An observational study of adults seeking emergency care in Cambodia

Bull World Health Organ 2015;93:84–92 | doi: http://dx.doi.org/10.2471/BLT.14.143917 Research 84 An observational study of adults seeking emergency care in Cambodia Lily D Yan,a Swaminatha V Mahadevan,a Mackensie Yore,a Elizabeth A Pirrotta,a Joan Woods,b Koy Somontha,b Yim Sovannra,c Maya Raman,d Erika Cornell,d Christophe Grundmannb & Matthew C Strehlowa Introduction Emergency medicine is a neglected component of health-care systems in most low- and middle-income countries. Nearly half of deaths and one third of disability adjusted life-years lost in these countries could be avoided by applying the basic principles of emergency care.1 However, despite the renewed interest shown by World Health Organization calls to expand emergency care infrastructure2 – these systems remain un- derdeveloped in most low- and middle-income countries and access to high-quality care is limited.1,3,4 The current health-care system in Cambodia exemplifies this gap in the provision of essential emergency care. Since the Cambodian Ministry of Health was established in 1993, the country has relied on a combination of public and private providers and international nongovernmental organizations to fulfil the medical needs of its people. In 2012, in the public sector, 1080 health centres provided primary care, first aid and maternal and child care (designated the minimum package of activity) in rural areas, while 90 referral hospitals provided secondary and tertiary care – designated the complementary package of activity. Hospitals offering care at complementary package of activity level 2 and above are required to provide emergency care at all times and each has an onsite physician and nurse, with a midwife available for obstetric emergencies.5 Nevertheless, many of these hospitals lack designated emer- gency departments, a formal triage process and staff trained in emergency medicine. Furthermore, emergency medicine is not recognized as a specialty by the Ministry of Health and there is no formal programme for training residents in the discipline. As functional emergency care systems vary between coun- tries and regions,3 accurate characterization of patients seeking emergency care is essential for developing locally appropriate systems. The 2013 academic emergency medicine consensus conference identified the lack of data on chief complaints as a critical gap in global emergency care research.6 The chief complaint is the primary consideration used by health-care providers to structure the evaluation and management of patients who present with an acute condition or with an acute presentation of a chronic disease. Moreover, the information obtained from a good understanding of chief complaints differs from that gleaned from discharge diagnoses.7 In countries with mature emergency care systems, chief complaints are standard- ized and mapped.8 However, few developing nations have the means to report or collate information on chief complaints,6 even though these data are essential for resource allocation, training, research and syndromic surveillance. The objectives of this study were to identify the character- istics and chief complaints of adults presenting for emergency care in Cambodia. Understanding the pattern of adult emer- gencies in Cambodia could help guide the development of policy on health-care interventions, such as triage systems and staff training for common conditions. This information could also provide a basis for future studies of the effectiveness and quality of emergency medical services and of patient outcomes. Methods We conducted a four-week observational study of unsched- uled visits to two provincial government referral hospitals Objective To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals. Methods Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation. Findings In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients’ mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired. Conclusion In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques. a Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States of America (USA). b University Research Co. Centre for Human Services, Phnom Penh, Cambodia. c Deutsche Gesellschaft für Internationale Zusammenarbeit, Phnom Penh, Cambodia. d Feinberg School of Medicine, Northwestern University, Chicago, USA. Correspondence to Mathew C Strehlow (email: strehlow@stanford.edu). (Submitted: 29 July 2014 – Revised version received: 31 October 2014 – Accepted: 6 November 2014 – Published online: 8 December 2014 ) Bull World Health Organ 2015;93:84–92| doi: http://dx.doi.org/10.2471/BLT.14.143917 85 Research Emergency care in CambodiaLily D Yan et al. in Cambodia: Sampov Meas Provincial Hospital and Battambang Provincial Hospital. Both were classified at com- plementary package of activity level 