Assessing the Efficacy of a Novel Massive Open Online Soft Skills Course for South Asian Healthcare Professionals.

In healthcare professions, soft skills contribute to critical thinking, decision-making, and patient-centered care. While important to the delivery of high-quality medical care, soft skills are often underemphasized during healthcare training in low-and-middle-income countries. Despite South Asia's large population, the efficacy and viability of a digital soft skills curriculum for South Asian healthcare practitioners has not been studied to date. We hypothesized that a web-based, multilingual, soft skills course could aid the understanding and application of soft skills to improve healthcare practitioner knowledge, confidence, attitudes, and intent-to-change clinical practice.In September 2019 a needs assessment observing soft skills practices was conducted in several Indian states. We developed a communication-focused soft skills curriculum that comprised seven 10-minute video lectures, recorded in spoken English and Hindi. Participants consisted of any practicing healthcare professionals and trainees in select South Asian countries age 18 and over. Participant knowledge, confidence, attitudes, and intent-to-change clinical practice were evaluated using pre- and post-course tests and surveys. Statistical analyses were performed using STATA and SPSS.From July 26, 2021 to September 26, 2021, 5750 registered and attempted the course, 2628 unique participants completed the pre-test, and 1566 unique participants completed the post-test. Participants demonstrated small but statistically significant gains in confidence (𝑝<0.001), attitudes toward course topics relevance (𝑝<0.001), and intent-to-change clinical practice (𝑝<0.001). There was no statistically significant gain in knowledge. A digital soft-skills massive open online course for healthcare practitioners in South Asia could serve as a viable approach to improve the quality of soft skills training in low-to-middle income countries.

Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. OUTCOMES AND ANALYSIS: We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. RESULTS: We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. CONCLUSIONS: Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Paediatric use of emergency medical services in India: A retrospective cohort study of one million children.

Background: Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness. Methods: We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory. Results: Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection. Conclusions: EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.

Utility of prehospital call center ambulance dispatch data for COVID-19 cluster surveillance: A retrospective analysis.

INTRODUCTION: Cluster surveillance, identification, and containment are primary outbreak management techniques; however, adapting these for low- and middle-income countries is an ongoing challenge. We aimed to evaluate the utility of prehospital call center ambulance dispatch (CCAD) data for surveillance by examining the correlation between influenza-like illness (ILI)-related dispatch calls and COVID-19 cases. METHODS: We performed a retrospective analysis of state-level CCAD and COVID-19 data recorded between January 1 and April 30, 2020, in Telangana, India. The primary outcome was a time series correlation between ILI calls in CCAD and COVID-19 case counts. Secondarily, we looked for a year-to-year correlation of ILI calls in the same period over 2018, 2019, and 2020. RESULTS: On average, ILI calls comprised 12.9% (95% CI 11.7%-14.1%) of total daily calls in 2020, compared to 7.8% (95% CI 7.6%-8.0%) in 2018, and 7.7% (95% CI 7.5%-7.7%) in 2019. ILI call counts from 2018, 2019, and 2020 aligned closely until March 19, when 2020 ILI calls increased, representing 16% of all calls by March 23 and 27.5% by April 7. In contrast to the significant correlation observed between 2020 and previous years' January-February calls (2020 and 2019-Durbin-Watson test statistic [DW] = 0.749, p < 0.001; 2020 and 2018-DW = 1.232, p < 0.001), no correlation was observed for March-April calls (2020 and 2019-DW = 2.012, p = 0.476; 2020 and 2018-DW = 1.820, p = 0.208). In March-April 2020, the daily reported COVID-19 cases by time series significantly correlated with the ILI calls (DW = 0.977, p < 0.001). The ILI calls on a specific day significantly correlated with the COVID-19 cases reported 6 days prior and up to 14 days after (cross-correlation > 0.251, the 95% upper confidence limit). CONCLUSIONS: The statistically significant time series correlation between ILI calls and COVID-19 cases suggests prehospital CCAD can be part of early warning systems aiding outbreak cluster surveillance, identification, and containment.

