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Introduction: Nearly three quarters of the suicides occur in developing world, however few evidenced-based health systems strategies exist to detect and prevent suicide in these contexts. This pilot study evaluates the feasibility of implementing a universal suicide risk screening program in a Nepalese emergency department. Methods: This study reports the preliminary training phases of a pilot implementation trial in the emergency department to evaluate the program. The approval was obtained from the Nepal Health Research Council (Approval no. 447/2021 P), and the Kathmandu University School of Medical Sciences Institutional Ethical Review Board (Approval no. 237/2021) and Yale University IRB (Protocol ID 2000029480). Implementation assessments included suicide screening acceptability, appropriateness, confidence, system priority, and myth knowledge of staff. Implementation strategies were selected, decolonized, and preliminarily trained followed by phased supportive coaching to initiate the screening package. We designed the implementation package through co-design staff focus groups and embedded ethnography. Results: Co-design focus groups (n=8) occurred with staff and leadership. We trained 26 (76.47%) the staff on the Nepali suicide screening tool followed by supported phased initial screening over two months. Implementation assessments demonstrated increased scores on appropriateness, confidence, system priority, and myth knowledge. The implementation package included key strategies to be deployed over six months. The embedded ethnographic observations revealed barriers to effective implementation, such as anticipated stigma, reluctance to engage families, and distrust in referral processes. Conclusions: The pilot study demonstrated that training improves staff appropriateness, confidence, system priority, and myth knowledge. Despite initial barriers, co-designed strategies and phased coaching facilitates screening uptake, highlighting the program's potential for sustainable implementation.

Introduction: Emergency Medicine Point of Care Ultrasound (EM-POCUS) is a diagnostic bedside tool for quick and accurate clinical decision-making. Comprehensive training in POCUS is a mandatory part of EM training in developed countries. In Nepal, we need to build an educational curriculum based on the local medical system, available resources, and educational environment. We used the modified Delphi method to develop a EM-POCUS curriculum. Methods: We formed an EM-POCUS core working group based on expertise in key identified areas. The core working group developed criteria for expert panelist selection and synthesized the data for panelists after each Delphi round. We recruited 46 expert panelists to participate in a series of electronic surveys. The literature review and the results of the first Delphi round identified a set of competencies. Quantitative methodology was performed for subsequent surveys. Data analysis of the frequency, percentage, median, and interquartile range of the 9-point Likert scale was performed. We deemed a minimum threshold of 80% agreement to retain items across Delphi rounds. The result of every round was disseminated before subsequent rounds for the expert panelists to review responses in light of the group’s response. Results: We identified 10 specific global competency categories and 132 objectives (Round 1, response rate 85%). Rounds 2 and 3 (response rates 78% and 81% respectively) developed consensus on 45 core objectives (34%). The list of EM-POCUS competencies with the median (IQR) was finalized. Conclusion: This expert, consensus-generated EM-POCUS curriculum provides detailed guidance for EM-POCUS education and applications in clinical practice in Nepal.

Introduction. Traumatic pneumothorax is a life-threatening condition requiring vigilant clinical assessment and urgent management. Lung ultrasound (LUS) is considered to be a safer, rapid, and accurate modality for the early diagnosis of traumatic pneumothorax. The principle objective of this study was to evaluate the diagnostic accuracy of bedside LUS performed by trained novice physicians in the diagnosis of traumatic pneumothorax as compared to supine chest X-rays (CXRs) and/or computed tomography (CT) scans and/or air leak during needle/tube thoracostomy as composite standard. Methods. It is a prospective, cross-sectional, single-blinded study using a nonprobability quota sampling technique. A total of 96 patients presenting to the emergency department (ED) with polytrauma and chest injuries within a period of twelve months were included. The diagnostic accuracy of bedside LUS performed by trained novice physicians was calculated in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and compared with the composite standard. Results. The sensitivity of LUS in diagnosing traumatic pneumothorax as compared to the composite standard was 100% (95% confidence interval (CI): 59.05%–100.00%), whereas its specificity was 97.75% (95% CI: 92.12%–99.73%). Similarly, the PPV and NPV of LUS were 77.7% (95% CI: 39.99%–97.19%) and 100% (95% CI: 95.85%–100.00%), respectively. Conclusion. The results of the study showed that the application of LUS in detecting traumatic pneumothorax had similar diagnostic accuracy as supine CXR. Bedside LUS is widely available, portable, and inexpensive. It also has the capability of real-time imaging and can be repeated as necessary with less risk of radiation exposure. Therefore, physicians working in tertiary and rural health institutions must be trained adequately in order to uplift the clinical utility of LUS for the timely and cost-effective detection of traumatic pneumothorax.