3, which indicates they provided obstetric, emergency and surgical services in ad- dition to a variety of specialty services. Sampov Meas Provincial Hospital has 162 inpatient beds and reported a total of 16 426 visits in 2012, which resulted in 6704 admissions. Battambang Provin- cial Hospital is a larger facility with 220 inpatient beds. It reported 55 138 visits in 2012, resulting in 14 411 admissions. All figures come from the Cambodian Ministry of Health database.9 At the start of the study, neither of the hospitals had a designated department for admissions, and Battambang Provincial Hospital did not have an emergency department. In effect, patients triaged themselves and initially presented to various locations, such as the emergency department, the intensive care unit, different wards and the operating room. Consequently, the study enrolled patients who presented throughout the hospital, not only at the emergency department. The study was approved by institutional review boards at Stanford University School of Medi- cine in the United States of America and the Cambodian Ministry of Health. We enrolled all patients aged 18 years or older who presented at the two study hospitals without an appoint- ment between each Sunday and Friday evening during four consecutive weeks in July and August 2012. Because of study logistics, data collection at weekends dif- fered between the two hospitals. At Sam- pov Meas Provincial Hospital, patients who presented between 17:00 on Friday and 17:00 on Sunday and who were still in hospital on Monday morning were enrolled; at Battambang Provincial Hos- pital, no weekend patients were enrolled. A repeat unscheduled visit was consid- ered a separate visit. Verbal consent was obtained from patients or guardians and interviews were conducted in Khmer through native-speaking translators. Patients presented infrequently during weekends when hospital staffing was limited. Sensitivity analyses showed that including the 63 weekend patients we enrolled did not substantially alter our study results: inclusion resulted in odds ratios (ORs) for predictors varying by around 2%. Thus, weekend patients were included in our multivariate analy- sis of surgery and functional impairment but not of admissions. Demographic and clinical data were collected by one research team at each hospital using a standardized, secure, web-based application: Research Electronic Data Capture (REDCap, Vanderbilt University, Nashville, USA), which is designed to support data cap- ture for research studies.10 Up to three chief complaints were recorded for each patient. The full list of chief complaints is available in Appendix A (available from: http://emed.stanford.edu/education/ international/pubs.html). Information was collected from patients, their friends or family and hospital staff and records, and was entered into REDCap via tablet computers connected to mobile telecommunications networks. Two re- search staff reviewed each patient record for consistency and inconsistencies were resolved by repeating patient interviews and by reviewing hospital records. Fol- low-up data on patient outcomes were collected 48 hours and 14 days after the patient’s initial visit, either directly from patients remaining in hospital or by tele- phone. Patients were considered lost to follow-up if they could not be contacted on three successive days. Data analysis The study’s primary outcomes were ad- mission, medical interventions, surgery, functional impairment and death. In Cambodia, patients may remain in the emergency department for treatment and monitoring for a week or more without being transferred to another department. We recorded only interven- tions completed within 48 hours of the initial presentation, thereby identifying the most urgent. Patients who stayed in hospital overnight were regarded as having been admitted. Functional impairment was defined as significant pain, significant limitation in perform- ing daily activities, confinement to bed or a comatose state. Multivariate modelling was per- formed to identify factors associated with admission, surgery and functional impairment. To avoid including patients who underwent minor procedures and were treated and released, we only used data on admitted patients when identifying factors were associated with surgery. Although we included women who presented with presumed labour in the demographic data, we excluded them from our analysis of outcomes in admitted patients and from multivari- ate analyses since all women in labour were admitted. As vital signs were com- monly not observed or documented, we included records with missing data for the respiratory rate, blood pressure or heart rate in the multivariate analyses by assuming that absent values were normal. Records with missing values for any other independent variable were excluded. Multivariate logistic regression