Emergency Medical Services (EMS) Utilization in Zimbabwe: Retrospective Review of Harare Ambulance System Reports.

Background: Emergency medical services (EMS) are a critical but often overlooked component of essential public health care delivery in low- and middle-income countries (LMICs). Few countries in Africa have established EMS and there is scant literature to provide guidance for EMS growth. Objective: This study aimed to characterize EMS utilization in Harare, Zimbabwe in order to guide system strengthening efforts. Methods: We performed a retrospective chart review of patient care reports (PCR) generated by the City of Harare ambulance system for patients transported and/or treated in the prehospital setting over a 14-month period (February 2018 - March 2019). Findings: A total of 875 PCRs were reviewed representing approximately 8% of the calls to EMS. The majority of patients were age 15 to 49 (76%) and 61% were female patients. In general, trauma and pregnancy were the most common chief complaints, comprising 56% of all transports. More than half (51%) of transports were for inter-facility transfers (IFTs) and 52% of these IFTs were maternity-related. Transports for trauma were mostly for male patients (63%), and 75% of the trauma patients were age 15-49. EMTs assessed and documented pulse and blood pressure for 72% of patients. Conclusion: In this study, EMS cared primarily for obstetric and trauma emergencies, which mirrors the leading causes of premature death in LMICs. The predominance of requests for maternity-related IFTs emphasizes the role for EMS as an integral player in peripartum maternal health care. Targeted public health efforts and chief complaint-specific training for EMTs in these priority areas could improve quality of care and patient outcomes. Moreover, a focus on strengthening prehospital data collection and research is critical to advancing EMS development in Zimbabwe and the region through quality improvement and epidemiologic surveillance.

Correction: Teaching From Afar: Development of a Telemedicine Curriculum for Healthcare Workers in Global Settings.

[This corrects the article DOI: 10.7759/cureus.20123.].

Is AVPU comparable to GCS in critical prehospital decisions? - A cross-sectional study.

BACKGROUND: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS. METHODS: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU. RESULTS: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable. CONCLUSION: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care.

A qualitative study of an undergraduate online emergency medicine education program at a teaching Hospital in Kampala, Uganda.

BACKGROUND: Globally, half of all years of life lost is due to emergency medical conditions, with low- and middle-income countries (LMICs) facing a disproportionate burden of these conditions. There is an urgent need to train the future physicians in LMICs in the identification and stabilization of patients with emergency medical conditions. Little research focuses on the development of effective emergency medicine (EM) medical education resources in LMICs and the perspectives of the students themselves. One emerging tool is the use of electronic learning (e-learning) and blended learning courses. We aimed to understand Uganda medical trainees' use of learning materials, perception of current e-learning resources, and perceived needs regarding EM skills acquisition during participation in an app-based EM course. METHODS: We conducted semi-structured interviews and focus groups of medical students and EM residents. Participants were recruited using convenience sampling. All sessions were audio recorded and transcribed verbatim. The final codebook was approved by three separate investigators, transcripts were coded after reaching consensus by all members of the coding team, and coded data were thematically analyzed. RESULTS: Twenty-six medical trainees were included in the study. Analysis of the transcripts revealed three major themes: [1] medical trainees want education in EM and actively seek EM training opportunities; [2] although the e-learning course supplements knowledge acquisition, medical students are most interested in hands-on EM-related training experiences; and [3] medical students want increased time with local physician educators that blended courses provide. CONCLUSIONS: Our findings show that while students lack access to structured EM education, they actively seek EM knowledge and practice experiences through self-identified, unstructured learning opportunities. Students value high quality, easily accessible EM education resources and employ e-learning resources to bridge gaps in their learning opportunities. However, students desire that these resources be complemented by in-person educational sessions and executed in collaboration with local EM experts who are able to contextualize materials, offer mentorship, and help students develop their interest in EM to continue the growth of the EM specialty.

A Deadly Infodemic: Social Media and the Power of COVID-19 Misinformation.

