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Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals without appointments: an observational study

Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals... Background: Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals. Methods: Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission. Results: This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever. Conclusions: While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission. Keywords: Chief complaints, Developing countries, Emergency medicine, Health systems, Pediatrics Background suffers residual effects of the Khmer Rouge regime of the In low- and middle-income countries (LMICs), an estimated 1970s, during which violence, famine, and preventable 45% of all deaths and 36% of disability-adjusted life years disease killed approximately two million people and (DALYs) are due to diseases and injuries typically addressed completely dismantled the healthcare infrastructure [2, 3]. by emergency medical services that are currently lacking in Developing emergency medicine in LMICs requires these regions [1]. Among these countries is Cambodia, a a great deal of specialized training for providers. lower middle-income nation in Southeast Asia which still Characterizing the potential emergency department population in LMICs is an important step in creating relevant training for future emergency clinicians. * Correspondence: mackensie.yore@gmail.com Department of Emergency Medicine, UCSF Fresno Center for Medical Understanding the distribution of chief complaints focuses Education and Research, 155 N Fresno St, Fresno, CA 93701, USA provider education on symptoms with the highest burden Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 2 of 9 of morbidity and mortality, thereby helping emergency hospital’s combined ED/ICU managed patients in serious care providers more effectively evaluate and manage condition, while patients with milder presentations patients [4]. Despite the importance of this information, presented elsewhere. At both facilities, study enroll- the 2013 Academic Emergency Medicine Consensus ment was hospital wide. Conference found insufficient data on chief complaints for most LMICs [4]. Helping address this knowledge gap, our group previously documented the epidemiology Selection of participants and outcomes of adult patients presenting for unsched- Pediatric patients (< 18 years) presenting without prior uled visits to public hospitals in Cambodia [5]; no appointments during the 4 weeks in July and August studies, however, have thus examined an analogous 2012 were invited to enroll; patients presenting for pediatric population in this setting. routine check-ups and vaccinations without appointment Pediatric patients account for 20–35% of all emergency were excluded. Repeat unscheduled visits were considered department (ED) visits globally [6–8]. Moreover, separate visits. Most enrollment occurred weekdays, 08:00 children present with a unique distribution of chief to 17:00, times of day with highest patient volume. complaints compared to adults and require different Patients presented infrequently during evening and clinical management [7, 9]. To address the specific weekend hours when hospital staffing was limited. needs of children presenting to EDs in LMICs, the Afterhours visits were included if the patient remained World Health Organization (WHO) developed guide- at the hospital the following morning. lines for the care of children with traumatic injuries and acute illnesses in resource-limited settings; however, limited training for diagnosing and treating Methods and measurements urgent medical conditions poses challenges to guideline A team at each site gathered real-time clinical and adherence, which may contribute to preventable mor- demographic data using Research Electronic Data bidity and mortality in LMICs [10–15]. The recently Capture (REDCap) forms [18]. Demographic information announced United Nations Sustainable Development and up to three chief complaints were obtained from Goals includes a call to reduce preventable mortality patients, guardians, and staff. A list of all chief complaints among children; strengthening pediatric emergency is included in the supplemental material (Additional file 1: care capacity in LMICs could help achieve this goal. Figure S1). Hospital records provided vital signs at The present study was conducted to identify the presentation, diagnostic tests, treatment interventions, characteristics, chief complaints, management, and disposition, and discharge dates. Two members of the outcomes of children presenting for unscheduled research team reviewed records for completeness and visits to two public referral hospitals in Cambodia in inconsistencies, which were addressed through repeat order to focus training to improve future care. interviews and hospital record reviews. Follow-up interviews with patients or their guardians were conducted in Khmer (the local language) at 48 h and 14 days following the initial Methods visit. Follow-up interviews were in-person if the patient Study design and setting remained hospitalized, or by telephone if discharged, We performed a 4-week prospective, cross-sectional and assessed patient location, survival, and functional study of unscheduled visits to two government provincial status. Patients were considered lost to follow-up after referral hospitals in Cambodia: Sampov Meas Provincial three failed contact attempts on successive days. Hospital (SMPH) and Battambang Provincial Hospital (BPH). SMPH and BPH are “CPA Level 3,” indicating that obstetric, emergency, and surgical services should be Outcome measures available [16]. SMPH has 162 inpatient beds and recorded Primary outcomes included admission, functional impair- 9722 visits in 2012, leading to 6564 admissions. BPH has ment, and mortality. Patients are typically treated for 220 inpatient beds and recorded 40,825 visits and 14,108 their entire hospital stay in the department where admissions in 2012 [17]. they initially presented, regardless of appropriateness; The level of emergency care offered at these two therefore, included interventions were limited to those hospitals was similar to that at other Cambodian provin- completed within the first 48 h of initial presentation, cial hospitals at the time of the study. Neither hospital thus identifying services most representative of a standard had an active triage system, and BPH had no ED, with ED setting. Patients staying overnight were considered patients presenting to a variety of departments for treat- admitted. Functional impairment was defined as con- ment. At BPH, most pediatric patients seeking urgent tinued hospitalization, significant pain or limitation in care came directly to the pediatric ward. At SMPH, the performing daily activities, bed confinement, or coma. Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 3 of 9 Data analysis Patient presentations and management Because a complete set of vital signs was not consist- For the 867 pediatric patients enrolled, 1615 total chief ently documented at participating hospitals, records with complaints were recorded, 35 of them distinct. Fever data missing for respiratory rate (RR), blood pressure was the most common chief complaint (62.5% of patients; (BP), or heart rate (HR) were included in multivariate 33.6% of complaints), followed by respiratory problems, analyses with absent values assumed normal. Records skin-related complaints, vomiting, and abdominal pain with missing values for all other independent variables (Fig. 1). Injury represented 2.8% of complaints (Fig. 1). were excluded from modeling. Sensitivity analysis showed Chief complaints of abdominal pain and fever resulted in no significant differences in predictors of admission with a significantly higher admission rate (p ≤ 0.05), while the conversion of missing vital signs to normal in respiratory problems and skin complaints correlated multivariate analysis. with lower admission rates (p ≤ 0.01). Of the seven Comparisons between outcomes for continuous deaths, chief complaints included respiratory problems variables