Brittany L. Murray

Causes of fever in outpatient Tanzanian children.

To the Editor: As physicians working in the only public emergency department in Tanzania, we are acutely aware of the need for better data to guide management of febrile illness in children, as described by D’Acremont et al. (Feb. 27 issue).1 However, we question the suggestion that it is safe to send febrile children home without antimicrobial treatment. In this study, 22% of febrile children had bacterial infections, and 10.5% had malaria. Since Tanzania has limited pediatric health care capabilities, follow-up cannot be ensured, and delayed treatment can lead to severe morbidity and mortality. In addition, in the studies that the authors cite to support the withholding of antimalarial drugs, investigators used rapid diagnostic testing,2-4 which is often unavailable. In the studies that they cite to support the withholding of antibiotics, the children had respiratory symptoms,4,5 not nonspecific febrile illness. Furthermore, since most medications are available without prescription, children often receive antimicrobial drugs before they arrive at a health center; the exclusion of children with previous treatment further limits generalizability. At this time, we would hesitate to support changing clinical practice. Hendry R. Sawe, M.D.

Surviving paediatric sepsis in Tanzania: a prospective cohort study to identify risk factors

Abstract Background In 2015, there were 5·9 million deaths in children aged under 5 years worldwide: mortality is highest in sub-Saharan Africa (81 per 1000 livebirths) and sepsis is an important cause of these deaths. Paediatric sepsis is preventable and treatable, yet remains a serious and life-threatening condition. Prompt recognition and early treatment can improve survival; however, the understanding of how to identify and manage paediatric sepsis in sub-Saharan Africa is poor because of a lack of regional data. These data are crucial for the identification of high-risk patients, development of triage systems, and the reduction of barriers to care. In this study, we aim to identify mortality risk factors for paediatric sepsis patients at a national referral hospital in Tanzania. Methods We conducted an exploratory analysis of prospective cohort pilot data. We included children aged between 28 days and 14 years in the emergency medicine department at Muhimbili National Hospital in Dar es Salaam with sepsis (defined as ≥2 clinical criteria for systemic inflammatory response syndrome). The primary outcome was in-hospital mortality and secondary outcomes included mortality in the emergency department and length of stay. We used t -tests and Wilcoxon rank-sum, Kruskal Wallis, χ 2 , and Fishers exact tests for data analysis. Findings Of the 2232 children screened between July 1 and September 30, 2017, 433 were eligible, 405 were enrolled, and 402 were followed to discharge or death. Median age was 25·2 months (IQR 11·4–63·5) and prevalence of malaria and HIV was 9·1% (28/307) and 1·7% (n=7), respectively. 247 (61·0%) patients were referred from outside health facilities and 116/244 (47·5%) had received antibiotics before arrival. Mortality was 14·2% (n=57): 89·5% (n=51) died on a hospital ward and 10·5% (n=6) died in the emergency department. Non-survivors were younger than survivors (median age 16 and 27 months, respectively, p=0·002), and more likely to have respiratory insufficiency (54 (94·7%) vs 293 (84·9%), p=0·046) or altered mental status (43 (75·4%) vs 171 (49·6%), p Interpretation We identified several risk factors for mortality, but only that of referral status can be modified. Most children—and a disproportionately high number of non-survivors—were assessed at other health facilities before coming to Muhimbili, suggesting that there could be an opportunity for improved sepsis identification and earlier intervention. Next steps include development of a clinical illness severity score to allow risk stratification of patients and also investigation of barriers to care. Data collection is ongoing. Funding University of California, San Francisco, Department of Pediatrics Clinical-Translational Pilot.