COVID-19 is currently the third leading cause of death in the United States, and unvaccinated people continue to die in high numbers. Vaccine hesitancy and vaccine refusal are fueled by COVID-19 misinformation and disinformation on social media platforms. This online COVID-19 infodemic has deadly consequences. In this editorial, the authors examine the roles that social media companies play in the COVID-19 infodemic and their obligations to end it. They describe how fake news about the virus developed on social media and acknowledge the initially muted response by the scientific community to counteract misinformation. The authors then challenge social media companies to better mitigate the COVID-19 infodemic, describing legal and ethical imperatives to do so. They close with recommendations for better partnerships with community influencers and implementation scientists, and they provide the next steps for all readers to consider. This guest editorial accompanies the Journal of Medical Internet Research special theme issue, "Social Media, Ethics, and COVID-19 Misinformation."

"So Why Should I Call Them?": Survivor Support Service Characteristics as Drivers of Help-Seeking in India.

Women in South Asia face the highest lifetime prevalence of intimate partner violence in the world, which is just one form of violence against women (VAW). In India, few women seek help after experiencing violence, particularly from formal resources, such as physicians or the police. While many studies have investigated the impact of survivor characteristics and patterns of violence on help-seeking behaviors, there is scant research on support service characteristics and their impact on help-seeking. The introduction of a novel crisis helpline in Gujarat, India provided an opportunity to better understand how successful help-seeking can be driven by the perceived and experienced characteristics of the helpline. We conducted in-depth interviews with helpline users to identify factors and pathways that promoted or discouraged help-seeking in general, help-seeking from a formal source, and help-seeking from this particular helpline. We analyzed 32 interviews of women who used the helpline. Participants were from eight districts across the state, representing a diverse range of sociodemographic backgrounds. After conducting a thematic analysis, we found that action-oriented service, timeliness, and women-focused staff influenced (positively and negatively) participants' feelings of safety, empowerment, and trust in the helpline, which ultimately impacted their decision to seek help from the helpline or even to seek help at all. This study illuminates how service characteristics, in and of themselves, can influence the likelihood that survivors will seek help, emphasizing the need for survivors to have a voice in the growth and refinement of VAW support services. Consequently, these areas must be a focus of future research and initiatives to improve help-seeking by VAW survivors.

Development and implementation of a novel Web-based gaming application to enhance emergency medical technician knowledge in low- and middle-income countries.

BACKGROUND: Increasing access to high-quality emergency and prehospital care is an important priority in low- and middle-income countries (LMICs). However, ensuring that emergency medical technicians (EMTs) maintain their clinical knowledge and proficiency with procedural skills is challenging, as continuing education requirements are still being introduced, and clinical instructional efforts need strengthening. We describe the development and implementation of an innovative asynchronous learning tool for EMTs in the form of a Web-based trivia game. METHODS: Over 500 case-based multiple-choice questions (covering 10 essential prehospital content areas) were created by experts in prehospital education, piloted with EMT educators from LMICs, and delivered to EMTs through a Web-based quiz game platform over a 12-week period. We enrolled 252 participants from nine countries. RESULTS: Thirty-two participants (12.7%) completed the entire 12-week game. Participants who completed the game were administered a survey with a 100% response rate. Ninety-three percent of participants used their mobile phone to access the game. Overall, participants reported that the interface was easy to use (93.8% agreed or strongly agreed), the game improved their knowledge (100% agreed or strongly agreed), and they felt better prepared for their jobs (100% agreed or strongly agreed). The primary motivators for participation were improving patient care (37.5%) and being recognized on the game's leaderboard (31.3%). All participants reported that they would engage in the game again (43.8% agreed and 56.3% strongly agreed) and would recommend the game to their colleagues (34.4% agreed and 65.6% strongly agreed). CONCLUSIONS: In conclusion, a quiz game targeting EMT learners from LMICs was viewed as accessible and effective by participants. Future efforts should focus on increasing retention and trialing languages in addition to English.

SARS-CoV-2 IgG Seropositivity and Acute Asymptomatic Infection Rate among Firefighter First Responders in an Early Outbreak County in California.