were conducted using Wilcoxon two sample (3 children), vomiting (3), fever (2), unconsciousness (1), T test, while the chi-square test was used for categorical convulsions/seizures (1), genital bleeding (1), and other (1). variables. A multivariate logistic regression was built for Approximately one quarter of all patient records the primary outcome of admission using predictors lacked vital sign data (Table 1). Patients treated and identified through univariate analysis, controlling for age released were less likely to have vital signs recorded than and gender; stepwise methods were not used. Statistical those admitted (p ≤ 0.05). Abnormal vital signs were analysis was completed using SAS Enterprise Guide for more frequent in admitted patients than those treated Windows, version 4.3 (SAS Institute Inc. Cary, NC). and released (p ≤ 0.05); similarly, admitted patients were more likely to present with pain (p ≤ 0.05). One third of patients received any diagnostic testing, Ethical considerations with laboratory tests being the most common (Table 2). We obtained verbal informed consent from patient Imaging, including chest X-ray, and other diagnostics were guardians or patients themselves if unaccompanied performed on less than 3% of patients (Table 2). The most and at least 16 years old. In-person, native-speaking common intervention within the first 48 h was medication translators obtained consent and conducted interviews therapy, administered to 81.6% of patients (Table 2). in Khmer. Intravenous fluids were provided to 40.7% of patients. All The Institutional Review Boards at Stanford University other interventions were infrequent, each received by less School of Medicine (IRB-24735) and the Cambodian than 5% of patients (Table 2). Ministry of Health approved this study. Patient disposition and outcomes The rate of admission was 51.3%, with a 3-day median Availability of data and materials length of stay (Table 3). Less than 1% of patients were The dataset supporting the conclusions of this article is transferred to an outside facility or left the hospital prior available in the Dryad repository, https://doi.org/10.5061/ to being seen or against medical advice (Table 3). dryad.7v8c4. Twenty-two patients (3.1%) were referred to surgery, 81.8% of whom were admitted. Results Follow-up rates were 82.9 and 74.9% at 48 h and Demographic characteristics 14 days, respectively (Table 3). Seven deaths were This 4-week study documented 867 unscheduled pediatric documented, for a 1.1% overall 14-day mortality (Table 3). patient visits. Mean patient age was 5.7 years with Two of the seven deaths occurred within 24 h of presenta- approximately half (54.3%) being male (Table 1). Private tion; the rest occurred after admission, one of whom died vehicles were the predominant mode of transport to after discharge. No deaths were documented in patients the hospitals, with nearly 90% of patients arriving via who were treated and released. motorbike, taxi, or tuk-tuk (motorized three-wheeled Morbidity was measured by asking patients or guardians rickshaw for hire); arrival by ambulance was infre- whether the patient had returned to baseline functioning. quent (2.9%). More than 69.9% of patients presented By 40 h and 14 days post-visit, 49.7 and 93.2% of patients, to the hospital with sudden (< 24 h) or recent (1–3days) respectively, had returned to baseline functioning (Table 3). symptoms (Table 1). About one quarter of patients were either transferred directly from another health- Admission multivariate logistic regression model care facility, typically a health center, or referred by A multivariate logistic regression model showed increased an outside medical provider (e.g., a practitioner private admission risk was associated with referral from another clinic) (Table 1). health provider (OR = 4.3, CI 2.4–7.8), direct transfer from Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 4 of 9 Table 1 Pediatric patients presenting unscheduled at two Table 1 Pediatric patients presenting unscheduled at two Cambodian hospitals, July–August 2012 Cambodian hospitals, July–August 2012 (Continued) Characteristic No. (%) of Characteristic No. (%) of a, b a, b patients patients All patients 867 Time before seeking any medical care Demographic characteristic Median time before seeking care in days (IQR) 1.5 (0.6–3) Site of presentation < = 24 h 339 (39.1) Battambang Provincial Hospital 550 (63.4) > 24 h 505 (58.3) Sampov Meas Provincial Hospital 317 (36.6) Examination findings Age Respiratory rate, blood pressure, and heart rate Age in years, mean (SD) 5.65 (4.8) Abnormal respiratory rate, blood pressure, 405 (46.7) or heart rate Infant (< 1 year) 136 (15.7) Abnormal respiratory rate 224 (25.8) Young child (1–5 years) 374 (43.1) Abnormal blood pressure 153 (17.6) Child (6–10 years) 182 (21.0) Abnormal heart rate 217 (25.0) Older child (11–13 years) 98 (11.3) Respiratory rate, blood pressure, 216 (24.9) Teen (14–17 years) 77 (8.9) or heart rate not recorded Gender Temperature Female 396 (45.7) Low temperature (< 36 °C) 80 (9.2) Male 471 (54.3) High temperature (> 38 °C) 153 (17.7) Socioeconomic characteristic Temperature not recorded 213 (24.6) Patient had low-income health insurance 444 (51.2) Pain Travel to hospital Pain documented as present 254 (29.3) Time IQR interquartile range, SD standard deviation Number of patients and percentages, unless otherwise stated Time in hours, median (IQR) 0.5 (0.3–1.0) Due to missing values for individual patients, not all categories sum to 100% Time < 0.5 h 482 (55.6) Except for more affluent patients who had private health insurance, most patients paid in cash Time 0.5–2 h 326 (37.6) See Additional file 2: Table S2 for age-appropriate vital signs used Time > 2 h 52 (6.0) Distance another health provider (OR = 7.8, CI 4.7–13.0), low- Distance in kilometers, median (IQR) 10 (3.0–30.0) income health insurance (proxy for low socioeconomic Presentation status) (OR = 1.5, CI 1.1–2.1), seeking care prior to 48 h before presentation without transfer/referral (OR = 2.4, Time of arrival 95% CI 1.–4.5), seeking care within 48 h of presentation Daytime Monday to Friday (i.e., 07.00–17.00) 765 (88.2) without transfer/referral (OR = 2.5, CI 1.4–4.5), symptom Overnight Sunday to Friday (i.e., 17.00–07.00) 68 (7.8) onset within 24 h of seeking care (2.1, CI 1.5–3.1), Weekend (i.e., Friday 17.00 to Sunday 17.00) 34 (3.9) abnormal temperature (OR = 1.5, CI 1.0–2.2), abnormal Care before presentation heart rate, respiratory rate, and/or blood pressure Transferred from another healthcare facility 163 (18.8) (OR = 3.2, CI 2.3–4.6), and chief complaint of abdominal pain (OR = 2.9; 95% CI 1.7–5.0) or fever (OR = 1.4, Referred by an external medical provider 81 (9.3) CI 1.0–2.0); a decreased risk of admission was Prior care of those not transferred or referred associated with skin-related chief complaints (OR = 0.4; Prior care received in the previous 48 h 79 (9.1) CI 0.2–0.5), such as rashes or blisters, and respiratory Prior care received more than 48 h earlier 65 (7.5) problems (OR = 0.4; CI 0.3–0.6), such as cough (n =793; No prior care 468 (54.0) c-statistic = 0.81). Symptom duration Sudden (< 24 h) 266 (30.7) Dermatologic and fever complaints sub-analysis Recent (1–3 days) 340 (39.2) A country-wide outbreak of enterovirus strain EV-71 Sub-acute (4–14 days) 206 (23.8) occurred during the study. Qualitatively, many more Chronic (> 14 days) 49 (5.7) children than expected presented with fever and/or skin complaints, such as rash or blisters, which are common Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 5 of 9 Fig. 1 Chief complaints and initial actions for children presenting without appointment at two Cambodian hospitals. Only the top 15 chief complaints are displayed. A maximum of three chief complaints per patient were recorded. Includes data for July–August 2012 symptoms of EV-71. The number of patients presenting Of the top ten chief complaints identified in the with skin complaints and fever increased sharply during the present study, only half match the list of top complaints study period before gradually decreasing, coinciding with documented in an analogous