Abstract Background Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to identify the frequency of unrecognized geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS. Methods This was a cross-sectional study of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into “no”, “mild-moderate” and “severe” depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviors were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach’s alpha was calculated to investigate reliability. Validity was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, Spearman’s correlation, receiver operating characteristic curve, and kappa coefficient. Results Two hundred eighty patients were enrolled with an overall prevalence of unrecognized depression of 45.7% [104 (81.3%) mild-moderate depression, and 24 (18.8%) severe depression]. The mean age of the sample was 71.36 with female predominance (61%), and 82.5% were illiterate. In the binary analysis, those who had more pain, visited the ED more often, had musculoskeletal diseases and sleep problems, mobility problems, visited local healers previously, and who reported self-perceived “heart and mind” disease showed statistically significant differences among the three categories. In multinomial regression analysis, visits to local healers, sleep problems and frequency of pain were significantly related to depression. The sensitivity, specificity, area under curve and Spearman’s correlation of GDS-5 were 75.8%, 96%, 0.919, and 0.827 respectively. Cronbach’s alpha for GDS-5 was low (0.416), therefore a new version was proposed which improved the sensitivity to 90.6% and Cronbach’s alpha to 0.623. Conclusions Unrecognized geriatric depression was highly prevalent which urges the need for ED-based interventions for screening and referral. The proposed brief GDS-5 correlated well with the GDS-15 with better validity and internal reliability and offers a more expeditious form of screening for geriatric depression in emergency settings in Nepal.

Abstract Background Children with emergency conditions require immediate life-saving intervention and resuscitation. Unlike adults, the pediatric emergency drug dose, equipment sizes, and defibrillation energy doses are calculated based on the weight of the individual child. Broselow tape is a color-coded length-based tape that utilizes height/weight correlations for children. However, in low-income countries like Nepal, due to factors like undernutrition, the Broselow tape may not accurately estimate weight in all ranges of pediatric age group. Methods This study was conducted in the Department of Pediatrics of Dhulikhel Hospital, Kathmandu University Teaching Hospital, in children less than 15 years of age. Our study aims to prospectively compare the actual weights of urban and rural Nepalese children with the estimated weights using the Broselow tape (2017 edition) and the updated APLS formula. The errors in the selection of endotracheal tube size and adrenaline dose using the Broselow tape were also explored. Results This study included 315 children with male to female ratio of 0.63:1. They were divided into 3 groups according to their estimated weight by the Broselow tape into 18 kg. There was a total agreement of the estimated color zone according to the Broselow tape with the actual weight in the gray zone (p = 0.01). There was a positive relationship between the actual body weight and the estimated body weight (correlation (r = 0.970, p = 0.01) and accuracy (r 2 = 0.941)). Our analysis showed that the accuracy of estimated weight with the Broselow tape decreases with increasing weight of children. The precision of the tape was relatively high in the lower length zones as compared to the higher length zones. The estimated size of the endotracheal tube (p = 0.01) and adrenaline dose (p = 0.08) by the Broselow tape was in agreement with that estimated using PALS formula in weight group of less than 18 kg, but decreases as the estimated weight increases further. Conclusions The accuracy of the Broselow tape in estimating the weight of a child, endotracheal tube size, and dose of adrenaline is higher in weight group of less than 18 kg, and accuracy decreases as the weight of child increases. The Broselow tape should be avoided in children weighing more than 18 kg. Hence, PALS age-based formula for ET tube size estimation and weight-based formula for adrenaline dose calculation are recommended for children weighing more than 18 kg.

