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CONTEXT: Outcomes for children with cancer in sub-Saharan Africa (SAA) are dismal due to delayed diagnosis and limited access to curative therapy. When establishing a pediatric hematology-oncology (PHO) program in low-resource settings, early integration of palliative care services becomes essential. While palliative care is a human right, equitable distribution is lacking. OBJECTIVES: We aim to describe our experience establishing a palliative care program, the services offered, and the distribution of patients served. METHODS: This is a brief description of our PHO palliative care program in Lilongwe, Malawi at a tertiary care center and a three-year retrospective review of activities (2017-2020). Services offered include inpatient, outpatient, home visits, end of life care, and strengthening of referral systems. RESULTS: Over the three-year period, 315 patients were enrolled. 57% (n=179) were male. The median age was seven years (5 months-22 years). Patients served were from 17 of 28 districts within Malawi. Diagnoses of patients included 43% solid tumors (n=135), 22% lymphoma (n=68), 15% leukemia (n=47), and 21% hematologic disease (n=65). 40% of patients have died (n=125), with 53% of deaths occurring at home (n=66), 22% in the hospital (n=28), and 25% at unknown locations (n=31). CONCLUSION: Palliative care is a critical component of PHO programs worldwide. Programs must leverage existing networks to ensure optimal care to children and families. We demonstrate the feasibility of integrating palliative care services within a PHO program in a low-resource setting, which could serve as a model for other countries in SSA.
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Hematología , Enfermería de Cuidados Paliativos al Final de la Vida , Neoplasias , Cuidado Terminal , Niño , Femenino , Humanos , Masculino , Oncología Médica , Neoplasias/terapia , Cuidados PaliativosRESUMEN
BACKGROUND/AIM: Low-cost commercial bCPAP devices have been deployed in resource-limited settings to treat neonatal respiratory failure. The use of these devices has increased access to pediatric respiratory support for infants. However, constrained resources may result in substitution of recommended consumables and/or use in older age groups. We hypothesized that commercially available bCPAP devices, the standard WHO-style device and various improvised adaptations would all generate effective, safe positive pressure at the patient interface. METHODS: Performance of 2 commercially available bCPAP devices was tested against the standard WHO-style bCPAP device, as well as several improvised modifications of these devices, by measuring positive pressure delivered at the patient interface. Variables tested included different flow rates, patient interfaces and respiratory circuit tubing. RESULTS: Both commercial devices utilized according to manufacturer recommendations generated the expected positive pressure at the patient interface. When testing the recommended WHO-style bCPAP device with recommended materials as well as other improvised modifications, we found variable and potentially unpredictable generation of positive pressure at the patient interface. CONCLUSIONS: Modified or improvised bCPAP devices should be used with extreme caution as the support provided may be more or less than expected depending on respiratory tubing and flow rates employed. Our data support the effectiveness of bCPAP in newborns and young infants. But, to our knowledge, there are no bCPAP patient interfaces for older children effective with low liter flow devices. Therefore, based on these results, we recommend against using WHO-style bCPAP devices for non-infant patients with respiratory failure and instead recommend using standard oxygen therapy with nasal cannulae or face-masks, as well as early consideration of transfer to a higher level of care.
