Background The importance of emergency medical care for the successful functioning of health systems has been increasingly recognised. This study aimed to evaluate emergency and trauma care facilities in four districts of the province of Sindh, Pakistan. Method We conducted a cross-sectional health facility survey in four districts of the province of Sindh in Pakistan using a modified version of WHO’s Guidelines for essential trauma care. 93 public health facilities (81 primary care facilities, nine secondary care hospitals, three tertiary hospitals) and 12 large private hospitals were surveyed. Interviews of healthcare providers and visual inspections of essential equipment and supplies as per guidelines were performed. A total of 141 physicians providing various levels of care were tested for their knowledge of basic emergency care using a validated instrument. Results Only 4 (44%) public secondary, 3 (25%) private secondary hospitals and all three tertiary care hospitals had designated emergency rooms. The majority of primary care health facilities had less than 60% of all essential equipments overall. Most of the secondary level public hospitals (78%) had less than 60% of essential equipments, and none had 80% or more. A fourth of private secondary care facilities and all tertiary care hospitals (n=3; 100%) had 80% or more essential equipments. The average percentage score on the physician knowledge test was 30%. None of the physicians scored above 60% correct responses. Conclusions The study findings demonstrated a gap in both essential equipment and provider knowledge necessary for effective emergency and trauma care.

BackgroundThe utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation.MethodsThe Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use.ResultsOut of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model.ConclusionUtilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.

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Objective: To evaluate causes of community-acquired and hospital-acquired acute kidney injury and the factors associated with increased inpatient mortality. Method: The observational prospective study was conducted at the Aga Khan University Hospital, Karachi, from September 2018 to March 2019, and comprised patients having acute kidney injury either at the time of admission in group A or developed it after 48 hours of hospital stay in group B. The patients were followed up for 12 weeks and outcomes were categorised as recovered, developed chronic kidney disease, died or remained dialysis-dependent. Data was analysed using SPSS 19. Results: Of the 400 patients, 347(86.8%) were in group A; 190(54.8%) males and 157(45.2%) females with an overall mean age of 57.2±17.0 years. The remaining 53(13.3%) were in group B; 31(58.5%) males and 22(41.5%) females with an overall mean age of 58.5±16.3 years. Urinary tract infection 105(30.3%) was the most frequent cause in group A, followed by volume depletion 73(21%). The causes in group B were multiple, with nephrotoxic antibiotics vancomycin 21(39.6%) and polymyxin 20(37.7%) being the most common. At 12 weeks, 224(56%) patients recovered, 55(13.8%) died, 82(20.5%) and 38(9.5%) developed new onset and progressive chronic kidney disease, respectively, and 1(0.25%) patient remained dialysis-dependent.  Chronic liver disease, renin angiotensin system inhibitors, infection, shock, invasive ventilation and increasing length of stay were associated with increased inpatient mortality (p<0.05). Conclusion: Acute kidney injury was largely community-acquired, and infection was the leading cause with better outcome in contrast to hospital-acquired acute kidney injury which was mostly multifactorial.