Objective: To discuss the referral mechanisms established for safe and expeditious inter-facility transfer of COVID 19 positive patients to ensure their referrals through establishing proper communication channels. Methods: Mobile phone and WhatsApp based groups, administrated by The Indus Hospital were established in April 2020. Through detailed reports and frequent communication, factors like bed and ventilator availability across these facilities are shared. Weekly reports through zoom meetings updating the key stake holders, discussion of problems faced and planning for the week ahead are also done. Result: The establishment of these groups has been successful in ensuring referral to and from The Indus Hospital to various healthcare facilities across Karachi using appropriate ambulance services. Conclusion: The development of referral mechanisms is the need of the day that has been highlighted through the COVID 19 pandemic. It is our hope that these mechanisms are sustained after the pandemic and result in improvement in patient outcome through proper referrals. doi: https://doi.org/10.12669/pjms.36.COVID19-S4.2803 How to cite this: Salman S, Saleem SG, Khatri A, Jamal I, Maroof Q, Alam A. Inter-hospital communication and transfer practices during COVID-19 Pandemic in Karachi, Pakistan. A brief overview. Pak J Med Sci. 2020;36(COVID19-S4):---------. doi: https://doi.org/10.12669/pjms.36.COVID19-S4.2803 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.

IntroductionHypertension is one of the leading causes of mortality worldwide. Fifty-four percent of strokes and forty-seven percent of cardiovascular deaths are caused by suboptimal control of blood pressure. Economically developing countries like Pakistan are heavily burdened with an ever-rising epidemic of cardiovascular disease and stroke morbidity and mortality. Therefore, urgent steps are required to treat, as well as modify, risk factors for cardiovascular disease, including hypertension.PurposeThe objective of this study was to ascertain the knowledge of hypertension and other sociodemographic variables and their impact on controlling blood pressures in the hypertensive population belonging to the low socioeconomic strata.MethodsThis cross-sectional study was conducted in the general medicine and cardiology outpatient clinics of a tertiary care charity hospital. Three-hundred thirty-five hypertensive patients of age >24 years were selected and informed consent was obtained. Hypertension-related knowledge was assessed using the Modified "Hypertensive Knowledge-Level Scale (HK-LS)" via a 15-20 min interview. Secondary variables in the questionnaire included social demographics, medical history, and assessment of body mass index (BMI) and blood pressure average values, which were measured during the interview. Knowledge was recorded based on the 33-point modified HK-LS scale, whereas secondary variables were not counted toward the assessment of knowledge.ResultsThe frequencies of low, moderate, and high levels of hypertension-related knowledge were recorded as 2.1%, 79.4%, and 62%, respectively. Among 335 patients, (57.3%) were male, the mean age was 52.5 ± 11.5 years, and 63.6% were professionally active. Median systolic blood pressure (SBP) and diastolic blood pressure (DBP) in hypertensive patients were 140 and 86 mmHg, respectively. Sixty-nine percent of patients reported existing comorbidities, 54% had diabetes, 20.7% had cardiovascular disease, and 24% reported renal disease. No significant association was observed between the levels of knowledge of hypertension and gender, blood pressure (BP) status, professional activity, and age groups (p=0.877, p=0.863, p=0.125, and p=0.400, respectively).ConclusionThe majority had adequate knowledge of hypertension but only 64.8% had controlled BP status. This depicts not a lack of knowledge and awareness but rather a lack of prevention of risk factors related to hypertension. Thus, further studies are advised to look into the preventive strategies employed by patients to control their BP and assess their effectiveness.

