Emergency Referrals Research Articles

The impact of the COVID-19 pandemic on psychiatric emergency consultations in adolescents

BackgroundThere is growing evidence that the COVID-19 pandemic, and its associated social distancing measures, affect adolescents’ mental health. We wanted to examine whether and how the number and characteristics of adolescents’ psychiatric emergency presentations have changed throughout the pandemic.MethodsWe extracted data from the records of 977 psychiatric emergency consultations of adolescents aged 12- 19 who had been referred to the mobile psychiatric emergency services in Rotterdam, the Netherlands between January 1st 2018 and January1st 2022. Demographic, contextual, and clinical characteristics were recorded. Time-series-analyses were performed using quasi-Poisson Generalized Linear Model to examine the effect of the first and second COVID-19 lockdown on the number of psychiatric emergency consultations, and to explore differences between boys and girls and internalizing versus externalizing problems.ResultsThe number of psychiatric emergency consultations regarding adolescents increased over time: from about 13 per month in 2018 to about 29 per month in 2021. During the COVID-19 pandemic, the increase was tempered. In the second wave a pronounced increase of psychiatric emergencies among adolescents with internalizing problems but not with externalizing problems was found.ConclusionDespite the reported increase of mental health problems in adolescents during the COVID-19 pandemic, we did find a smaller increase in psychiatric emergency consultations in this group then would be expected considering the overall trend. Besides changes in help-seeking and access to care, a possible explanation may be that a calmer, more orderly existence, or more parental supervision led to less psychiatric emergency situations in this age group. In the second wave the number of emergency consultations increased especially among girls with internalizing problems. While there has been a particular fall in emergency referrals of adolescents with externalizing problems since the start of the pandemic it is still too early to know whether this is a structural phenomenon. It would be important to elucidate whether the changes in emergency referrals reflect a true change in prevalence of urgent internalizing and externalizing problems in adolescents during the pandemic or a problem related to access to care.

Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators.

Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360min) is associated with poor outcomes in this cohort of ED referrals. This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3. Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64min (IQR 35-105min). Age ≥ 65years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034). Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.

Outcome of Operated Colorectal Cancers in Relation to the Type of Initial Referral.

Aim Since the introduction of the target referral system, there has been controversy about its value and whether it affected the short- and long-term outcomes of colorectal cancer surgeries. With contradicting results, this study highlights differences in personal and tumour characteristics, management differences, and outcomes in each referral pathway, including target pathway referrals for suspected cancers, emergency presentations, routine referrals, and incidentally discovered cancers during screening. Methods A retrospective study of colorectal cancer (CRC) patients operated on between January 1, 2010, and December 31, 2014, with records dating to the end of the five-year follow-up, was extracted anonymously from the database of CRC outcomes at the North Middlesex University Hospital NHS Trust, London. The total number of patients operated on through the four pathways was 176, with full records and competent follow-ups. Patients were classified according to the mode of referral: two-week wait (2WW or target), routine, emergency, and incidental discovery referrals. Comparisons were made between these groups with regard to personal and tumour characteristics, management, and outcome. Results It has been demonstrated by this study that targetreferrals present mainly with stage I cancers as compared to emergency referrals that present with more stage II (IIa+ IIb+ IIc). The highest percentage of cancer locations within the large bowel was rectal, followed by sigmoid in both target and emergency groups; 8.8% of target patients needed neoadjuvant chemoradiotherapy in the form of FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin) chemotherapy protocol with the addition of radiotherapy in patients with advanced rectal cancers, compared to 13.3% of emergency patients. Conclusion The colorectal 2WW system was the main pathway supplying colorectal cancer operations; it mostly showed earlier cancers than the other referral groups; its cancers were mostly rectosigmoid with less need for adjuvant chemotherapy; fewer recurrences; and it also showed a lower five-year mortality rate than the emergency group.

Ventricular penetration with a rigid drainage catheter as a procedural complication caused by space‐occupying intrathoracic mass with significant cardiac displacement in a dog

AbstractA 3‐year‐old, female, entire labrador retriever was presented as an emergency referral for suspected iatrogenic cardiac trauma during thoracostomy tube placement for perceived pyothorax. The patient initially presented for non‐specific lethargy and anorexia and upon investigations was found to have a mass on the external thoracic wall and what appeared to be a large‐volume pleural effusion. During thoracostomy drain placement, fresh, clotting blood was aspirated through the drain. The patient was haemodynamically stable on arrival at the referral centre with a normal electrocardiogram. Imaging revealed penetration of the left ventricular free wall and septum and significant displacement of the heart due to a large intrathoracic space‐occupying mass. Cytology of the mass was suggestive of soft tissue sarcoma. The patient was euthanased.

