Bedside lung ultrasound for the diagnosis of pneumonia in children presenting to an emergency department in a resource-limited setting.

BACKGROUND: Lung ultrasound (LUS) is an effective tool for diagnosing pneumonia; however, this has not been well studied in resource-limited settings where pneumonia is the leading cause of death in children under 5 years of age. OBJECTIVE: The objective of this study was to evaluate the diagnostic accuracy of bedside LUS for diagnosis of pneumonia in children presenting to an emergency department (ED) in a resource-limited setting. METHODS: This was a prospective cross-sectional study of children presenting to an ED with respiratory complaints conducted in Nepal. We included all children under 5 years of age with cough, fever, or difficulty breathing who received a chest radiograph. A bedside LUS was performed and interpreted by the treating clinician on all children prior to chest radiograph. The criterion standard was radiographic pneumonia, diagnosed by a panel of radiologists using the Chest Radiography in Epidemiological Studies methodology. The primary outcome was sensitivity and specificity of LUS for the diagnosis of pneumonia. All LUS images were later reviewed and interpreted by a blinded expert sonographer. RESULTS: Three hundred and sixty-six children were enrolled in the study. The median age was 16.5 months (IQR 22) and 57.3% were male. Eighty-four patients (23%) were diagnosed with pneumonia by chest X-ray. Sensitivity, specificity, positive and negative likelihood ratios for clinician's LUS interpretation was 89.3% (95% CI 81-95), 86.1% (95%CI 82-90), 6.4, and 0.12 respectively. LUS demonstrated good diagnostic accuracy for pneumonia with an area under the curve of 0.88 (95% CI 0.83-0.92). Interrater agreement between clinician and expert ultrasound interpretation was excellent (k = 0.85). CONCLUSION: Bedside LUS when used by ED clinicians had good accuracy for diagnosis of pneumonia in children in a resource-limited setting.

Lung ultrasound training and evaluation for proficiency among physicians in a low-resource setting.

BACKGROUND: Lung ultrasound (LUS) is helpful for the evaluation of patients with dyspnea in the emergency department (ED). However, it remains unclear how much training and how many LUS examinations are needed for ED physicians to obtain proficiency. The objective of this study was to determine the threshold number of LUS physicians need to perform to achieve proficiency for interpreting LUS on ED patients with dyspnea. METHODS: A prospective study was performed at Patan Hospital in Nepal, evaluating proficiency of physicians novice to LUS. After eight hours of didactics and hands-on training, physicians independently performed and interpreted ultrasounds on patients presenting to the ED with dyspnea. An expert sonographer blinded to patient data and LUS interpretation reviewed images and provided an expert interpretation. Interobserver agreement was performed between the study physician and expert physician interpretation. Cumulative sum analysis was used to determine the number of scans required to attain an acceptable level of training. RESULTS: Nineteen physicians were included in the study, submitting 330 LUS examinations with 3288 lung zones. Eighteen physicians (95%) reached proficiency. Physicians reached proficiency for interpreting LUS accurately when compared to an expert after 4.4 (SD 2.2) LUS studies for individual zone interpretation and 4.8 (SD 2.3) studies for overall interpretation, respectively. CONCLUSIONS: Following 1 day of training, the majority of physicians novice to LUS achieved proficiency with interpretation of lung ultrasound after less than five ultrasound examinations performed independently.

Prospective evaluation of World Health Organization guidelines for diagnosis of pneumonia in children presenting to an emergency department in a resource-limited setting.