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Presión de las Vías Aéreas Positiva Contínua , Síndrome de Dificultad Respiratoria del Recién Nacido , Adolescente , Anciano , Niño , Humanos , Lactante , Recién Nacido , Terapia por Inhalación de Oxígeno , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Organización Mundial de la SaludRESUMEN
OBJECTIVE: Shift work on a pediatric emergency medicine (PEM) rotation makes didactic scheduling difficult, thereby limiting teaching opportunities. These constraints make this rotation an ideal setting to supplement resident education with an online curriculum. We aimed to determine if implementation of an online curriculum during a resident PEM rotation improves posttest performance and increases satisfaction with resident educational experience. METHODS: This was a prospective before/after study of pediatric and emergency medicine residents on a 1-month rotation in a tertiary care pediatric emergency department. A curriculum was developed consisting of 17 online modules. In the first 5 months of the study, 42 control residents received traditional bedside teaching. In the last 12 months, 80 intervention residents completed at least 8 modules during their rotation. Both groups completed a pretest at rotation start and a posttest and end-of-rotation survey at rotation end. RESULTS: Control group pretest and posttest scores were not significantly different. In the intervention group, posttest scores were significantly increased compared with pretest scores (68 vs 59, P < 0.01). A low percentage of residents completed the study. Only 42% of the 189 residents enrolled in the intervention group completed the posttest and 28% completed the survey. CONCLUSIONS: Implementing an online PEM curriculum significantly improved knowledge. As residency programs face new duty hour requirements, online curricula may provide an effective way to supplement teaching. However, to capitalize on this self-directed curriculum, the low participation rates in this study suggest we must first determine and establish ways to overcome barriers to online learning.
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Educación a Distancia/métodos , Medicina de Emergencia/educación , Internado y Residencia/métodos , Medicina de Urgencia Pediátrica/métodos , Competencia Clínica , Curriculum , Evaluación Educacional , Femenino , Humanos , Conocimiento , Masculino , Médicos , Estudios Prospectivos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Triage process implementation has been shown to be effective at improving patient outcomes. This study sought to develop, implement and assess the impact of an Emergency Triage Assessment and Treatment (ETAT)-based emergency triage process in the paediatric emergency department (PED) of a public hospital in Guatemala. METHODS: The study was a quality improvement comparison with a before/after design. Uptake was measured by percentage of patients with an assigned triage category. Outcomes were hospital admission rate, inpatient length of stay (LOS), and mortality as determined by two distinct medical record reviews for 1 year pre- and post-intervention: a random sample (RS) of all PED patients and records for all critically-ill (CI) children [serious diagnoses or admission to the paediatric intensive care unit (PICU)]. Demographics, diagnoses and disposition were recorded. RESULTS: The RS totalled 1027 (51.4% male); median ages pre- and post-intervention were 2.0 and 2.4 years, respectively. There were 196 patients in the CI sample, of whom 56.6% were male and one-third were neonates; median ages of the CI group pre- and post-intervention were 3.1 and 5.6 months, respectively. One year after implementation, 97.5% of medical records had been assigned triage categories. Triage categories (RS/CI) were: emergency (2.9%/54.6%), priority (47.6%/44.4%) and non-urgent (49.4%/1.0%). The CI group was more frequently diagnosed with shock (25%/1%), seizures (9%/0.5%) and malnutrition (6%/0.5%). Admission rates for the RS (8% vs 4%, P=0.01) declined after implementation. For the CI sample, admission rate to the PICU (47% vs 24%, P=0.002) decreased and LOS (7.3 vs 5.7 days, P=0.09) and mortality rates (12% vs 6%, P=0.15) showed trends toward decreasing post-implementation. CONCLUSIONS: Paediatric-specific triage algorithms can be implemented and sustained in resource-limited settings. Significant decreases in admission rates (both overall and for the PICU) and trends towards decreased LOS and mortality rates of critically ill children suggest that ETAT-based triage systems have the potential to greatly improve patient care in Latin America.
