Epidemiology and clinical characteristics of adult patients presenting to a low resource, tertiary care emergency department in Pakistan: Challenges & Outcomes

Failure rate of the pulmonary embolism rule-out criteria rule for adults 35 years or younger: Findings from the RIETE Registry

BACKGROUND

The use of a computed tomography pulmonary angiogram to diagnose pulmonary embolism (PE) has increased, leading not only to higher PE diagnoses but also to overdiagnosis and unnecessary radiation exposure, even in young patients despite a lower PE incidence. The aim of this study was to assess the failure rate of the pulmonary embolism rule-out criteria 35 (PERC-35) rule developed to reduce unnecessary testing in individuals aged ≤35 years among patients included in the Registro Informatizado de la Enfermedad TromboEmbolica Venosa (RIETE) Registry.

METHODS

This retrospective cohort study used data from the RIETE Registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the missed PE rate using PERC-35 criteria. Secondary outcomes included the comparison of demographic and clinical characteristics, PE localization, treatment strategies, and outcomes between PERC-negative (PERC-35N) versus PERC-positive (PERC-35P) patients.

RESULTS

Of 58,918 adult patients with acute PE, the PERC-35 rule demonstrated a low missed PE rate of 0.35% (n = 204), with an upper 95% confidence interval [CI] of 0.40%. The missed rate was 7.0% (95% CI 6.0%-7.9%) in the 18- to 35-year subgroup. Compared to PERC-35P patients, PERC-35N patients were younger (mean age 28.4 years), with a lower body mass index, and included a higher proportion of pregnant/postpartum women. PERC-35N patients had a significantly lower rate of chronic diseases and presented less frequently with dyspnea or syncope but more often with chest pain. They showed lower rates of positive D-dimer and troponin levels. PERC-35N patients experienced fewer major bleeding episodes, similar recurrence rates of PE/deep vein thrombosis, and no deaths during anticoagulation.

CONCLUSIONS

The PERC-35 rule demonstrated a low failure rate to exclude PE in patients aged 18-35 years and could reduce imaging and radiation exposure in young patients with a low PE pretest probability if confirmed prospectively.

Code Not-So-Blue: Burden and Predictors of Non-urgent Visits to the Surgical Emergency Room in Peshawar, Pakistan

BACKGROUND

Non-urgent visits to surgical emergency rooms (SERs) are an unnecessary burden on emergency health services, especially in low-resource settings. The aim of this study was to quantify the burden and determine predictors of non-urgent surgical ER visits in a tertiary care setting.

METHODS

This is a prospective analysis of the non-urgent visits in our SER over a 15-day period. We included patients of all ages and genders who presented to the SER at the time of data collection. Patients were excluded if they were detained, dead on arrival, or refused to consent. Patients were stratified into two groups based on the surgical urgency: group U (urgent) and group NU (non-urgent), and compared for the baseline characteristics, comorbid conditions, and referral route. Multivariable analyses were used to identify the independent predictors of these non-urgent presentations while controlling for potential confounders.

RESULTS

Non-urgent visits accounted for 147 (35%) of all visits and were associated with younger age, female sex, rural residence, low income, and limited education (p<0.001). Most non-urgent cases were triage-referred (110 (74.8%), p=0.012). Diabetes mellitus (DM) and obesity were more common in urgent cases (p<0.05). Independent predictors of non-urgent visits included female sex (adjusted odds ratio (aOR): 1.50, 95% CI (1.10 - 2.05), p = 0.020), rural residence (aOR: 1.30, 95% CI (1.02 - 1.65), p < 0.040), low income (aOR: 1.40, 95% CI (1.05 - 1.88), p = 0.030), and chronic kidney disease (CKD) (aOR: 1.80, 95% CI (1.10 - 3.20), p = 0.040).

CONCLUSION

Our study identified the common predictors of non-urgent SER visits in our settings, such as younger age, rural residence, poor socioeconomic status, and lower education level. Combined efforts should focus on improving the triage protocols, access to primary care, patient education, and public health initiatives. Further research should also assess the effectiveness of urgent care clinics and telemedicine in reducing non-urgent ER presentations.

Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia

Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.

Research contributions by Indus Hospital Health & Network faculty

doi: https://doi.org/10.12669/pjms.40.2(ICON).9129 How to cite this: Jawid SA. Research contributions by Indus Hospital Health & Network faculty. Pak J Med Sci. 2024;40(2):S1-S2. doi: https://doi.org/10.12669/pjms.40.2(ICON).9129 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.