Background & Objective: Understanding the demographics of mortality and its burden in the emergency department of a tertiary care setup can lead to better planning and allocation of resources to streamline process flow. This can be achieved systematically through mortality audit that can identify the loopholes and areas of improvement. Our objective was to characterize the epidemiology of ED mortality in a tertiary care hospital of Karachi, Pakistan. Methods: A five-year retrospective chart review of 322 adult mortalities presenting between January l, 2014 – December 31, 2018 was conducted in the emergency department (ED) of The Indus Hospital (TIH), Karachi. All expiries in ED were included while those brought dead and with do not resuscitate order (DNAR) were excluded. Results: Mortality incidence of 0.076% (7.6/10,000 ED visits in five years) was reported. Amongst 507,759 adult ED visits, 322 mortalities were documented. Mean time lapse before presentation was 44±147 hours and mean length of stay before death was 3.4±2.8 hours. Acute coronary syndrome (ACS) was the predominant cause of death with 109 (33.8%) expiries. Significant association was reported between no history of prior care and high priority (P1) cases (p=0.013). Conclusions: This study identified the contributing factors to adverse outcome such as delayed presentation with systemic gaps in management and unknown disposition. The need to improve these factors at local and national level can lead to improvement in Pakistani healthcare sector. doi: https://doi.org/10.12669/pjms.37.3.3680 How to cite this:Mukhtar S, Saleem SG, Ali S, Khatri SA, Yaffee AQ. Standing at the edge of mortality; Five-year audit of an emergency department of a tertiary care hospital in a low resource setup. Pak J Med Sci. 2021;37(3):---------. doi: https://doi.org/10.12669/pjms.37.3.3680 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: 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).