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

Pakistan is a resource-poor country in South Asia that has recently taken significant steps to improve its national healthcare delivery. Despite its efforts, Pakistan continues to perform poorly on many international health indicators, especially with regard to its pediatric population. In 2016, its neonatal, infant, and under-five mortality rates were 46, 64, and 79 per 1000 live births, respectively, giving Pakistan the world’s highest neonatal mortality rate, as well as the 11th highest infant and 20th highest under-five mortality rates [1]. One contributor to high pediatric morbidity and mortality in Pakistan is the absence of an organized emergency care system, which could account for nearly half of deaths and one-third of disability-adjusted life years (DALYs) [2].

Recent work in Pakistan has identified serious issues which hinder access to quality emergency care, including overall dissatisfaction with emergency medical services, low staff confidence in their ability to handle emergencies, and a general shortage of essential equipment and supplies [3]. While improving access to quality emergency care is recognized internationally as an important step in reducing morbidity and mortality in low- and middle-income countries (LMICs) [4], there is a dearth of data describing the epidemiology of patients seeking emergency care in Pakistan, particularly pediatric patients.

Characterization of patients seeking emergency care services is essential to determine a country’s emergency care resource needs and develop a locally appropriate emergency healthcare system [5]. The 2013 Academic Emergency Medicine consensus conference, “Global Health and Emergency Care: A Research Agenda,” highlighted the lack of published data on chief complaints as a critical gap in global emergency care research [6]. We seek to bridge this gap by describing the epidemiology and outcomes of children presenting to the emergency department of Pakistan’s largest government children’s hospital, the National Institute of Child Health (NICH).

This report is the first in-depth investigation of the epidemiology of patients presenting to a pediatric emergency department in Pakistan and one of only a handful of such studies conducted to-date in developing countries [8‐11]. Prior studies in Pakistan have focused primarily on the epidemiology of pediatric traumatic injuries, which account for only 3.7% of patients in our study [12]. We sought to characterize the population of all pediatric patients seeking acute care in Pakistan and found a high burden of infant visits and an alarming cumulative 14-day mortality rate, which was particularly high among neonates.

In comparison to urban pediatric emergency departments in other LMICs, our overall reported pediatric mortality rate (19.6%) was exceedingly high, with a full one-third (33.3%) of neonates having died within 14-days of their ED visit. In comparison, an Indian study reported a substantially lower in-hospital mortality rate of 12.2%, although this number does not include patients who were sent home from the ED. [13] In our study, 4.3% of children died while in the ED, a similar rate to that published in a separate study (5.7%) of Indian children between 1995 and 2000 [8]. Dramatically lower ED mortality rates have been reported in Egypt (0.9%) and Turkey (2.6%), an unexpected contrast given their similar resource and training limitations [9, 14]. Pakistan’s high death rates also stand in sharp contrast to the numbers reported from countries with developed emergency care infrastructures. Studies in the United States demonstrate few deaths in the ED, with a < 0.1% mortality rate among pediatric patients [15]. To our knowledge, there are no other studies that track all patients following ED discharge to assess for delayed mortality. As the majority of deaths in our study occurred after the patient left the ED (a post-ED mortality rate of 15.3%, accounting for 66% of deaths), our study highlights a need to monitor the progression of patients following ED disposition.

Many factors likely contribute to the exceedingly high mortality rate we observed. First and foremost, delays in care seeking likely exacerbated delays in reaching the appropriate healthcare facility. One study of Pakistani households reported that less than half of family members with emergency medical conditions were taken to the nearest primary care facility for treatment [16]. In our study, almost two-thirds of our patients were seen by outside health care providers prior to their arrival in the ED, but only a quarter (22.0%) were transferred by ambulance from that initial medical facility. Most patients travelled to the ED via public or private vehicle, therefore benefiting from neither the speed nor the en route emergency medical treatment that ambulance transport provides. Our results, therefore, complement the findings of a prior study that described prolonged travel times to the appropriate health care facility as an important contributor to pediatric deaths in Karachi [17].