National Cancer Diagnosis Audits for England 2018 versus 2014: a comparative analysis.

Timely diagnosis of cancer in patients who present with symptoms in primary care is a quality-improvement priority. To examine possible changes to aspects of the diagnostic process, and its timeliness, before and after publication of the National Institute for Health and Care Excellence's (2015) guidance on the referral of suspected cancer in primary care. Comparison of findings from population-based clinical audits of cancer diagnosis in general practices in England for patients diagnosed in 2018 or 2014. GPs in 1878 (2018) and 439 (2014) practices collected primary care information on the diagnostic pathway of cancer patients. Key measures including patient characteristics, place of presentation, number of pre-referral consultations, use of primary care investigations, and referral type were compared between the two audits by descriptive analysis and regression models. Among 64 489 (2018) and 17 042 (2014) records of a new cancer diagnosis, the percentage of patients with same-day referral (denoted by a primary care interval of 0 days) was higher in 2018 (42.7% versus 37.7%) than in 2014, with similar improvements in median diagnostic interval (36 days versus 40 days). Compared with 2014, in 2018: fewer patients had ≥3 pre-referral consultations (18.8% versus 26.2%); use of primary care investigations increased (47.9% versus 45.4%); urgent cancer referrals increased (54.8% versus 51.8%); emergency referrals decreased (13.4% versus 16.5%); and recorded use of safety netting decreased (40.0% versus 44.4%). In the 5-year period, including the year when national guidelines were updated (that is, 2015), there were substantial improvements to the diagnostic process of patients who present to general practice in England with symptoms of a subsequently diagnosed cancer.

A comparison of the Sepsis-2 and Sepsis-3 definitions for assessment of mortality risk in dogs with parvovirus.

To evaluate the use of a modified Sepsis-3 (mSepsis-3) definition compared to the currently used modified Sepsis-2 (mSepsis-2) definition to determine whether the mSepsis-2 or mSepsis-3 stratifications were able to identify populations of dogs ultimately more likely to die from canine parvovirus (CPV) infection. Retrospective, January 2009 to March 2020. A private, small animal, urban, referral emergency and specialty hospital. Fifty-nine client-owned dogs hospitalized for treatment of CPV. None. Dogs were divided into mSepsis-2 and mSepsis-3 categories based on the highest level of illness severity reached during hospitalization. Greater illness severity based on mSepsis-2 criteria (ie, sepsis, severe sepsis, septic shock) was associated with an increase in average length of stay (P<0.001), increase in average cost of stay (P<0.01), and presence of leukopenia (P<0.05). An increase in illness severity within the mSepsis-2 criteria was not associated with hyperlactatemia (P=0.29), presence of neutropenia (P=0.12), or mortality (P=0.35). Greater illness severity based on mSepsis-3 criteria (ie, infection only, sepsis, septic shock) was associated with an increase in mortality (P<0.05), increase in average length of stay (P<0.001), increase in average cost of stay (P<0.01), presence of leukopenia (P<0.01), and presence of neutropenia (P<0.05). The mSepsis-3 criteria were not associated with the presence of hyperlactatemia (P=0.68). There was no significant difference between survivors and nonsurvivors in the presence of leukopenia (P=0.19), neutropenia (P=0.67), or hyperlactatemia (P=0.58). The mSepsis-3 diagnostic criteria appear to better identify dogs with CPV at higher risk for mortality compared to the mSepsis-2 criteria.

Malignant upper urinary tract obstruction: A prospective evaluation of patients presenting as an emergency to urology and their long-term real-life outcomes

