Transforming the delivery of care from "I" to "We" by developing the crisis resource management skills in pediatric interprofessional teams to handle common emergencies through simulation.

BACKGROUND: The healthcare system is highly complex, and adverse events often result from a combination of human factors and system failures, especially in crisis situations. Crisis resource management skills are crucial to optimize team performance and patient outcomes in such situations. Simulation-based training offers a promising approach to developing such skills in a controlled and realistic environment. METHODS: This study employed a mixed-methods (quantitative-qualitative) design and aimed to assess the effectiveness of a simulation-based training workshop in developing crisis resource management skills in pediatric interprofessional teams at a tertiary care hospital. The effectiveness of the intervention was evaluated using Kirkpatrick's Model, focusing on reaction and learning levels, employing the Collaboration and Satisfaction about Care Decisions scale, Clinical Teamwork Scale, and Ottawa Global Rating Scale for pre- and post-intervention assessments. Focused group discussions were conducted with the participants to explore their experiences and perceptions of the training. RESULTS: Thirty-nine participants, including medical students, nurses, and residents, participated in the study. Compared to the participants' pre-workshop performance, significant improvements were observed across all measured teamwork and performance components after the workshop, including improvement in scores in team communication (3.16 ± 1.20 to 7.61 ± 1.0, p < 0.001), decision-making (3.50 ± 1.54 to 7.16 ± 1.42, p < 0.001), leadership skills (2.50 ± 1.04 to 5.44 ± 0.6, p < 0.001), and situation awareness (2.61 ± 1.13 to 5.22 ± 0.80, p < 0.001). No significant variations were observed post-intervention among the different teams. Additionally, participants reported high levels of satisfaction, perceived the training to be highly valuable in improving their crisis resource management skills, and emphasized the importance of role allocation and debriefing. CONCLUSIONS: The study underscores the effectiveness of simulation-based training in developing crisis resource management skills in pediatric interprofessional teams. The findings suggest that such training can impact learning transfer to the workplace and ultimately improve patient outcomes. The insights from our study offer additional valuable considerations for the ongoing refinement of simulation-based training programs. There is a need to develop more comprehensive clinical skills evaluation methods to better assess the transferability of these skills in real-world settings. The potential challenges unveiled in our study, such as physical exhaustion during training, must be considered when refining and designing such interventions.

Exploring the Long-Term Disability Outcomes in Trauma Patients: Study Protocol.

Objectives: Post-discharge patient-reported outcomes from trauma registries can be used to measure trauma care quality. However, studies reflecting the Asian experience are limited. Therefore, we aim to develop a digital trauma registry to prospectively capture patient-reported outcomes (PROs) at one-, three-, six-, and twelve-months post-injury in Pakistan. Methods: We will use a cohort study design to develop a digital trauma registry at two tertiary care facilities (Aga Khan University Hospital & Jinnah Postgraduate Medical Center) in Karachi, Pakistan. The registry will include all admitted adult trauma patients (≥18 years). Data collection will be digital using tablets, with mortality, level of disability, and functional status, quality of life being the outcomes. Telephonic interviews will be conducted with the patients and caregivers for follow-up data collection. Discussion: The high disability burden following accidental trauma imposes a significant burden and cost on individuals and society. Therefore, the trauma registry would fill this gap by capturing post-discharge long-term PROs. It will provide the injured patient's post-discharge situation, challenges, and future directions for incorporating long-term PROs in low-resource settings. Including long-term measures in routine follow-ups will provide insights into physical, social, and policy barriers and help advance injury care research.

Methodological analysis of a community-based training initiative using the EPIS framework: an ongoing initiative to empower 10 million bystanders in CPR and bleeding control.