population of adults [5]. timing of the EV-71 outbreak (Fig. 2). These results mirror data from EDs in the USA, which similarly show that the frequency and distribution of pediatric chief complaints differ markedly from adults [9]. Discussion The unique distribution and frequency of presentations in This study describes the characteristics, chief complaints, children with undifferentiated conditions compared to management, and health outcomes of children seeking adults in LMICs underscores the need for specialty unscheduled acute care at two public referral hospitals in training that specifically addresses pediatric emergencies. Cambodia. Our findings provide essential information to Regarding pre-hospital care, only 2.9% of patients in inform emergency care provider education and guide our study arrived by ambulance, compared to 15–17% in development of emergency care systems in Cambodia other studies in LMICs [27, 28]. Low frequency of and other LMICs. ambulance transport—despite more than one quarter of Top chief complaints in this study (fever, respiratory all unscheduled patients coming from another care problems, abdominal pain, vomiting, and diarrhea) are provider—reflects the relative underdevelopment of similar to other published reports characterizing un- Cambodia’s regional pre-hospital and EMS systems. scheduled or ED pediatric presentations in other LMICs Currently, laypeople provide most patient transfers [6, 8, 19, 20]. The top five chief complaints in our popu- in Cambodia. Low-cost, community-based interven- lation accounted for 75% of all reported complaints. In tions aimed at equipping laypeople with first aid contrast to several other studies, the percentage of ED skills and facilitating transport have shown promise visits attributed to trauma in this study (2.8%) was in South Africa [29]. substantially lower. For example, trauma among children Vital signs, which provide low-cost, objective data that presenting for emergency care accounted for 27–29% of can help prioritize patients during triage and guide visits in Korea and Malaysia and 25% of visits in the initial therapy, were not measured or recorded in nearly USA [8, 21, 22]. The underrepresentation of trauma in one quarter of enrolled patients. Emphasis on obtaining our study may have been due to the presence of an vital signs should be included in all training for NGO-run trauma hospital near the study sites, which emergency care providers to improve management for might have received the bulk of trauma patients. The pediatric patients presenting for acute care. top chief complaints in our and other studies often have We also observed that respiratory complaints and infectious etiologies [23, 24]. While infections such as fever were the two most common complaints, yet pneumonia, diarrhea, and malaria are the leading diagnostic chest X-rays (CXR) were infrequently contributors to mortality in children under 5 years world- performed, even for admitted patients. Furthermore, wide, [25] infectious symptoms also account for a large despite the high prevalence of tuberculosis in Cambodia percentage of ambulatory care-sensitive conditions [26]. (817/100,000 population) relative to other countries in Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 6 of 9 Table 2 Diagnostics and interventions within 48 h in children Table 3 Outcomes and follow-up in children presenting presenting unscheduled at two Cambodian hospitals unscheduled at two Cambodian hospitals, July–August 2012 a, b b, c Diagnostic test No. (%) presenting No (%) admitted Outcome No. (%) presenting or intervention (n = 867) (n = 445) (n = 867) Diagnostic test Initial visit Any test 278 (32.1) 263 (59.1) Patient treated and released 403 (46.5) Laboratory test 270 (31.1) 259 (58.2) Patient transferred to another facility 8 (0.9) Diagnostic imaging 19 (2.2) 14 (3.2) Patient left hospital without being seen 4 (0.5) or against medical advice Diagnostic peritoneal 2 (0.2) 2 (0.5) lavage Patient died within 24 h of presentation 2 (0.2) Ultrasound scanning 1 (0.1) 1 (0.2) Patient admitted 445 (51.3) Medication administered Length of stay of patients admitted in days, 3(2–4) median (IQR) Any medication 707 (81.6) 343 (77.1) 48-h follow-up Analgesic 602 (69.4) 288 (64.7) (excluding aspirin) Patient followed up at 48 h 719 (82.9) c, d Antibiotic 412 (47.5) 172 (38.7) Patient remained functionally impaired 362 (50.3) Antiparasitic 62 (7.2) 7 (1.6) Patient seen by another healthcare 45 (5.6) provider after discharge Drug administered 29 (3.3) 18 (4.0) by nebulizer Patient died between 24 and 48 h 4 (0.6) Antimalarial 7 (0.8) 7 (1.6) 14-day follow-up Aspirin 3 (0.4) 0 Patient followed up at 14 days 649 (74.9) d, e Antituberculosis drug 1 (0.1) 0 Patient remained functionally impaired 44 (6.8) Other 255 (29.4) 94 (21.1) Patient seen by another healthcare 86 (13.3) provider after discharge Other interventions Patient died between 48 h and 14 days 1 (0.2) Any intervention other 380 (43.8) 356 (80.0) than medication Cumulative outcomes Intravenous fluids 353 (40.7) 345 (77.5) Patient had any surgical procedure 22 (3.4) Intravenous medication 42 (4.8) 41 (9.2) Cumulative mortality at 14 days 7 (1.1) IQR interquartile range Emergency cooling 35 (4.0) 35 (7.9) Number presenting and percentage, unless otherwise stated Oxygen therapy 33 (3.8) 29 (6.5) Includes only patients transferred to another facility without first being admitted and receiving care Oral hydration 29 (3.3) 19 (4.3) Percentage of the 719 patients followed up for 48 hours Wound closure 13 (1.5) 11 (2.5) Functional impairment was defined as significant pain, significant limitation in performing daily activities, confinement to bed, or a comatose state Urethral catheterization 6 (0.7) 6 (1.3) e Percentage of the 649 patients followed up for 14 days Gastric decontamination 6 (0.7) 6 (1.3) Dental procedures 4 (0.5) 0 Finally, we observed a high admission rate (51.3%) Blood transfusion 3 (0.3) 2 (0.4) compared to other published pediatric studies (15–35%) Endotrachial intubation 3 (0.3) 3 (0.7) [8, 19, 20]. Sinceour 48-h mortalityrate, amarkerof Categories may sum to more than 100% because some patients had more than patient severity, of 0.7%, was comparable to the 24-h one diagnostic test or intervention Overall, 26 (3.0%) patients did not undergo any diagnostic test or receive any mortality rate reported in other studies examining intervention and, for 82 (9.5%) of patients, no information on diagnostic tests or similar patient populations, it is likely that a portion interventions was collected of the admitted patients did not require inpatient care Overall, four (0.9%) admitted patients did not undergo any diagnostic test or receive any intervention and, for 49 (11.0%) patients, no information on diagnostic [20, 27]. Inappropriate admissions unnecessarily consume tests or interventions was collected healthcare resources and place patients at increased risk for hospital-acquired infections, a known hazard in the South-East Asia Region [30], only one patient received LMICs [31]. Such a high admission rate coupled with a treatment for tuberculosis. These findings indicate relatively low mortality rate reinforces the need for a more that further studies are needed to assess the diagnostic organized emergency and acute care system in which evaluation among children with respiratory complaints to providers are equipped to rapidly initiate diagnostic ensure that tuberculosis and other respiratory illnesses are workup, provide timely treatment, and make informed recognized and adequately treated. decisions about patient disposition. Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 7 of 9 Fig. 2 Presentation of children with specific chief complaints. a Skin-related chief complaints without fever complaint. b Chief complaint of fever without skin-related complaint. c Both skin-related and fever chief complaint. d All other chief complaints other than skin-related or fever. Patients who presented during weekends are not included, due to low weekend enrollment Our study found a high frequency of skin complaints to hospitals in Cambodia. This paper builds on previous and fever among enrolled patients relative to other work characterizing the unscheduled adult population studies. This was likely associated with the concurrent, and finds important differences. Since pediatric pa- widely publicized outbreak of a severe strain of entero- tients have a different spectrum and frequency of chief virus, EV-71. Symptoms included fever, rash or blisters complaints from adults in emergency care settings, this inside the mouth and on the hands and feet, and, in paper finds a need for both dedicated research into the severe cases, encephalitis and respiratory distress [32]. In unique presentations of children and specific training mid-July 2012, the Cambodian Ministry of Health for medical professionals for emergency pediatric care. organized public education campaigns on symptoms of For next steps, results presented here can help inform EV-71, recommending medical care for children with the development of chief complaint-oriented training severe symptoms [33, 34]. The increase in patient visits modules for medical providers who will staff newly during the outbreak, particularly during the peak stretch founded emergency departments in Cambodia and from 14 July 2012 to 25 July 2012, suggests that these similar settings. Results may also be useful to Cambodian campaigns effectively increased health-seeking behavior hospital administrators and public health officials to among patients with relevant symptoms. further inform resource allocation for patient care, for example, by ensuring hospitals have sufficient equipment Limitations for measuring vital signs or investing in the implementa- Key limitations of this study included inability to capture tion of a triage system. In addition, some specific results seasonal variations in illness patterns during the 4-week from this study may also serve as baseline metrics for study period or regional variation due to the close patient outcomes—including admission rate, morbidity, proximity of study hospitals to one another, the likely and mortality—against which progress can be measured impact of the concurrent outbreak of EV-71, and lack of as emergency medicine matures as a distinct specialty and data collected on weekends and overnight. As stated practice in Cambodia and other LMICs. above, the low frequency of trauma complaints at our study sites may be due to a nearby NGO-run hospital, Additional files and, therefore, is not generalizable across Cambodia. Additional file 1: Figure S1. Chief complaints. All chief complaints reported by patients were coded by researchers as one of the complaints Conclusions listed. (PDF 1287 kb) As far as we know, this is the first paper to report on the Additional file 2: Table S1. Criteria for abnormal vital signs. (PDF 171 kb) epidemiology of pediatric patients presenting unscheduled Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 8 of 9 Abbreviations Received: 1 September 2017 Accepted: 15 February 2018 BP: Blood pressure; BPH: Battambang Provincial Hospital; DALYs: Disability-adjusted life years; ED: Emergency department; HR: Heart rate; LMICs: Low- and middle-income countries; References REDCap: Research Electronic Data Capture; RR: Respiratory rate; 1. Kobusingye OC, Hyder AA, Bishai D, et al. Chapter 68: emergency medical SMPV: Sampov Meas Provincial Hospital; WHO: World Health Organization services. In: Jamison DT, Breman JG, Measham AR, et al, editors. Disease control priorities in developing countries. Second ed. New York, NY: Oxford Acknowledgements University Press; 2006. p.1261-1280. We thank Phan Chamroen, Van Chamroeun, Chan Dara, 2. Heuveline P. ‘Between one and three million’: towards the demographic Sam Ol Vichet, Liong Sao, Soy Serey, Chuum Sophea, and Ou Souvichet, reconstruction of a decade of Cambodian history (1970-79). Popul Stud who provided language interpretation and assisted with the data collection. (Camb). 1998;52:49–65. We also thank Anne Tecklenburg Strehlow for her comments on the 3. Heng MB, Key PJ. Cambodian health in transition. BMJ. 1995;311:435–7. manuscript and Andrew Martin for his technical support. We are grateful to 4. Mowafi H, Dworkis D, Bisanzo M, et al. Making recording and analysis of the staff of the Battambang and Sampov Meas provincial hospitals who chief complaint a priority for global emergency care research in low-income provided guidance on study logistics. Last but not least, we acknowledge with countries. Acad Emerg Med. 2013;20:1241–5. gratitude all of the patients and families who participated. 5. Yan LD, Mahadevan SV, Yore M, et al. An observational study of adults seeking emergency care in Cambodia. Bull World Health Organ. 2015;93:84–92. Funding 6. Goh AY, Chan TL, Abdel-Latiff ME. Paediatric utilization of a general We obtained funding through the Stanford MedScholars Program and emergency department in a developing country. Acta Paediatr. United States Agency for International Development under the Better 2003;92:965–9. Health Services project (Cooperative agreement no. 442-A-00–09–00007–00; 7. Nawar EW, Niska RW, National Hospital XJ. Ambulatory medical care survey: http://www.urc-chs.com/projects/better-health-services-bhs). 2005 emergency department summary. Advance data from vital and health statistics; no. 386. Hyattsville, MD: National Center for Health Statistics; 2007. 8. Kwak YH, Kim do K, Jang HY. Utilization of emergency department by Availability of data and materials children in Korea. J Korean Med Sci. 2012;27:1222–8. Original data are stored in Dryad (DOI https://doi.org/10.5061/dryad.7v8c4) 9. National hospital ambulatory medical care survey: 2011 emergency and will be made publicly available upon publication. department summary tables. 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Annual Health Statistics Report 2012. Phnom Penh: Department of Planning and Health Information, Ministry of Health Cambodia. 2012 Competing interests http://www.hiscambodia.org/public/fileupload/Annual_Statistic_2012.pdf. The authors declare that they have no competing interests. Accessed 4 Mar 2016. 18. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for Publisher’sNote providing translational research informatics support. J Biomed Inform. Springer Nature remains neutral with regard to jurisdictional claims in 2009;42:377–81. published maps and institutional affiliations. 19. Bazaraa HM, El Houchi S, Rady HI. Profile of patients visiting the pediatric emergency service in an Egyptian university hospital. Pediatr Emerg Care. Author details 2012;28:148–52. Department of Emergency Medicine, UCSF Fresno Center for Medical 20. Salaria M, Singhi SC. Profile of patients attending pediatric emergency Education and Research, 155 N Fresno St, Fresno, CA 93701, USA. service at Chandigarh. Indian J Pediatr. 2003;70:621–4. Department of Emergency Medicine, Stanford University School of 21. Goh AY, Abdel-Latif M, Lum LC, Abu-Bakar MN. Outcome of children with Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA. Department of different accessibility to tertiary pediatric intensive care in a developing Internal Medicine, Boston University Medical Center, Boston, MA, USA. country—a prospective cohort study. Intensive Care Med. 2003;29:97–102. 4 5 USAID Central Asia, Almaty, Kazakhstan. University Research Co., LLC, 22. Rasooly IR, Mullins PM, Alpern ER, et al. US emergency department use by Centre for Human Services, Phnom Penh, Cambodia. GIZ-Social Health children, 2001-2010. Pediatr Emerg Care. 2014;30:602–7. Protection Program Cambodia, Phnom Penh, Cambodia. University of 23. Oguonu T, Adaeze Ayuk C, et al. 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Accessed 12 Aug 2015. 33. Biswas T. Enterovirus 71 causes hand, foot and mouth disease outbreak in Cambodia. Natl Med J India. 2012;25:316. 34. Seiff A. Cambodia unravels cause of mystery illness. Lancet. 2012;380:206. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Emergency Medicine Springer Journals

Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals without appointments: an observational study

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Springer Journals
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Copyright © 2018 by The Author(s).