Objective: The objective of this study was to evaluate the management and survival outcomes of patients referred to urology as an emergency with malignant upper urinary tract obstruction (MUUTO). Patients and Methods: Between 2019 and 2020, the outcomes of all emergency referrals with MUUTO to the Urology team at a single institution were prospectively analysed. Results: In total, 119 patients, median age 77 years, were referred to the urology team with MUUTO. Of these, 59% (70/119) had bilateral and 41% (49/119) unilateral obstruction. The three commonest primary underlying malignancies were bladder (41% (49/119)), prostate (19% (23/119)), and colorectal (8% (10/119)) cancer. The commonest indication for referral was acute kidney injury (86% (103/119)), the remainder had sepsis (13% (15/119)), and pain (1% (1/119)). Median in-patient stay for the admission was 7 days. Median estimated glomerular filtration rate (eGFR/1.73 m2) measured on discharge improved irrespective of whether intervention for MUUTO was received. Overall survival of the cohort was 13% (16/119). Conclusions: Patients referred with MUUTO as an emergency have a poor prognosis. Renal function does not significantly deteriorate in the short term in this patient group with no intervention, and overall survival is not significantly improved after intervention unless further treatment is received. Multidisciplinary team discussion, including patients and oncologists, should be best practice before intervention in this challenging situation. Level of evidence: 2b

Nurse Experience in Making Inter-Island Referrals for Emergency Patients: A Phenomenological Study

Making referrals for emergency patients is an activity that a nurse must do in remote areas. Referrals with trips that must pass by land and sea that take a long time will definitely encounter many obstacles and hindrances. Unpredictable obstacles experienced by a nurse in making referrals include accidents, port closures, and tidal waves. This study aimed to explore the experiences of nurses in making inter-island emergency referrals. This study is an interpretive qualitative research of phenomenology. The sampling technique used purposive sampling with criteria for nurses who had made inter-island emergency referrals. The participants were 25 nurses, with saturated data on the 14th participant. The process of collecting data was in-depth interviews until no new or saturated answers were found. From the results of the study, there were 3 themes, namely nurses' feelings (sad, happy, dejected, anxious, irritated, angry), obstacles (preparation, process, handover), and expectations (means, honorarium, energy, ease of transfer). Therefore, in the referral process, competent nurses, adequate facilities and infrastructure during trips, and the ability to communicate with various parties to ensure a smooth referral process must be prepared.

Emergency referrals to a paediatric dental A&amp;E service in London: where do we stand post-pandemic?

Introduction The paediatric dentistry department at St Thomas’ Hospital transformed its walk-in emergency service to an urgent dental centre during the COVID-19 pandemic, accepting referrals via the NHS 111 service. There are conflicting ethical duties for tertiary care clinicians managing paediatric dental patients. This study measured the current activity levels of the dental emergency service at St Thomas’ Hospital, the appropriateness of NHS 111 referrals, the proportion of referrals accepted for care and the outcomes of those accepted referrals. Methods A retrospective service evaluation was undertaken including 125 patients referred by the NHS 111 service to the dental emergency clinic at St Thomas’ Hospital between 1 September and 29 October 2021. Results Half (50%) of the patients seen were aged between 0 and 5 years. A quarter (24%) of referrals were true dental emergencies. Patients were referred for isolated dental pain (58%), facial swelling (25%), trauma (13%), broken fillings (3%) and other conditions (2%). Three-quarters (74%) were accepted for treatment. Most accepted patients were added to waiting lists for treatment under general anaesthesia (66%), local anaesthesia (5%) or inhalation sedation (4%). Two-thirds of accepted patients (67%) were not registered with a dentist while over three-quarters of rejected patients (79%) had their own dentist in primary care. Conclusions Following the pandemic, paediatric dental emergency services continue to be overwhelmed by children requiring non-urgent dental care. Solutions to deteriorating patient access are crucial, ensuring that provision of care remains ethical and that those who require urgent dental care are prioritised.

Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records

BackgroundThe provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women’s homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births.MethodsWe assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019–20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019.ResultsThe percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days.ConclusionsThe increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

Six-Month Clinical and Ecological Momentary Assessment Follow-Up of Patients at High Risk of Suicide

Objective: In this study, we combined ecological momentary assessment (EMA) with traditional clinical follow-up to explore correlates of suicidal relapse in patients with a history of suicidal behavior. Methods: Over 6 months, we followed up with 393 patients who completed baseline and follow-up interviews and were monitored through smartphone-based EMA via the MEmind app. Recruitment was conducted between February 2018 and March 2020. We recorded the occurrence of clinical suicidal events and EMA suicidal events, the latter defined as extreme scores on questions on passive suicide ideation. Results: Fifteen percent of participants had a new clinical suicidal event during follow-up (9.2% suicide attempt ; 5.9% emergency referral for suicidal ideation ). Of the 319 participants who installed the MEmind app, 20.7% presented with EMA suicidal events. EMA suicidal events were statistically significantly associated with clinical suicidal events at 2-month follow-up but not at 6-month follow-up. In the Cox multivariate regression model, 5 factors were independently associated with clinical suicidal events: number of previous SAs, SA in the past year, SA in the past month (risk factors), female gender, and age (protective factors). Conclusions: Our study confirms some of the risk factors classically associated with risk of suicide reattempt, such as history of suicidal behavior, while questioning others, such as female gender. Risk factors associated with EMA events differed from risk factors associated with traditional clinical suicide events, supporting the existence of distinct suicidal phenotypes.