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Enfermedad Crítica/terapia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Mejoramiento de la Calidad , Triaje/métodos , Niño , Mortalidad del Niño , Preescolar , Servicio de Urgencia en Hospital/normas , Femenino , Guatemala , Hospitales Públicos , Humanos , Lactante , Recién Nacido , Masculino , Pediatría , Estudios Prospectivos , Estudios Retrospectivos , Triaje/estadística & datos numéricosRESUMEN
OBJECTIVES: To describe the creation of the first known combined Pediatric Emergency Medicine-Global Health (PEM-GH) fellowship for graduates of pediatric or emergency medicine residency programs. METHODS: We detail the necessary infrastructure for a successfully combined PEM-GH fellowship including goals, objectives, curriculum, timeline, and funding. The fellowship is jointly supported by the department of pediatrics, section of pediatric emergency medicine (PEM), and the hospital. Fellows complete all requirements for the PEM fellowship and Global Health, the latter requiring an additional 12 months of training. Components of the Global Health fellowship include international fieldwork, scholarly activity abroad, advanced degree coursework, disaster training, and didactic curricula. RESULTS: Since 2005, 9 fellows (8 pediatric-trained and 1 emergency medicine-trained) have completed or are enrolled in the PEM-GH fellowship; 3 have graduated. All fellows have completed or are working toward advanced degrees and have or will participate in the disaster management course. Fellows have had 7 presentations at national or international meetings and have published 6 articles in peer-reviewed journals. Of the three graduates, all are working in academic PEM-GH programs and work internationally in Africa and/or Latin America. CONCLUSIONS: Our response to a global trend toward improvement in PEM care was the development of the first combined PEM-GH fellowship program. Recognizing the value of this program within our own institution, we now offer it as a model for building such programs in the future. This fellowship program promises to be a paradigm that can be used nationally and internationally, and it establishes a foundation for a full-fledged accredited and certified subspecialty.
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Medicina de Emergencia/educación , Becas , Salud Global/educación , Internado y Residencia , Medicina de Urgencia Pediátrica , África , Niño , Curriculum , Manejo de la Enfermedad , HumanosRESUMEN
OBJECTIVES: This study aimed to develop and implement an Emergency Triage Assessment and Treatment (ETAT) training program at a Guatemalan public hospital. Collaborators included Baylor College of Medicine/Texas Children's Hospital, the Guatemalan Ministry of Health, and the Pan American Health Organization. METHODS: The ETAT is a World Health Organization program to teach pediatric assessment, triage, and initial management to health care workers in resource-limited settings. The Baylor College of Medicine/Texas Children's Hospital created ETAT training materials in Spanish (Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas [CETEP]) and conducted a train-the-trainer course for Hospital Nacional Pedro Bethancourt (HNPB) health care leadership. The HNPB subsequently conducted local trainings using a modified curriculum. Midcourse modifications based on evaluations and focus groups included distribution of manuals before training and an adding a day to the course.Course quality was assessed using participant evaluations and comparing pretest and posttest scores. Effectiveness was defined as 90% concordance between triage levels assigned by participants and facilitators. RESULTS: A total of 249 health care workers were trained by 24 HNPB facilitators. Mean pretest and posttest scores were 55 and 70, respectively (P < 0.001). On a 4-point scale, participants rated overall course quality and effectiveness as 3.6. Mean pretest (49 vs 58, P = 0.002) and posttest scores (68 vs 72, P = 0.01) improved for groups trained after modifications, as did evaluations for course quality (3.4 vs 3.7, P < 0.001) and effectiveness (3.4 vs 3.8, P < 0.001). Triage levels were assigned with 95% concordance (confidence interval, 91.9-97.3) between participants and facilitators. CONCLUSIONS: Hospital Nacional Pedro Bethancourt experts conducted high-quality trainings with locally relevant CETEP (ETAT) material. Trainings were effective and well received. The pediatric emergency department at HNPB now uses a triage system based on CETEP (ETAT).
