Background: Provision of timely care to critically ill children is essential for good outcome. Referral from smaller peripheral hospitals to higher centers for intensive care is common. However, lack of an organized referral and feedback system compromises optimal care. We studied the quality of referral letters coming to our Emergency Department (ED) with respect to their demography, association with severity of illness and mortality before and after referral education. Methods: Our study was completed in three phases in the Pediatric ED; Pre-intervention, Intervention and Post intervention phases. Quality of referral letter was matched with a quality checklist proforma and graded as 'good', 'fair' and 'poor' if it scored > 7, 5-7 and < 5 points respectively. A peer reviewed referral education module was prepared using case studies, expert opinions, and lacunae observed in the first phase and administered to health care providers (HCP's) of referring hospitals. Quality of referral letter was compared between pre and post intervention phases. Results: Most referrals belonged to the neighboring states of Punjab (48.2%) and Haryana (22.4%). Major referring hospitals were from public sector (80.9%), of which the teaching hospitals topped the list (53.6%). Government run ambulance services (85.5%) was commonest mode of transport used and need for a PICU bed and/or mechanical ventilation (50.4%) was the commonest reason for referral. The post intervention phase saw a significant decline in the proportion of poor (93.2 vs.78.2%; p = 0.001) and a significant increase in the proportion of fair (6.1 vs 18%; p = 0.001) and good referral letters (0.7 vs 18%; p = 0.001). The proportion of children with physiological decompensation at triage had reduced significantly in the post intervention phase [513 out of 1403 (36.5%) vs. 310 out of 957 (32.3%); p = 0.001].

Exogenous lipoid pneumonia (ELP) is an uncommon cause of respiratory distress. The practice of oil massage and oil instillation into the nostrils is common in the Indian subcontinent. Accidental aspiration of baby oil may lead to significant chemical pneumonitis. This presentation may vary from subtle to severe respiratory distress requiring intensive care management. Spontaneous air leaks are rare in acute ELP. We successfully managed a six-month-old girl presenting with mineral oil-induced ELP and air leaks. However, these children require long-term follow-up, as a small proportion may evolve into chronic lung disease.

Neonatal Antiphospholipid syndrome (APS) is a rare disease related to transplacental passage of antiphospholipid (aPL) antibodies from the mother or de novo production of aPL in a newborn. Neonatal aPL antibodies have rarely been associated with thrombosis. We describe a 5-week-old infant who developed fever, portal vein thrombosis and livedo reticularis like skin rash. Evaluation for thrombosis revealed high titers of antiphospholipid (aPL) antibodies (dual positive) in the child without any evidence of aPL antibodies in the mother, suggesting a de novo production in the child. Autopsy findings revealed umbilical vein sepsis with thrombosis of portal vein secondary to gram positive cocci which led to multiple liver and lung abscesses. Additionally, the baby had disseminated Cytomegalovirus (CMV) disease (acquired postnatally) involving walls of umbilical and portal vein, liver, lungs, adrenals, pancreas, thymus, and kidneys. Our case highlights the need for testing of aPL in every neonate with arterial or venous thrombosis even when the mother may have no features suggestive of an autoimmune disease.

Background: Provision of timely care to critically ill children is essential for good outcome. With development of specialized pediatric critical care units, referral from community and smaller peripheral hospitals has received greater impetus. Our tertiary care hospital caters to referrals from a wide geographical area. Since there is no standard referral and feedback system in India, we decided to evaluate the quality of referrals coming to our Emergency Room (ER) with respect to their demography, association with severity of illness and mortality. We plan to use this data to establish a standard referral and feedback process to streamline our ER referrals. Methods: Our study was completed in three phases in Pediatric ER;Pre-intervention, Intervention and Post intervention phases. Quality of referrals was graded by granting one score to presence of each item when matched with a quality checklist performa. A referral was graded ‘good’, ‘fair’ and ‘poor’ if it scored >7, 5 –7 and < 5 points respectively. Case studies, expert opinions, and lacunae observed in first phase were taken into consideration while preparing the referral education module, that was administered to health care providers of referring hospitals. Quality of referrals was compared between pre and post intervention phases. Results: Majority of inpatient admissions were ‘referred’ patients (99.3%). Most referrals belonged to the neighboring states of Punjab (48.2%) and Haryana (22.4%). Major referrals were from public sector hospitals (80.9%) of which the teaching hospitals topped the list (53.6%). Most common mode of transport was government run ambulance services(85.5%) and the common reason for referral was need for PICU bed and/or mechanical ventilation (50.4%). The post intervention phase saw a significant decline in the proportion of poor referrals (93.2 vs.78.2%;p=0.001) and a significant increase in the proportion of fair(6.1 vs 18%; p=0.001)and good referrals (0.7 vs 18%;p=0.001) Proportion of children presenting to triage with physiological decompensation with respect to poor referrals had significantly decreased in post intervention phase [580(79.8%) vs 1025(93.7%); p=0.0001]. Conclusion:Referral education had significantly improved the quality of referrals coming to our ER. Continuing education will be required for sustained and increased benefits. Key words: Quality of referral, Pediatric emergency, Triage

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