Background: Moving away from invasive ventilation towards timed position change and non-invasive ventilation is especially of benefit in low and middle income countries, where judicious use of the available healthcare resources is the need of the day. Our study was conducted prospectively to develop strategies for non-invasive ventilation in combination with timed position change of patients to see its impact on their outcome.Objectives: Non-invasive ventilation has proven to be of benefit in COVID-19 related acute lung injury. The objective of this prospective, cross sectional study was to develop a protocol for the use of non-invasive ventilation with timed position change to improve COVID-19 patients’ outcomes in the Emergency Department (ED). Methods: All patients presenting with confirmed or suspected COVID-19 were enrolled in the study from March 2020 to October 2020. Data was collected to see the effect of timed position change and non-invasive ventilation on these patients and its effect on delaying or avoiding invasive ventilation. Results: Of the 207 COVID-19 patients presenting to the IHHN ED, 109(52.7%) had oxygen saturation in the nineties in supine position followed by right lateral in 37(17.9%), sitting up in 30(14.5%), left lateral in 29(14%) and prone position in 2(1%). Maximal oxygenation was achieved with non rebreather mask (NRM) and nasal prongs in 87(42%) of the patients, followed by the use of continuous positive airway pressure (CPAP) in 29(14%). Conclusion: Most of the patients preferred to stay in the supine position and described it as the position of comfort. When used in combination supine position, patients on NRM with nasal prongs and on CPAP, had oxygen saturation in the nineties. Central obesity was found to be the prime reason for the inability to prone our patients. This needs to be followed up in the current fourth wave of COVID-19 to see the effectiveness of the said modalities. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5772 How to cite this:Ali S, Khatri A, Ghouri N, Mukhtar S, Zawawi S, Saleem SG. Combining Non-invasive Ventilation with timed position change in the Emergency Department to improve oxygenation and outcomes in patients with COVID-19: A prospective analysis from a low resource setup. Pak J Med Sci. 2022;38(2):375-379. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5772 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.

Background: Most Emergency Departments (EDs) in low- and middle-income countries (LMICs), particularly in Pakistan, are staffed by physicians not formally trained in Emergency Medicine (EM). As of January 2022, there were only 13 residency training programs in EM throughout all of Pakistan. Therefore, an intermediate solution—a one-year training program in EM—was developed to build capacity. Objective: To determine the impact of a novel training program in EM on clinical metrics and outcomes. Methods: The first cohort of a novel, one-year training program—the Certification Program in Emergency Medicine (CPEM)—completed the program in June 2019. The program consisted of two arms: CPEM-Clinical (CPEM-C), which included physicians from the Indus Hospital and Health Network (IHHN) ED; and CPEM-Didactic (CPEM-D), which included physicians from EDs across Karachi. Both groups participated in weekly conferences, such as didactics, small group discussions, workshops, and journal clubs. CPEM-C learners also received clinical mentorship from local and international faculty. Mortality, length of stay (LOS), and time-to-evaluation, as well as metrics in four key areas—patients at risk for cardiovascular disease/acute coronary syndrome, sepsis, respiratory illness, and intra-abdominal trauma—were assessed before and after the initial cohort at IHHN and compared with other groups in IHHN. Findings and Conclusions: More than 125,000 patients were seen from July to December 2017 (pre-CPEM) and July to December 2019 (post-CPEM). Overall, there were significant improvements in all clinical metrics and outcomes, with the exception of LOS and time-to-evaluation, and a trend toward improved mortality. In comparing CPEM graduates to other groups in IHHN ED, most metrics and outcomes significantly improved or trended toward improvement, including mortality. Implementation of a medium-duration, intensive EM training program can help improve patient care and the development of EM as a new specialty in lower-resource settings.

Introduction: The ability to identify and address the negative Social Determinants of Health (SDH) through education in Social Emergency Medicine (SEM) can lead to improvement in Emergency Medicine (EMed) process flow, bounce back and acuity of patients. This can have far reaching implications in a resource limited country like Pakistan. Method: A SEM based curriculum was administered to the EMed residents at a tertiary care center in Karachi, Pakistan. Pre, Post and Delayed Post-test was conducted for knowledge of EMed residents and analyzed using Repeated Measures ANOVA (RMANOVA). Bounce back and acuity of patients was compared in the pre-intervention (2020) and post-intervention year (2021) using frequency with percentages. Result: A significant improvement was seen in post intervention (p < 0.001) and follow up knowledge (p < 0.001) of residents. Bounce back rate was higher in 2020, pre SEM curriculum (43%) as compared to the post SEM curriculum year 2021 (27.7%). The acuity at bounce back was P1 (more seriously ill) in 826 (47.2%) and P2 in 532 (30.4%) in 2020 out of the 125 (7.1%) patients with Acuity P1 at their Index visit (p < 0.001). In 2021, this reduced to Acuity P4 (less seriously ill) in 65.2% patients with their initial Acuity at Index Visit being P3 in 301 (65.6%) and P2 in 97 (21.1%) (p < 0.001). Conclusion: The study highlights the beneficial impact of an educational intervention in SEM upon the bounce back and acuity of patients in the EMed department of a low resource setup. This can be scaled up to other EMed departments across Pakistan for the improvement of EMed process flow and Key Performance Indicators (KPIs).