Comparison of Maternal and Perinatal Outcomes of Pregnancy with Systemic Lupus Erythematosus in Planned Referrals Compared to Emergency Referrals Based on the Maternal Fetal Triage Index at Dr. Kariadi General Hospital, Semarang, Indonesia

Background: Systemic lupus erythematosus (SLE) is an autoimmune disease that attacks the skin and the musculoskeletal, kidney, neuropsychiatric, hematological, cardiovascular, pulmonary, and reproductive systems. In pregnancies with SLE, early referral to the hospital with the involvement of obstetricians and rheumatologists, and other specialists as needed, as well as individual management plans, regular reviews, and early recognition of flares and complications, are important. This study aimed to determine the differences in maternal and perinatal outcomes referred by planned referrals compared to emergency referrals, especially in pregnant patients with SLE.&#x0D; Methods: This study was an analytic observational study with a retrospective cohort approach. A total of 40 subjects participated in this study. Data analysis using SPSS software was carried out univariate and bivariate to examine the relationship between types of referrals and maternal and perinatal outcomes.&#x0D; Results: There were significant differences between the types of emergency referrals and planned referrals in the variable incidence of preeclampsia and SLE exacerbations. There were no significant differences between the types of emergency referrals and planned referrals on the variable incidence of lupus nephritis, maternal death, premature delivery, fetal growth restriction, fetal death, and the incidence of neonatal lupus syndrome.&#x0D; Conclusion: The incidence of severe preeclampsia and SLE exacerbation was lower in planned referrals compared to emergency referrals in pregnant patients with SLE at Dr. Kariadi General Hospital, Semarang, Indonesia.

HPB P56 Outcomes of laparoscopic versus percutaneous cholecystostomy in high-risk patients with acute calculus cholecystitis

Abstract Background Around 10–15% population in the UK have gallstones. (1) Gall stone related disease account for 1/3rd of the emergency surgical admissions and referrals. (2) Acute cholecystitis, which is the inflammation of the gall bladder can develop in 1–3% of these patients. (3) Without treatment, acute cholecystitis may resolve spontaneously within 1–7 days. However, 25–30% of people will require surgery or develop complications. (4) Laparoscopic cholecystectomy is the standard technique for management of acute cholecystitis. However, in the patients who are high risk, LC can result in significant mortality and morbidity. According to the Dutch guidelines for management of Gall Bladder stones disease, high risk patients such as those with multiple comorbidities or those who present with sepsis, LC is not the best management option. (5) In such patients percutaneous cholecystostomy (PC) is sometimes accepted as a bridge to the definitive management. (6) (7) Percutaneous image guided cholecystostomy is a safe and important in such scenarios. However, in those patients who present to the hospital at occasions during which interventional radiology service is not available, laparoscopic cholecystostomy would remain a safe and efficient temporary alternative for management of acute cholecystitis not responding to medical treatment. (8) Methods A retrospective analysis of the 29 patients who were admitted in our hospital and had cholecystostomy between 2015–2021 was done. Eleven (11) patients had Laparoscopic cholecystostomy were allocated to Group A and ten 18 patients who underwent US guided cholecystostomy were assigned to Group B. The data was collected regarding the timing of procedure (Day/Night), 30 days and 1 year mortality, duration of hospital stay, Rate of dislodgement/blockage of cholecystostomy tube and outcome after procedure (definitive management, planned cholecystectomy). Inclusion criteria: High risk patients with multiple comorbidities (ASA 2–4) who presented with acute cholecystitis and underwent laparoscopic cholecystostomy after failed conservative management were included in this study. Exclusion criteria: Those patients who had either hepato-pancreatic-biliary malignancy (HPB) or ascites, and those who underwent open cholecystostomy were excluded from the study. Results In group A, 7 patients were females and 4 were males while in Group B, 9 patients were females and 9 were males. 8 patients in group A had the procedure over night while only 3 patients had the procedure during day while in group B, only 1 patient had procedure during the night and the rest of them had procedure during the day. All the patients in group A had their cholecystectomy except one who died within 30 days of the cholecystostomy. In group B, only 6 patients had further LC while 12 patients did not require further operation. Out of all the patients, only 1 patient in each group died within 30 days after the procedure. None of the patients experienced one year mortality after the procedure in group A whereas, in group B, 7/18 patients died within 1 year after the procedure. Dislodgment of drain occurred in 2/11 patients in the group A and 4/18 patients in the group B. None of the patients in both the groups A &amp; B had any post cholecystostomy complications. Conclusions This study concludes that Laparoscopic cholecystostomy can be as a viable alternative to open cholecystectomy in technically difficult cases and alternative to percutaneous cholecystostomy in hospitals without interventional radiology services or during the times when IR services are not available.

