COVID-19 Remodeled & Restructured processes for entry to and pathways through care for children in a hospital setting in Pakistan Prof. Dr. Junaid Rashid Head & Professor of Pediatric Medicine The Children’s Hospital & the Institute Child Health Lahore, Pakistan
Routine (ETAT) Pediatric Emergency Patient Inflow in Children’s Hospital, Lahore Pakistan ▪ Discharged Pediatric ▪ Short Stay Pediatric EMO Medicine ▪ Indoor Surgery ▪ ICU Neonatology Indoor Emergency ▪ Cardiology NICU ▪ Gastroenterology TRIAGE Counter ▪ Neurology ▪ Nephrology ▪ Endocrinology ▪ Hematology/Onco ▪ Rheumatology Pediatric ▪ Orthopedics ▪ Urology Specialties ▪ Plastic Surgery
COVID -19: Levels of Emergency Triage 1. Identify the COVID-19 Patient: Suspect or Confirmed (PCR) Airway Shock or obstruction or Circulatory Respiratory Impairment Distress 2. Record Assessment History & Findings ETAT COVID-19 3. Prioritize the patient’s need for medical treatment & transport from the emergency scene: Mild, Moderate, Severe or Critical Altered 4. Track the patient progress through the triage consciousness Severe process Coma or Dehydration Convulsions 5. Identify additional hazards e.g. Contamination i.e. Donning & Doffing
Screening of Patients at arrival: COVID Case definitions MIS-C COVID-19 Critical COVID-19 Persistent fever (> 3 days) & Severe COVID-19 ANY TWO of the following: • Respiratory failure Moderate COVID-19 : requiring Mechanical • Fast breathing with 1.Symptoms like Kawasaki Ventilation chest indrawing disease • Fast breathing (as per 2. Shock • ARDS, Sepsis with Shock WHO ARI criteria) with • X-ray Infiltrates > 50% NO chest indrawing 3. Myocardial dysfunction, • Drowsy or unconscious pericarditis, valvulitis, or • SPO2 <90% in room • SPO2 between 90-94% coronary abnormalities • (MODS) Multiple organ air at room air dysfunction syndrome 4. Coagulopathy • X-ray Infiltrates > 30% • Danger signs: 5. GI symptoms (vomiting, • diarrhea, pain abdomen), • No Danger signs of raised CRP, ESR. Severe Disease
How to Sustain ETAT for COVID & Non-COVID: Restructuring • Mild • Moderate • COVID • Registration If COVID Triage: On- Pt arriving • Severe (Special Then duty PGR & in • Screening by Area) • Critical Classify Consultant emergency EMO • Non-COVID Shift to COVID Isolation • Assess the • General Separate • Discharge If Non- severity Medical COVID & Defined • Short Stay indoor Treatment • Any specialty Any other Routes for • Admit in opinion • Specialty NCD shifting Indoor required Indoor
Pediatric Emergency Reorganizing to Sustain ETAT & Triage
Pre & Post COVID-19: Effect on Patient Inflow 80,000 3,000 70,000 2,500 60,000 2,000 50,000 1,500 40,000 30,000 1,000 20,000 500 10,000 0 0 January April May NN Emergency Asthma clinic OPD Admissions Cardiology Acc & Emergency Surgeries Children vaccinated
COVID-19 (3 (30 Confirmed Children) Disease severity Age Groups 2 15 40 36.7% 6 (7%) (50%) (20%) 35 30 26.7% 25 20% 20 16.6% 7 15 (23%) 10 Asymptomatic Mild 5 Moderate 0 Severe <1 yr 1-5 yrs 5-10 yrs 10-15 yrs
Sustaining high quality Essential Health Services • ‘Work Force’ distribution: For Non-COVID & COVID 24/7 as required • Special Fever/Filter Clinics/Specialty Clinics: For Non-COVID & COVID, NCDs etc. diabetes, CHD, Asthma, pulmonology OPD for chronic lung diseases, Celiac, Nephrology & Neurology clinic • Auxiliary Services: Reorganized by 2 Separate Lab & separate radiology service plan: Non-COVID & COVID. • Continuity of essential critical indoor therapies/services managed e.g. Chemotherapy, dialysis • Elective surgeries restarted • Special hospital staff & Community Trainings: Of hospital staff, Webinars for community Pediatricians & Handbook of COVID • Dengue Clinic: working parallel to COVID • Diagnosis & treatment of other infectious diseases like TB is not effected
Challenges in COVID to Sustain Emergency Triage • Safety of Health care workers • COVID scare & stigma in society, so hiding of COVID contact or positive reports etc. • Varied presentation of COVID e.g. GI Symptoms, cardiac (MIS-C), coagulopathy • NCDs coming with positive COVID RT-PCRs • Handling of Surgical emergencies without COVID testing • Grossly effected Targeted referral to pediatric sub-specialties due to Transport lockdown • Emergence of Vaccine preventable diseases e.g. measles, diphtheria, pertussis • Unemployment leading to increase in malnutrition , micro & macro nutrient deficiencies in children • Neonatal Mortality • Child Abuse
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