Abstract Background Simulation is well established as an effective strategy to train health care professionals in both technical and nontechnical skills and to prevent errors. Despite its known efficacy, adequate implementation is restricted due to the financial burden in resource-limited settings like ours. We therefore pursued to introduce cost-effective in situ simulation (ISS) in the emergency department (ED) to explore its impact on perception and learning experience among multidisciplinary health care professionals and to identify and remediate the latent safety threats (LST). Methods This is a prospective cross-sectional study with a mixed method research design, which was conducted in the ED of Dhulikhel Hospital-Kathmandu University Hospital. The pretest questionnaire was used to determine baseline knowledge, attitude, and confidence of the staff. The ISS with minimal added cost was conducted involving multidisciplinary healthcare workers. The LSTs were recorded and appropriate remediation was performed. Voluntary post simulation feedback was collected after the sessions. Results Overall 56 staff participated in at least one of the 35 simulation sessions, among which 45 (80%) responded to the questionnaires`. Twenty participants (45.5%) were reluctant to use the defibrillator. The self-reported confidence level of using defibrillator was low 29 (64.6%). The knowledge score ranged from 0 to 8 with the median score of 3 and a mean of 3.29 ± 1.8. There was no statistically significant difference in knowledge scores among participants of different occupational backgrounds, previous training, duration of work experience, and previous use of a defibrillator. A total of 366 LSTs {individual (43%), medication (17%), equipment (4%), and system/team (36%)} were identified (10.45 LST per ISS). The overall feedback from the participants was positive. Eighty percent of participants reported increased skills to use a defibrillator, and 82% reported increased confidence for managing such cases. They also agreed upon the need and continuity of such type of simulation in their workplace. Conclusions The baseline knowledge score and the confidence level of the staff were low. Self-reported feedback suggested increased confidence level and teamwork skills after ISS. It promoted identification and remediation of latent safety threats. ISS serves as a cost-effective powerful educational model that can be implemented even in settings where finances and space are limited.

Background: Bacteriological aetiology and its culture sensitivity pattern is an important parameter for evaluating antibiotic use in Emergency Department. Blood-stream infections cause significant morbidity and mortality, increase in length of hospital stay and increased cost of care. Frequent inappropriate antibiotic use contributes to emergence of drug-resistant bacteria pathogens. Objectives: The objective of this study was to identify likely etiologic agents’ and antibiotic sensitivity profile of bacteria from blood stream infection in Emergency Department of Patan Hospital. Methodology: The study was conducted at tertiary care hospital from July to August 2014 blood culture was done and antibiotic susceptibility test was performed following Kirby Bauer disc diffusion technique and growth and sensitivity pattern of organisms isolated were analyzed. Results: There were 282 blood culture sent from the Emergency Department. The most common bacterial isolates were Enterobacter species. Second most common bacteria were Streptococcus pneumoniae. Enterobacter species was more sensitive to Chloramphenicol, Amikacin and Gentamycin. While Streptococcus pneumoniae was sensitive to most of the antibiotics, we also found that 65.3% bacterial isolates were resistant to Cephalosporin. Conclusion: Contaminated blood samples were found higher therefore, emphasis should be given in reducing the contamination. Proper cleaning of skin with antiseptic and guidelines to draw blood for culture should be familiarized and strictly followed while drawing the blood and others from Emergency Department of Patan Hospital.

The COVID-19 pandemic is a global challenge that is not just limited to the physical consequences but also a significant degree of a mental health crisis. Self-harm and suicide are its extreme effects. We aim to explore the impact of this pandemic on suicide and self-harm in our Emergency Department. A cross-sectional study was conducted including all fatal and nonfatal self-harm patients presenting to the emergency department during the lockdown period (March 24-June 23, 2020; Period1), matching periods in the previous year (March 24-June 23,2019; Period 2) and 3 months period prior (December 24 2019-March 23, 2020; Period 3) were included through the electronic medical record system. The prevalence and the clinical profile were compared between these three periods. A total of 125 (periods 1 = 55, 2 = 38, and 3 = 32) suicide and self-harm cases were analyzed. Suicide and self-harm had increased by 44% and 71.9% during the lockdown in comparison to periods 2 and 3. Organophosphate poisoning was the most common mode. Females were predominant in all three periods with a mean age of 32 (95%CI: 29.3-34.7). There was a significant delay in arrival of the patients in period 1 (p = 0.045) with increased hospital admission (p = 0.003) and in-hospital mortality (18.2% vs 2.6% and 3.1%) (p

IntroductionHead injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians.MethodsWe consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians' education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels.ResultsThe implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions.ConclusionThe implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians.