models, which controlled for age and gender, were built for the primary out- comes using predictors identified by univariate analysis. Stepwise methods were not used. Statistical analysis was performed using SAS Enterprise Guide for Windows, version 4.3 (SAS Institute Inc., Cary, USA). ORs and 95% confi- dence intervals (CI) were calculated for all model variables. Results During the study period, 2162 visits without a prior appointment were docu- mented at the two study hospitals. Of these, 1295 (59.9%) were visits by adult patients aged 18 years or older; these patients comprised the study cohort. We were able to follow up 84.8% (1098) of patients at 48 hours and 76.7% (993) at 14 days. The patients’ mean age was 42 years and most patients were female and employed (Table 1). The predomi- nant mode of transport to hospital was by private vehicle: 55.8% (722) of pa- tients arrived by motorbike and 24.1% (312), by taxi or tuk-tuk, whereas only 9.3% (120) arrived by ambulance. Travel times to the study hospitals were typi- cally short (i.e. less than 2 hours). Overall, 31.4% (407) of patients presented with an acute complaint (i.e. onset within the past 24 hours), 20.4% (264) with a recent complaint (i.e. symptom onset within 1 to 3 days) and 24.4% (316) with a subacute complaint (i.e. within 4 to 14 days). More than one third were transferred directly to the study hospital from another health- care facility or referred by a medical provider; only 10.1% (131) had received prior care for their chief complaint and had not been transferred from another facility or referred by a medical provider (Table 1). Abdominal pain was the chief complaint of 36.1% (468) of patients. Fif- teen percent (196) of patients reported respiratory problems and 13.4% (174) reported headache. Only 4.0% (52) of patients presented with vomiting and Bull World Health Organ 2015;93:84–92| doi: http://dx.doi.org/10.2471/BLT.14.14391786 Research Emergency care in Cambodia Lily D Yan et al. 1.8% (23) with diarrhoea. Fever was a chief complaint in only 7.5% (97) of cases. Injuries accounted for 11.3% (146) of visits and one death. The proportion of patients admitted was higher for those complaining of abdominal pain, injury, obstetrical problems or vomit- ing (Fig. 1). The overall admission rate was 60.5% (783) and the median hospital stay was 3.9 days (Table 2). Of those admitted, 166 patients underwent surgery. Obstet- ric surgery accounted for 39.1% (65/166) of all surgical procedures (Table 2). Abdominal pain accounted for 44.8% (351) of all admissions. Even after women with abdominal pain associated with presumed labour were excluded from the analysis, abdominal pain still accounted for 32.3% (253) of all admissions. Vital signs were either not observed or not recorded for around 20% (245) of patients (Table 1) and 58.4% (756) did not receive any diagnostic tests. The investigations most frequently ordered within 48 hours were laboratory tests and diagnostic imaging (Table 3). Other investigations, such as electrocardiog- raphy, were rarely done (1.2% [15]). Computed tomography and magnetic resonance imaging were unavailable at the two hospitals. In the first 48 hours, the intervention most commonly re- ceived was medication; (84.1% [1089] of all patients), 40.5% (524) received intravenous fluids (Table 3). Overall, 14-day mortality in our cohort was 3.9% (39/993). Nearly half of the deaths occurred in the first 48 hours (Table 2). No patient who was treated and discharged or who under- went surgery died during follow-up. However, 34 patients with conditions that hospital staff deemed untreatable were discharged. By 14 days, six of these patients had died, five were still alive and 23 were lost to follow up. There were 232 pregnancy-related visits and of them 205 pregnant patients were past 20 weeks’ gestation. Of the pregnant women past 20 weeks’ gestation, 81.9% (168/205) gave birth during the study period, most frequently within 48 hours of presentation (see Appendix B, avail- able from: http://emed.stanford.edu/ education/international/pubs.html). In addition, 28% (65/232) of women with pregnancy-related complaints under- went obstetric surgery. No maternal deaths were noted during follow-up. Multivariate logistic regression analysis identified several factors as- Table 1. Adults presenting without appointments at two Cambodian hospitals, July– August, 2012 Characteristic No. (%) of patientsa,b All patients 1295 (100) Demographic characteristic Site of presentation Battambang Provincial Hospital 678 (52.4) Sampov Meas Provincial Hospital 617 (47.6) Age Age in years, mean (SD) 42.0 (17.1) Aged 18–64 years 1132 (87.4) Aged 65 years or more 163 (12.6) Sex Female 823 (63.6) Male 472 (36.4) Socioeconomic characteristic Patient had low-income health insurancec 572 (44.2) Occupation Employed 809 (62.5) Unemployed 380 (29.3) Other, such as a