Emergency blood transfusion practices among anaemic children presenting to an urban emergency department of a tertiary hospital in Tanzania

BackgroundSevere anaemia contributes significantly to mortality, especially in children under 5xa0years of age. Timely blood transfusion is known to improve outcomes. We investigated the magnitude of anaemia and emergency blood transfusion practices amongst children under 5xa0years presenting to the Emergency Department (ED) of Muhimbili National Hospital (MNH) in Tanzania.MethodsThis prospective observational study enrolled children under 5xa0years old with anaemia, over a 7-week period in August and September of 2015. Anaemia was defined as haemoglobin of <11xa0g/dL. Demographics, anaemia severity, indications for transfusion, receipt of blood, and door to transfusion time were abstracted from the charts using a standardized data entry form. Anaemia was categorized as severe (Hb <7xa0g/dL), moderate (Hb 7–9.9xa0g/dL) or mild (Hb 10–10.9xa0g/dL).ResultsWe screened 777 children, of whom 426 (55%) had haemoglobin testing. Test results were available for 388/426 (91%), 266 (69%) of whom had anaemia. Complete data were available for 257 anaemic children, including 42% (nxa0=xa0108) with severe anaemia, 40% (nxa0=xa0102) with moderate anaemia and 18% (nxa0=xa047) with mild anaemia. Forty-nine percent of children with anaemia (nxa0=xa0125) had indications for blood transfusion, but only 23% (29/125) were transfused in the ED. Among the non-transfused, the provider did not identify anaemia in 42% (nxa0=xa040), blood was not ordered in 28% (nxa0=xa027), and blood was ordered, but not available in 30% (nxa0=xa029). The median time to transfusion was 7.8 (interquartile range: 1.9) hours. Mortality was higher for the children with severe anemia who were not transfused as compared with those with severe anaemia who were transfused (29% vs 10%, pxa0=xa00.03).ConclusionThe burden of anaemia is high among children under 5 presenting to EMD-MNH. Less than a quarter of children with indications for transfusion receive it in the EMD, the median time to transfusion is nearly 8xa0h, and those not transfused have nearly a 3-fold higher mortality. Future quality improvement and research efforts should focus on eliminating barriers to timely blood transfusion.

The Burden and Outcomes of Abdominal Pain among Children Presenting to an Emergency Department of a Tertiary Hospital in Tanzania: A Descriptive Cohort Study

Background Abdominal pain in children can represent benign conditions or life-threatening emergencies. Aetiologies of paediatric abdominal pain vary geographically and have not been studied in acute care settings in East Africa. This study describes the clinical profiles and outcomes of children presenting with undifferentiated abdominal pain to the Emergency Department of Muhimbili National Hospital (ED-MNH). Methods This was a prospective cohort study of children below 18 years of age presenting to the ED-MNH with abdominal pain. A structured case report form was used to collect data on patients from June to December 2016. Data included demographics, clinical presentation, and mortality. Data were summarised using descriptive statistics. Results Out of 1855 children who presented to ED-MNH, 184 (9.9%) met inclusion criteria, and all were enrolled. The median age was 3.5 years (IQR: 1.3–7.0 years) and 124 (67.4%) were male. Most (138 [75.0%]) were referred from peripheral hospitals. The most frequent ED providers diagnoses were hernia (34 [18.5%]) and intra-abdominal malignancy (19 [10.3%]). From the ED, 37 (20.1%) were discharged home, 83 (45.1%) were admitted to medical wards, and 48 (26.1%) were admitted to surgical wards. 16 (8.7%) underwent an operation. 24-hour, seven-day, and three-month mortality rates were 1.1%, 6.5%, and 14.5%, respectively. The overall in-hospital mortality rate was 12.2%. Multivariate analysis showed that age below 5 years, female sex, and haemoglobin less than 10.9u2009g/dl were significant factors associated with in-hospital mortality. Discussion and Conclusion Abdominal pain is a common complaint among paediatric patients presenting to the ED-MNH. This presentation was associated with a high admission rate and a high mortality rate. Age below 5 years, female sex, and haemoglobin less than 10.9u2009g/dl were associated with mortality. Further studies and quality improvement efforts should focus on identifying aetiologies, risk stratification, and appropriate interventions to optimise patients outcomes.

