DHECARE - Dhulikhel Emergency Care study - PhD

Emergency diseases or conditions contribute to substantial disease burden, disabilities and deaths. Globally in 2015, 28.3 million deaths were due to emergency medical diseases, and the burden in low-income countries (LICs) is 4.4 times that of high-income countries (HICs). However, emergency health care systems in many LICs, and in Nepal, are underdeveloped. Knowledge of emergency patient characteristics is essential to consolidating and strengthening emergency health care systems. Despite this necessity, few reports have provided high-quality data regarding the emergency population in Nepal. This project aimed to describe the characteristics of emergency patients presented to Dhulikhel Hospital (DH) in Nepal. In addition, we aimed to evaluate mortality at 90 days after emergency care and associated mortality risk factors. We established an electronic emergency patient registry system and introduced a triage system to the emergency department (ED) of DH. Patients seeking emergency care from September 2013 to December 2016 and registered into the emergency patient registry were included in the study. Patient households were followed up at 90 days after emergency care to assess mortality after emergency care by structured telephone interviews. In the first study, we assessed the burden of emergency patients to DH during the 2015 earthquakes in Nepal. We observed a high caseload in the first few days, and the patient burden was particularly high before the international field hospitals were established. The proportions of severely injured patients and hospital mortality were relatively low, indicating that the most severely injured patients probably did not reach the hospital. The implementation of the simplified triage system was used for patient management and timely treatment according to severity. In the second study, we described characteristics of adult patients seeking emergency care at DH and assessed mortality at 90 days after emergency care. We observed that nearly one-third of the patients presented with injuries and that the majority of these were young men. Mortality after emergency care was more than 20-fold the ED mortality. Nearly one in four patients with respiratory and cardiovascular complaints died within 90 days after emergency care. The highest mortality was in individuals with chronic lung disease. Illiteracy and exposure to both tobacco smoke and traditional cooking stoves were strong determinants for mortality after emergency care in women but not in men. The third study describes patient characteristics, distribution of triage categories and mortality at 90 days after emergency care in children (≤16 years) at DH. The majority of paediatric emergencies were injuries and infections. Emergency health care-seeking among girls was less frequent compared to boys, but mortality after emergency care was higher among girls and among infants. Red and orange triage categories were strongly associated with intensive care treatment and mortality after emergency care. This study was performed in a Nepalese hospital, and, to our knowledge, it is the first study to describe in detail the characteristics and severity of a large number of patients seeking emergency care in Nepal. The findings from this study highlight the need to strengthen local health care systems to ensure that they are capable of managing natural disasters such as earthquakes while also maintaining adequate regular medical care. The high proportions of injured patients in a relatively young population underline a need to prioritize injury prevention programs at national levels and to strengthen organized trauma services in health care facilities. Our findings on mortality after emergency care are new and indicate an urgent need for more follow-up studies in similar settings. The local experience may support the use of triage systems, the need to establish follow-up systems after hospital discharge and the need for interventions that can reduce mortality after emergency care. The information provided by the current project may be used to develop cost-effective interventions, better resource allocation, infrastructure development, training needs, and inferences for policymakers to standardize ED and underlines a need for investments in strengthening the health care system. Research-based knowledge must be used by policymakers, health care providers and managers. This project highlights the need to strengthen emergency health care beyond ED care and for further studies that include multiple sites.