Objective: Firefighter first responders and other emergency medical services (EMS) personnel have been among the highest risk healthcare workers for illness during the SARS-CoV-2 pandemic. We sought to determine the rate of seropositivity for SARS-CoV-2 IgG antibodies and of acute asymptomatic infection among firefighter first responders in a single county with early exposure in the pandemic. Methods: We conducted a cross-sectional study of clinically active firefighters cross-trained as paramedics or EMTs in the fire departments of Santa Clara County, California. Firefighters without current symptoms were tested between June and August 2020. Our primary outcomes were rates of SARS-CoV-2 IgG antibody seropositivity and SARS-CoV-2 RT-PCR swab positivity for acute infection. We report cumulative incidence, participant characteristics with frequencies and proportions, and proportion positive and associated relative risk (with 95% confidence intervals). Results: We enrolled 983 out of 1339 eligible participants (response rate: 73.4%). Twenty-five participants (2.54%, 95% CI 1.65-3.73) tested positive for IgG antibodies and 9 (0.92%, 95% CI 0.42-1.73) tested positive for SARS-CoV-2 by RT-PCR. Our cumulative incidence, inclusive of self-reported prior positive PCR tests, was 34 (3.46%, 95% CI 2.41-4.80). Conclusion: In a county with one of the earliest outbreaks in the United States, the seroprevalence among firefighter first responders was lower than that reported by other studies of frontline health care workers, while the cumulative incidence remained higher than that seen in the surrounding community.

Teaching From Afar: Development of a Telemedicine Curriculum for Healthcare Workers in Global Settings.

The Stanford Department of Emergency Medicine joined forces with Digital Medic to create educational materials to teach global healthcare providers how to evaluate patients via telemedicine in the setting of COVID-19. Users then asked for additional education on best practices surrounding the use of telemedicine as a communication medium. Here, we describe our experience in the creation of this additional module and provide some basic feedback received from end-users. We scripted, filmed, and edited a video module for this application over the course of 14 weeks. It was subsequently deployed as part of the larger COVID-19 educational program. To date, the course has had over 28,000 participants. Each was asked to take a pre- and post-test to assess the knowledge of telemedicine best practices before and after the video module; 19,412 elected to take the pre-test and 19,364 took the post-test with overall scores of 84% and 95%, respectively. Anecdotal feedback has been positive. Telemedicine systems have proliferated rapidly around the world, but best practices for physician-to-patient interactions have not been similarly disseminated. We conclude that video modules can be used to fill this educational need quickly and economically.

Medevac Utilization and Patient Characteristics in Rural Alaska 2010 to 2018.

OBJECTIVE: Little is known about medevac utilization in remote, rural Alaska where there is no road access and communities are reliant on medevacs for emergency care. With high financial costs and risks to flight crews, there is an urgent need to understand medevac utilization in rural Alaska. This article aimed to describe medevac utilization and patient characteristics over 9 years in the remote, air transport dependent in Alaska. METHODS: Deidentified data (2010-2018) were obtained for all medevacs originating within the Yukon-Kuskokwim Delta. Descriptive statistics were calculated, and chi-square tests of independence were conducted to identify differences. RESULTS: Four thousand nine hundred ninety-one medevacs were performed, averaging 555 (standard deviation = 67.7) per year. Medevacs for respiratory complaints were predominant for children, whereas trauma predominated for adults 18 to 40 years old. Traumatic injury was more common in males than females aged < 65 years but was more common in females than males aged ≥ 65 years. Significant variability occurred in medevacs based on the community and the hour of the day. CONCLUSION: Medevacs are a critical part of health care in rural, remote Alaska but appear subject to clinical and nonclinical determinants. These baseline data provide a foundation for future studies aiming to increase medevac safety and provide decision-making support.

Continuing Education for Prehospital Healthcare Providers in India - A Novel Course and Concept.

BACKGROUND: Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India. METHODS: From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide). LESSONS LEARNED: During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials. CONCLUSION: These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

Correction to: Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan.

An amendment to this paper has been published and can be accessed via the original article.

Defining High-risk Emergency Chief Complaints: Data-driven Triage for Low- and Middle-income Countries.