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Servicio de Urgencia en Hospital/normas , Personal de Salud/educación , Hospitales Pediátricos/normas , Triaje/normas , Femenino , Guatemala , Humanos , Masculino , Mejoramiento de la Calidad , Recursos HumanosRESUMEN
OBJECTIVES: The rapid growth of computed tomography (CT) has resulted in increased concerns of ionizing radiation exposure and its subsequent risk of cancer development. We evaluated the impact of a new protocol using rapid sequence magnetic resonance imaging (rsMRI) instead of CT in children presenting with possible ventriculoperitoneal shunt (VPS) malfunction to promote patient safety. METHODS: This is a retrospective case series of pediatric patients who received a neuroimaging study for emergency evaluation of possible VPS malfunction at New York University's Tisch Hospital Emergency Department between January 2010 and July 2011. Radiology Charge Master was queried to identify the patient database. The trend in the use of rsMRI and CT was calculated for 3 patient age groups and compared across 3 chronological intervals. The effective dose of ionizing radiation per CT scan was calculated using the CT dose index and dose-length product for each patient. RESULTS: Total of 365 patients with the mean age of 8.87 years received either rsMRI or CT study during the study period. One hundred forty-four of these patients required the imaging studies because of VPS malfunction. Overall, 62% of all VPS malfunction cases used rsMRI instead of CT. The ratio of the number of patients receiving rsMRI divided by CT studies has progressively increased from 1.4:1 to 2.1:1 over 3 chronologic periods. CONCLUSIONS: Children with VPS are subject to multiple neuroimaging studies throughout their lifetime. Rapid sequence MRI is an effective alternative to CT while providing no ionizing radiation exposure or risk of developing radiation-induced cancer.
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Neoplasias Encefálicas/diagnóstico , Servicio de Urgencia en Hospital , Imagen por Resonancia Magnética/métodos , Neoplasias Inducidas por Radiación/etiología , Tomografía Computarizada por Rayos X/métodos , Derivación Ventriculoperitoneal/efectos adversos , Adolescente , Encéfalo/diagnóstico por imagen , Encéfalo/patología , Neoplasias Encefálicas/etiología , Niño , Preescolar , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Neoplasias Inducidas por Radiación/epidemiología , New York/epidemiología , Dosis de Radiación , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendenciasRESUMEN
BACKGROUND: Improvements in triage have demonstrated improved clinical outcomes in resource-limited settings. In 2009, the Accident and Emergency (A&E) Department at the Princess Marina Hospital (PMH) in Botswana identified the need for a more objective triage system and adapted the South African Triage Scale to create the PMH A&E Triage Scale (PATS). AIM: The primary purpose was to compare the undertriage and overtriage rates in the PATS and pre-PATS study periods. METHODS: Data were collected from 5 April 2010 to 1 May 2011 for the PATS and compared with a database of patients triaged from 1 October 2009 to 24 March 2010 for the pre-PATS. Data included patient disposition outcomes, demographics and triage level assignments. RESULTS: 14â 706 (pre-PATS) and 25â 243 (PATS) patient visits were reviewed. Overall, overtriage rates improved from 53% (pre-PATS) to 38% (PATS) (p<0.001); likewise, undertriage rates improved from 47% (pre-PATS) to 16% (PATS) (p<0.001). Statistically significant decreases in both rates were found when paediatric and adult cases were analysed separately. PATS was more predictive of inpatient admission, Intensive Care Unit (ICU) admission and death rates in the A&E than was the pre-PATS. The lowest acuity category of each system had a 0.6% (pre-PATS) and 0% (PATS) chance of death in the A&E or ICU admission (p<0.001). No change in death rate was seen between the pre-PATS and PATS, but ICU admission rates decreased from 0.35% to 0.06% (p<0.001). CONCLUSIONS: PATS is a more predictive triage system than pre-PATS as evidenced by improved overtriage, undertriage and patient severity predictability across triage levels.