student or monk 70 (5.4) Travel to hospital Time Time in hours, median (IQR) 0.5 (0.3–1.3) Time < 0.5 hours 670 (51.7) Time 0.5–2 hours 495 (38.2) Time > 2 hours 98 (7.6) Distance Distance in kilometres, median (IQR) 17 (5–32) Distance ≤ 30 km 930 (71.8) Distance 31–60 km 179 (13.8) Distance > 60 km 139 (10.7) Presentation Time of arrival Monday to Friday 07.00–17.00 1069 (82.5) Overnight Sunday to Friday (i.e. 17.00–07.00) 163 (12.6) Weekend (i.e. Friday 17.00 to Sunday 17.00) 63 (4.9) Care before presentation Transferred from another health-care facility 316 (24.4) Referred by an external medical provider 170 (13.1) Prior care of those not transferred or referred Prior care received in the previous 48 hours 25 (1.9) Prior care received more than 48 hours earlier 106 (8.2) No prior care 627 (48.4) Examination findings Respiratory rate, blood pressure and heart rate Abnormal respiratory rate, blood pressure or heart rate 280 (21.6) Abnormal respiratory rate 88 (6.8) Abnormal blood pressure 103 (8.0) Abnormal heart rate 181 (14.0) Respiratory rate, blood pressure or heart rate not measured 245 (18.9) Temperature Low temperature (< 36 °C) 99 (7.6) High temperature (> 38 °C) 97 (7.5) Temperature not measured 285 (22.0) (continues. . .) Lily D Yan et al. Emergency care in Cambodia Research 87Bull World Health Organ 2015;93:84–92| doi: http://dx.doi.org/10.2471/BLT.14.143917 sociated with an increased risk of admission (n = 729, c-statistic: 0.815). Patients who presented with an acute or recent complaint were more likely to be admitted than those who did not (OR: 5.09; 95% CI: 3.49–7.42). Similarly, the likelihood of admission was increased in those with abnormal blood pres- sure, respiratory rate or heart rate (OR: 3.22; 95% CI: 2.09–4.95) or fever (OR: 3.01; 95% CI: 1.50–6.03). Multivariate analysis also identified factors associ- ated with an increased risk of surgery (n = 450, c-statistic: 0.776). Surgery was more likely in patients with a genito- urinary complaint (OR: 3.46; 95% CI: 1.78–6.75) or a traumatic injury (OR: 2.33; 95% CI: 1.14–4.78) and in those who presented at Battambang Provincial Hospital (OR: 3.83; 95% CI: 2.17–6.78). Conversely, surgery was less likely in patients with an abnormal blood pres- sure, respiratory rate or heart rate (OR: 0.51; 95% CI: 0.28–0.91). Predictors of functional impairment at 14 days iden- tified by multivariate analysis (n = 397, c-statistic: 0.668) were traumatic injury (OR: 2.16; 95% CI: 1.12–4.16) or an acute complaint (OR: 0.55; 95% CI: 0.33–0.92). Details of the multivariate analyses are presented in Appendices C, D and E (available from: http://emed. stanford.edu/education/international/ pubs.html). Discussion This study of adults presenting without an appointment at two large public referral hospitals in Cambodia helps to describe the patient population seeking acute care in Cambodia and South-East Asia. Demographic data showed that the patients’ mean age was 18 years older than the median age of the Cambodian population. In addition, 12.6% of the study cohort was aged 65 years or more, whereas only 7.7% of the country’s population is older than 60 years.11 The most common chief complaint was abdominal pain, which accounted for over one third of visits and 45% of admis- sions. Other gastrointestinal complaints, such as vomiting and diarrhoea, were infrequent. The next most common chief complaints were respiratory problems, headache, injury and chest pain, respec- tively. Few comparative studies of chief complaints at emergency departments in health-care systems in low- and middle- income countries have been reported in the literature. A recent study at a single health centre in Kenya found that road traf- fic injuries, vaginal bleeding and altered mental status were the most common chief complaints; the most common emer- gency department diagnosis was injury (20%).12 In our study, injuries accounted for 11.3% of visits and one death. Fever Characteristic No. (%) of patientsa,b Pain Pain present 916 (70.7) No pain 284 (21.9) Risky behaviour in the previous 24 hours No risky behaviour 1092 (84.3) Tobacco use 98 (7.6) Alcohol use 88 (6.8) Illegal drug use 2 (0.2) IQR: interquartile range; SD: standard deviation. a Number of patients and percentages, unless otherwise stated. b Not all categories sum to 100% as some values are missing. c Most of the other patients paid in cash, except for the more affluent who had health insurance. Fig. 1. Chief complaintsa,b and initial actions for adults presenting without appointments at two Cambodian hospitals, July–August, 2012 Abdominal pain Respiratory problems Headache Injury Chest pain Weakness Fever Genitourinary problem Dizziness or vertigo Obstetrical problem Back pain Ear, nose or throat problem Joint pain Vomiting Oedema or swelling Percentage of cohort (n = 1295) 0 5 10 15 20 25 30 35 40 Chief complaint 27.1 8.4 6.4 9.5 3.6 