{"paper_id":"17b53003-d9ef-47f7-962d-9de43e13d521","body_text":"Prioritizing Pediatric Emergency Transfers: Identifying Clinical and Resource-Based Indicators for PICU Admission in a Tertiary Care Hospital in Karachi, Pakistan. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prioritizing Pediatric Emergency Transfers: Identifying Clinical and Resource-Based Indicators for PICU Admission in a Tertiary Care Hospital in Karachi, Pakistan. Saleem Akhtar, Surraiya Bano, Momal A. Wasim, Zeeshan Allana, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9042477/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 20 You are reading this latest preprint version Abstract Background: Pediatric critical care remains a major challenge in low- and middle-income countries (LMICs) because of the limited PICU capacity. This often forces critically ill children to be managed in emergency departments (EDs) for long periods, exhausting the already scarce resources. This delays care and contributes to poor outcomes. The purpose of this study was to describe the characteristics, triage levels, and outcomes of children admitted from the ED to the PICU at a tertiary hospital in Pakistan. Methods We reviewed charts of all children between 1 month and 18 years who were admitted from the ED to the PICU during 2021. Information on age, sex, presenting symptoms, diagnosis, triage level, ED resource use, length of stay, and outcomes was collected. Results: Among 418 patients, most were under 5 years of age (66.9%) and male (58.6%). The majority (83%) arrived in the ED as P1 (critical) triage. Respiratory diseases were the leading cause of PICU transfer (30.6%), followed by infectious illnesses (21.2%) and central nervous system disorders (15.7%). Pneumonia (18.5%), septic shock (13.2%), and meningoencephalitis (9.4%) were frequent diagnoses. These groups also consumed the greatest share of ED resources. By contrast, trauma, gastrointestinal, and endocrine/metabolic disorders required fewer transfers and shorter stays. Conclusion: In this LMIC setting, most children transferred from ED to PICU were very young and critically ill with respiratory, infectious, or CNS diseases. Earlier transfer and expansion of intermediate-level PICUs may help reduce ED strain and improve outcomes. Clearer admission and transfer guidelines are also needed to avoid unnecessary PICU use and preserve limited resources. Pediatric Emergency Department (PED) Pediatric Intensive Care Unit (PICU) Triage Resource Utilization Critical Care Low and Middle Income Countries (LMICs) Length of Stay (LoS) Figures Figure 1 Figure 2 Figure 3 KEY MESSAGE ED - PICU strain in LMICs : Limited PICU beds and resources in low- and middle-income countries (LMICs) force critically ill children to be managed in the ED. This leads to resource strain, delays in care, worsened outcomes, and increased staff burden. Respiratory illnesses are the leading drivers of PICU transfers , especially among critically ill (P1) triage patients, placing the heaviest burden on ED resources. Limited PICU capacity in LMICs leads to delayed or avoidable transfers , prolonged ED stays, and increased strain on staff and resources. INTRODUCTION Pediatric critical care is an essential pillar of pediatric healthcare. However, in low- and middle-income countries, pediatric critical care is limited due to constrained healthcare resources in most hospitals [ 1 ]. Access to critical care is a life-changing intervention and can drastically improve patient outcomes, as has been seen in high-income countries [ 2 ]. However, in LMICs, the pediatric intensive care unit (PICU) and pediatric emergency department (PED) access is limited due to a lack of infrastructure and trained healthcare providers [ 3 , 4 ]. Unfortunately, we face a dilemma here, as many LMICs face a heavy burden of pediatric illnesses, including infectious diseases, respiratory distress, sepsis, and dehydration. Lack of immediate medical intervention causes many preventable deaths [ 5 ]. LMICs have much higher mortality rates than High-Income Countries (HICs) due to a lack of resources and availability of healthcare [ 6 ]. A recent study in