Aga Khan University Hospital, Karachi, Pakistan.
ChildLife Foundation, Karachi, Pakistan.
Am J Emerg Med. 2024 Sep;83:91-94. doi: 10.1016/j.ajem.2024.06.010. Epub 2024 Jun 13.
This study aims to assess compliance with medical protocols and outcomes, as well as determine the consistency in clinical practice across different Pediatric Emergency Departments (PED) in public sector hospitals of a low-middle income country.
A retrospective analysis was conducted on patients presenting to PEDs of five public sector hospitals, namely Civil Hospital Karachi (PED 1), National Institute of Child Health (PED 2), Abbasi Shaheed Hospital (PED 3), Sheikh Zayed Hospital Larkana (PED 4), and Ghulam Muhammad Mahar College Hospital Sukkur (PED 5). The analysis covered a three-month period from February 1, 2023, to April 30, 2023. Patients diagnosed with Acute asthma, Sepsis, and Septic Shock during the study duration were included. Outcomes for each disease were evaluated based on compliance with standardized protocols.The statistical significance of data was measured by adding the p values.
110,450 patients visited PED during the study period and mortality rate was 2% (n=2193). 12% (13,240) were diagnosed with the three diseases during the study period. Sepsis was on top (74%, n=9,751), followed by Septic Shock (14%, n=1898), and Acute Asthma (12%, n=1591). The overall compliance rate for the three diseases was 77% (n = 10,240). Adherence to standard protocols were 98% (n = 1561) for acute asthma, 85% (n = 8240) for Sepsis, and 23% (n = 439) for Septic Shock across the five emergency departments. Of the patients who were managed according to standard protocol, 31% (n = 3135) were discharged, 30% (n- 3094) were admitted, 11% (n = 1151) were referred, 15% (n = 1501) left against medical advice and 13% (n = 1359) did not survive. On the other hand, in patients where there was noncompliance to standard protocols, 27% (n = 805) did not survive, 27% (n = 807) were discharged, 24% (n = 710) were admitted, 8% (n = 260) were referred and 14% (n = 418) left against medical advice. The differences in adherence rates among the three diseases were statistically significant (p < 0.001).
The overall mortality rate was 2% in these five emergency departments and the medical protocol was followed in every third patient out of fourth in those three diseases. The survival rate till ED disposition was doubled in those patients for whom medical protocols were followed as compared to those for non-compliant. The majority of PED demonstrated good compliance with standardized practices. However, this study identified areas that require attention and further training, especially early recognition and management of septic shock where compliances seem alarmingly low. Our data analysis indicates that adherence to guidelines has resulted in uniformity in clinical practice and the provision of early evidence-based quality care. Nevertheless, there is still room for improvement in ensuring consistent adherence to medical protocols in pediatric emergency settings and thus improving patient outcomes.
本研究旨在评估医疗协议的遵守情况和结果，并确定在低中等收入国家的公立医院儿科急诊部门（PED）之间临床实践的一致性。
对来自五个公立医院的 PED 的患者进行回顾性分析，即卡拉奇民事医院（PED1）、国家儿童健康研究所（PED2）、阿巴西谢赫扎耶德医院（PED3）、拉尔卡纳谢赫扎耶德医院（PED4）和苏库尔古拉姆穆罕默德马哈尔学院医院（PED5）。分析涵盖了 2023 年 2 月 1 日至 4 月 30 日的三个月期间。研究期间，将诊断为急性哮喘、脓毒症和感染性休克的患者纳入研究。根据标准化协议的遵守情况评估每种疾病的结果。数据的统计显著性通过添加 p 值来衡量。
在研究期间，有 110450 名患者到 PED 就诊，死亡率为 2%（n=2193）。在研究期间，有 12%（n=13240）被诊断出患有这三种疾病。脓毒症发病率最高（74%，n=9751），其次是感染性休克（14%，n=1898）和急性哮喘（12%，n=1591）。这三种疾病的总依从率为 77%（n=10240）。在五个急诊室中，急性哮喘的标准方案依从率为 98%（n=1561），脓毒症为 85%（n=8240），感染性休克为 23%（n=439）。根据标准方案进行管理的患者中，31%（n=3135）出院，30%（n=3094）住院，11%（n=1151）转诊，15%（n=1501）违背医嘱，13%（n=1359）未存活。另一方面，在不遵守标准方案的患者中，27%（n=805）未存活，27%（n=807）出院，24%（n=710）住院，8%（n=260）转诊，14%（n=418）违背医嘱。这三种疾病的依从率差异具有统计学意义（p<0.001）。
这五个急诊室的总体死亡率为 2%，在这三种疾病中，每四个患者中就有三个遵守了医疗方案。与不遵守医疗方案的患者相比，遵守医疗方案的患者在急诊科处置时的存活率提高了一倍。大多数 PED 对标准化实践表现出良好的依从性。然而，本研究发现需要关注和进一步培训的领域，特别是在脓毒症休克的早期识别和管理方面，遵守情况似乎低得令人震惊。我们的数据分析表明，遵循指南导致临床实践的一致性，并提供了早期基于证据的高质量护理。然而，在确保在儿科急诊环境中始终如一地遵守医疗方案以改善患者结局方面，仍有改进的空间。