OBJECTIVES: Emergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints (CCs) are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether CCs independently predict emergency unit patient outcomes. METHODS: Patient data collected in a Ugandan emergency unit between 2009 and 2018 were randomized into validation and derivation data sets. A recursive partitioning algorithm stratified CCs by 3-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, CCs were categorized as "high-risk" (>2× baseline mortality), "medium-risk" (between 2 and 0.5× baseline mortality), and "low-risk" (<0.5× baseline mortality). Risk categories were then included in a logistic regression model to determine if CCs independently predicted 3-day mortality. RESULTS: Overall, the derivation data set included 21,953 individuals with 7,313 in the validation data set. In total, 43 complaints were categorized, and 12 CCs were identified as high-risk. When controlled for triage data including age, sex, HIV status, vital signs, level of consciousness, and number of complaints, high-risk CCs significantly increased 3-day mortality odds ratio (OR = 2.39, 95% confidence interval [CI] = 1.95 to 2.93, p < 0.001) while low-risk CCs significantly decreased 3-day mortality odds (OR = 0.16, 95% CI = 0.09 to 0.29, p < 0.001). CONCLUSIONS: High-risk CCs were identified and found to predict increased 3-day mortality independent of vital signs and other data available at triage. This list can be used to expand local triage systems and inform emergency training programs. The methodology can be reproduced in other LMIC settings to reflect their local disease patterns.

Experiences of Workplace Violence Among Healthcare Providers in Myanmar: A Cross-sectional Survey Study.

Background Healthcare providers face enormous threats to personal safety from workplace violence (WPV). Prior investigations estimate a highly varied prevalence of WPV in the United States and around the world, including both verbal and physical assault. Little is known about WPV in Myanmar. Only a single prior study has evaluated WPV experiences among physicians in Myanmar, reporting an unusually low prevalence of verbal (8.7%) and physical (1.0%) assault. Given this much lower prevalence compared with similar studies in other low- and middle-income countries (LMICs), we embarked on a study to identify the prevalence of WPV in a separate cohort of healthcare providers in Myanmar. Methods This was a cross-sectional analysis of WPV prevalence among healthcare providers who attended a national emergency medicine conference in Myanmar in November 2018. The survey instrument was adapted from a validated survey from the Joint Program on Workplace Violence in the Healthcare Sector (International Labour Office, International Council of Nurses, World Health Organization, and Public Services International), which had been used in other global settings. Results Sixty-three participants completed the survey questionnaire, including 35 women (55.6%) and 26 men (41.3%). Among them, 25 (39.7%) were primary care providers. Overall, the combined prevalence of WPV in the previous 12 months was found to be 47.6% (n = 30; 95% CI: 34.9-60.6%). The prevalence of verbal assault was 47.6% (n = 30; 95% CI: 34.9-60.6%), and that of physical assault was 4.8% (n = 3; 95% CI: 1.0-13.3%). Twenty-four participants (42.4%) reported that they were encouraged to report violence in the workplace, and five (8.1%) reported they had received training on how to manage WPV. Respondents who were 30-34 years in age and those working in private facilities were significantly less likely to report WPV on univariate analysis. Conclusion Although our cohort comprised a limited sample of a select group of providers, we found a dramatically higher prevalence of WPV experiences among healthcare providers attending an emergency medicine conference in Myanmar when compared with a prior investigation. Very few participants had received training on WPV, and less than half reported a work culture where WPV reporting is encouraged. To combat healthcare provider shortages, more investigation is required into WPV to understand its impact and identify amelioration strategies.

Acute respiratory illness among a prospective cohort of pediatric patients using emergency medical services in India: Demographic and prehospital clinical predictors of mortality.

BACKGROUND: In India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India's public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint. METHODS: Pediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of "shortness of breath", or a "fever" with associated "difficulty breathing" or "cough", were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality. RESULTS: A total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0-28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation <95% (OR: 3.18 CI: 1.77-5.71) and respiratory distress (OR: 3.72 CI: 2.17-6.36) were the strongest predictors of mortality at 30 days. CONCLUSIONS: This is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population.