Pakistan revealed that children die from preventable causes, such as infections and injuries, due to inadequate treatment [ 7 ]. Abdelatif et al. examined structural differences—specifically in human and physical resources—between two pediatric intensive care units (PICUs), one in Egypt (a low- and middle-income country, LMIC) and the other in Japan (a high-income country, HIC). They reported a mortality rate of 41.6% in the LMIC PICU compared to 2.4% in the HIC PICU [ 13 ]. Resource-limited settings, such as sub-Saharan Africa and Latin America, have found that bed and healthcare staff shortages created significant challenges in the PICU [ 8 ]. This leads to critical patients having to be managed in the ED for several hours. A study found that patients in the emergency department who experienced a delay of six hours or more before being transferred to the ICU tended to remain hospitalized longer and had a higher risk of dying in the ICU or during their hospital stay [ 9 ]. This exacerbates the pre-existing burnout among ED physicians and nursing staff. One of the top-most contributing factors is shift work, which is made more challenging by increased workload from delayed transfers from the ED to the ICU [ 10 , 11 ]. Mathews et al. conducted a study in the US regarding transfers from ED to ICU for critically ill patients, showing that the transfers are solely dependent on bed availability. Additionally, extended boarding times in the ED were associated with poorer patient outcomes, suggesting that focused care may be needed for those awaiting ICU placement [ 12 ]. Unfortunately, in LMICs, bed availability is much more limited than HICs [ 13 ]. However, there is still a need for evidence-based guidelines to optimize patient outcomes from PED to PICU, recognizing which patients can best be treated in the ED versus the PICU. It is essential to identify patients who are likely to survive with only brief ICU support to maximize the effectiveness of triage allocation during prolonged emergencies. However, no validated tool currently exists for either children or adults [ 14 ]. Additionally, there is a need to identify the patient population in the PED with the highest resource utilization and facilitate early transfers to reduce and redirect the limited ED resources. METHODS Materials and Methods Ethical Considerations The study was approved by the Institutional Ethical Review Committee (ERC) in 2021. Informed consent was waived due to the retrospective design, and patient confidentiality was maintained. ERC # 2020579915319. Clinical trial number: not applicable. Study Design and Setting This retrospective chart review was conducted in the pediatric emergency department (ED) of a tertiary care hospital in 2021. The ED has 23 beds (3 resuscitation, 8 monitored, 12 non-monitored) and uses the Emergency Severity Index (ESI) for triage. The hospital has an 8-bed pediatric intensive care unit (PICU) managed by intensivists and fellows, who also attend ED patients when required. PICU admission was limited by bed availability and financial clearance; in their absence, patients remained in the ED or were referred elsewhere. Study Population All patients aged 1 month to 18 years admitted from the ED to the PICU during the study period were eligible. Both sexes were included. Race/ethnicity was not consistently documented and, therefore, not analyzed. Inclusion Criteria Age 1 month–18 years Admission from ED to PICU Exclusion Criteria Age < 1 month Direct outpatient admissions Referrals already intubated Patients receiving CPR in the ED Sampling Strategy Non-probability convenience sampling was used. Data Collection and Variables Data extracted from electronic records included demographics (age, sex), triage category, ED management, PICU admission, and outcomes. Statistical Analysis All data were analyzed using Stata version 17.0. Descriptive statistics were used to summarize patient demographics, clinical characteristics, triage levels, resource utilization, and outcomes. Categorical variables (e.g., sex, triage category, diagnosis, and mortality) were presented as frequencies and percentages. Continuous variables (e.g., age, laboratory parameters, and length of stay were assessed for normality using the Shapiro–Wilk test. Variables with a normal distribution were reported as mean ± standard deviation (SD), while non-normally distributed variables were summarized as median with interquartile range (IQR). Data visualizations were generated using R version 4.4.2. RESULTS A total of 418 patients were included in this study, of which 245 (58.61%) were males and 173 (41.39%) were females. Most of our patients were categorized under Triage Category P1 upon arrival at the ED (83.1%), indicating that their conditions were critical from the onset, with the majority of patients being under 5 years of age (66.91%) ( Table 1 ). Table 1 Demographics and Health-Related Characteristics of Patients Admitted in the Emergency Unit Variables Total 418 (100%) Age (in years) <1 years 138 (34.07) 1–5 years 133 (32.84) 6–10 years 48 (11.85) >10 years 86 (21.23) Gender Male 245 (58.61) Female 173 (41.39) Triage P1 342 (83.01) P2 56 (13.59) P3 14 (3.40) Laboratory Investigation Hemoglobin (g/dL) * 10.20 (8.70–11.70) TLC – Leucocytes count (10³/µL) * 13.40 (8.20–19.60) Platelets (10³/µL) * 312 (170–452) Bicarbonates * 16.95 (8.30–21.65) Blood Sugar * 117 (91–168) *Median (Interquartile Range) We found that under the P1 Triage category, the most common systemic involvement was respiratory diseases (24.45%), followed by infectious diseases (17.85%) and central nervous system (CNS) disorders (12.47% ) ( Table 2 ). Most of our patients that transferred from ED to PICU belonged to the P1 triage category. Patients with respiratory diseases (30.6%) were the most likely to need PICU care, followed by those with infectious diseases (21.2%) and central nervous system (CNS) conditions (15.66%). Table 2 Patient Characteristics by Triage Category and Associated Treatments Variables Total P1 342 (81.82) P2 56 (13.40) P3 20 (4.78) Systemic disease CNS 65 (15.66) 51 (12.47) 12 (2.93) 2 (0.49) Cardiovascular System 28 (6.75) 24 (5.87) 4 (0.98) - Endocrine and Metabolic 23 (5.54) 18 (4.40) 4 (0.98) 1 (0.24) Gastro Hepatobiliary 23 (5.54) 18 (4.40) 3 (0.73) 2 (0.49) Infectious 88 (21.20) 73 (17.85) 9 (2.20) 6 (0.49) Malignancy 19 (5.58) 16 (3.91) 3 (0.73) - Others 12 (2.93) 12 (2.93) - - Respiratory 127 (30.60) 100 (24.45) 20 (4.89) 7 (1.47) Trauma and Environment 30 (7.23) 27 (6.60) 1 (0.24) 2 (0.48) Length of stay (Hours) 7.95 + 6.39 7.33 + 0.38 9.55 + 1.07 9.72 + 1.77 Vasoactive Medication None 235 (56.22) 189 (55.26) 32 (57.14) 14 (70.00) Epinephrine 143 (34.21) 122 (35.67) 16 (28.57) 5 (25.00) Norepinephrine 6 (1.44) 2 (0.58) 4 (7.14) - Milrione 15 (3.59) 12 (3.51) 3 (5.36) - Other 19 (4.55) 17 (4.97) 1 (1.79) 1 (5.00) Antibiotics None 69 (16.51) 51 (14.91) 17 (30.36) 1 (5.00) Ceftriaxone 128 (30.62) 110 (32.16) 11 (19.64) 7 (35.00) Tazocin 15 (3.59) 6 (1.75) 7 (12.50) 2 (10.00) Meropenam 41 (9.81) 34 (9.94) 5 (8.93) 2 (10.00) Vancomycin 151 (36.12) 130 (38.01) 13 (23.21) 8 (40.00) Other 14 (0.35) 11 (3.21) 3 (5.36) - Blood Transfusion None 370 (88.52) 304 (88.89) 48 (85.71) 18 (90.00) Packed Cell 22 (5.26) 20 (5.85) 2 (3.57) - Platelet 7 (1.67) 5(1.46) 2 (3.57) - FFP 19 (4.55) 13 (3.80) 4 (7.14) 2 (10.00) Endotracheal Tube No 341 (81.97) 270 (79.41) 53 (94.64) 18 (90.00) Yes 75 (18.03) 70 (20.59) 3 (5.36) 2 (10.00) Fluid Bolus No 144 (34.87) 111 (32.94) 26 (46.43) 7 (35.00) Yes 269 (65.13) 226 (67.06) 30 (53.57) 13 (65.00) Fever (47%) was the most common presenting complaint, followed by respiratory distress (34%), cough and chest congestion (20%), with less frequent symptoms including vomiting, drowsiness, seizures, and trauma. Further details are shown in Fig. 1 . Among respiratory diseases, Pneumonia (18.51%) and Acute Exacerbation of Asthma (4.57%) were the most common diagnoses requiring admission from the Pediatric Emergency Department to the PICU. Under Infectious disease, we found patients with Septic Shock (13.22%) in the ED, requiring PICU transfer. Patients diagnosed with Meningoencephalitis (9.38%) were also critical and were transferred to the PICU (Table 3) . Based on this data, we conclude that patients admitted under the P1 triage category with these