Subject
Medicine & Public Health; Emergency Medicine; Pediatrics; Internal Medicine; Angiology; Cardiology
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1865-1372
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1865-1380
DOI
10.1186/s12245-018-0172-0
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Abstract

Background: Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals. Methods: Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission. Results: This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever. Conclusions: While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission. Keywords: Chief complaints, Developing countries, Emergency medicine, Health systems, Pediatrics Background suffers residual effects of the Khmer Rouge regime of the In low- and middle-income countries (LMICs), an estimated 1970s, during which violence, famine, and preventable 45% of all deaths and 36% of disability-adjusted life years disease killed approximately two million people and (DALYs) are due to diseases and injuries typically addressed completely dismantled the healthcare infrastructure [2, 3]. by emergency medical services that are currently lacking in Developing emergency medicine in LMICs requires these regions [1]. Among these countries is Cambodia, a a great deal of specialized training for providers. lower middle-income nation in Southeast Asia which still Characterizing the potential emergency department population in LMICs is an important step in creating relevant training for future emergency clinicians. * Correspondence: mackensie.yore@gmail.com Department of Emergency Medicine, UCSF Fresno Center for Medical Understanding the distribution of chief complaints focuses Education and Research, 155 N Fresno St, Fresno, CA 93701, USA provider education on symptoms with the highest burden Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 2 of 9 of morbidity and mortality, thereby helping emergency hospital’s combined ED/ICU managed patients in serious care providers more effectively evaluate and manage condition, while patients with milder presentations patients [4]. Despite the importance of this information, presented elsewhere. At both facilities, study enroll- the 2013 Academic Emergency Medicine Consensus ment was hospital wide. Conference found insufficient data on chief complaints for most LMICs [4]. Helping address this knowledge gap, our group previously documented the epidemiology Selection of participants and outcomes of adult patients presenting for unsched- Pediatric patients (< 18 years) presenting without prior uled visits to public hospitals in Cambodia [5]; no appointments during the 4 weeks in July and August studies, however, have thus examined an analogous 2012 were invited to enroll; patients presenting for pediatric population in this setting. routine check-ups and vaccinations without appointment Pediatric patients account for 20–35% of all emergency were excluded. Repeat unscheduled visits were considered department (ED) visits globally [6–8]. Moreover, separate visits. Most enrollment occurred weekdays, 08:00 children present with a unique distribution of chief to 17:00, times of day with highest patient volume. complaints compared to adults and require different Patients presented infrequently during evening and clinical management [7, 9]. To address the specific weekend hours when hospital staffing was limited. needs of children presenting to EDs in LMICs, the Afterhours visits were included if the patient remained World Health Organization (WHO) developed guide- at the hospital the following morning. lines for the care of children with traumatic injuries and acute illnesses in resource-limited settings; however, limited training for diagnosing and treating Methods and measurements urgent medical conditions poses challenges to guideline A team at each site gathered real-time clinical and adherence, which may contribute to preventable mor- demographic data using Research Electronic Data bidity and mortality in LMICs [10–15]. The recently Capture (REDCap) forms [18]. Demographic information announced United Nations Sustainable Development and up to three chief complaints were obtained from Goals includes a call to reduce preventable mortality patients, guardians, and staff. A list of all chief complaints among children; strengthening pediatric emergency is included in the supplemental material (Additional file 1: care capacity in LMICs could help achieve this goal. Figure S1). Hospital records provided vital signs at The present study was conducted to identify the presentation, diagnostic tests, treatment interventions, characteristics, chief complaints, management, and disposition, and discharge dates. Two members of the outcomes of children presenting for unscheduled research team reviewed records for completeness and visits to two public referral hospitals in Cambodia in inconsistencies, which were addressed through repeat order to focus training to improve future care. interviews and hospital record reviews. Follow-up interviews with patients or their guardians were conducted in Khmer (the local language) at 48 h and 14 days following the initial Methods visit. Follow-up interviews were in-person if the patient Study design and setting remained hospitalized, or by telephone if discharged, We performed a 4-week prospective, cross-sectional and assessed patient location, survival, and functional study of unscheduled visits to two government provincial status. Patients were considered lost to follow-up after referral hospitals in Cambodia: Sampov Meas Provincial three failed contact attempts on successive days. Hospital (SMPH) and Battambang Provincial Hospital (BPH). SMPH and BPH are “CPA Level 3,” indicating that obstetric, emergency, and surgical services should be Outcome measures available [16]. SMPH has 162 inpatient beds and recorded Primary outcomes included admission, functional impair- 9722 visits in 2012, leading to 6564 admissions. BPH has ment, and mortality. Patients are typically treated for 220 inpatient beds and recorded 40,825 visits and 14,108 their entire hospital stay in the department where admissions in 2012 [17]. they initially presented, regardless of appropriateness; The level of emergency care offered at these two therefore, included interventions were limited to those hospitals was similar to that at other Cambodian provin- completed within the first 48 h of initial presentation, cial hospitals at the time of the study. Neither hospital thus identifying services most representative of a standard had an active triage system, and BPH had no ED, with ED setting. Patients staying overnight were considered patients presenting to a variety of departments for treat- admitted. Functional impairment was defined as con- ment. At BPH, most pediatric patients seeking urgent tinued hospitalization, significant pain or limitation in care came directly to the pediatric ward. At SMPH, the performing daily activities, bed confinement, or coma. Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 3 of 9 Data analysis Patient presentations and management Because a complete set of vital signs was not consist- For the 867 pediatric patients enrolled, 1615 total chief ently documented at participating hospitals, records with complaints were recorded, 35 of them distinct. Fever data missing for respiratory rate (RR), blood pressure was the most common chief complaint (62.5% of patients; (BP), or heart rate (HR) were included in multivariate 33.6% of complaints), followed by respiratory problems, analyses with absent values assumed normal. Records skin-related complaints, vomiting, and abdominal pain with missing values for all other independent variables (Fig. 1). Injury represented 2.8% of complaints (Fig. 1). were excluded from modeling. Sensitivity analysis showed Chief complaints of abdominal pain and fever resulted in no significant differences in predictors of admission with a significantly higher admission rate (p ≤ 0.05), while the conversion of missing vital signs to normal in respiratory problems and skin complaints correlated multivariate analysis. with lower admission rates (p ≤ 0.01). Of the seven Comparisons between outcomes for continuous deaths, chief complaints included respiratory problems variables were conducted using Wilcoxon two sample (3 children), vomiting (3), fever (2), unconsciousness (1), T test, while the chi-square test was used for categorical convulsions/seizures (1), genital bleeding (1), and other (1). variables. A multivariate logistic regression was built for Approximately one quarter of all patient records the primary outcome of admission using predictors lacked vital sign data (Table 1). Patients treated and identified through univariate analysis, controlling for age released were less likely to have vital signs recorded than and gender; stepwise methods were not used. Statistical those admitted (p ≤ 0.05). Abnormal vital signs were analysis was completed using SAS Enterprise Guide for more frequent in admitted patients than those treated Windows, version 4.3 (SAS Institute Inc. Cary, NC). and released (p ≤ 0.05); similarly, admitted patients were more likely to present with pain (p ≤ 0.05). One third of patients received any diagnostic testing, Ethical considerations with laboratory tests being the most common (Table 2). We obtained verbal informed consent from patient Imaging, including chest X-ray, and other diagnostics were guardians or patients themselves if unaccompanied performed on less than 3% of patients (Table 2). The most and at least 16 years old. In-person, native-speaking common intervention within the first 48 h was medication translators obtained consent and conducted interviews therapy, administered to 81.6% of patients (Table 2). in Khmer. Intravenous fluids were provided to 40.7% of patients. All The Institutional Review Boards at Stanford University other interventions were infrequent, each received by less School of Medicine (IRB-24735) and the Cambodian than 5% of patients (Table 2). Ministry of Health approved this study. Patient disposition and outcomes The rate of admission was 51.3%, with a 3-day median Availability of data and materials length of stay (Table 3). Less than 1% of patients were The dataset supporting the conclusions of this article is transferred to an outside facility or left the hospital prior available in the Dryad repository, https://doi.org/10.5061/ to being seen or against medical advice (Table 3). dryad.7v8c4. Twenty-two patients (3.1%) were referred to surgery, 81.8% of whom were admitted. Results Follow-up rates were 82.9 and 74.9% at 48 h and Demographic characteristics 14 days, respectively (Table 3). Seven deaths were This 4-week study documented 867 unscheduled pediatric documented, for a 1.1% overall 14-day mortality (Table 3). patient visits. Mean patient age was 5.7 years with Two of the seven deaths occurred within 24 h of presenta- approximately half (54.3%) being male (Table 1). Private tion; the rest occurred after admission, one of whom died vehicles were the predominant mode of transport to after discharge. No deaths were documented in patients the hospitals, with nearly 90% of patients arriving via who were treated and released. motorbike, taxi, or tuk-tuk (motorized three-wheeled Morbidity was measured by asking patients or guardians rickshaw for hire); arrival by ambulance was infre- whether the patient had returned to baseline functioning. quent (2.9%). More than 69.9% of patients presented By 40 h and 14 days post-visit, 49.7 and 93.2% of patients, to the hospital with sudden (< 24 h) or recent (1–3days) respectively, had returned to baseline functioning (Table 3). symptoms (Table 1). About one quarter of patients were either transferred directly from another health- Admission multivariate logistic regression model care facility, typically a health center, or referred by A multivariate logistic regression model showed increased an outside medical provider (e.g., a practitioner private admission risk was associated with referral from another clinic) (Table 1). health provider (OR = 4.3, CI 2.4–7.8), direct transfer from Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 4 of 9 Table 1 Pediatric patients presenting unscheduled at two Table 1 Pediatric patients presenting unscheduled at two Cambodian hospitals, July–August 2012 Cambodian hospitals, July–August 2012 (Continued) Characteristic No. (%) of Characteristic No. (%) of a, b a, b patients patients All patients 867 Time before seeking any medical care Demographic characteristic Median time before seeking care in days (IQR) 1.5 (0.6–3) Site of presentation < = 24 h 339 (39.1) Battambang Provincial Hospital 550 (63.4) > 24 h 505 (58.3) Sampov Meas Provincial Hospital 317 (36.6) Examination findings Age Respiratory rate, blood pressure, and heart rate Age in years, mean (SD) 5.65 (4.8) Abnormal respiratory rate, blood pressure, 405 (46.7) or heart rate Infant (< 1 year) 136 (15.7) Abnormal respiratory rate 224 (25.8) Young child (1–5 years) 374 (43.1) Abnormal blood pressure 153 (17.6) Child (6–10 years) 182 (21.0) Abnormal heart rate 217 (25.0) Older child (11–13 years) 98 (11.3) Respiratory rate, blood pressure, 216 (24.9) Teen (14–17 years) 77 (8.9) or heart rate not recorded Gender Temperature Female 396 (45.7) Low temperature (< 36 °C) 80 (9.2) Male 471 (54.3) High temperature (> 38 °C) 153 (17.7) Socioeconomic characteristic Temperature not recorded 213 (24.6) Patient had low-income health insurance 444 (51.2) Pain Travel to hospital Pain documented as present 254 (29.3) Time IQR interquartile range, SD standard deviation Number of patients and percentages, unless otherwise stated Time in hours, median (IQR) 0.5 (0.3–1.0) Due to missing values for individual patients, not all categories sum to 100% Time < 0.5 h 482 (55.6) Except for more affluent patients who had private health insurance, most patients paid in cash Time 0.5–2 h 326 (37.6) See Additional file 2: Table S2 for age-appropriate vital signs used Time > 2 h 52 (6.0) Distance another health provider (OR = 7.8, CI 4.7–13.0), low- Distance in kilometers, median (IQR) 10 (3.0–30.0) income health insurance (proxy for low socioeconomic Presentation status) (OR = 1.5, CI 1.1–2.1), seeking care prior to 48 h before presentation without transfer/referral (OR = 2.4, Time of arrival 95% CI 1.