Background Thoracoabdominal trauma presents a diagnostic challenge for the emergency physician. The introduction of bedside ultrasonography (USG) provides a screening tool to detect hemoperitoneum, hemothorax, pneumothorax and pericardial effusion in torso injuries.Aim To evaluate the accuracy of extended focused assessment with sonography for trauma (EFAST) for chest and abdominal injuries performed by first responders in a tertiary care hospital of Nepal.Methods This was a prospective study including all trauma patients who obtained either an Injury Severity Score ≥15 or direct trauma to the trunk in 1 year period in the emergency department (ED) of Dhulikhel Hospital-Kathmandu University Hospital. The results of the EFAST were then compared with contrast-enhanced CT (CECT), radiology ultrasound (USG)/chest X-ray, or intraoperative findings when the EFAST was positive. The negative EFAST cases were observed for a minimum of 4 hours in the ED. Descriptive statistics and sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated.Results Out of 267 cases, 261 patients underwent an EFAST examination. The sensitivity and specificity were 94.8% and 99.5%, respectively. The negative predictive value was 98.53% whereas the positive predictive value was 98.21%. The overall accuracy was 99.4%.Conclusion The results of this study suggest that EFAST examination performed by first-line healthcare providers is a useful method for assessment of thoracic and abdominal injuries. EFAST was found to have a high specificity (99.5%) and positive predictive value (98.21%) which indicates that it is an effective technique for detecting intra-abdominal or thoracic injuries. However, the effectiveness of EFAST is limited by its being operator dependent, and thereby human error. For negative EFAST cases, we recommend a monitoring period of at least 4 hours, serial fast scan, or further investigation through other methods such as a CECT.Level of evidence Level I

Introduction: Dyspnea is a common presenting complaint in the emergency department worldwide and a diagnostic challenge for emergency physicians. Our study aims to find the prevalence of dyspnea among patients attending emergency department in our hospital. Methods: A descriptive cross-sectional study was conducted in the emergency department of Dhulikhel hospital from May 2019 to July 2019 after ethical approval from the institutional review committee. Total 1200 samples were collected by consecutive sampling method. All patients were triaged in the emergency department as a part of regular protocol. The participants were included in the study after obtaining an informed consent from the patient or caretaker (if the patient were not able to provide it). Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. The statistical analysis was done using R version 3.5.3 (2019-03-11). Results: The prevalence of dyspnea among patients attending emergency department of a tertiary care hospital was 107 (8.9%) (4.6%-13.2%) at 95% confidence interval. The patients triaged into red, orange and yellow categories were 14 (13.1%), 50 (46.7%) and 43 (40.2%) respectively. Median age was 64 years and 74 (69%) were ≥60 years. Sixty-seven (62.6%) were females and 40 (37.4%) were males. Forty-four (41.1%) arrived by ambulance. Most commonly associated symptoms were cough and fever 59 (51.1%) and 44 (41.1%) respectively. Conclusions: The prevalence of dyspnea among patients attending emergency department of our hospital is higher compared to that of other studies. This warrants structured and prompt management of dyspnea for quality improvement.

Introduction: Basic life support is foundation to save lives. In contrast to the developed countries, there is still no national standard BLS training module in Nepal. Basic life support training is being provided by various institutions but lack in consistency and coordination. The Nepal basic life support Course is the video based training in Nepali language with reference to recent advances which was intended for all health care personnel of Nepal in urban as well as rural setting. We aimed to describe the features of this video based training module in local language, to analyse the differences of knowledge and find out the participants perception and satisfaction with this course. Methods: This is a descriptive cross-sectional study based on data of trainings conducted over the study period. Ethical approval was taken. The post-test score was recorded and compared with the occupational using ANOVA. On the spot and delayed feedbacks from the participants were collected voluntarily and summarized. Results: Total of 576 participants (435 clinical doctors, 92 nurses/paramedics, 18 non-clinical doctors and 41 intern doctors) successfully completed the training. The difference in post test scores (mean = 12.9±1.8) among the different occupational background was not significant (P=0.159). The feedbacks from the participants were mostly positive and encouraging. Conclusions: The knowledge of basic life support improved significantly irrespective of the occupation of the participants. A universal, nationwide video based training module in Nepali language should be developed focusing all health care personnel of urban as well rural Nepal.

Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nepal, it is in preliminary phase.2 EM is not only restricted to urban emergency departments but also a multifaceted discipline.3 Several EM training modules are currently practiced fragmented with different curriculum and duration.4,5 Pre-hospital emergency medical services (EMS), hospitals, trauma centres, and public health are working in silos and most of them devoid of proper emergency facility.2 This brought us to the realization of an urgent need of bringing all the stakeholders together in a symposium like this. The symposium was arranged into four different sessions as listed below: • To familiarize with the history and current state of EM from Global Emergency Medicine perspective. • To highlight the different clinical experiences and advancements in EM in Nepal. • To emphasize the importance and possibilities in EM education and research in Nepal. • To discuss the roadmap to develop and establish EM as a recognized medical speciality in Nepal. The overall objectives of the symposium were to discuss the challenges faced by current Emergency Medicine providers and identify the opportunities for the future development and recognition in Nepal. The most important current task for Nepal’s emergency physicians of advocating for policies, programs, and funding to support further development of the specialty was realized. Rural and urban emergency service providers from academic and non-academic institutions, governmental/non-governmental organizations and international medical institutions attended the symposium. General Practice (GP) residents, medical officers, medical students, interns and paramedics were among active participants.

Aim: To determine the prevalence of H. pylori based on endoscopic biopsy and to investigate the association between H. pylori and endoscopy diagnosis and histopathological diagnosis. Materials and Methods: Over a period of two years, 228 endoscopic biopsies were included. Endoscopy diagnosis, histopathological diagnosis, and colonization with H. pylori were recorded and compared using appropriate statistical tests. Results: The overall prevalence of H. pylori was 68%; 69.6% in males and 66.7% in females. Duodenal and gastric ulcers were seen more in males (63.2% and 60%) compared with females (32.1% and 40%) (P < 0.001). The total rate of colonization of H. pylori in duodenal ulcer and gastric ulcer (85.7% and 84%, respectively) was significantly higher than those in gastritis, duodenitis, and gastric cancer (61.8%, 69.2%, and 60%, respectively) (P = 0.046). Histologically, chronic active gastritis and chronic follicular gastritis was significantly higher in duodenal ulcer and gastric ulcer (57.1%, 44% and 21%, 40%) in comparison to chronic persistent gastritis (21.4%, 16%) with P value < 0.001. Similarly, chronic active gastritis and chronic follicular gastritis had higher prevalence of H. pylori infection in comparison to chronic persistent gastritis (85.3%, 83.3% vs. 41.4%) with P value < 0.001. Conclusion: This study reveals that the overall prevalence of H. pylori infection is high in our setting with no significant difference in gender. Peptic ulcers were common in males. Those with peptic ulcers had higher rates of H. pylori colonization. Chronic active gastritis and chronic follicular gastritis were common histological findings in ulcerative diseases with significantly higher H. pylori positivity.

Background: Basic life support (BLS), a key component of the chain of survival decreases the arrest - cardiopulmonary resuscitation interval and increases the rate of hospital discharge. The study aimed to explore the knowledge of and attitude towards basic life support (BLS) among medical/paramedical professionals., Methods: An observational study was conducted by assessing response to self prepared questionnaire consisting of the demographic information of the medical/paramedical staff, their personnel experience/attitude and knowledge of BLS based on the 2005 BLS Guidelines of European Resuscitation Council., Results: After excluding incomplete questionnaires, the data from 121 responders (27 clinical faculty members, 21 dental and basic sciences faculty members, 29 house officers and 44 nurses and health assistants) were analyzed. Only 9 (7.4%) of the 121 responders answered ≥11, 53 (43%) answered 7-10, and 58 (48%) answered <7 of 15 questions correctly. The clinical faculty members, house officers and nurses/HA had a mean score of 7.4±3.15, 7.37±2.02 and 6.63±2.16 respectively, while dental/basic sciences faculty members attained a least mean score of 4.52 ±2.13 (P<0.001). Those who had received cardiopulmonary resuscitation (CPR) training within 5 years obtained a highest mean score of 8.62±2.49, whereas those who had the training more than 5 years back or no training obtained a mean score of 5.54±2.38 and 6.1±2.29 respectively (P=0.001). Those who were involved in resuscitation frequently had a higher median score of 8 in comparison to those who were seldom involved or not involved at all (P<0.001)., Conclusions: The average health personnel in our hospital lack adequate knowledge in CPR/BLS. Training and experience can enhance knowledge of CPR of these personnel. Thus standard of CPR/BLS training and assessment are recommended at our hospital.