diagnoses are high-priority cases that cannot be managed solely in the ED and require the specialized care, highly trained staff, and advanced resources available in the PICU. In terms of resource utilization, the maximum resources were used by patients with diagnoses under respiratory, infectious, and CNS disease ( Fig. 2 ) . However, the majority of these patients were eventually transferred out to the PICU. This suggests that earlier transfer of high-priority patients to the PICU is crucial to save time and resources. By transferring them sooner, critical resources and ED staff time could be spared. This would allow the emergency department to better manage other patients who can be stabilized and recover without needing PICU admission. Patients diagnosed with trauma, gastrointestinal and hepatobiliary diseases, as well as endocrine and metabolic disorders, made up a smaller fraction of transfers to PICU (Table 3), suggesting effective treatment in the PED. Additionally, these patients also used fewer ED resources (Fig. 1 ), had shorter lengths of stay (LoS) (Fig. 2 ), and most had favorable (alive) outcomes (Table 4 ). Table 3 Systematic Diagnostic Categories of Patients Admitted to PICU. System Disease Frequency (Percentage) CNS 65 (15.66) Meningoencephalitis 39 (9.38) Status Epilepticus 10 (2.40) Intracranial bleed 5 (1.20) Other Neurological 11 (2.64) Respiratory 127 (30.60) Pneumonia 77 (18.51) Acute Exacerbation of Asthma 19 (4.57) Bronchiolitis 7 (1.68) Foreign body ingestion 6 (1.44) Pleural Effusion 9 (2.16) Croup 4 (0.96) Other Diagnosis 5 (1.20) Infectious 88 (21.20) Septic Shock 55 (13.22) Dengue 11 (2.64) Enteric Shock 10 (2.40) Other infection 12 (2.88) Cardiovascular 28 (6.75) Myocarditis 12 (2.88) Arrhythmias 3 (0.72) Tet spell 4 (0.96) Hypertensive emergencies 5 (1.20) Congestive and Structural Diseases 3 (0.72) Congenital or Cyanotic Disease 2 (0.48) Gastro and Hepatobiliary 23 (5.54) Gastroenteritis with MODS 10 (2.40) Acute Liver failure 13 (3.13) Trauma and Environmental 30 (7.23) Trauma 17 (4.09) Environmental 13 (3.13) Endocrine and metabolic 23 (5.54) DKA 15 (3.61) IEM 8 (1.92) Malignancy 19 (5.58) Malignancy 19 (4.57) Others 12 (2.93) Others 12 (2.88) Table 4 - Mean Length of Stay (LoS) with patient mortality outcomes. ED LOS (Hours) Outcome Alive Dead CNS 6.84 + 0.55 51 (14.61) 14 (20.29) Respiratory 7.96 + 0.56 104 (29.80) 24 (34.78) Infectious 7.59 + 0.63 78 (22.35) 10 (14.49) Cardiovascular 10.27 + 1.29 22 (6.30) 6 (8.70) Gastro and Hepatobiliary 8.06 + 1.44 20 (5.73) 4 (5.80) Trauma and Environmental 7.10 + 0.80 26 (7.45) 4 (5.80) Endocrine and metabolic 6.84 + 1.15 19 (5.44) 4 (5.80) Malignancy 8.14 + 1.65 16 (4.58) 3 (4.35) Others 10.50 + 2.54 13 (3.72) 0 Patients with the longest LoS were under the P3 triage category, followed by P2 and then P1 ( Table 2 ) . Additionally, patients with malignancy, cardiac issues, or endocrine/metabolic issues had the longest stays by disease category. ( Fig. 3 , Table 4 ). DISCUSSION This study represents a pioneering investigation into the clinical characteristics of pediatric patients who presented to the emergency department (ED) of a tertiary care hospital and were subsequently admitted to the Pediatric Intensive Care Unit (PICU) in a resource-limited country, such as Pakistan. Our findings provide important insights into the critical factors influencing pediatric care in emergency care settings in resource-limited environments. Our findings indicated that a majority of patients present under the Critical Triage (P1) category. P1 category patients are the most critical and therefore need advanced interventions and more ED resources, such as mechanical ventilation or admission to the PICU, in contrast to P2 triage patients [ 15 ]. The majority of the patients transferred to the PICU were males, which could indicate higher admissions of males to the Pediatric Emergency department. This pattern was also noted in a study carried out in Boston, United States. The study documented that access to healthcare is greater for males than for females in children [ 16 ]. In contrast, another study noted that the overall hospitalization rate to the