Improvement in the diagnosis and practices of emergency healthcare providers for heat emergencies after HEAT (heat emergency awareness & treatment) an educational intervention: a multicenter quasi-experimental study.

BACKGROUND: The incidence of heat emergencies, including heat stroke and heat exhaustion, have increased recently due to climate change. This has affected global health and has become an issue of consideration for human health and well-being. Due to overlapping clinical manifestations with other diseases, and most of these emergencies occurring in an elderly patient, patients with a comorbid condition, or patients on poly medicine, diagnosing and managing them in the emergency department can be challenging. This study assessed whether an educational training on heat emergencies, defined as heat intervention in our study, could improve the diagnosis and management practices of ED healthcare providers in the ED setting. METHODS: A quasi-experimental study was conducted in the EDs of four hospitals in Karachi, Pakistan. Eight thousand two hundred three (8203) patients were enrolled at the ED triage based on symptoms of heat emergencies. The pre-intervention data were collected from May to July 2017, while the post-intervention data were collected from May to July 2018. The HEAT intervention, consisting of educational activities targeted toward ED healthcare providers, was implemented in April 2018. The outcomes assessed were improved recognition-measured by increased frequency of diagnosing heat emergencies and improved management-measured by increased temperature monitoring, external cooling measures, and intravenous fluids in the post-intervention period compared to pre-intervention. RESULTS: Four thousand one hundred eighty-two patients were enrolled in the pre-intervention period and 4022 in the post-intervention period, with at least one symptom falling under the criteria for diagnosis of a heat emergency. The diagnosis rate improved from 3% (n = 125/4181) to 7.5% (n = 7.5/4022) (p-value < 0.001), temperature monitoring improved from 0.9% (n = 41/4181) to 13% (n = 496/4022) (p-value < 0.001) and external cooling measure (water sponging) improved from 1.3% (n = 89/4181) to 3.4% (n = 210/4022) (p-value < 0.001) after the administration of the HEAT intervention. CONCLUSION: The HEAT intervention in our study improved ED healthcare providers' approach towards diagnosis and management practices of patients presenting with health emergencies (heat stroke or heat exhaustion) in the ED setting. The findings support the case of training ED healthcare providers to address emerging health issues due to rising temperatures/ climate change using standardized treatment algorithms.

Perception of the healthcare professionals towards the current trauma and emergency care system in Kabul, Afghanistan: a mixed method study.

BACKGROUND: Trauma and injury contribute to 11% of the all-cause mortality in Afghanistan. The study aimed to explore the perceptions of the healthcare providers (pre and in-hospital), hospital managers and policy makers of the public and private health sectors to identify the challenges in the provision of an effective trauma care in Kabul, Afghanistan. METHODS: A concurrent mixed method design was used, including key-informant interviews (healthcare providers, hospital managers and policy makers) of the trauma care system (N = 18) and simultaneous structured emergency care system assessment questionnaire (N = 35) from July 15 to September 25, 2019. Interviews were analyzed using content analysis approach and structured questionnaire data were descriptively analyzed. RESULTS: Four themes were identified that describe the challenges: 1) pre-hospital care, 2) cohesive trauma management system, 3) physical and human resources and 4) stewardship. Some key challenges were found related to scene and transportation care, in-hospital care and emergency preparedness within the wider trauma care system. Less than 25% of the population is covered by the pre-hospital ambulance system (n = 23, 65.7%) and there is no communication process between health care facilities to facilitate transfer (n = 28, 80%). Less than 25% of patients with an injury requiring emergent surgery have access to surgical care in a staffed operating theatre within 2 h of injury (n = 19, 54.2%) and there is no regular assessment of the ability of the emergency care system to mobilize resources (human and physical) to respond to disasters, and other large-scale emergencies (n = 28, 80%). CONCLUSION: This study highlighted major challenges in the delivery of trauma care services across Kabul, Afghanistan. Systematic improvement in the workforce training, structural organization of the trauma care system and implementing externally validated clinical guidelines for trauma management could possibly enhance the functions of the existing trauma care services. However, an integrated state-run trauma care system will address the current burden of traumatic injury more effectively within the wider healthcare system of Afghanistan.

Road safety hazards for children while commuting to school: Findings from a pilot study in Karachi, Pakistan.