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Servicio de Urgencia en Hospital/organización & administración , Triaje/organización & administración , Adolescente , Adulto , Anciano , Botswana , Niño , Preescolar , Estudios de Cohortes , Femenino , Hospitalización , Hospitales Urbanos , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Gravedad del Paciente , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVE: Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in the developing world. This deficiency contributes to high inpatient mortality rates, particularly early during hospitalization. Our referral hospital in Lilongwe, Malawi, experiences high volume, acuity, and mortality rates. The entry point to our hospital for most children presenting with acute illness is the Under-5 Clinic. We hypothesized that early inpatient mortality and total inpatient mortality rates would decrease with an intervention to prioritize and improve pediatric emergency care at our hospital. METHODS: We implemented the following changes as part of our intervention: (1) reallocation of senior-level clinical support from other areas of the hospital to the Under-5 Clinic for supervision of emergency care, (2) institution of a formal triage process that improved patient flow, and (3) treatment and stabilization of patients before transfer to the inpatient ward. We compared early inpatient and total inpatient mortality rates before and after the intervention. RESULTS: After the intervention, early mortality decreased from 47.6 to 37.9 deaths per 1000 admissions (relative risk 0.80, 95% confidence interval 0.67-0.93). Total mortality also decreased from 80.5 to 70.5 deaths per 1000 admissions after the intervention (relative risk 0.88, 95% confidence interval 0.78-0.98). CONCLUSIONS: Simple, inexpensive interventions to improve pediatric emergency care at this underresourced hospital in sub-Saharan Africa were associated with decreased hospital mortality rates. The description of this process and the associated results may influence practice and resource allocation strategies in similar clinical environments.
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Servicios de Salud del Niño/organización & administración , Mortalidad del Niño , Servicios Médicos de Urgencia , Mortalidad Hospitalaria/tendencias , Servicio Ambulatorio en Hospital/organización & administración , Triaje , Niño , Hospitalización , Humanos , Lactante , Malaui/epidemiologíaRESUMEN
OBJECTIVE: To determine the interrater reliability of triage acuity ratings by healthcare workers (HCW) using a previous triage system (PTS) and the Princess Marina Hospital accident and emergency centre triage scale (PATS), a local adaptation of the widely used and studied South African triage scale. METHODS: A cross-sectional study was performed on HCW in an emergency department (ED) in Botswana to determine the interrater reliability of triage acuity ratings when using PTS and PATS to assign triage categories to 25 written vignettes after PATS training. The intraclass correlation coefficient (ICC) was calculated to assess interrater reliability, and graphic displays were used to portray rating distributions for vignettes with a mean rating of different acuity categories for PTS and PATS. RESULTS: 44 HCW completed the scenarios. The ICC for the group of HCW was 0.52 (95% CI 0.37 to 0.67) using PTS and 0.87 (95% CI 0.80 to 0.93) using PATS. The ICC values were higher for PATS than PTS regardless of the number of years of experience of the HCW and the level of the HCW (specialist, medical officer, nurse, nurse aide). Graphic displays showed that there was less variability at all acuity levels when using PATS compared with PTS. CONCLUSION: The reliability measures in this study indicate very high interrater agreement and limited variability in acuity ratings when using the PATS as opposed to moderate agreement and increased variability in acuity ratings when using PTS. This suggests that PATS is reliably applied by all levels of HCW and supports the feasibility of the further implementation of PATS in ED in Botswana and in other similar settings.
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Servicio de Urgencia en Hospital/normas , Triaje/normas , Adulto , Botswana , Niño , Estudios Transversales , Femenino , Humanos , Masculino , Variaciones Dependientes del Observador , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: Bateys are impoverished areas of housing for migrant Haitian sugar cane workers in the Dominican Republic (DR). In these regions, preventative health care is almost non-existent, public service accessibility is limited, and geographic isolation prevents utilization of care even by those families with resources. Consequently, the development of a viable mobile system is vital to the delivery of acute and preventative health care in this region. AIMS: This study evaluated an existing mobile medical system. The primary goal was to describe the population served, diseases treated, and resources utilized. A secondary goal was to determine qualitatively an optimal infrastructure for sustainable health care delivery within the bateys. METHODS: Information on basic demographic data, diagnosis, chronicity of disease, and medications dispensed was collected on all pediatric patients seen in conjunction with an existing mobile medical system over a 3-month period in the DR. Health statistics for the region were collected and interviews were conducted with health care workers (HCWs) and community members on existing and optimal health care infrastructure. RESULTS: Five hundred eighty-four pediatric patients were evaluated and treated. Median age was 5 years (range 2 weeks to 20 years), and 53.7% of patients seen were 5 years of age or younger. The mean number of complaints per patient was 2.8 (range 0 to 6). Thirty-six percent (373) of all diagnoses were for acute complaints, and 64% (657) were chronic medical problems. The most common pediatric illnesses diagnosed clinically were gastrointestinal parasitic infection (56.6%), skin/fungal infection (46.2%), upper respiratory tract infections (URIs) (22.8%), previously undiagnosed asthma and allergies (8.2%), and symptomatic anemia (7.2%). Thirty HCWs and community members were interviewed, and all cited the need for similar resources: a community clinic and hospital referral site, health promoters within each community, and the initiation of pediatric training for community HCWs. CONCLUSION: A mobile medical system is a sustainable, efficient mechanism for delivering acute and preventive care in the Haitian bateys of the Dominican Republic. The majority of patients served were 8 years of age or younger with multiple presenting symptoms. A pediatric protocol for identifying the most appropriate drugs and supplies for mobile units in the DR can be created based upon diseases evaluated. Qualitative data from HCWs and community members identified the need for an integrative health care delivery infrastructure and community health promoters versed in pediatric care who can aid in education of batey members and monitor chronic and acute illnesses. We are planning follow-up visits to implement these programs.