Background: Out-of-hospital cardiac arrest (OHCA) and life-threatening bleeding from trauma are leading causes of preventable mortality globally. Early intervention from bystanders can play a pivotal role in increasing the survival rate of victims. While great efforts for bystander training have yielded positive results in high-income countries, the same has not been replicated in low and middle-income countries (LMICs) due to resources constraints. This article describes a replicable implementation model of a nationwide program, aimed at empowering 10 million bystanders with basic knowledge and skills of hands-only cardiopulmonary resuscitation (CPR) and bleeding control in a resource-limited setting. Methods: Using the EPIS (Exploration, Preparation, Implementation and Sustainment) framework, we describe the application of a national bystander training program, named 'Pakistan Life Savers Programme (PLSP)', in an LMIC. We discuss the opportunities and challenges faced during each phase of the program's implementation and identify feasible and sustainable actions to make them reproducible in similar low-resource settings. Results: A high mortality rate owing to OHCA and traumatic life-threatening bleeding was identified as a national issue in Pakistan. After intensive discussions during the exploration phase, PLSP was chosen as a potential solution. The preparation phase oversaw the logistical administration of the program and highlighted avenues using minimal resources to attain maximum outreach. National implementation of bystander training started as a pilot in suburban schools and expanded to other institutions, with 127 833 bystanders trained to date. Sustainability of the program was targeted through its addition in a single national curriculum taught in schools and the development of a cohesive collaborative network with entities sharing similar goals. Conclusion: This article provides a methodological framework of implementing a national intervention based on bystander response. Such programs can increase bystander willingness and confidence in performing CPR and bleeding control, decreasing preventable deaths in countries having a high mortality burden. Level of evidence: Level VI.

Which curve is better? A comparative analysis of trauma scoring systems in a South Asian country.

Objectives: A diverse set of trauma scoring systems are used globally to predict outcomes and benchmark trauma systems. There is a significant potential benefit of using these scores in low and middle-income countries (LMICs); however, its standardized use based on type of injury is still limited. Our objective is to compare trauma scoring systems between neurotrauma and polytrauma patients to identify the better predictor of mortality in low-resource settings. Methods: Data were extracted from a digital, multicenter trauma registry implemented in South Asia for a secondary analysis. Adult patients (≥18 years) presenting with a traumatic injury from December 2021 to December 2022 were included in this study. Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), Mechanism/GCS/Age/Pressure score and GCS/Age/Pressure score were calculated for each patient to predict in-hospital mortality. We used receiver operating characteristic curves to derive sensitivity, specificity and area under the curve (AUC) for each score, including Glasgow Coma Scale (GCS). Results: The mean age of 2007 patients included in this study was 41.2±17.8 years, with 49.1% patients presenting with neurotrauma. The overall in-hospital mortality rate was 17.2%. GCS and RTS proved to be the best predictors of in-hospital mortality for neurotrauma (AUC: 0.885 and 0.874, respectively), while TRISS and ISS were better predictors for polytrauma patients (AUC: 0.729 and 0.722, respectively). Conclusion: Trauma scoring systems show differing predictability for in-hospital mortality depending on the type of trauma. Therefore, it is vital to take into account the region of body injury for provision of quality trauma care. Furthermore, context-specific and injury-specific use of these scores in LMICs can enable strengthening of their trauma systems. Level of evidence: Level III.

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC.

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.

Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan.

OBJECTIVES: To evaluate nationwide pediatric critical care facilities and resources in Pakistan. DESIGN: Cross-sectional observational study. SETTING: Accredited pediatric training facilities in Pakistan. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring. CONCLUSIONS: There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.

Disparities in adult critical care resources across Pakistan: findings from a national survey and assessment using a novel scoring system.

BACKGROUND: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan's baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities. METHODS: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles. RESULTS: A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public-private and metropolitan-rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks. CONCLUSION: Pakistan has an underdeveloped critical care network with significant inequity between public-private and metropolitan-rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities.

Profile and outcomes of in-hospital cardiac arrest in a paediatric emergency department.

A retrospective study was conducted to determine the profile and outcome of patients who experienced in-hospital cardiac arrest (IHCA) in an emergency department (ED), from January to December 2017. Newborns of day one till children 14 years of age who suffered cardiac arrest during their stay in the ED of National Institute of Child Health, Karachi, Pakistan, were included in the study. The outcome variables were the return of spontaneous circulation and survival before final discharge from the ED. IHCA was observed in 935 (4.82%) out of the 19,385 children studied, while in 568 (61%) children spontaneous circulation was restored. Most of the patients who suffered IHCA were infants, i.e. 719 (77%). A significant association of return of spontaneous circulation and survival till final discharge from the ED was observed with age (p-value <0.001) and mode of arrival at the hospital (p-value <0.001). Thus, IHCA was reported in approximately five percent of patients and return of spontaneous circulation was reported in 61 percent.

The pediatric disease spectrum in emergency departments across Pakistan: data from a pilot surveillance system.