INTRODUCTION: Road traffic injuries are a leading cause of mortality and morbidity among children. Travelling to and from school is a major risk exposure for children around the globe. OBJECTIVE: The purpose of this study was to assess road traffic injury hazards for school children during dropp-off or picked-up times. METHODS: This observational cross-sectional study included 94 public and private schools in Karachi, Pakistan. A structured observational tool was used to collect data on school demographics, the road traffic environment, infrastructure, injury hazards in vehicles used by school children, and child pedestrian injury risk and road use behaviors. RESULTS: A total of 860 observations of school children, drivers of vehicles transporting children, schools, and vehicles were recorded. Most schools (n = 83, 88%) did not have designated parking spaces around the school; only one public school had a parking area. Only one private school had a zebra crossing around the school premises. Very few schools (n = 13, 14%), mostly private (n = 12) had pedestrian sidewalks. Only 35 (18%) adult motorcyclists, out of 199, were wearing a helmet, and eight (6%), out of 145, car passengers were wearing seatbelts. Compressed natural gas (CNG) cylinders were installed in 83 (35%), out of 235, observed vehicles. The remaining 152 (65%) did not have CNG cylinders or they were not visible to our data collectors. In 55 (23%) observations, bus passengers stepped off the bus in the middle of the road. Most pedestrians (n = 266, 99.5%) did not use a Zebra crossing. More than a quarter (n = 74, 28%) of pedestrians looked left and right before crossing the road. CONCLUSION: While traveling to school, either by walking or taking vehicular trips, children face many road traffic injury hazards in Karachi. Pedestrians and passengers exhibited risky behaviors while using roads. Further initiatives are advised from a public health viewpoint aiming at minimizing transport-related hazards.

Tip-over injuries among children: Data from an urban emergency department of Karachi, Pakistan.

INTRODUCTION: Most unintentional injuries among children occur in the home environment. Tip-overs, defined as incidents where heavy objects fall on children due to some type of interaction, are one of the reasons for injuries inside the home. This study aims to determine injury patterns and outcomes for child injuries resulting from tip-overs in the home environment as reported in the emergency department. METHODS: We performed a retrospective chart review of pediatric (under 18 years) tip-overs injuries occurred in years 2010 to 2015 at the Aga Khan University Hospital. Furthermore, parents of injured children participated in phone interviews to provide information about the injury scene. File review and telephonic interviews were conducted in the year 2015 and 2016. RESULTS: A total of 75 children visited the emergency department with tip-over injuries, out of which 55 (73%) were boys. The majority of incidents (75.5%) happened inside the home, and the most common places were the living room and bedroom (32% and 21% respectively). More than half (53%) of the children were not under adult supervision at the time of the incident and less than half (47%) of the household took safety measures after the incident. Tip-over injuries were common among 3-year-old children with decreasing frequency as children grew older. The most common causes of tip-overs were TV/TV trolley (32%), followed by furniture (28%), and wall and roof (23%). The most common sites of injuries were head (n = 33, 44%) and extremities (n = 33, 44%). A majority of the cases (n = 66, 88%) were admitted to the hospital from the emergency department, under care of both general (n = 51, 68%) and critical care units (n = 15, 20%). More than a quarter (n = 27, 36%) required at least one surgical procedure during their hospital stay. The median length of hospital stay was one days (interquartile range, IQR 1-5 days). There were two cases of mortality (3%). CONCLUSION: Most tip-over injuries among children were caused by TV, furniture, and TV trolleys. These injuries can be prevented with public education around home safety measures, such as mounting them on the wall.

Injury hazard assessment in schools: Findings from a pilot study in Karachi, Pakistan.

INTRODUCTION: Injuries are a major public health concern and one of the leading causes of death and disability worldwide. Childhood injuries contribute to a major proportion of this burden. OBJECTIVE: To identify injury hazards within school premises and playgrounds in Karachi, Pakistan. METHODS: This observational cross-sectional study took place in 107 public and private schools of Karachi, Pakistan using a self-structured standard injury risk assessment tool. This tool was developed after an extensive literature review, expert consultation, and field visits to a few local schools. Data related to school demographics, administrative data and injury hazards within the school boundaries were collected in schools offering education from nursery to secondary grades (through 10th grade, matriculation). Descriptive analysis were calculated. RESULTS: Out of 107 schools, only 12 were recording school-related injuries. A quarter (25%) of schools had some type of disaster drill exercises and built-in fire exits. Fire alarms were placed in 10 schools (9%), all of which were private. In 16 schools (15%), students had access to rooftop doors. There were multiple injury hazards in the school playgrounds. More than half of the schools had hazardous playground surfaces, such as slippery, concrete and uneven ground. Over 80% of schools were not supervising the children during playtime and did not have a separate play area for children under 6 years old. In 38 schools (22%), there were multiple injury hazards in the play rides, such as broken equipment, rusted parts, and sharp edges. Moreover, nine schools (7%) had loose nuts, bolts, edges, belts, steps, or rails in their play rides. Inside, almost a quarter (24%, n = 76) of schools did not have proper insulation of electric wires. Protruded metal nails, which could be high risk for prick and cut injuries, were observed in 20% of the observed furniture. CONCLUSION: In conclusion, there are multiple injury hazards in the private and public schools of Karachi, Pakistan.