BACKGROUND: Clinicians in resource-limited settings commonly use the World Health Organization criteria to diagnose pneumonia in children. AIM: The aim of this study was to prospectively evaluate the diagnostic accuracy of the WHO criteria compared with chest radiograph for the diagnosis of pneumonia in children under 5 years of age presenting to an emergency department (ED) in Nepal. METHODS: A prospective cross-sectional study of children presenting to an ED with respiratory complaints in Nepal was conducted. It included all children under 5 years of age with cough or difficulty breathing who received a chest radiograph. Paediatric pneumonia was diagnosed according to WHO criteria when a child presented with a cough or difficulty breathing and met the age-related WHO-defined respiratory rate for tachypnoea. The criterion standard was radiographic pneumonia. The primary outcome was the sensitivity and specificity of the WHO criteria for diagnosis of pneumonia. RESULTS: Of 324 patients enrolled, 72 had radiographic pneumonia. The median (IQR) age was 17 (23) months. Overall, WHO criteria had a sensitivity of 71% (95% CI 59-81) and specificity of 57% (95% CI 50-63). Respiratory rate had poor diagnostic accuracy for pneumonia with an area under the curve of 0.65. CONCLUSION: The WHO criteria had poor sensitivity and specificity for the diagnosis of pneumonia in children presenting to the ED in a resource-limited setting.

Establishing a Low-Resource Simulation Emergency Medicine Curriculum in Nepal.

Introduction: High-fidelity medical simulation is widely used in emergency medicine training because it mirrors the fast-paced environment of the emergency department (ED). However, simulation is not common in emergency medicine training programs in lower-resourced countries as cost, availability of resources, and faculty experience are potential limitations. We initiated a simulation curriculum in a low-resource environment. Methods: We created a simulation lab for medical officers and students on their emergency medicine rotation at a teaching hospital in Patan, Nepal, with 48,000 ED patient visits per year. We set up a simulation lab consisting of a room with one manikin, an intubation trainer, and a projector displaying a simulation cardiac monitor. In this environment, we ran a total of eight cases over 4 simulation days. Debriefing was done at the end of each case. At the end of the curriculum, an electronic survey was delivered to the medical officers to seek improvement for future cases. Results: All eight cases were well received, and learners appreciated the safe learning space and teamwork. Of note, the first simulation case that was run (the airway lab) was more difficult for learners due to lack of experience. Survey feedback included improving the debriefing content and adding further procedural skills training. Discussion: Simulation is a valuable experience for learners in any environment. Although resources may be limited abroad, a sustainable simulation lab can be constructed and potentially play a supportive role in developing an emergency medicine curriculum.

Impact of bedside lung ultrasound on physician clinical decision-making in an emergency department in Nepal.

BACKGROUND: Lung ultrasound is an effective tool for the evaluation of undifferentiated dyspnea in the emergency department. Impact of lung ultrasound on clinical decisions for the evaluation of patients with dyspnea in resource-limited settings is not well-known. The objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making for patients presenting with dyspnea to an emergency department in the resource-limited setting of Nepal. METHODS: A prospective, cross-sectional study of clinicians working in the Patan Hospital Emergency Department was performed. Clinicians performed lung ultrasounds on patients presenting with dyspnea and submitted ultrasounds with their pre-test diagnosis, lung ultrasound interpretation, post-test diagnosis, and any change in management. RESULTS: Twenty-two clinicians participated in the study, completing 280 lung ultrasounds. Diagnosis changed in 124 (44.3%) of patients with dyspnea. Clinicians reported a change in management based on the lung ultrasound in 150 cases (53.6%). Of the changes in management, the majority involved treatment (83.3%) followed by disposition (13.3%) and new consults (2.7%). CONCLUSIONS: In an emergency department in Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment.

Impact of Nepal Earthquake on Patients Presenting for Emergency Care at Patan Hospital.

OBJECTIVE: Natural disasters have a significant impact on the health sector. On April 25, 2015, Nepal was struck by a 7.8 magnitude earthquake. The aim of the study was to compare patient volumes and clinical conditions presenting to the emergency department pre- and post-earthquake. METHODS: A retrospective study was done at Patan Hospital Emergency Department in Kathmandu, Nepal. Volume, demographics, and patient diagnoses were collected for 4 months post-disaster and compared with cases seen the same months the year before the disaster to control for seasonal variations. RESULTS: After the 2015 Nepal earthquake, 12,180 patients were seen in the emergency department. This was a significant decrease in patient volume compared with the 14,971 patients seen during the same months in 2014 (P=0.04). Of those, 5496 patients (4093 pre-disaster and 1433 post-disaster) had a chief complaint or diagnosis recorded for analysis. An increase in cardiovascular and respiratory cases was seen as well as an increase in psychiatric cases (mostly alcohol related) and cases of anemia. There was a decrease in the number of obstetrics/gynecology, infectious disease, and poisoning cases post-earthquake. CONCLUSIONS: Understanding emergency department utilization after the earthquake has the potential to give further insight into improving disaster preparedness plans for post-disaster health needs. (Disaster Med Public Health Preparedness. 2019;13:211-216).