4.1 5.3 2.7 3.2 5.9 2.3 3.0 2.7 3.9 1.9 1.5 3.5 4.0 4.1 4.2 2.8 5.6 2.9 6.4 3.5 6.5 2.0 7.5 3.6 7.9 4.9 8.6 1.5 11.3 6.2 13.4 6.2 15.1 8.1 36.1 Hospital admission Treated and released Unknown Initial action a Up to three chief complaints were recorded per patient. b Only the 15 most common chief complaints are shown. (. . .continued) Bull World Health Organ 2015;93:84–92| doi: http://dx.doi.org/10.2471/BLT.14.14391788 Research Emergency care in Cambodia Lily D Yan et al. ranked seventh as the primary reason for a hospital visit in our study and was the ninth most common reason in the Kenyan study.12 Although infectious disease still accounts for a large proportion of the dis- ease burden in low- and middle-income countries, our results are consistent with previous research which suggests that noncommunicable disease is an increas- ingly common reason for seeking acute care.5,13,14 Abdominal pain is reportedly the chief complaint of 9% of adults seek- ing care at emergency departments in the United States of America.15 According to these nationally-representative statistics, 7% of adults presented with chest pain while headache, shortness of breath and back pain each accounted for 3% of emer- gency department visits. Our observations in Cambodia show that diagnostic tests are seldom used during the first 48 hours following an emergency admission. Electrocardi- ography, radiography and ultrasound imaging were available at the two hospitals. This meant that standard evaluations were not done for most chief complaints. The lack of diagnostic evaluations was probably due to both limited resources and inadequate train- ing. We found that over 40% (572) of patients held government-subsidized health equity fund insurance cards. Since the health equity fund awards a fixed amount per patient-visit and many employed people live in poverty, patients may not have been able to pay for even low-cost diagnostic tests. Poor diagnostic and treatment prac- tices may be due in part to gaps in con- tinuing medical education. Currently, continuing education is not mandatory for health-care providers in Cambodia. Furthermore, most educational pro- grammes approved by the Ministry of Health concentrate on identifying and managing infectious diseases, such as tuberculosis, and on maternal care. Although it is important to address com- mon infectious diseases, our data sug- gest that the majority of patients present with undifferentiated complaints caused by noncommunicable diseases. Focus- ing diagnostic resources and provider education on the most common condi- tions would improve the evaluation and management of these patients. This study identified several simple, yet important, changes that could po- tentially improve health-care delivery at Cambodian referral hospitals. First, de- spite a low number of deaths in the short term, a high percentage of patients were admitted (60.5%). Comparable studies in other low- and middle-income coun- tries, report about 40% admissions.16 Identifying patients who can be safely discharged would substantially reduce unnecessary admissions and, therefore, health-care costs. Most referral hospi- tals in Cambodia do not have a central point of entry for patients seeking treat- ment with undifferentiated complaints. Moreover, neither hospital in our study had a triage system. In the absence of an emergency department and a triage system, inefficiencies, delays in care and inconsistencies in treatment are likely to arise. Consequently, admission criteria at the two study hospitals may have varied according to where in the hospital the patient presented. Relatively simple changes could address these defi- cits, such as deploying a triage system, designating an area for evaluating new patients and improving staff capacity for managing patients with undifferentiated complaints. Second, nearly half of the study pa- tients had previously consulted an out- side provider for their presenting com- plaint. There is no coordinated system in Cambodia for referring patients, for sharing medical information between facilities or for transferring patients.17 Strengthening health management information systems and introducing phone-based referral centres could improve communications between government facilities, save time and help avoid repeating procedures during the evaluation and treatment of patients. Finally, vital signs were not reliably measured or reported at either study Table 2. Actions, surgical interventions and follow-up in adults presenting without appointments at two Cambodian hospitals, July–August, 2012 Outcome No. (%) presentinga (n = 1295)b Initial action Patient treated and released 468 (36.1) Patient transferred to another centrec 11 (0.9) Patient left hospital without being seen or against medical advice 20 (1.5) Patient died within 24 hours of presentation 6 (0.5) Patient admitted 783 (60.5) Surgery