Patterns, Predictors and Outcome of Time to Presentation among Critically Ill Paediatric Patients at Emergency Department of Muhimbili National Hospital, Dar Es Salaam

Abstract

Background: On a global scale, half of the deaths among children under 5 years occur in SubSaharan Africa with 1 in 13 children dying before they reach their fifth birthday. One factor contributing to these early deaths, that has been suggested in prior studies in other countries, is the timeliness of presentation to the hospital. However, little is known about the patterns, predictors, outcome and the association between time to presentation and mortality among critically ill children who present to tertiary health care facilities for definitive care in limited resource settings. Aim: To determine the patterns and predictors of time to presentation of critically ill paediatric patients aged 28 days to 14 years attending MNH ED, and the association between time to presentation and mortality. Method: A hospital based prospective descriptive cohort study of critically ill paediatric patients aged 28 days to 14 years with level 1 triage at MNH ED from September 2019 and January 2020. A structured case report form was used to document demographics, timing of presentation and clinical course of critically ill children attending MNH ED. Data was transferred to and analysed by SPSS software version 26. Descriptive analysis was summarized as frequencies and median with interquartile range (IQR). The principal component analysis was used to manage the wealth index. Delay was considered presentation to the ED more than 48 hours from the onset of the current illness. Overall proportion of delayed critically ill paediatric patients was calculated and contingency tables were made for bivariate analysis to explore the associated factors. Relative risk was carried out to measure the relationship between delay and the primary outcome of mortality. Results: A total of 440(59.1%) paediatric patients triaged ESI level 1 were enrolled into the study. The median age was 12 [IQR =9-60] months and 63.9% were males. The median time from onset of illness to arrival at the MNH ED was 3 days [IQR=1-5]. The proportion of critically ill paediatric patients with delayed presentation to the ED was 249 (56.6%). Age, type of referral and belonging to the poorest socioeconomic status were independent predictors of timeliness of presentation. Those who were below 1 year had 2.2 times increased odds of (OR=2.2 (95%CI 1.3-3.8) presenting late to the MNH ED. Critically ill paediatric patients who were referred from facilities were more likely to be delayed whilst presenting to the ED (OR=1.8 (95% CI 1.1-2.8). The poorest socioeconomic status was 2.24 times more likely to present late to the ED (OR=2.4 (CI:1.2-4.8) The overall proportion of 30-day in-hospital mortality was 99(26.5%). Out of these, 64(29.5%) presented late to the ED compared to 35(22.3%) who came early. Those who presented late to the ED were 1.3 times more likely to die than those who presented early (RR=1.3, CI: 0.9-1.9). Delay was significantly associated with late (>24 hours) in-hospital mortality (P-value=0.021). Conclusion: Delayed presentation to the ED of more than two days from onset of illness was associated with a high rate of late mortality of children who were admitted in the wards. A larger study is needed to evaluate the care pathway of critically ill paediatric patients to identify preventable failures in the care provided before reaching a tertiary level of care.