–4.5), seeking care within 48 h of presentation Daytime Monday to Friday (i.e., 07.00–17.00) 765 (88.2) without transfer/referral (OR = 2.5, CI 1.4–4.5), symptom Overnight Sunday to Friday (i.e., 17.00–07.00) 68 (7.8) onset within 24 h of seeking care (2.1, CI 1.5–3.1), Weekend (i.e., Friday 17.00 to Sunday 17.00) 34 (3.9) abnormal temperature (OR = 1.5, CI 1.0–2.2), abnormal Care before presentation heart rate, respiratory rate, and/or blood pressure Transferred from another healthcare facility 163 (18.8) (OR = 3.2, CI 2.3–4.6), and chief complaint of abdominal pain (OR = 2.9; 95% CI 1.7–5.0) or fever (OR = 1.4, Referred by an external medical provider 81 (9.3) CI 1.0–2.0); a decreased risk of admission was Prior care of those not transferred or referred associated with skin-related chief complaints (OR = 0.4; Prior care received in the previous 48 h 79 (9.1) CI 0.2–0.5), such as rashes or blisters, and respiratory Prior care received more than 48 h earlier 65 (7.5) problems (OR = 0.4; CI 0.3–0.6), such as cough (n =793; No prior care 468 (54.0) c-statistic = 0.81). Symptom duration Sudden (< 24 h) 266 (30.7) Dermatologic and fever complaints sub-analysis Recent (1–3 days) 340 (39.2) A country-wide outbreak of enterovirus strain EV-71 Sub-acute (4–14 days) 206 (23.8) occurred during the study. Qualitatively, many more Chronic (> 14 days) 49 (5.7) children than expected presented with fever and/or skin complaints, such as rash or blisters, which are common Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 5 of 9 Fig. 1 Chief complaints and initial actions for children presenting without appointment at two Cambodian hospitals. Only the top 15 chief complaints are displayed. A maximum of three chief complaints per patient were recorded. Includes data for July–August 2012 symptoms of EV-71. The number of patients presenting Of the top ten chief complaints identified in the with skin complaints and fever increased sharply during the present study, only half match the list of top complaints study period before gradually decreasing, coinciding with documented in an analogous population of adults [5]. timing of the EV-71 outbreak (Fig. 2). These results mirror data from EDs in the USA, which similarly show that the frequency and distribution of pediatric chief complaints differ markedly from adults [9]. Discussion The unique distribution and frequency of presentations in This study describes the characteristics, chief complaints, children with undifferentiated conditions compared to management, and health outcomes of children seeking adults in LMICs underscores the need for specialty unscheduled acute care at two public referral hospitals in training that specifically addresses pediatric emergencies. Cambodia. Our findings provide essential information to Regarding pre-hospital care, only 2.9% of patients in inform emergency care provider education and guide our study arrived by ambulance, compared to 15–17% in development of emergency care systems in Cambodia other studies in LMICs [27, 28]. Low frequency of and other LMICs. ambulance transport—despite more than one quarter of Top chief complaints in this study (fever, respiratory all unscheduled patients coming from another care problems, abdominal pain, vomiting, and diarrhea) are provider—reflects the relative underdevelopment of similar to other published reports characterizing un- Cambodia’s regional pre-hospital and EMS systems. scheduled or ED pediatric presentations in other LMICs Currently, laypeople provide most patient transfers [6, 8, 19, 20]. The top five chief complaints in our popu- in Cambodia. Low-cost, community-based interven- lation accounted for 75% of all reported complaints. In tions aimed at equipping laypeople with first aid contrast to several other studies, the percentage of ED skills and facilitating transport have shown promise visits attributed to trauma in this study (2.8%) was in South Africa [29]. substantially lower. For example, trauma among children Vital signs, which provide low-cost, objective data that presenting for emergency care accounted for 27–29% of can help prioritize patients during triage and guide visits in Korea and Malaysia and 25% of visits in the initial therapy, were not measured or recorded in nearly USA [8, 21, 22]. The underrepresentation of trauma in one quarter of enrolled patients. Emphasis on obtaining our study may have been due to the presence of an vital signs should be included in all training for NGO-run trauma hospital near the study sites, which emergency care providers to improve management for might have received the bulk of trauma patients. The pediatric patients presenting for acute care. top chief complaints in our and other studies often have We also observed that respiratory complaints and infectious etiologies [23, 24]. While infections such as fever were the two most common complaints, yet pneumonia, diarrhea, and malaria are the leading diagnostic chest X-rays (CXR) were infrequently contributors to mortality in children under 5 years world- performed, even for admitted patients. Furthermore, wide, [25] infectious symptoms also account for a large despite the high prevalence of tuberculosis in Cambodia percentage of ambulatory care-sensitive conditions [26]. (817/100,000 population) relative to other countries in Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 6 of 9 Table 2 Diagnostics and interventions within 48 h in children Table 3 Outcomes and follow-up in children presenting presenting unscheduled at two Cambodian hospitals unscheduled at two Cambodian hospitals, July–August 2012 a, b b, c Diagnostic test No. (%) presenting No (%) admitted Outcome No. (%) presenting or intervention (n = 867) (n = 445) (n = 867) Diagnostic test Initial visit Any test 278 (32.1) 263 (59.1) Patient treated and released 403 (46.5) Laboratory test 270 (31.1) 259 (58.2) Patient transferred to another facility 8 (0.9) Diagnostic imaging 19 (2.2) 14 (3.2) Patient left hospital without being seen 4 (0.5) or against medical advice Diagnostic peritoneal 2 (0.2) 2 (0.5) lavage Patient died within 24 h of presentation 2 (0.2) Ultrasound scanning 1 (0.1) 1 (0.2) Patient admitted 445 (51.3) Medication administered Length of stay of patients admitted in days, 3(2–4) median (IQR) Any medication 707 (81.6) 343 (77.1) 48-h follow-up Analgesic 602 (69.4) 288 (64.7) (excluding aspirin) Patient followed up at 48 h 719 (82.9) c, d Antibiotic 412 (47.5) 172 (38.7) Patient remained functionally impaired 362 (50.3) Antiparasitic 62 (7.2) 7 (1.6) Patient seen by another healthcare 45 (5.6) provider after discharge Drug administered 29 (3.3) 18 (4.0) by nebulizer Patient died between 24 and 48 h 4 (0.6) Antimalarial 7 (0.8) 7 (1.6) 14-day follow-up Aspirin 3 (0.4) 0 Patient followed up at 14 days 649 (74.9) d, e Antituberculosis drug 1 (0.1) 0 Patient remained functionally impaired 44 (6.8) Other 255 (29.4) 94 (21.1) Patient seen by another healthcare 86 (13.3) provider after discharge Other interventions Patient died between 48 h and 14 days 1 (0.2) Any intervention other 