PICU was higher for boys than for girls [ 17 ]. A study done in India reported that immunization coverage is higher in boys, as compared to girls [ 18 ]. We found that the most common systemic involvement was respiratory diseases, under the P1 triage category, eventually transferring out to the PICU. Siddiqui et al. reported a similar pattern in their study, also conducted at a tertiary center in a LMIC in Pakistan, where they found asthma, bronchiolitis, and pneumonia to be the most common diagnoses under P1 being further escalated to the PICU [ 15 ]. A similar pattern was noted in a study done in the United States, where they found respiratory distress to be the most common reason for transfer from the ED to PICU in the pediatric population [ 19 ]. After respiratory diseases, a significant number of patients with infectious diseases, such as septic shock, and CNS disorders/infections, such as meningoencephalitis, required PICU care and were transferred from the ED to the PICU. Lipsett et al. found a similar pattern; however, their study also assessed seasonal trends in pediatric infectious diseases. [ 20 ] Another way to decrease the ED and potential pediatric visits is to improve immunization practices, especially in LMICs. However, a study done in Pakistan showed that vaccinated children might still get diseases at the completion of the Expanded Program on Immunization (EPI) [ 21 ]. Triage categorization in an ED can influence the length of patient stay in ED, cost of ED stays and resource utilization. Critically ill P1 triage patients put a significant burden on the ED [ 15 ]. This suggests a need for a speedy PICU transfer for critical patients, especially presenting with respiratory, CNS, or infectious disease. However, in LMICs such as Karachi, Pakistan, PICU facilities are limited. A systematic review conducted on ICU capacity in LMICs found beds to be significantly reduced in contrast to their need [ 22 ]. To add to this issue, some transfers to PICU are potentially avoidable, as found in a study where more than half of the transfers from the general care unit to PICU were potentially avoidable transfers (PATs) [ 19 ]. We found that patients diagnosed with trauma, GI, endocrine, and metabolic disorders had the fewest transfers to PICU. ED overcrowding has been a growing issue internationally [ 23 ], and due to limited PICU availability, ED stays are prolonged. Additionally, prolonged ED stays could also be due to other factors such as consultations, diagnostic tests, or the triage level. [ 24 ] This adds to the overall ED burden, resource utilization, and ED staff burnout. We saw that certain conditions had a higher resource utilization in the ED, such as respiratory illnesses. Prompt transfer would help preserve the limited ED resources. We also found a need for a more efficient collaboration between the ED and PICU would help the physicians, nursing staff, and patients to assist in early transfer of high-priority patients. An example where this was successfully introduced was the usage of an SBAR tool. This project introduced a tailored SBAR handoff tool and trained the ED and PICU nurses in a collaborative bedside process for verifying medications and lines or drains. After implementation, PICU nurses noted more structured care transitions and greater confidence in having the information needed to safely manage critically ill patients [ 25 ]. Our study also found that the significant burden placed on pediatric emergency departments in resource-limited settings is due to delays and constraints in PICU availability. Most critically ill children require PICU transfer, which is a challenge in LMICs. The majority of our PICU admissions were respiratory illnesses, followed by infectious and CNS disorders. These systems also consumed substantial ED resources. Timely triage and early transfer to the PICU can potentially help to optimize resource utilization and improve patient outcomes. Some transfers might be avoidable with clearer admission criteria or guidelines for intradepartmental transfer. Our study has some limitations. As a retrospective, single-center study, the findings may not be fully