Emergency care interventions for paediatric severe acute respiratory infections in low- and middle-income countries: A systematic review and narrative synthesis.

Background: Severe acute respiratory infections (SARIs) are the leading cause of paediatric death globally, particularly in low- and middle-income countries (LMICs). Given the potential rapid clinical decompensation and high mortality rate from SARIs, interventions that facilitate the early care are critical to improving patient outcomes. Through this systematic review, we aimed to evaluate the impact of emergency care interventions on improving clinical outcomes of paediatric patients with SARIs in LMICs. Methods: We searched PubMed, Global Health, and Global Index Medicus for peer-reviewed clinical trials or studies with comparator groups published before November 2020. We included all studies which evaluated acute and emergency care interventions on clinical outcomes for children (29 days to 19 years) with SARIs conducted in LMICs. Due to observed heterogeneity of interventions and outcomes, we performed narrative synthesis. We assessed bias using the Risk of Bias 2 and Risk of Bias in Non-Randomized Studies of Interventions tools. Results: We screened 20 583, 99 of which met the inclusion criteria. Conditions studied included pneumonia or acute lower respiratory infection (61.6%) and bronchiolitis (29.3%). Studies evaluated medications (80.8%), respiratory support (14.1%), and supportive care (5%). We found the strongest evidence of benefit for decreasing risk of death for respiratory support interventions. Results were inconclusive on the utility of continuous positive airway pressure (CPAP). We found mixed results for interventions for bronchiolitis, but a possible benefit for hypertonic nebulised saline to decrease hospital length of stay. Early use of adjuvant treatments such as Vitamin A, D, and zinc for pneumonia and bronchiolitis did not appear to have convincing evidence of benefit on clinical outcomes. Conclusions: Despite the high global burden of SARI in paediatric populations, few emergency care (EC) interventions have high quality evidence for benefit on clinical outcomes in LMICs. Respiratory support interventions have the strongest evidence for benefit. Further research on the use of CPAP in diverse settings is needed, as is a stronger evidence base for EC interventions for children with SARI, including metrics on the timing of interventions. Registration: PROSPERO (CRD42020216117).

A systematic review of acute and emergency care interventions for adolescents and adults with severe acute respiratory infections including COVID-19 in low- and middle-income countries.

Background: Severe acute respiratory infections (SARIs) remain a leading cause of death globally, particularly in low- and middle-income countries (LMICs). Early intervention is critical, considering the potential for rapid decompensation in patients with SARIs. We aimed to evaluate the impact of acute and emergency care interventions on improving clinical outcomes in patients >10 years old with SARIs in LMICs. Methods: A systematic literature search was performed in PubMed, Global Health, and Global Index Medicus databases to identify peer-reviewed studies containing SARI, LMICs, and emergency care interventions. Studies published prior to November 2020 focusing on patients >10 years old were included. A narrative synthesis was performed due to the heterogeneity of identified articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias In Non-Randomized Studies of Interventions tools. Results: 20 223 studies were screened and 58 met the inclusion criteria. Thirty-four studies focused on coronavirus-2019 (COVID-19), 15 on pneumonia, seven on influenza, one study on severe acute respiratory syndrome, and one on undifferentiated SARI. Few COVID-19 studies found a benefit of the tested intervention on clinical status, mortality, or hospital length-of-stay. Little to no benefit was found for azithromycin, convalescent plasma, or zinc, and potential harm was found for hydroxychloroquine/chloroquine. There was mixed evidence for immunomodulators, traditional Chinese medicine, and corticosteroids among COVID-19 studies, with notable confounding due to a lack of consistency of control group treatments. Neuraminidase inhibitor antivirals for influenza had the highest quality of evidence for shortening symptom duration and decreasing disease severity. Conclusions: We found few interventions for SARIs in LMICs with have high-quality evidence for improving clinical outcomes. None of the included studies evaluated non-pharmacologic interventions or were conducted in low-income countries. Further studies evaluating the impact of antivirals, immunomodulators, corticosteroids, and non-pharmacologic interventions for SARIs in LMICs are urgently needed. Registration: PROSPERO registration number: CRD42020216117.

Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia.

AIMS AND OBJECTIVES: The aim of this study was to evaluate the impact of the introduction of Emergency Nurse Practitioner Candidates (ENPC) on waiting times and length of stay of patients presenting to a major urban Emergency Department (ED) in Melbourne, Australia. BACKGROUND: As part of a Victorian state funded initiative to improve patient outcomes, the role of the Emergency Nurse Practitioner has been developed. The integration and implementation of this role, is not only new to the Alfred Emergency and Trauma Centre but to EDs in Melbourne, Australia, with aims of providing holistic and comprehensive care for patients. DESIGN: A retrospective case series of all patients with common ED diagnostic subgroups were included. The ENPC group (n = 572) included all patients managed by the ENPC and the Traditional Model (TM) group (n = 2584) included all patients managed by the traditional medical ED model of care. Outcome measures included waiting times and length of stay. RESULTS: Statistically significant differences were evident between the two groups in waiting times and length of stay in the ED. The overall median waiting time for emergency patients to be seen by the ENPC was less than for the TM group [median (IQR): ENPC 12 (5.5-28) minutes; TM 31 (11.5-76) minutes (Wilcoxon p < 0.001)]. Length of stay in the ED was also significantly reduced in the ENPC group [median (IQR): ENPC 94 (53.5-163.5) minutes; TM 170 (100-274) minutes (Wilcoxon p < 0.001)]. The comparison of overall waiting times for ENPC shifts vs. non-ENPC shifts revealed significant differences [median (IQR): ENPC rostered 24 (9-52) minutes; ENPC not rostered 33 (13-80.5) minutes (Wilcoxon p < 0.001)]. CONCLUSIONS: This study has demonstrated that ENPCs implementation in Melbourne, Australia were associated with significantly reduced waiting times and length of stay for emergency patients. Emergency Nurse Practitioners should be considered as a potential long term strategy to manage increased service demands on EDs. Relevance to clinical practice. This study is the first in Australia with a significant sample size to vigorously compare ENPC waiting times and length of stay outcomes with the TM model of care in the ED. The study suggests that ENPCs can have a favourable impact on patient outcomes with regard to waiting times and length of stay.