Development of a simple, practice-based tool to assess quality of paediatric emergency care delivery in resource-limited settings: identifying critical actions via a Delphi study

Objective Provision of timely, high-quality care for the initial management of critically ill children in African hospitals remains a challenge. Monitoring the completion of critical actions during resuscitations can inform efforts to reduce variability and improve outcomes. We sought to develop a practice-based tool based on contextually relevant actions identified via a Delphi process. Our goal was to develop a tool that could identify gaps in care, facilitate identification of training and standardised assessment to support quality improvement efforts. Design Six sentinel conditions were selected based on disease epidemiology and mortality at rural and urban African emergency departments. Potential critical actions were identified through focused literature review. These actions were evaluated within a three-round modified Delphi process. A set of logistical filters was applied to the candidate list to derive a practice-based tool. Setting and participants Attendees at an international emergency medicine conference comprised an expert panel of 25 participants, with 84% working primarily in African settings. Consensus rounds allowing novel responses were conducted via online and in-person surveys. Results The expert panel generated 199 actions that apply to six conditions in emergently ill children. Application of appropriateness criteria refined this to 92 candidate actions across the following seven categories: core skills, active seizure, altered mental status, diarrhoeal illness, febrile illness, respiratory distress and polytrauma. From these, we identified 28 actions for inclusion in a practice-based tool contextually relevant to the initial management of critically ill children in Africa. Conclusions A group consensus process identified critical actions for severely ill children with select sentinel conditions in emergency paediatric care in an African setting. Absence of these actions during resuscitation might reflect modifiable gaps in quality of care. The resulting practice-based tool is context relevant and can serve as a foundation for training and quality improvement efforts in African hospitals and emergency departments.

The clinical presentation, utilization, and outcome of individuals with sickle cell anaemia presenting to urban emergency department of a tertiary hospital in Tanzania

BackgroundSickle cell anaemia (SCA) is prevalent in sub-Saharan Africa, with high risk of complications requiring emergency care. There is limited information about presentation of patients with SCA to hospitals for emergency care. We describe the clinical presentation, resource utilization, and outcomes of SCA patients presenting to the emergency department (ED) at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania.MethodsThis was a prospective cohort study of consecutive patients with SCA presenting to ED between December 2014 and July 2015. Informed consent was obtained from all patients or patients’ proxies prior to being enrolled in the study. A standardized case report form was used to record study information, including demographics, relevant clinical characteristics and overall patients outcomes. Categorical variables were compared with chi-square test or Fisher’s exact test; continuous variables were compared with two-sample t-test or Mann-Whitney U-test.ResultsWe enrolled 752 (2.7%) people with SCA from 28,322 patients who presented to the MNH-ED. The median age was 14xa0years (Interquartile range [IQR]: 6–23xa0years), and 395 (52.8%) were female. Pain 614 (81.6%), fever 289 (38.4%) were the most frequent presenting complaint. Patients with fever, hypoxia, altered mental status and bradycardia had statistically significant relative risk of mortality of 10.4, 153, 50 and 12.1 (pu2009<u20090.0001) respectively, compared to patients with normal vitals. Overall, 656 (87.2%) patients received Complete Blood Cell counts test, of these 342 (52.1%) had severe anaemia (haemoglobin <u20097xa0g/dl), and a 30.3 (pu2009=u20090.02) relative risk of relative risk of mortality compare to patients with higher haemoglobin. Patients who had malaria, elevated renal function test and hypoglycemia, had relative risk of mortality of 22.9, 10.4 and 45.2 (pu2009<u20090.0001) respectively, compared to patient with normal values. Most 534 (71.0%) patients were hospitalized for in patients care, and the overall morality rate was 16 (2.1%).ConclusionsWe described the clinical presentation, management, and outcomes of patients with SCA presenting to the largest public ED in Tanzania, as well as information on resource utilization. This information can inform development of treatment guidelines, clinical staff education, and clinical research aimed at optimizing care for SCA patients.

Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania

BackgroundHypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania.MethodsThis was a descriptive cohort study of adult patients aged 18xa0years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency.ResultsWe screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45–67xa0years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively.ConclusionIn our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.