Estimating the weight of children in Nepal by Broselow, PAWPER XL and Mercy method.

BACKGROUND: Resuscitation of a critically-ill child requires an accurate weight for fluids and medication dosing; however, weighing children on a scale while critically ill is not always practical. The objective of this study is to determine the accuracy of three different weight estimation methods (Broselow, PAWPER XL and Mercy tape) of children presenting to Patan Hospital, Nepal. METHODS: This was a prospective, cross-sectional study that included children presenting to the emergency department and under-fourteen outpatient clinic at Patan Hospital. Measured weight was compared to estimated weight of Broselow, PAWPER XL, and Mercy tapes. The mean percentage error and percentage of estimated weights that were within 10% (PW10) and 20% (PW20) of actual weight were calculated. Acceptable accuracy was determined as a PW10>70% and PW20>95%. A Bland-Altman analysis was done to determine agreement between each weight estimation method and actual weight. RESULTS: The study included 813 children. The mean age was 4.2 years (ranging from 4 days to 14 years) with 60% male. The mean percentage error (MPE) for Broselow, PAWPER XL and Mercy were -1.0% (SD 11.8), 0.7% (10.5) and 4.2% (11.9) respectively. The predicted weight within 10% was highest for the PAWPER XL (71.5%) followed by Broselow (63.2%) and Mercy (58.1%). The predicted weight within 20% of actual weight was 95.2%, 91.5% and 91.3% for PAWPER XL, Broselow and Mercy respectively. CONCLUSION: The PAWPER XL tape was the only method found to be accurate in estimating the weight of Nepalese children.

Diagnostic use of lung ultrasound compared to chest radiograph for suspected pneumonia in a resource-limited setting.

BACKGROUND: Lung ultrasound is an effective tool for diagnosing pneumonia in developed countries. Diagnostic accuracy in resource-limited countries where pneumonia is the leading cause of death is unknown. The objective of this study was to evaluate the sensitivity of bedside lung ultrasound compared to chest X-ray for pneumonia in adults presenting for emergency care in a low-income country. METHODS: Patients presenting to the emergency department with suspected pneumonia were evaluated with bedside lung ultrasound, single posterioranterior chest radiograph, and computed tomography (CT). Using CT as the gold standard, the sensitivity of lung ultrasound was compared to chest X-ray for the diagnosis of pneumonia using McNemar's test for paired samples. Diagnostic characteristics for each test were calculated. RESULTS: Of 62 patients included in the study, 44 (71%) were diagnosed with pneumonia by CT. Lung ultrasound demonstrated a sensitivity of 91% compared to chest X-ray which had a sensitivity of 73% (p = 0.01). Specificity of lung ultrasound and chest X-ray were 61 and 50% respectively. CONCLUSIONS: Bedside lung ultrasound demonstrated better sensitivity than chest X-ray for the diagnosis of pneumonia in Nepal. TRIAL REGISTRATION: ClinicalTrials.gov, registration number NCT02949141 . Registered 31 October 2016.

Qualitative study of healthcare providers' current practice patterns and barriers to successful rehydration for pediatric diarrheal illnesses in Kenya.