188. Review of a regional paediatric trauma service

Sheffield Children’s NHS Foundation Trust (SCH) is a paediatric major trauma centre, covered by a regional on-call oral and maxillofacial surgery (OMFS) team. Referrals are taken from across South Yorkshire and North Derbyshire. We carried out a retrospective review of all emergency referrals to OMFS to establish indications for referral and review management.

Dam-mediated flooding impact on outpatient attendance and diarrhoea cases in northern Ghana: a mixed methods study

BackgroundFloods are the most frequently occurring natural disaster and constitute a significant public health risk. Several operational satellite-based flood detection systems quantify flooding extent, but it is unclear how far the choice of satellite-based flood product affects the findings of epidemiological studies of associated public health risks. Few studies of flooding’s health impacts have used mixed methods to enrich understanding of these impacts. This study therefore aims to evaluate the relationship between two satellite-derived flood products with outpatient attendance and diarrhoeal disease in northern Ghana, identifying plausible reasons for observed relationships via qualitative interviews.MethodsA convergent parallel mixed methods design combined an ecological time series with focus group discussions and key informant interviews. Through an ecological time series component, monthly outpatient attendance and diarrhoea case counts from health facilities in two flood-prone districts for 2016–2020 were integrated with monthly flooding map layers classified via the Moderate Resolution Imaging Spectroradiometer (MODIS) and Landsat satellite sensors. The relationship between reported diarrhoea and outpatient attendance with flooding was examined using Poisson regression, controlling for seasonality and facility catchment population. Four focus group discussions with affected community members and four key informant interviews with health professionals explored flooding’s impact on healthcare delivery and access.ResultsFlooding detected via Landsat better predicted outpatient attendance and diarrhoea than flooding via MODIS. Outpatient attendance significantly reduced as LandSat-derived flood area per facility catchment increased (adjusted Incidence Rate Ratio = 0.78, 95% CI: 0.61–0.99, p < 0.05), whilst reported diarrhoea significantly increased with flood area per facility catchment (adjusted Incidence Rate Ratio = 4.27, 95% CI: 2.74—6.63, p < 0.001). Key informants noted how flooding affected access to health services as patients and health professionals could not reach the health facility and emergency referrals were unable to travel.ConclusionsThe significant reduction in outpatient attendance during flooding suggests that flooding impairs healthcare delivery. The relationship is sensitive to the choice of satellite-derived flood product, so future studies should consider integrating multiple sources of satellite imagery for more robust exposure assessment. Health teams and communities should plan spatially targeted flood mitigation and health system adaptation strategies that explicitly address population and workforce mobility issues.

Is conservative treatment efficient in isolated retropneumoperitoneum of sigmoidal origin?

Sigmoidal diverticulitis is a regular reason for emergency referral. Although the treatment is well established, we describe an unusual complication that raises concerns about its etiopathogeny and treatment: an isolated pneumoretroperitoneum complicating a sigmoidal diverticulitis.

The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa.

Paediatric intensive care, a valuable resource that improves the outcomes of critically ill children, is often scarce. To evaluate the need for paediatric intensive care beds and compare the outcomes of admitted and non-admitted deserving cases. A prospective evaluation of all bed requests, in terms of need for intensive care and outcomes of those admitted and not admitted to a paediatric intensive care unit (PICU), was performed between July 2017 and June 2018. Factors for refusal and for poor outcomes were evaluated. Of the 811 bed requests, 32.6% (n=264, p<0.001) were denied access. Of the 231 deserving cases who were denied access, 85.7% (n=198) were due to unavailability of a PICU bed. Patients not admitted to PICU had a twofold increased risk of dying compared with those admitted (34.4% v. 15.5% respectively, p<0.001), even though the patient characteristics of both groups were similar (age, gender and nutritional status). In those admitted, risk factors for mortality were requiring transfusion of blood and platelets (56.0%, p<0.001), requiring two or more inotropes (52.5%, p<0.001), instability on admission (41.3%, p<0.001), prior cardiac arrest (32.0%, p=0.021), severe acute malnutrition (26.9%, p=0.043), fungal infection (22.2%, p=0.004) and emergency admission (18.0%, p<0.001). In those not admitted, prior cardiac arrest (100%, p<0.001) and emergency referral (42.3%, p<0.001) were associated with adverse outcomes. The need for PICU beds exceeds availability, with a consequent twofold increase in mortality among cases not admitted to PICU. Paediatric critical care services have increased at appropriate sites of need following completion of this study.