Patient had any surgical procedured 166 (15.1) Patient had obstetric surgeryd 65 (5.9) Length of stay for patients admitted in days, mean (SD) 3.9 (4.8) Cumulative mortality at 14 dayse 39 (3.9) 48-hour follow-up Patient followed up at 48 hours 1098 (84.8) Patient remained functionally impairedd,f 653 (59.5) Patient seen by another health-care provider after discharged 44 (4.0) Patient returned to workg 198 (27.0) Patient died between 24 and 48 hoursd 11 (1.0) 14-day follow-up Patient followed up for 14 days 993 (76.7) Patient remained functionally impairede,f 192 (19.3) Patient seen by another health-care provider after dischargee 122 (12.3) Patient returned to workh 362 (51.5) Patient died between 48 hours and 14 dayse 22 (2.2) SD: standard deviation. a Number presenting and percentage, unless otherwise stated. b Percentage of 1295 patients presenting, unless otherwise indicated. c Includes only patients transferred to another centre without first being admitted and receiving care. An additional five patients were transferred after being admitted. d Percentage of the 1098 patients followed up for 48 hours. e Percentage of the 993 patients followed up for 14 days. f Functional impairment was defined as significant pain, significant limitation in performing daily activities, confinement to bed or a comatose state. g Percentage of the 732 patients followed up for 48 hours who worked before visiting hospital. h Percentage of the 703 patients followed up for 14 days who worked before visiting hospital. Bull World Health Organ 2015;93:84–92| doi: http://dx.doi.org/10.2471/BLT.14.143917 89 Research Emergency care in CambodiaLily D Yan et al. صخلم ايدوبمك في ئراوطلا ةياعر نوسمتلي نيذلا ينغلابلل ةظحلالما لىع ةمئاق ةسارد ةياعر نوسمتلي نيذلا ينغلابلا صئاصخ فصو ضرغلا ايدوبمك في تاعطاقلما ىوتسم لىع ةلاحلإل ينيفشتسم في ئراوطلا .ةيسيئرلا مهاواكشو اودجاوت نيذلا رثكأف ًاماع 18 نس في ينغلابلا ليجست مت ةقيرطلا لىع ةمئاق ةسارد في دعوم نود ةلاحلإل ينماع ينيفشتسم في ديدتحو ةيفارغميدلاو ةيريسرلا تانايبلا عجم متو .ةظحلالما 48 ةدلم ضىرلما ةعباتم متو .ىفشتسلما لوخدب ةلصلا تاذ لماوعلا .ىفشتسلما لىإ ملهوخد دعب ًاموي 14و ةعاس .ىفشتسلما لىإ لوخد ةلاح 1295 قيثوت مت ،لياجمإ لكشب جئاتنلا % 77و ةعاس 48 ةدلم ضىرلما نم )1098( % 85 ةعباتم نم انكتمو تناكو ةنس 42 ضىرلما رمع طسوتم ناكو .ًاموي 14 ةدلم )993( ىفشتسلما لىإ مهمظعم لوصو ناكو .)823( % 64 ثانلإا ةبسن كوت كوتلا وأ ةرجلأا ةرايس وأ )722( ةيرانلا ةجاردلا مادختساب 36( نطبلاب لمأ ًاعويش ةيسيئرلا ىواكشلا رثكأ تناكو .)312( hospital. For approximately one in five patients, temperature was not measured. A similar proportion of patients had no records of respiratory rate, blood pres- sure and heart rate. Again, the absence of a central point of entry and of a triage system for new patients may have con- tributed to inconsistencies in measure- ments or documentation. As vital signs are important markers of the severity of illness and have been shown to be reliable predictors of death following trauma and acute poisoning in low- and middle-income countries, these should be measured and documented in every patient.18,19 The study had several limitations: patients were not enrolled 24 hours a day, seven days a week; reliable discharge diagnoses could not always be obtained; and it was difficult to track discharged patients. Although our findings may not be generalizable to other locations, the two study sites did serve different com- munities and provinces. In summary, we have characterized the chief complaints, initial care and outcomes of adults seeking emergency care in two public hospitals in Cambo- dia. We identified several opportuni- ties for operational and educational improvements, including better docu- mentation of vital signs and increased use of diagnostic techniques. Further study is required to elucidate the fac- tors underlying the high admission- to-death ratio and the limited use of diagnostic tests. ■ Acknowledgements We thank Phan Chamroen, Van Cham- roeun, Em Chandara, Chan Dara, Andrew Martin, Sam Ol Vichet, Chea Piseth, Soy Serey, Chuum Sophea, Ou Souvichet, Anne Tecklenburg, Bonsak Yoeum, and the staff of the Battambang and Sampov Meas provincial hospitals. Funding: Funding was obtained through the Stanford MedScholars Program, which had no role in the design, execu- tion or analysis of the study. Additional funding was provided by USAID under the Better Health Services project (Co- operative agreement no. 442-A-00–09– 00007–00). Competing interests: None declared. Table 3. Diagnostic tests and interventions within 48 hours in adults presenting without appointments at two Cambodian hospitals, July–August 2012 Diagnostic test or intervention No. (%) presentinga,b (n = 1295) No. (%) admitteda,c (n = 783) Diagnostic test Any test 539 (41.6) 464 (59.3) Laboratory test 457 (35.3) 415 (53.0) Diagnostic imaging 175 (13.5) 141 (18.0) Electrocardiography 15 (1.2) 14 (1.8) Ultrasound