generalizable. In addition, since it was conducted at a well-resourced private tertiary care center, the results may not fully reflect the realities of more resource-constrained public sector settings, such as the government-run hospitals in LMICs. In low- and middle-income countries like Pakistan, we suggest expanding pediatric critical care capacity through intermediate-level PICUs. As the majority of critically ill patients simply require respiratory support like oxygen, High-Flow Nasal Cannula (HFNC), and a very small number require intubation, vasopressors, and invasive monitoring, so in a resource-limited setting like Pakistan, we should build some intermediate-level PICUs where we can treat and manage patients with less intensive care requirements. A potential solution could be a novel Emergency Department-based ICU model (EC3). Gunnerson et al. created and studied its impact on critically ill patients in Michigan, US. They found its implementation was linked to improved 30-day survival and fewer inpatient ICU admissions. Findings suggest ED-based ICUs may help alleviate ICU strain and improve outcomes [ 26 ]. There is also a need for guidelines for higher priority transfers between ED and PICU teams, outlining key strategies to reduce overcrowding, preserve limited resources, and improve survival among critically ill children. Abbreviations PED Pediatric Emergency Department PICU Pediatric Intensive Care Unit ED Emergency Department LMIC Low- and Middle-Income Country ESI Emergency Severity Index LoS Length of Stay CNS Central Nervous System ERC Ethical Review Committee Declarations Ethics approval and consent to participate: This study was approved by the Ethical Review Committee (ERC), Aga Khan University Hospital, Karachi, Pakistan (ERC #2020579915319). The study was conducted in accordance with the principles of the Declaration of Helsinki. Given the retrospective nature of the study, the requirement for informed consent was waived by the ERC. As the study involved pediatric participants, the ERC determined that parental/legal guardian consent was not required due to the use of de-identified retrospective data. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors declare that they have no competing interests. Funding: No funding was received for this research. Authors' contributions: Conceptualization: Saleem Akhtar, Momal A. Wasim, Surraiya Bano Methodology: Surraiya Bano, Momal A. Wasim Software: Zeeshan Allana Validation: Surraiya Bano, Saleem Akhtar Formal analysis: Zeeshan Allana Investigation: Sara Fatima, Ammara Hameed Resources: Sara Fatima, Ammara Hameed Data curation: Sara Fatima, Ammara Hameed Writing - original draft: Momal A. Wasim Writing - review & editing: Momal A. Wasim, Saleem Akhtar, Surraiya Bano Visualization: Momal A. Wasim, Surraiya Bano Supervision: Surraiya Bano Project administration: Surraiya Bano All authors read and approved the final manuscript. Acknowledgements: The authors would like to acknowledge the support of the Emergency Department and Pediatric Intensive Care Unit staff at Aga Khan University Hospital for their assistance in data collection and patient care. References Slusher TM, Kiragu AW, Day LT, Bjorklund AR, Shirk A, Johannsen C, Hagen SA. Pediatric critical care in resource-limited settings—overview and lessons learned. Front Pead. 2018;6:49. Kelly FE, Fong K, Hirsch N, Nolan JP. Intensive care medicine is 60 years old: the history and future of the intensive care unit. Clin Med. 2014;14(4):376–9. Hsu BS, Hill V, Frankel LR, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9042477\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":621824697,\"identity\":\"4e5e9dd5-824d-4c3e-83f3-7e2d925bd32b\",\"order_by\":0,\"name\":\"Saleem Akhtar\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Saleem\",\"middleName\":\"\",\"lastName\":\"Akhtar\",\"suffix\":\"\"},{\"id\":621824698,\"identity\":\"351073f6-ab31-46bb-9284-c56df8a23a8e\",\"order_by\":1,\"name\":\"Surraiya Bano\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYNACAyCWADEqwEwIm0gtZ4jWAlPG2EaEFvkZuc8+/Cg4LM8g3fzswcd5dsYGB5gP3ubB56Qb6cYzewwOGzbIHDM3nLkt2czgAFuyNV4tEmnMDDwGhxkbJBLMpHm3MdsYHOAxk8anRX5GGjPjH4PD9g0S6d+keefUA7Xwf8OrheFGGjMz0JbEBokcoC0Nh4EO42HDq8XgzDNmZhmD9OQ2mTNlkjOOHTeWPMxmbDkHn8PagQ5788fatl+6fZvEh5pqw77jzQ9vvMHnMAhoZmCDs5kJKweBOuKUjYJRMApGwcgEAGVqQ/NNv5+7AAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Surraiya\",\"middleName\":\"\",\"lastName\":\"Bano\",\"suffix\":\"\"},{\"id\":621824699,\"identity\":\"e0dab28f-3b2b-40db-b51d-0f2024a39d51\",\"order_by\":2,\"name\":\"Momal A. Wasim\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Momal\",\"middleName\":\"A.