BACKGROUND: There is an increasing number of urgently ill and injured children being seen in emergency departments (ED) of developing countries. The pediatric disease burden in EDs across Pakistan is generally unknown. Our main objective was to determine the spectrum of disease and injury among children seen in EDs in Pakistan through a nationwide ED-based surveillance system. METHODS: Through the Pakistan National Emergency Department Surveillance (Pak-NEDS), data were collected from November 2010 to March 2011 in seven major tertiary care centers representing all provinces of Pakistan. These included five public and two private hospitals, with a collective annual census of over one million ED encounters. RESULTS: Of 25,052 children registered in Pak-NEDS (10% of all patients seen): 61% were male, 13% under 5 years, while almost 65% were between 10 to < 16 years. The majority (90%) were seen in public hospital EDs. About half the patients were discharged from the EDs, 9% admitted to hospitals and only 1.3% died in the EDs. Injury (39%) was the most common presenting complaint, followed by fever/malaise (19%) and gastrointestinal symptoms (18%). Injury was more likely in males vs. females (43% vs. 33%; p < 0.001), with a peak presentation in the 5-12 year age group (45%). CONCLUSIONS: Pediatric patients constitute a smaller proportion among general ED users in Pakistan. Injury is the most common presenting complaint for children seen in the ED. These data will help in resource allocation for cost effective pediatric ED service delivery systems. Prospective longer duration surveillance is needed in more representative pediatric EDs across Pakistan.

Frequency of retinopathy of prematurity in premature neonates with a birth weight below 1500 grams and a gestational age less than 32 weeks: a study from a tertiary care hospital in a lower-middle income country .

INTRODUCTION: Retinopathy of prematurity (ROP) is a treatable cause of blindness in neonates. In Pakistan, ROP is often not recognized early because screening and treatment programs are not yet in place in most neonatal units, even in tertiary care hospitals. It is hoped that this report will help inform medical professionals of the magnitude of the problem and help to design appropriate management strategies. OBJECTIVES: The aim was to determine the frequency of ROP in premature and very low birth weight (BW) neonates (BW<1500 g and gestational age (GA) <32 weeks). STUDY DESIGN: Cross-sectional study. STUDY SETTING: Neonatal intensive care unit (NICU) of a tertiary care hospital in Karachi, Pakistan. STUDY DURATION: From June 2009 to May 2010. SUBJECTS AND METHODS: Neonates with a Birth weight (BW) <1500 g and Gestational Age (GA) <32 weeks who were admitted to the NICU and received an eye examination, or were referred for a ROP eye examination as an outpatient, were included in the study. GA was estimated from intrauterine ultrasound findings. Neonates with major congenital malformations, syndromes or congenital cataracts or tumors of the eyes, and those that died before the eye examination or did not attend the out patients department for an eye examination, were excluded. The neonatal eye examination was performed by a trained ophthalmologist at 4 or 6 weeks of age. RESULTS: Out of 86 neonates, ROP was identified in nine neonates (10.5%) at the first eye examination. ROP was significantly associated with BW (P = 0.037), GA (P = 0.033), and chronological age (P<0.001). CONCLUSIONS: we identified ROP in 10.5% of neonates at first eye examination. Significant associations between ROP and a GA<32 weeks and a BW<1500 g were also observed.we also stress that serial follow-up of neonates at risk for ROP is important when making a final diagnosis.

Salmonella cholecystitis: atypical presentation of a typical condition.

Salmonella cholecystitis is a rare but important complication of Salmonella typhi infection. We are reporting an 11 years old female child who presented with complaints of high-grade fever, jaundice and right sided abdominal pain (Charcot's triad). Her examination showed tender hepatomegaly. Initial blood results revealed high white cell counts with left shift, deranged liver function tests. Abdominal ultrasonography revealed distended gallbladder with minimal layer of sludge seen within its lumen along with streak of pericholecystic fluid. Blood culture grew Salmonella typhi. She was successfully treated with intravenous ceftriaxone.

Incomplete Kawaski disease: are we missing it?

Kawasaki disease, also known as mucocutaneous lymph node syndrome or infantile polyarteritis nodosa is an acute febrile vasculitis of unknown etiology with a predilection for coronary arteries and potential for aneurysm formation. In Incomplete Kawasaki disease, children with fever lack the sufficient number of criteria to fulfill the epidemiologic case definition and are diagnosed when coronary artery disease is detected. We present a case report of a one and a half years old girl who came with features of incomplete Kawasaki disease, high grade fever, irritability, history of conjunctivitis and cracking of lips. She was investigated and had a platelet count of 902 x 10(9)/L, ESR was 71 mm/hr and CRP was also raised to 12.8 mg/l. Cardiac evaluation and echocardiography was done which showed dilated coronary arteries >3mm on the left side and 4mm on the right side with early aneurysmal changes. She was treated with immunoglobulin and aspirin and improved.