scanning 6 (0.5) 6 (0.8) Diagnostic peritoneal lavage 4 (0.3) 4 (0.5) Medication administered Any medication 1089 (84.1) 666 (85.1) Analgesic (excluding aspirin) 688 (53.1) 460 (58.7) Antibiotic 471 (36.4) 325 (41.5) Antiparasitic 169 (13.1) 107 (13.7) Aspirin 43 (3.3) 2 (0.3) Drug administered by nebulizer 13 (1.0) 9 (1.1) Antimalarial 9 (0.7) 9 (1.1) Antituberculosis drug 2 (0.2) 2 (0.3) Anti-HIV drug 2 (0.2) 1 (0.1) Other 772 (59.6) 475 (60.7) Other interventions Any intervention other than medication 627 (48.4) 598 (76.4) Intravenous fluids 524 (40.5) 513 (65.5) Wound closure 128 (9.9) 125 (16.0) Intravenous medication 127 (9.8) 124 (15.8) Emergency childbirth 118 (9.1) 118 (15.1) Urethral catheterization 93 (7.2) 89 (11.4) Oxygen therapy 81 (6.3) 76 (9.7) Emergency cooling 49 (3.8) 49 (6.3) Other 187 (14.4) 171 (21.8) HIV: human immunodeficiency virus. a Categories may sum to more than 100% because some patients had more than one diagnostic test or intervention. b Overall, 42 (3.2%) patients did not undergo any diagnostic test or receive any intervention and, for 76 (5.9%) patients, no information on diagnostic tests or interventions was collected. c Overall, 8 (1.0%) admitted patients did not undergo any diagnostic test or receive any intervention and, for 49 (6.3%) admitted patients, no information on diagnostic tests or interventions was collected. Bull World Health Organ 2015;93:84–92| doi: http://dx.doi.org/10.2471/BLT.14.14391790 Research Emergency care in Cambodia Lily D Yan et al. 摘要 柬埔寨成年人寻求急诊治疗的观察性研究 目的 描述两所柬埔寨省级转诊医院成年人寻求急诊治 疗的特征和主诉。 方法 将两所公共转诊医院没有预约的 18 岁及以上成 年人纳入观察性研究。收集临床和人口数据，并确定 与入院相关的因素。在就医 48 小时和 14 天后对患者 进行跟踪随访。 结果 总计记录了 1295 个医院就医情况。我们能够在 48 小时随访 85%（1098）的病人，在 14 天随访 77%（993） 的病人。病人平均年龄为 42 岁，64%（823）为女性。 大多数通过摩托车（722）或者的士或嘟嘟车（312） 前来就医。最普遍的主诉是腹痛（36% ；468）、呼吸 道问题（15% ；196）和头痛（13% ；174）。在记录生 命体征的 1050 位患者中，280 位抵达时有异常值（除 体温外）。对 539 位病人记录了执行过的诊断性测试 ： 1.2%（15）病人有心电图，14%（175）有诊断性影像。 其后，783（60%）位病人入院，其中 166 位病人接受 了手术。住院的显著预测因子包括前来就医之前 3 天 内的症状发作、异常生命体征和发烧。截至 14 天随访 时，有 3.9%（39/993）病人死亡，19%（192/993）病 人依然保持功能性受损状态。 结论 在柬埔寨两所公立医院的紧急住院中，住院死亡 率较高，诊断技术的应用有限。我们确定改进流程的 方法，包括更好的生命体征病案记录和对诊断技术的 更多使用。 Résumé Une étude observationnelle des adultes recourant aux soins d’urgence au Cambodge Objectif Décrire les caractéristiques et les principales affections des adultes qui ont recours aux soins d’urgence dans deux hôpitaux cambodgiens provinciaux de référence. Méthodes Les adultes âgés de plus de 18 ans qui se sont présentés sans rendez-vous à deux hôpitaux publics de référence, ont été inscrits à une étude observationnelle. Les données cliniques et démographiques ont été recueillies et les facteurs associés à l’hospitalisation ont été identifiés. Les patients ont été suivis 48 heures et 14 jours après leur présentation. Résultats Au total, 1295 présentations à l’hôpital ont été documentées. Nous avons pu suivre 85% (1098) des patients 48 heures et 77% (993) 14 jours après leur présentation. L’âge moyen des patients était de 42 ans et 64% (823) des patients étaient des femmes. La plupart des patients étaient arrivés en moto (722), en taxi ou en tuk-tuk (312). Les principales affections communes étaient en majorité des douleurs abdominales (36%; 468), des problèmes respiratoires (15%; 196) et des maux de tête (13%; 174). Parmi les 1050 patients dont les signes vitaux ont été enregistrés, 280 avaient des valeurs anormales, hormis la température, lors de leur arrivée. Les tests diagnostiques réalisés ont été enregistrés pour 539 patients: 1,2% (15) des patients avait bénéficié d’une électrocardiographie et 14% (175) des patients avaient bénéficié de l’imagerie diagnostique. Par la suite, 783 (60%) patients ont été hospitalisés et 166 d’entre eux ont subi une opération chirurgicale. Les indicateurs significatifs d’hospitalisation comprenaient l’apparition des symptômes dans les 3 jours précédant la présentation, des signes vitaux anormaux et la fièvre. À l’issue du suivi des 14 jours, 3,9% (39/993) des patients étaient décédés et 19% (192/993) des patients présentaient des capacités fonctionnelles diminuées. Conclusion Dans les hospitalisations d’urgence dans les deux hôpitaux publics au Cambodge, il y a un rapport hospitalisation-décès élevé et une application limitée des techniques de diagnostic. Nous avons identifié des moyens pour améliorer les procédures, y compris la meilleure documentation des signes vitaux et l’utilisation accrue des techniques de diagnostic. Резюме Обсервационное исследование взрослых, обратившихся за неотложной помощью в Камбодже Цель Описать характеристики и основные жалобы взрослых, обратившихся за неотложной помощью в два камбоджийских провинциальных лечебно-диагностических центра. Методы В данное обсервационное исследование были включены взрослые старше 18 лет, которые самостоятельно, без назначения, обратились в два государственных лечебно-диагностических центра. Были собраны клинические и демографические данные и определены факторы, связанные с госпитализацией. Пациенты повторно наблюдались спустя 48 часов и 14 дней после обращения в центры. Результаты В общей сложности, было задокументировано 1295 случаев обращения в центры. Наблюдение велось за )ًاصخش 196 ؛% 15( ةيسفنت تلاكشمو )ًاصخش 468 ؛% مت ًاضيرم 1050 لصأ نمو .)