in a developing country: process and lessons learnt.

BACKGROUND: Road Traffic Injuries (RTIs) are one of the leading causes of death and disability worldwide with 90% of global mortality concentrated in the low and middle income countries. RTI surveillance is recommended to define the burden, identify high risk groups, plan intervention and monitor their impact. Despite its stated importance in the literature, very few examples of sustained surveillance systems are reported from low income countries. This paper shares the experience of setting up an urban RTI surveillance program in the emergency departments of five major hospitals in Karachi, Pakistan. METHOD: We describe the process of establishing a surveillance system including assembling a multi-institution research group, developing a data collection methodology, carrying out data collection and analysis and dissemination of information to the relevant stakeholders. In the absence of a road safety agency, the surveillance system required developing individual partnerships with industry, police, city government, media and many other stakeholders. Impact of the surveillance is demonstrated by some initiatives in the local trauma system and improvements in road design to effect hazard reduction. CONCLUSION: We demonstrated that a functional RTI surveillance program can be established, and effectively managed in a developing country, despite lack of infrastructure and limitation of resources. Data utilization in the absence of well defined road safety infrastructure within the government is a challenge. More effective actions are hampered by the limited capacity in the transport and health sectors to do in-depth analysis through road safety audits and trauma registries.

Impact of community education on heat-related health outcomes and heat literacy among low-income communities in Karachi, Pakistan: a randomised controlled trial.

BACKGROUND: Extreme heat exposure is a growing public health concern. In this trial, we tested the impact of a community health worker (CHW) led heat education programme on all-cause mortality, unplanned hospital visits and changes in knowledge and practices in Karachi, Pakistan. METHODS: The Heat Emergency Awareness and Treatment trial was a community-based, open-label, two-group, unblinded cluster-randomised controlled trial that implemented a CHW-led educational intervention between March and May 2018 in Karachi, Pakistan. We randomly assigned (1:1) 16 clusters, each with ~185 households or 1000 population, to the intervention or usual care (control group). We collected data on all-cause mortality, unplanned hospital visits, evidence of heat illness through surveillance and a knowledge and practice survey during the summer months of 2017 (preintervention) and 2018 (postintervention). FINDINGS: We recruited 18 554 participants from 2991 households (9877 individuals (1593 households) in the control group and 8668 individuals (1398 households) in the intervention group). After controlling for temporal trends, there was a 38% (adjusted OR 0.62, 95% CI 0.49 to 0.77) reduction in hospital visits for any cause in the intervention group compared with the control group. In addition, there was an improvement in many areas of knowledge and practices, but there was no significant difference in all-cause mortality. INTERPRETATION: A CHW-led community intervention was associated with decreased unscheduled hospital visits, improved heat literacy and practices but did not impact all-cause mortality. CHWs could play an essential role in preparing communities for extreme heat events. TRIAL REGISTRATION NUMBER: NCT03513315.

Burden and factors associated with highway work-zone crashes, on a section of the Karachi-Hala Road, Pakistan.

OBJECTIVE: To assess the burden and factors associated with highway work-zone (HWZ) crashes. DESIGN: Historical cohort. SETTING: Section of the Karachi-Hala Road, Pakistan (196 km). DATA: Police-reported crashes and traffic statistics from January 2006 to December 2008. ANALYSIS: Crash and death risk between the HWZ and other zones for a 50 km section were compared. Crash locations were described for a further 146 km section on which factors associated with HWZ crashes were assessed. RESULTS: HWZ crashes accounted for 15.0% of traffic crashes (N = 180) and 30.8% of road fatalities (N = 91) on the 196 km section. Rates were higher in the HWZ than other zones for crashes (rate ratio (RR) = 2.35, 95% CI = 1.17 to 4.70) and deaths (RR = 4.70, 95% CI = 2.11 to 10.46). Opposite-direction crashes (adjusted OR (aOR) = 10.65, 95% CI = 3.22 to 35.25) and traffic crashes involving pedestrians (aOR = 6.03, 95% CI = 1.39 to 26.20) and on wet surfaces (aOR = 7.26, 95% CI = 4.15 to 48.89) were significantly associated with the HWZ. CONCLUSION: These results support the introduction of prevention measures such as strict traffic enforcement, traffic separation, improving pedestrian visibility, and hazard signage at HWZs in Pakistan. The feasibility and effectiveness of these measures remains to be evaluated.

Establishing a successful pre-hospital emergency service in a developing country: experience from Rescue 1122 service in Pakistan.

As in many other developing countries, emergency medical services, especially pre-hospital emergency care, has long been neglected in Pakistan. Consequently, patients are brought to the emergency departments by relatives or bystanders in private cars, taxis or any other readily available mode of transportation. Ambulances, where they exist, have barely a stretcher and arrangements for oxygen supply. Modern emergency services are considered too costly for many countries. A model of pre-hospital emergency services, called Rescue 1122 and established in Punjab province of Pakistan, is presented. The system is supported by government funding and provides a quality service. The article describes the process of establishment of the service, the organisational structure, the scope of services and the role it is currently playing in the healthcare of the region it serves.

Application of geographical information system (GIS) for mapping road traffic injuries using existing source of data in Karachi, Pakistan--a pilot study.

OBJECTIVE: To assess the feasibility of using Geographical Information System for mapping of road traffic injuries with an existing data source in a developing country. METHODS: The study was a retrospectives case series of road traffic injury cases registered with the medico-legal office located in the three major trauma centers in Karachi for the period of January 1, 2004 till December 31st, 2004. Spatial data analysis was performed using ARCVIEW 3.1. RESULTS: Out of 3650 of all road traffic injury, only 3% had locations detailed and accurate enough allowing mapping on a GIS map in the first attempt. Even after using detailed town maps and field exercises more than a quarter cases (n=1088; 30%) of road traffic injuries (RTIs) could not be properly located. We identified 25 areas of one kilometer or less in Karachi accounting for 27% of all RTIs. Five corridors of road measuring 27.7 km accounted for 590 (23%) of all RTIs with known locations. CONCLUSIONS: Existing sources of data from the medico-legal system in Karachi failed to provide exact information on crash site. Such datasets can however be used to define high risk areas/neighbourhoods.