ABSTRACT
Background: Paediatric injuries are among the leading causes of morbidity and mortality globally, especially in low- and middle-income countries. We aimed to characterize paediatric injuries as predictors of disposition from Mbarara Regional Referral Hospital Emergency Department (ED) Southwestern Uganda. Methods: This was a prospective cohort study done from 12th December 2022 to 31st March 2023. We described the characteristics of injuries sustained by children and evaluated the predictors of 24-hour disposition from the ED using logistic regression. Results: Of the 160 children followed up, 64.4% were male with a median age of 7 years, brought in with road traffic accidents (RTAs) (40.6%) and falls (35.6%) as the commonest mechanism of injury. Over half of the patients were triaged as yellow (urgent); polytrauma and head injuries were the top injury patterns. The majority (45.6%) of the children were admitted to the inpatient surgical ward. Only 1.9% and 5.0% ended up in intensive care unit (ICU) and died (to mortuary), respectively. The median time to disposition was 8 h and 14% stayed in the ED beyond 24-hours. Patients who needed more intensive initial treatment, including additional medications or interventions, were significantly more likely to be admitted to the ward (AOR= 5.3, 95%CI: 2.0-13.0, p <0.01). Conclusion: Paediatric injuries were caused mainly by RTAs and presenting with polytrauma and head injuries. Most patients were disposed of to the inpatient surgical ward within 24 h with severe KTS and initial management being strongest predictors of admission. These findings can be used to tailor quick risk stratification and decision-making tools and improve ED disposition of paediatric injuries in Low- and Middle- income countries.
ABSTRACT
Background: Hypoxia is a common presentation in the Emergency Department (ED) worldwide. It affects 9-12% of hospitalized adults in Sub-Saharan Africa. Timely diagnosis of the multiple causes such as pneumonia, heart failure among others is challenging. Chest X-Ray (CXR), one of the most utilized imaging modalities has many limitations, and the gold standard (Computed Tomography scan) is inaccessible. Point of care ultrasound (PoCUS) is more available and increasingly being used, however little is known of its performance in resource limited EDs. The study aimed to assess the diagnostic performance of PoCUS compared with CXR in identifying the causes of hypoxia in the medical ED. Methods: 49 adults presenting with hypoxia (SP02 ≤ 88%) in the medical ED were evaluated. Ultrasound of the lungs and heart (PoCUS) was done, then CXR obtained. Lung ultrasound (LUS) was compared with CXR (first reference standard). Chest X-Ray and PoCUS were each compared to the physician diagnosis (second reference standard) to determine agreement using an acceptable disagreement cut-off of 15%. Results: 31% more abnormalities were identified by LUS than CXR. Lung ultrasound findings agreed with CXR in 86% of the participants with moderate reliability (ĸ=0.75). There was no significant difference between the actual findings of the two tests (X2= 2, p 0.1). Using the second reference, 82% of the CXRs were similar with weak reliability (ĸ=0.5) compared to 98% of PoCUS findings with strong reliability (ĸ=0.9). Compared to PoCUS, CXRs significantly differed from the physician diagnosis (X2= 0.85, p 0.38 vs X2= 8.5, p 0.004 respectively). Conclusion: Overall, PoCUS was not inferior to CXR when compared to final physician diagnosis in identifying causes of hypoxia, and LUS and CXR had comparable performance. Significantly more abnormalities were identified on PoCUS and it demonstrated better agreement and strong reliability with the physician diagnosis than CXR. We recommend PoCUS use in patients with hypoxia attending resource limited in- and pre-hospital settings.
ABSTRACT
OBJECTIVES: To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda. DESIGN: Retrospective cohort analysis with multivariable logistic regression. SETTING: Single rural Ugandan emergency unit. PARTICIPANTS: All patients presenting for care from 2009 to 2019. INTERVENTIONS: Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: 'Direct Supervision' (2009-2010) emergency medicine physicians directly supervised all care; 'Indirect Supervision' (2010-2015) emergency medicine physicians were consulted as needed; 'Independent Care' (2015-2019) no emergency medicine physician supervision. PRIMARY OUTCOME MEASURE: Three-day mortality. RESULTS: 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts ('Direct' 3.8%, 'Indirect' 3.3%, 'Independent' 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals ('Direct' 32%, 'Indirect' 19%, 'Independent' 13%, p<0.001). After controlling for vital sign abnormalities, 'Direct' and 'Indirect' supervision were both significantly associated with reduced OR for mortality ('Direct': 0.57 (0.37 to 0.90), 'Indirect': 0.71 (0.55 to 0.92)) when compared with 'Independent Care'. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals ('Direct': 0.44 (0.22 to 0.85), 'Indirect': 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals ('Direct': 0.81 (0.44 to 1.49), 'Indirect': 0.82 (0.58 to 1.16)). CONCLUSIONS: Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.