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Although clinical conditions associated with dysfunction of the ad-renal gland are often subtle, even insidious, in their presentation,and diagnosis and treatment usually are confined to outpatient clinics and offices, there are several situations that warrant the attention of emergency physicians. Recognition of the spectrum of presentations of pheochromocytoma, adrenal insufficiency, and pituitary apoplexy, and the sequelae of corticosteroid therapy and withdrawal, are critically important areas to emergency medicine. Prompt diagnosis with appropriate treatment and referral will reduce morbidity and mortality in many patients each year. A related topic pertinent to emergency physicians is the management of incidental adrenal masses that are discovered on abdominal radio-logic imaging.
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Neoplasias de las Glándulas Suprarrenales , Glándulas Suprarrenales/fisiología , Insuficiencia Suprarrenal/fisiopatología , Hidrocortisona , Insuficiencia Multiorgánica/etiología , Feocromocitoma , Neoplasias de las Glándulas Suprarrenales/complicaciones , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/fisiopatología , Glándulas Suprarrenales/metabolismo , Insuficiencia Suprarrenal/tratamiento farmacológico , Insuficiencia Suprarrenal/etiología , Adulto , Servicio de Urgencia en Hospital , Femenino , Humanos , Hidrocortisona/biosíntesis , Hidrocortisona/fisiología , Persona de Mediana Edad , Feocromocitoma/complicaciones , Feocromocitoma/diagnóstico , Feocromocitoma/fisiopatologíaRESUMEN
OBJECTIVE: To determine the usefulness of oblique cervical spine radiography (OCSR) in the management of children who have sustained blunt cervical spine injury, particularly if OCSR is abnormal when no acute abnormalities are shown on standard cervical spine radiography (SCSR). METHODS: We carried out a blinded radiographic review of 109 patients younger than 16 years evaluated at an academic pediatric trauma center and a community hospital between July 1990 and December 1997. All patients had SCSR (anteroposterior/lateral views) and OCSR performed for a trauma-related event within 7 days of injury. RESULTS: In 105 patients (96.3%), radiographic impression after review of SCSR and OCSR did not differ from that after SCSR review alone (95% confidence interval 90.9%, 99.0%). Radiographic impression was revised after OCSR review in 4 patients, all with equivocal findings on SCSR, to normal in three patients and abnormal in one patient (subluxation). Of 78 patients without acute abnormalities on SCSR, no patient had acute abnormalities on OCSR (95% CI, 0-3.8%). CONCLUSIONS: In our series of 109 children who underwent acute radiographic evaluation of blunt cervical spine trauma, oblique views were unlikely to be abnormal if no acute abnormalities were evident on standard anteroposterior and lateral radiographs. Although few patients are likely to benefit from the addition of these views on a routine basis, a useful role for oblique cervical spine radiographs in detecting cervical spine injury in children cannot be excluded based on the results of this study.