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Brought in dead cases to a tertiary referral paediatric emergency department in India: a prospective qualitative
Kumar Praveen1, Karthi Nallasamy1, Muralidharan Jayashree1
1Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Insights
Social and system factors contribute to children presenting as brought in dead (BID). Improving the referral process and transport to hospital care can reduce mortality in pediatric emergency departments.
Area of Science:
- Pediatric Emergency Medicine
- Public Health
- Health Systems Research
Background:
- Brought in dead (BID) presentation in children is influenced by prehospital factors, including disease-related, social, and system determinants.
- Understanding these factors is crucial for identifying gaps in healthcare services and improving outcomes.
Purpose of the Study:
- To identify prehospital variables associated with brought in dead (BID) presentation in children.
- To recognize gaps in health services contributing to BID cases in a pediatric emergency department.
Main Methods:
- Prospective enrollment of 100 children aged 12 years or younger presenting in cardiac arrest between April 2016 and March 2017.
- Data collection from referral documents, parent interviews, and field observations at referring facilities in North India.
Main Results:
- 55% of BID cases were neonates; low birth weight and malnutrition were common. Breathing difficulty was the most frequent symptom.
- Most children (89%) were referred from other facilities due to progressive illness severity or lack of expertise. Ambulance transport averaged 80 km and 120 minutes.
- Cardiopulmonary resuscitation (CPR) was rarely initiated during transport, with only two cases achieving return of spontaneous circulation at the referral center.
Conclusions:
- Social and system-related factors significantly contribute to children presenting as brought in dead (BID).
- Streamlining referral processes and improving transport-linked hospital care can reduce decompensated referrals.
- These improvements have the potential to decrease child mortality in pediatric emergency settings.
Objectives:
Brought in dead (BID) presentation is profoundly related to prehospital variables including disease-related determinants and social and system-related factors. Identifying these factors would help us recognise various gaps in health services.
Setting:
Tertiary paediatric emergency department (ED) in north India.
Patients:
Children aged 12 years or younger presented in cardiac arrest between April 2016 and March 2017 were prospectively enrolled irrespective of outcome of cardiopulmonary resuscitation (CPR). Data were collected from multiple sources including referral documents, direct interview from parents and field observations at the referring facility.
Results:
Of 100 BID cases enrolled, 55 were neonates. Low birth weight (n=43, 78%) and malnutrition (n=31, 69%) were respectively common in neonates and postneonatal children. The most frequent symptom was breathing difficulty (n=80). Common diagnoses included respiratory distress syndrome (n=21, 38%), birth asphyxia (n=19, 35%) and sepsis (n=11, 20%) in neonates, and pneumonia (n=11, 25%), congenital heart disease (n=6, 13%) and acute gastroenteritis (n=5, 11%) in postneonatal children. Eighty-nine cases were referred from another healthcare facility, majority after first healthcare contact (n=77, 87%). Progressive severity of illness (n=61, 71%) and lack of expertise for acute care (n=35, 39%) were the common reasons for referral. Ambulance (n=77) was the most common mode of transport; median (IQR) distance and duration of travel were 80 (25-111.5) km and 120 (60-180) min, respectively. Respiratory support during transport included supplemental nasal oxygen (n=41, 46%) and bag and tube ventilation (n=30, 34%). Clinical deterioration was recognised in 62 children during transport, only five received CPR en route. Ninety-five children underwent CPR at the referral centre, two had return of spontaneous circulation.
Conclusion:
Social and system-related factors contribute to children presenting to ED in BID state. Streamlining the referral process and linking transport to hospital care could reduce decompensated referrals and thereby decrease child mortality.
