Predictors and outcome of time to presentation among critically ill paediatric patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania

Critical illness is a life-threatening process which, without timely medical or surgical intervention, is highly likely to result in death [1]. Half of the deaths among children under five years globally occurred in sub-Saharan Africa in 2017. Unlike in high income countries where 1 in 185 children died before the age of five years, 1 in 13 died before the age of five in Sub-Saharan Africa. The risk of dying for a child in sub-Saharan Africa is 15 times higher than in Europe. Most of these children die due to treatable and preventable causes such as complications of during birth, pneumonia, diarrhea, malaria and neonatal sepsis [2]. A 2010 survey by the ministry of health in Tanzania showed high mortality rate in under-fives with 75% of deaths occurring in the first 24 to 48 h after admission [3]. The unfolding of events in the process of critical illness is influenced by multiple factors which can potentially modify and affect the outcome of critical illness. In addition to improvements in the quality of care for children reducing delays in critical illness is among the main approaches to reducing mortality.

Paediatric critical illness in the Low-and Middle-Income Countries (LMICs) differs from the developed countries in that children tend to be younger and suffer more from infectious causes of illnesses. Late presentations to the hospital due to referrals and travels through long distances to reach hospitals are common occurrence which contribute to an increased disease severity and mortality upon admission [4].

Delayed presentation to the hospital in the course of paediatric critical illness has been shown to be one of the factors that negatively influence health outcomes [5]. Delayed health care seeking of more than 48 h has been observed in 35% of paediatric patients in the acute phase of illness in Kigali, Rwanda [6]. In Southwestern Uganda, 50% of paediatric patients who presented late to the health facility and were admitted died within 24 h of admission [7]. At a tertiary hospital in Ethiopia about 4. 1% of children died at the Paediatric Emergency Department, which translates to a mortality of 8.2 per 1000 children. Delay of more than 48 h since the onset of symptoms was among the top causes of early mortality [5]. In Dodoma Tanzania, the median time of delay to seek care among children under five years with fever was 2 days [8].There is an association between delayed Intensive Care Unit (ICU) admission and mortality. Fraction of mortality attributable to ICU delay was 30% [9]. Many studies in this area have looked at timeliness at the level of the family which affects the first phase in the Thaddeus and Maine’s delay model [10].

Presence of a full capacity ED, Paediatric ICU and definitive paediatric services at MNH (Muhimbili National Hospital) have provided early resuscitation, stabilization and other management for critically ill paediatric patients. The objective of this study was to describe patterns, determine factors associated with delay and find out whether delay made a difference in mortality outcome among critically ill children who sought care at the ED of a national tertiary referral hospital.

A total of 3616 paediatric patients attended the ED during the study period, of whom 745 (20.6%) were triaged “emergent”. A total of 440 (59.1%) patients were eligible and consented to participate in the study. Of the 99(26.5%) who died within 30 days of presentation, 64(64.6%) presented late (after 48 h) and 35 (35.4%) presented early (before 48 h) (Fig. 1).

This prospective cohort study aimed to determine factors associated with delay to presentation among critically ill children who seek care at a tertiary referral hospital.

Delay to seek care has been reported in several studies as a cause of avoidable morbidity and mortality in children. In our study over fifty percent of critically ill paediatric patients presented late (after 48 h from onset of illness) to the ED. This is similar to findings by a study in Ethiopia but higher than that observed in Rwanda with delay of thirty five percent of paediatric patients [5, 6]. A possible explanation could be differences in sociodemographic characteristics and lifestyle of the study settings. The hierarchical referral system in the setting of this study could contribute to the observed delay as this study was conducted in tertiary hospital which is the highest destination in the chain of referral [11].

In this cohort almost a quarter of the critically ill children who presented to the ED after 48 h from onset of illness died with almost two- thirds of the deaths occurring beyond 24 h of hospital admission. This is similar to findings by a study done at a tertiary hospital in Ethiopia [5]. This may signify the impact of resuscitation and stabilization at the ED before admission that presumably prolonged their lives beyond 24 h but later decompensated [12]. However, limited number of beds in paediatric ICU could explain the occurrence of death beyond ED stabilization. Scarcity of beds in the paediatric ICU deterred doctors at the emergency department from admitting critically ill paediatric patients to the ICU. They instead admitted them to general wards which had no intensive care capacity.

We also found that critically ill children below one year of age were more likely to present late to the ED. Non-specific symptoms especially in infants and caretakers’ poor knowledge on danger signs of critical illnesses might contribute to delay in this age group [13]. Our study also found coming from the poorest households independently doubled the odds of a critically ill paediatric patient being late to the tertiary hospital during a critical illness. This is in keeping with a study conducted in Ethiopia which had similar findings [14].

About two thirds of the critically ill paediatric patients who delayed were referred from primary health care facilities with no capability to care for critically ill children. Failure to recognize critical illness with series of evaluations by primary health care providers before they are referred to definitive care significantly lead to delay with limited management [15]. The existing referral system in place [11] doesn’t take into account the urgency to definitive care hence more delay with poor outcome observe.

This study was conducted in urban settings and single center tertiary hospital with full capacity to resuscitate and stabilize critically ill paediatric patients. However, the MNH ED receives referrals from all over the country, the patients sampled are likely to provide a true representation of the Tanzanian population of critically ill paediatric patients.

Patients were only enrolled when researchers were in the department; some of potential participants might have been missed. However, as the researchers worked different shifts, there is no reason to expect that the missed patients were different from those that were enrolled.

There was loss to follow up encountered in this study. However, it was mitigated by including 10% loss to follow up rate during the estimation of the sample size of the study participants who were to be included during the development of the study protocol.

The proportion of delayed presentation to tertiary hospital among critically ill paediatric patients is substantially high. The risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value. Age below one year, being referred from a primary healthcare facility and being in the poorest category of socioeconomic status predicted delay to appropriate care facility. Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill paediatric patients to identify preventable delays in care.