BACKGROUND: For children worldwide, diarrhea is the second leading cause of death. These deaths are preventable by fluid resuscitation. Nasogastric tubes (NGs) have been shown to be equivalent to intravenous fluids for rehydration and recommended by the World Health Organization (WHO) for use in severe dehydration. Despite this, NGs are rarely used for rehydration in Kenya. Our objective was to evaluate clinicians' adherence to rehydration guidelines and to identify barriers to the use of NGs for resuscitating dehydrated children. METHODS: A case-based structured survey was administered to pediatric care providers in western Kenya to determine their choices for alternative rehydration therapies when oral rehydration and intravenous fluids fail. Providers then participated in a qualitative, semi-structured interview to identify barriers to using nasogastric tubes for rehydration. Analysis included manual, progressive coding of interview transcripts to identify emerging central themes. RESULTS: Of 44 participants, only four (9%) followed WHO guidelines that recommend quickly switching to NG for rehydration in their case responses. Participants identified that placing intravenous lines in dehydrated children is a challenge. However, when discussing NG use, many believed NGs are not effective for rehydration. Other participants' concerns surrounded knowledge and training regarding guidelines as well as not having NGs available. DISCUSSION: Healthcare providers in western Kenya do not report using NGs for rehydration in accordance with WHO guidelines for diarrheal illness with severe dehydration. Barriers to the use of NG tubes were lack of knowledge and availability. Education and implementation of guidelines using NG tubes for rehydration may improve outcomes of children suffering from diarrheal illness with severe dehydration.

To research (or not) that is the question: ethical issues in research when medical care is disrupted by political action: a case study from Eldoret, Kenya.

While considerable attention has been focused on understanding the myriad of ethical analysis in international research in low and middle income countries, new issues always arise that have not been anticipated in guidelines or studied extensively. The disruption of medical care arising as a direct result of political actions, including strikes, postelection violence and related activities, is one such issue that leaves physician-researchers struggling to manage often conflicting professional responsibilities. This paper discusses the ethical conflicts that arise for physician-researchers, particularly when disruption threatens the completion of a study or completion is possible but at the expense of not addressing unmet medical needs of patients. We review three pragmatic strategies and the ethical issues arising from each: not starting research, stopping research that has already started, and continuing research already initiated. We argue that during episodes of medical care disruption, research that has been started can be continued only if the ethical standards imposed at the beginning of the study can continue to be met; however, studies that have been approved but not yet started should not begin until the disruption has ended and ethical standards can again be assured.

Availability of mobile phones for discharge follow-up of pediatric Emergency Department patients in western Kenya.

Objective. Mobile phones have been successfully used for Emergency Department (ED) patient follow-up in developed countries. Mobile phones are widely available in developing countries and may offer a similar potential for follow-up and continued care of ED patients in low and middle-income countries. The goal of this study was to determine the percentage of families with mobile phones presenting to a pediatric ED in western Kenya and rate of response to a follow-up phone call after discharge. Methods. A prospective, cross-sectional observational study of children presenting to the emergency department of a government referral hospital in Eldoret, Kenya was performed. Documentation of mobile phone access, including phone number, was recorded. If families had access, consent was obtained and families were contacted 7 days after discharge for follow-up. Results. Of 788 families, 704 (89.3%) had mobile phone access. Of those families discharged from the ED, successful follow-up was made in 83.6% of cases. Conclusions. Mobile phones are an available technology for follow-up of patients discharged from a pediatric emergency department in resource-limited western Kenya.

Descriptive study of an emergency centre in western Kenya: challenges and opportunities

Introduction:With the highest global burden of disease and injury; there is an urgent need for Emergency Centres (EC) and physicians in Africa. Essential to this is the need for information on demographics; complaints; and acuity of patients presenting for acute care in Sub-Saharan Africa. The goal of this study was to determine the characteristics of EC patients in Eldoret; Kenya. Methods : Between January 1; 2011 and December 31; 2011; patient demographics; chief complaints; diagnoses; and dispositions were recorded for all patients presenting to an EC in Eldoret; Kenya. Patient volumes were averaged by month; week; and time of day. EC provider diagnoses were categorized according to the World Health Organization (WHO) ICD-10 Classifications. Dispositions were categorized into the following categories: admitted; observed; discharged; died; or unknown. Results:20;666 patients were seen with 17;336 (83.9) having complete visit information. The average age was 35.6 years and 52.6 of patients were female. The majority of patients (70) presented between the hours of 8 am and 5 pm.Deaths were highest in the early morning. The most common diagnoses were related to injury (20.2) followed by infectious diseases (11.7) and mental health disorders (11.3). Patient acuity was high as 58.6 of patients required observation or admission. Conclusions: The most common presentation for acute care in western Kenya was injury related. However; the severity of illness; lack of pre-hospital transportation; and lack of community mental health services provide significant challenges and opportunities for developing ECs in sub-Saharan Africa

Clinical and translational research in global health and emergency care: a research agenda.