Most of our study deaths occurred following ED evaluation and disposition, suggesting the failure of ED medical staff to recognize illness severity and promptly initiate life-saving therapy [18]. One study in northern Pakistan found that misinterpretation of symptom severity by the initial providers and mis-triage at the initial medical facility led to poor outcomes in many cases of surgically treatable illnesses [19]. Despite vital signs being important markers of illness acuity and reliable predictors of death in emergency settings [20], initial vital signs were not reliably documented or reported at our study hospital. Obtaining a complete set of vital signs and implementing effective ED triage have been shown to reduce mortality in resource-poor settings [21]. Our results suggest that improved training for Pakistani medical staff on the importance of taking and documenting vital signs may lead to the proper identification of the most severely ill patients, thus reducing overall mortality.

The observed elevated mortality rates are also likely impacted by both a lack of essential equipment and inadequate physician education regarding its use when available [22, 23]. Research has identified significant gaps in the availability of essential emergency equipment and medications, as well as the knowledge necessary for Pakistani physicians to use these resources effectively in relevant settings [22]. Remarkably, much of the frequently unavailable equipment, such as suction catheters and pediatric-sized blood pressure cuffs, consists of relatively inexpensive items capable of saving lives in emergency scenarios.

Finally, a significant percentage (10.9%) of patients left against medical advice (AMA). As one-eighth (12.2%) of these children died within 14 days of their initial presentation, clearly leaving AMA was a significant contributor to our high mortality rates. This behavior has previously been identified as a common problem in Karachi hospitals [24]. Many parents and guardians cited delays in care and inadequate communication from hospital staff about the ED process as reasons for leaving the hospital prematurely. It has been shown that leaving AMA is associated with higher mortality and readmission rates [25]. Therefore, improving patient-provider communication and the hospital efficiency should be further studied as these factors may be contributing to families leaving AMA.

The most common chief complaints (fever, diarrhea/vomiting, and respiratory problems) reported during our study were similar, but varied in frequency, to those previously reported in other developing countries [8‐11]. Respiratory (23.4%) and gastrointestinal illness (23.3%) accounted for almost half of visits to a pediatric ED in India [8]. In Egypt and Tunisia, respiratory complaints accounted for 41.7 and 39.9% of visits, respectively [9, 10]. Respiratory complaints may have been lower in our study because our data was collected during the summer months, when such illness tend to diminish. While injuries were the most common complaint for pediatric ED patients in a Malaysian study, fever (24%), breathing difficulties (16.6%), and diarrhea/vomiting (9.7%) were the next most frequent presentations [11]. The observed trend of similar chief complaints among LMICs in connection with high mortality rates suggests that focusing on these specific chief complaints in developing provider training materials and patient management protocols may be effective in reducing mortality. A recent WHO study also reports that the majority ED providers in LMICs have no specialty training in emergency medicine [26]. Additional study exploring the training local providers receive on managing chief complaints associated with high mortality would be of further benefit.

Our study documents a staggeringly high mortality rate at Pakistan’s largest children’s emergency department. Addressing this mortality rate, which even significantly exceeds other comparable resource-limited countries, is crucial for Pakistan to achieve its goal of improving its national healthcare delivery. Focusing training on the most common regional chief complaints may ultimately improve patient management and outcomes. Additional studies are needed to further characterize which factors – delays in seeking and accessing care, inadequate triage, gaps in physician education, lack of necessary equipment, or others – are the greatest contributors to the high mortality observed at our study site. Likewise, investigating the quality of care patients received and the appropriateness of discharge in patients who were not admitted is vital to decreasing morbidity and mortality at the National Institute of Child Health in Karachi and other similar hospitals.

This first investigation of pediatric emergency epidemiology in Pakistan has provided a broader understanding of the most common presentations and resulting outcomes. Our study’s findings can be used to inform quality improvement and policy changes in ED management, create guidelines and needs-based training materials for local healthcare providers, and serve as a baseline for measurement of future trends in health outcomes. Future work should focus on identifying high-risk patients earlier in their clinical course by improving triage, training staff to increase their competency in managing the most common chief complaints, especially neonatal complaints, improving local prenatal and neonatal care, and assessing the impact of such interventions on morbidity and mortality. Much of the knowledge gained from this study will have applicability and value to other developing nations facing similar challenges.