380 (43.8) 356 (80.0) than medication Cumulative outcomes Intravenous fluids 353 (40.7) 345 (77.5) Patient had any surgical procedure 22 (3.4) Intravenous medication 42 (4.8) 41 (9.2) Cumulative mortality at 14 days 7 (1.1) IQR interquartile range Emergency cooling 35 (4.0) 35 (7.9) Number presenting and percentage, unless otherwise stated Oxygen therapy 33 (3.8) 29 (6.5) Includes only patients transferred to another facility without first being admitted and receiving care Oral hydration 29 (3.3) 19 (4.3) Percentage of the 719 patients followed up for 48 hours Wound closure 13 (1.5) 11 (2.5) Functional impairment was defined as significant pain, significant limitation in performing daily activities, confinement to bed, or a comatose state Urethral catheterization 6 (0.7) 6 (1.3) e Percentage of the 649 patients followed up for 14 days Gastric decontamination 6 (0.7) 6 (1.3) Dental procedures 4 (0.5) 0 Finally, we observed a high admission rate (51.3%) Blood transfusion 3 (0.3) 2 (0.4) compared to other published pediatric studies (15–35%) Endotrachial intubation 3 (0.3) 3 (0.7) [8, 19, 20]. Sinceour 48-h mortalityrate, amarkerof Categories may sum to more than 100% because some patients had more than patient severity, of 0.7%, was comparable to the 24-h one diagnostic test or intervention Overall, 26 (3.0%) patients did not undergo any diagnostic test or receive any mortality rate reported in other studies examining intervention and, for 82 (9.5%) of patients, no information on diagnostic tests or similar patient populations, it is likely that a portion interventions was collected of the admitted patients did not require inpatient care Overall, four (0.9%) admitted patients did not undergo any diagnostic test or receive any intervention and, for 49 (11.0%) patients, no information on diagnostic [20, 27]. Inappropriate admissions unnecessarily consume tests or interventions was collected healthcare resources and place patients at increased risk for hospital-acquired infections, a known hazard in the South-East Asia Region [30], only one patient received LMICs [31]. Such a high admission rate coupled with a treatment for tuberculosis. These findings indicate relatively low mortality rate reinforces the need for a more that further studies are needed to assess the diagnostic organized emergency and acute care system in which evaluation among children with respiratory complaints to providers are equipped to rapidly initiate diagnostic ensure that tuberculosis and other respiratory illnesses are workup, provide timely treatment, and make informed recognized and adequately treated. decisions about patient disposition. Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 7 of 9 Fig. 2 Presentation of children with specific chief complaints. a Skin-related chief complaints without fever complaint. b Chief complaint of fever without skin-related complaint. c Both skin-related and fever chief complaint. d All other chief complaints other than skin-related or fever. Patients who presented during weekends are not included, due to low weekend enrollment Our study found a high frequency of skin complaints to hospitals in Cambodia. This paper builds on previous and fever among enrolled patients relative to other work characterizing the unscheduled adult population studies. This was likely associated with the concurrent, and finds important differences. Since pediatric pa- widely publicized outbreak of a severe strain of entero- tients have a different spectrum and frequency of chief virus, EV-71. Symptoms included fever, rash or blisters complaints from adults in emergency care settings, this inside the mouth and on the hands and feet, and, in paper finds a need for both dedicated research into the severe cases, encephalitis and respiratory distress [32]. In unique presentations of children and specific training mid-July 2012, the Cambodian Ministry of Health for medical professionals for emergency pediatric care. organized public education campaigns on symptoms of For next steps, results presented here can help inform EV-71, recommending medical care for children with the development of chief complaint-oriented training severe symptoms [33, 34]. The increase in patient visits modules for medical providers who will staff newly during the outbreak, particularly during the peak stretch founded emergency departments in Cambodia and from 14 July 2012 to 25 July 2012, suggests that these similar settings. Results may also be useful to Cambodian campaigns effectively increased health-seeking behavior hospital administrators and public health officials to among patients with relevant symptoms. further inform resource allocation for patient care, for example, by ensuring hospitals have sufficient equipment Limitations for measuring vital signs or investing in the implementa- Key limitations of this study included inability to capture tion of a triage system. In addition, some specific results seasonal variations in illness patterns during the 4-week from this study may also serve as baseline metrics for study period or regional variation due to the close patient outcomes—including admission rate, morbidity, proximity of study hospitals to one another, the likely and mortality—against which progress can be measured impact of the concurrent outbreak of EV-71, and lack of as emergency medicine matures as a distinct specialty and data collected on weekends and overnight. As stated practice in Cambodia and other LMICs. above, the low frequency of trauma complaints at our study sites may be due to a nearby NGO-run hospital, Additional files and, therefore, is not generalizable across Cambodia. Additional file 1: Figure S1. Chief complaints. All chief complaints reported by patients were coded by researchers as one of the complaints Conclusions listed. (PDF 1287 kb) As far as we know, this is the first paper to report on the Additional file 2: Table S1. Criteria for abnormal vital signs. (PDF 171 kb) epidemiology of pediatric patients presenting unscheduled Yore et al. International Journal of Emergency Medicine (2018) 11:17 Page 8 of 9 Abbreviations Received: 1 September 2017 Accepted: 15 February 2018 BP: Blood pressure; BPH: Battambang Provincial Hospital; DALYs: Disability-adjusted life years; ED: Emergency department; HR: Heart rate; LMICs: Low- and middle-income countries; References REDCap: Research Electronic Data Capture; RR: Respiratory rate; 1. Kobusingye OC, Hyder AA, Bishai D, et al. Chapter 68: emergency medical SMPV: Sampov Meas Provincial Hospital; WHO: World Health Organization services. In: Jamison DT, Breman JG, Measham AR, et al, editors. Disease control priorities in developing countries. Second ed. New York, NY: Oxford Acknowledgements University Press; 2006. p.1261-1280. We thank Phan Chamroen, Van Chamroeun, Chan Dara, 2. Heuveline P. ‘Between one and three million’: towards the demographic Sam Ol Vichet, Liong Sao, Soy Serey, Chuum Sophea, and Ou Souvichet, reconstruction of a decade of Cambodian history (1970-79). 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Published: Mar 13, 2018

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