ANALYSIS IMPLEMENTATIONS OF MATERNAL AND NEONATAL REFERAL NETWORK INFORMATION AT PUSKESMAS TANAH TINGGI TANGERANG BANTEN

One of the efforts to reduce the maternal mortality rate (MMR) is to adopt the EMAS (Expanding Maternal And Neonatal Survival) program SIJARIEMAS (Information System for Maternal and Neonatal Referrals in the prevention of '3 Too Late. This study aims to obtain an overview of the implementation of SIJARIEMAS in terms of sources. Human resources, the availability of facilities and infrastructure, as well as procedures at the Tanah Tinggi Public Health Center. The research was carried out using the Rapid Assessment Procedure (RAP), a technique of collecting data using a quick assessment to obtain in-depth and relatively brief information. These are Doctors on Watch, Midwives, and Nurses. The data were collected with 3 focus group discussions. The data were analyzed descriptively. The results showed that officers still found it difficult to refer patients to the hospital due to the long response of the SIJARIEMAS Call Center in finding a hospital. There are still officers who do not follow the referral soup. Obstacles faced by officers in making emergency referrals resulted in delays in handling that could lead to death. Conclusion: SIJARIEMAS makes referrals easier, but the response of the old SIJARIEMAS call center, Puskesmas officers, still deviates from the SIJARIEMAS procedure. Efforts are needed to improve call center response and services by Puskesmas officers.

Health services during Covid-19: What do we know of the degree of service disruption and size of the backlogs?

Abstract Since the onset of the COVID-19 pandemic, there have been concerns that shifting health system capacities towards acute COVID-19 cases can affect the provision of non-COVID-19 essential health services, causing severe disruptions and lack of care. Examples of this have been seen during other epidemic outbreaks, such as the 2014-2016 Ebola outbreak in West Africa. To capture the degree of service disruption across the European and Central Asian region, we analysed data from the World Health Organization's Pulse Survey on the Continuity of Essential Health Services, conducted in three rounds in 2020 and 2021. The key findings include: – Health service provision has been heavily disrupted in virtually all countries. 91% of countries reported service disruptions in late 2021, indicating that health services continue to be disrupted at large scale. – Service discontinuation has been substantial across all levels of care and in most service areas, often resulting in delays and cancellations of elective and emergency procedures, routine visits, prescription renewals, and referrals to specialty care. This has led to growing backlogs and record waiting times for services. – Countries have been affected to varying degrees and report different levels of service disruption, size of the backlog, recovery of services aiming for pre-pandemic levels, and interventions to manage waiting lists. The findings indicate that even as health systems are better learning to care for acute COVID-19 patients, the pandemic's impact on essential health services is massive and likely to affect the care for people's health and well-being post the acute phase of the public health emergency. Measuring the size of backlogs and implementing innovative care solutions are urgent and paramount.

A service evaluation of the management of patients with suspected cauda equina syndrome from an outpatient physiotherapy service in the United Kingdom

BackgroundThe expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources. AimTo evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome. DesignService evaluation with an embedded case series of patients with radiological CES. MethodThe records of patients who were identified by their outpatient physiotherapists as having suspected CES (n-231) over a 27-month period were included. Data was extracted from patients’ medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series. ResultsIn 79% of cases, it was decided that emergency referral was not required. The remaining 21% of patients were referred to the emergency department and 49% of these had an emergency MRI. In the case series of seven patients with cauda equina compression on MRI, four patients had a disc bulge and underwent emergency surgery. One patient had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis. Two patients had stenosis and decided against surgical intervention. ConclusionsFindings from this service evaluation suggest support for the use of safety netting and an effective communication chain to facilitate effective management of patients with suspected CES.