As policy-makers increasingly recognize emergency care to be a global health priority, the need for high-quality clinical and translational research in this area continues to grow. As part of the proceedings of the 2013 Academic Emergency Medicine consensus conference, this article discusses the importance of: 1) including clinical and translational research in the initial emergency care development plan, 2) defining the burden of acute disease and the barriers to conducting research in resource-limited settings, 3) assessing the appropriateness and effectiveness of local and global acute care guidelines within the local context, 4) studying the local research infrastructure needs to understand the best methods to build a sustainable research infrastructure, and 5) studying the long-term effects of clinical research programs on health care systems.

Estimating the weight of children in Kenya: do the Broselow tape and age-based formulas measure up?

STUDY OBJECTIVE: Validated methods for weight estimation of children are readily available in developed countries; however, their utility in developing countries with higher rates of malnutrition and infectious disease is unknown. The goal of this study is to determine the validity of a height-based estimate, the Broselow tape, compared with age-based estimations among pediatric patients in Western Kenya. METHODS: A prospective cross-sectional study of all sick children presenting to the emergency department of a government referral hospital in Eldoret, Kenya, was performed. Measured weight was compared with predicted weights according to the Broselow tape and commonly used advanced pediatric life support (APLS) and Nelson's age-based formulas. A Bland-Altman analysis was used to determine agreement between each method and actual weight. The method for weight prediction was determined a priori to be equivalent to the actual weight if the 95% confidence interval for the mean percentage difference between the predicted and actual weight was less than 10%. RESULTS: Nine hundred sixty-seven children were included in analysis. The overall mean percentage difference for the actual weight and Broselow predicted weight was -2.2%, whereas APLS and Nelson's predictions were -5.2% and -10.4%, respectively. The overall agreement between Broselow color zone and actual weight was 65.5%, with overestimate typically occurring by only 1 color zone. CONCLUSION: The Broselow tape and APLS formula predict the weights of children in western Kenya. According to its better performance, ease of use, and provision of drug dosing and equipment size, the Broselow tape is superior to age-based formulas for estimation of weight in Kenyan children.

Emergency department transport rates of children from the scene of motor vehicle collisions: do booster seats make a difference?

BACKGROUND: Motor vehicle collisions (MVCs) are the leading cause of death and disability among children older than 1 year. Many states currently mandate all children between the ages of 4 and 8 years be restrained in booster seats. The implementation of a booster-seat law is generally thought to decrease the occurrence of injury to children. We hypothesized that appropriate restraint with booster seats would also cause a decrease in emergency department (ED) visits compared with children who were unrestrained. This is an important measure as ED visits are a surrogate marker for injury. OBJECTIVE: The main purpose of this study was to look at the rate of ED visits between children in booster seats compared with those in other or no restraint systems involved in MVCs. Injury severity was compared across restraint types as a secondary outcome of booster-seat use after the implementation of a state law. METHODS: A prospective observational study was performed including all children 4 to 8 years old involved in MVCs to which emergency medical services was dispatched. Ambulance services used a novel on-scene computer charting system for all MVC-related encounters to collect age, sex, child-restraint system, Glasgow Coma Scale score, injuries, and final disposition. RESULTS: One hundred fifty-nine children were studied with 58 children (35.6%) in booster seats, 73 children in seatbelts alone (45.2%), and 28 children (19.1%) in no restraint system. 76 children (47.7%), 74 by emergency medical services and 2 by private vehicle, were transported to the ED with no significant difference between restraint use (P = 0.534). Utilization of a restraint system did not significantly impact MVC injury severity. However, of those children who either died (n = 2) or had an on-scene decreased Glasgow Coma Scale score (n = 6), 75% (6/8) were not restrained in a booster seat. CONCLUSIONS: The use of booster-seat restraints does not appear to be associated with whether a child will be transported to the ED for trauma evaluation.