ًاصخش 174 ؛13%( عادصلاو ًاضيرم 280 ىدل ناك ،ملهوصو ىدل ةيويلحا متهاملاع ليجست ليجست لياتلا وحنلا لىع متو .ةرارلحا ةجرد ءانثتساب ،ةذاش ميق :ًاضيرم 539 صوصخب اهؤارجإ مت يتلا ةيصيخشتلا تارابتخلاا بلقلا ةيئابرهك طيطتخ ءارجلإ ضىرلما نم )15( % 1.2 عضخ كلذ لىتو .صييخشتلا ريوصتلا ءارجلإ )175( % 14 عضخو ًاضيرم 166 عضخو ىفشتسلما لىإ ًاضيرم )% 60( 783 لاخدإ ةمالها نهكتلا لماوع تلمتشاو .ةحارلجا لىإ ضىرلما ءلاؤه نم ةثلاثب ىفشتسلما لوخد لبق ضارعلأا ءدب لىع ىفشتسلما لوخدب ةعباتلما جئاتن ترفسأو .ىملحاو ةيويلحا تاملاعلا ذوذشو مايأ 19 لظو )993/39( % 3.9 ةافو نع ًاموي 14 اتهدم تغلب يتلا .يفيظو روصق نم نوناعي )993/192( % ةيدودمحو ةافولا لىإ ىفشتسلما لوخد ةبسن في عافترا ةمث جاتنتسلاا تلااح في ىفشتسلما لوخد ىدل صيخشتلا تاينقت مادختسا في قرط ديدحتب انمقو .ايدوبمك في ينماع ينيفشتسم في ئراوطلا ةيويلحا تاملاعلا قيثوت ينستح كلذ في ماب ،تاءارجلإا ينسحتل .صيخشتلا تاينقت مادختسا ةدايزو Bull World Health Organ 2015;93:84–92| doi: http://dx.doi.org/10.2471/BLT.14.143917 91 Research Emergency care in CambodiaLily D Yan et al. 85% (1098) пациентов спустя 48 часов и 77% (993) пациентов спустя 14 дней. Средний возраст пациентов составлял 42 года, и 64% (823) из них были женщины. Большинство пациентов прибыли в центры на мотоцикле (722), на такси или тук-туке (312). Основными, наиболее распространенными жалобами являлись боли в области живота (36%; 468), нарушения со стороны дыхательной системы (15%; 196) и головная боль (13%; 174). Из 1050 пациентов с зарегистрированными основными показателями жизнедеятельности у 280 пациентов по прибытии были выявлены несоответствующие нормам показатели жизнедеятельности, за исключением температуры. Результаты диагностических исследований были зарегистрированы у 539 пациентов: 1,2% (15) пациентов прошли электрокардиографию и 14% (175) пациентов – диагностическую визуализацию. Впоследствии 783 (60%) пациента были госпитализированы и 166 из них перенесли операцию. В число значимых параметров для госпитализации входили следующие: появление симптомов в течение трех дней до обращения, несоответствующие нормам показатели жизнедеятельности и повышенная температура. При проведении 14-дневного наблюдения выяснилось, что 3,9% (39/993) пациентов скончались и 19% (192/993) оставались с ограниченной подвижностью. Вывод При проведении экстренной госпитализации в двух государственных больницах в Камбодже наблюдается высокий коэффициент смертности относительно числа принимаемых на лечение пациентов и ограниченное применение диагностических методов. Были определены способы улучшения процедур лечения, включая улучшенное документирование основных показателей жизнедеятельности и более частое использование диагностических методов. Resumen Un estudio observacional de adultos que solicitan atención de emergencia en Camboya Objetivo Describir las características y quejas principales de los adultos que solicitan atención de emergencia en dos hospitales provinciales de remisión de Camboya. Métodos Se inscribió a adultos mayores de 18 años que acudieron sin cita previa a dos hospitales públicos de remisión en un estudio observacional. Se recogieron datos clínicos y demográficos y se identificaron los factores relacionados con el ingreso hospitalario. Se realizó un seguimiento a los pacientes durante 48 horas y 14 días después de la visita hospitalaria. Resultados En total, se documentaron 1295 visitas hospitalarias. Se logró realizar un seguimiento del 85 % (1098) y del 77 % (993) de los pacientes a las 48 horas y a los 14 días, respectivamente. La edad media de los pacientes fue de 42 años y el 64 % (823) eran mujeres. La mayoría acudió en motocicleta (722), taxi o tuk-tuk (312). Las quejas principales más comunes fueron dolor abdominal (36 %; 468), problemas respiratorios (15 %; 196) y cefalea (13 %; 174). De los 1050 pacientes con registro de constantes vitales, 280 presentaron valores anómalos, a excepción de la temperatura corporal, a su llegada. Se registraron las pruebas diagnósticas realizadas en 539 pacientes: se realizó una electrocardiografía al 1,2 % (15) e imágenes diagnósticas al 14 % (175) de los pacientes. Posteriormente, 783 (60 %) de los pacientes fueron ingresados, de los cuales 166 se sometieron a cirugía. Los predictores significativos para el ingreso incluyeron la aparición de los síntomas 3 días antes de la visita hospitalaria, constantes vitales anómalas y fiebre. Antes de finalizar el seguimiento de 14 días, el 3,9 % (39/993) de los pacientes había fallecido y el 19 % (192/993) seguía presentando discapacidades funcionales. 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