Emergency centre diagnosis and treatment of purulent pericarditis: A case report from Tanzania

Introduction Purulent pericarditis poses diagnostic and therapeutic challenges, especially in resource-limited settings due to the unavailability of diagnostic tools, equipment, and expertise. Case report A three-year-old female presented to the emergency centre at Muhimbili National Hospital in Dar es Salaam, Tanzania with altered mental status, lethargy, intermittent fevers, worsening difficulty in breathing, and progressive lower extremity swelling over two months. The child was in shock upon arrival. Point-of-care ultrasound demonstrated cardiac tamponade secondary to purulent pericarditis. An ultrasound guided pericardiocentesis and lavage was successfully done in the emergency centre and antibiotics were started. Though definitive management (pericardiectomy) was delayed, the child survived to hospital discharge. Conclusion Pericardiocentesis, pericardial lavage, and the initiation of broad spectrum antibiotics are the mainstay of early treatment of purulent pericarditis. This treatment can be done safely in an emergency centre with little specialised equipment aside from point-of-care ultrasound.

Clinical Presentation and Outcomes among Children with Sepsis Presenting to a Public Tertiary Hospital in Tanzania

Background Pediatric sepsis causes significant global morbidity and mortality and low- and middle-income countries (LMICs) bear the bulk of the burden. International sepsis guidelines may not be relevant in LMICs, especially in sub-Saharan Africa (SSA), due to resource constraints and population differences. There is a critical lack of pediatric sepsis data from SSA, without which accurate risk stratification tools and context-appropriate, evidence-based protocols cannot be developed. The study’s objectives were to characterize pediatric sepsis presentations, interventions, and outcomes in a public Emergency Medicine Department (EMD) in Tanzania. Methods Prospective descriptive study of children (28u2009days to 14u2009years) with sepsis [suspected infection with ≥2 clinical systemic inflammatory response syndrome (SIRS) criteria] presenting to a tertiary EMD in Dar es Salaam, Tanzania (July 1 to September 30, 2016). Outcomes included: in-hospital mortality (primary), EMD mortality, and hospital length of stay. We report descriptive statistics using means and SDs, medians and interquartile ranges, and counts and percentages as appropriate. Predictive abilities of SIRS criteria, the Alert-Verbal-Painful-Unresponsive (AVPU) score and the Lambaréné Organ Dysfunction Score (LODS) for in-hospital, early and late mortality were tested. Results Of the 2,232 children screened, 433 (19.4%) met inclusion criteria, and 405 were enrolled. There were 247 (61%) subjects referred from an outside facility. Approximately half (54.1%) received antibiotics in the EMD, and some form of microbiologic culture was collected in 35.8% (nu2009=u2009145) of subjects. In-hospital and EMD mortality were 14.2 and 1.5%, respectively, median time to death was 3u2009days (IQR 1–6), and median length of stay was 6u2009days (IQR 1–12). SIRS criteria, the AVPU score, and the LODS had low positive (17–27.1, 33.3–43.9, 18.3–55.6%, respectively) and high negative predictive values (88.6–89.8, 86.5–91.2, 86.8–90.5%, respectively) for in-hospital mortality. Conclusion This pediatric sepsis cohort had high and early in-hospital mortality. Current criteria and tested clinical scores were inadequate for risk-stratification and mortality prediction in this population and setting. Pediatric sepsis management must take into account the local patient population, etiologies of sepsis, healthcare system, and resource availability. Only through studies such as this that generate regional data in LMICs can accurate risk stratification tools and context-appropriate, evidence-based guidelines be developed.

Compassion fatigue in emergency providers: Experiences from Sub‐Saharan Africa

Emergencies happen every day across the globe, and health systems shoulder the responsibility for the care of emergencies, regardless of their capability to do so adequately. Nowhere is this more apparent than in Sub-Saharan Africa (SSA) where there is a disproportionate burden of disease and injury. Emergency medicine (EM) in SSA is a developing field. However, EM is complex, and implementing highquality, affordable emergency care is difficult. EM systems in SSA remain poorly developed despite evidence that emergency care is an efficient and costeffective method of preventing further complications. Existing EM resources in SSA are overstretched and overburdened. Frontline EMproviders can experience physical and psychological effects from witnessing significant morbidity and mortality every day. In this article, we will discuss factors contributing to compassion fatigue in emergency providers working in low-income countries using experiences from SSA.