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.

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.

Challenges and health outcomes of the exposure to soybean dust in the harbor neighborhood of Karachi, Pakistan: a wake-up call.

BACKGROUND: Chemical disasters are common worldwide and result from technological failure, war, and terrorism activities. Pakistan imports huge quantities of hazardous chemicals to meet its industrial and energy needs. Hence there is a risk of chemical disaster at the ports, during transportation of such material and processing in the chemical industry. This study aimed to review the challenges and health outcomes of cases of soybean dust exposure in Kemari district (harbor neighborhood) of Karachi, Pakistan. METHODS: A cross-sectional survey was conducted with all the affected people from a chemical incident of soybean dust which was reported in the Keamari district of Karachi, Pakistan. Included patients ≥ 18 years who visited the two major tertiary care hospitals of Karachi, Pakistan after the incident between February 17 to 23, 2020. A total of 574 patients were brought to these two major tertiary care hospitals. We collected data on basic demographics, event details, and major signs and symptoms of the affected individuals. Calculated frequencies and percentages for categorical variables. Mean ± standard deviation (SD) was calculated for continuous variables. RESULTS: The mean ± (SD) age of the victims were 32 (13.5) years. Of the 574 patients, majority of the patients (n = 319, 56%) were males. In 28 cases (41%), the onset of symptoms occurred at home, in 27 cases (39%) the onset of symptoms started in the workplace and the remaining cases (n = 14, 20%) experienced the first symptoms while roaming around the roadside. The most common reported co-morbidity was a history of asthma (56%), followed by diabetes mellitus (22%). The most common clinical manifestation was shortness of breath, reported in 94% of the cases, followed by neurological symptoms such as drowsiness, unconsciousness, or seizures experienced by 10% of the victims. A total of 9 deaths (1.5%) were recorded. CONCLUSION: A multi-sectoral systematic approach is also required to address these incidents comprehensively including the trained and equipped pre-hospital system, integrated emergency medical response, and community-wide emergency response system.

Helmet Wearing Saves the Cost of Motorcycle Head Injuries: A Case Study from Karachi, Pakistan.

PURPOSE: To estimate the difference in healthcare cost of head injuries among motorcycle helmet users and non-users. METHODS: Motorcycle crash victims with head injuries that were brought to a public, tertiary care emergency room in Karachi were studied through a descriptive cross-sectional design. A standard questionnaire was used to collect data on demographics, injury pattern, helmeting practice, length of hospital stay, out-of-pocket payments (OOPs), and healthcare service utilization at the facility to estimate total healthcare and other costs applying micro-costing methods during the hospitalization period. RESULTS: A total of 323 motorcyclists involved in crash were brought to a public tertiary care ER, 112 patients had head injuries and were enrolled in the study. The helmeted motorcyclists had a significantly lower median total healthcare cost of PKR 10,796 ($69) [IQR 9851 ($63)-PKR 12,581 ($80)] compared to higher cost of PKR 12,113 ($77) [IQR 10,431 ($66)-50,545 ($322)] (p value = 0.046) in non-helmeted. Helmet users expended significantly less cost on laboratory tests, PKR 365 ($2) [IQR 365 ($2)-548 ($3)] compared to PKR 3650 ($23) [IQR 365 ($2)-5840 ($37)] (p value =0.027) among non-users. Furthermore, cost of radiological investigations was also low among helmeted patients compared to non-helmeted ones, median PKR 4096 ($26) [IQR 3166 ($20)-5678 ($36)] vs 4750 ($30) [3166 ($20)-11,358 ($72)] (p value =0.049). The out-of-pocket payments (OOPs) for healthcare services were lower among helmet users as compared to non-users, with cost of PKR 17,750 ($113) [IQR 16,650 ($106)-18,000 ($115)] vs PKR 19,800 ($126) [IQR 12,300 ($78)-30,900 ($197)] (p value =0.03), respectively. CONCLUSION: The result of this study demonstrates that helmet use among motorcyclists significantly reduced healthcare costs and healthcare resource utilizations during hospitalization for head injuries in Pakistan. Thus, it is important to implement strict helmet wearing laws to decrease head injuries and the cost burden on the healthcare facility and patients.