This study describes the characteristics, chief complaints, management, and health outcomes of children seeking unscheduled acute care at two public referral hospitals in Cambodia. Our findings provide essential information to inform emergency care provider education and guide development of emergency care systems in Cambodia and other LMICs.
Top chief complaints in this study (fever, respiratory problems, abdominal pain, vomiting, and diarrhea) are similar to other published reports characterizing unscheduled or ED pediatric presentations in other LMICs [6, 8, 19, 20]. The top five chief complaints in our population accounted for 75% of all reported complaints. In contrast to several other studies, the percentage of ED visits attributed to trauma in this study (2.8%) was substantially lower. For example, trauma among children presenting for emergency care accounted for 27–29% of visits in Korea and Malaysia and 25% of visits in the USA [8, 21, 22]. The underrepresentation of trauma in our study may have been due to the presence of an NGO-run trauma hospital near the study sites, which might have received the bulk of trauma patients. The top chief complaints in our and other studies often have infectious etiologies [23, 24]. While infections such as pneumonia, diarrhea, and malaria are the leading contributors to mortality in children under 5 years worldwide, [25] infectious symptoms also account for a large percentage of ambulatory care-sensitive conditions [26].
Of the top ten chief complaints identified in the present study, only half match the list of top complaints documented in an analogous population of adults [5]. These results mirror data from EDs in the USA, which similarly show that the frequency and distribution of pediatric chief complaints differ markedly from adults [9]. The unique distribution and frequency of presentations in children with undifferentiated conditions compared to adults in LMICs underscores the need for specialty training that specifically addresses pediatric emergencies.
Regarding pre-hospital care, only 2.9% of patients in our study arrived by ambulance, compared to 15–17% in other studies in LMICs [27, 28]. Low frequency of ambulance transport—despite more than one quarter of all unscheduled patients coming from another care provider—reflects the relative underdevelopment of Cambodia’s regional pre-hospital and EMS systems. Currently, laypeople provide most patient transfers in Cambodia. Low-cost, community-based interventions aimed at equipping laypeople with first aid skills and facilitating transport have shown promise in South Africa [29].
Vital signs, which provide low-cost, objective data that can help prioritize patients during triage and guide initial therapy, were not measured or recorded in nearly one quarter of enrolled patients. Emphasis on obtaining vital signs should be included in all training for emergency care providers to improve management for pediatric patients presenting for acute care.
We also observed that respiratory complaints and fever were the two most common complaints, yet diagnostic chest X-rays (CXR) were infrequently performed, even for admitted patients. Furthermore, despite the high prevalence of tuberculosis in Cambodia (817/100,000 population) relative to other countries in the South-East Asia Region [30], only one patient received treatment for tuberculosis. These findings indicate that further studies are needed to assess the diagnostic evaluation among children with respiratory complaints to ensure that tuberculosis and other respiratory illnesses are recognized and adequately treated.
Finally, we observed a high admission rate (51.3%) compared to other published pediatric studies (15–35%) [8, 19, 20]. Since our 48-h mortality rate, a marker of patient severity, of 0.7%, was comparable to the 24-h mortality rate reported in other studies examining similar patient populations, it is likely that a portion of the admitted patients did not require inpatient care [20, 27]. Inappropriate admissions unnecessarily consume healthcare resources and place patients at increased risk for hospital-acquired infections, a known hazard in LMICs [31]. Such a high admission rate coupled with a relatively low mortality rate reinforces the need for a more organized emergency and acute care system in which providers are equipped to rapidly initiate diagnostic workup, provide timely treatment, and make informed decisions about patient disposition.
Our study found a high frequency of skin complaints and fever among enrolled patients relative to other studies. This was likely associated with the concurrent, widely publicized outbreak of a severe strain of enterovirus, EV-71. Symptoms included fever, rash or blisters inside the mouth and on the hands and feet, and, in severe cases, encephalitis and respiratory distress [32]. In mid-July 2012, the Cambodian Ministry of Health organized public education campaigns on symptoms of EV-71, recommending medical care for children with severe symptoms [33, 34]. The increase in patient visits during the outbreak, particularly during the peak stretch from 14 July 2012 to 25 July 2012, suggests that these campaigns effectively increased health-seeking behavior among patients with relevant symptoms.
Limitations
Key limitations of this study included inability to capture seasonal variations in illness patterns during the 4-week study period or regional variation due to the close proximity of study hospitals to one another, the likely impact of the concurrent outbreak of EV-71, and lack of data collected on weekends and overnight. As stated above, the low frequency of trauma complaints at our study sites may be due to a nearby NGO-run hospital, and, therefore, is not generalizable across Cambodia.