\",\"lastName\":\"Wasim\",\"suffix\":\"\"},{\"id\":621824700,\"identity\":\"01d4f664-905c-42a7-9c4f-32c0fff99e0a\",\"order_by\":3,\"name\":\"Zeeshan Allana\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zeeshan\",\"middleName\":\"\",\"lastName\":\"Allana\",\"suffix\":\"\"},{\"id\":621824701,\"identity\":\"8c772278-cae1-41c2-bf9d-390b86681668\",\"order_by\":4,\"name\":\"Ammara Hameed\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"National Institute of Child Health\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ammara\",\"middleName\":\"\",\"lastName\":\"Hameed\",\"suffix\":\"\"},{\"id\":621824702,\"identity\":\"b7f6e07c-04d2-4690-91d6-581b0d19c7c5\",\"order_by\":5,\"name\":\"Sara Fatima\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sara\",\"middleName\":\"\",\"lastName\":\"Fatima\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-05 16:25:05\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9042477/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9042477/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":106961609,\"identity\":\"499ced46-89da-4a1d-bca2-50c5302bc663\",\"added_by\":\"auto\",\"created_at\":\"2026-04-15 09:26:15\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":194098,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSee image above for figure legend\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Slide1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9042477/v1/7b516e1bcfa190a8881dddf9.png\"},{\"id\":106994389,\"identity\":\"4de8b5e1-dae2-4cbe-b3e5-b16539f1bcee\",\"added_by\":\"auto\",\"created_at\":\"2026-04-15 15:08:14\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":164697,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSee image above for figure legend\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Slide2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9042477/v1/c6c71e2b5ea061e0d6f746c1.png\"},{\"id\":106947072,\"identity\":\"7c9eff67-7d39-4b09-bcdf-e7eea8a90b88\",\"added_by\":\"auto\",\"created_at\":\"2026-04-15 06:48:13\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":89811,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSee image above for figure legend\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Slide3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9042477/v1/34d457da9dd0dfbe0b54d26e.png\"},{\"id\":106995050,\"identity\":\"257c3662-c7d6-4f97-9bdc-16c0b051a4b1\",\"added_by\":\"auto\",\"created_at\":\"2026-04-15 15:21:29\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1469997,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9042477/v1/136d1262-f7e4-46dd-9fa3-5185b698f38f.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Prioritizing Pediatric Emergency Transfers: Identifying Clinical and Resource-Based Indicators for PICU Admission in a Tertiary Care Hospital in Karachi, Pakistan.\",\"fulltext\":[{\"header\":\"KEY MESSAGE\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eED - PICU strain in LMICs\\u003c/strong\\u003e: Limited PICU beds and resources in low- and middle-income countries (LMICs) force critically ill children to be managed in the ED. This leads to resource strain, delays in care, worsened outcomes, and increased staff burden.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRespiratory illnesses are the leading drivers of PICU transfers\\u003c/strong\\u003e, especially among critically ill (P1) triage patients, placing the heaviest burden on ED resources.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLimited PICU capacity in LMICs leads to delayed or avoidable transfers\\u003c/strong\\u003e, prolonged ED stays, and increased strain on staff and resources.\\u003c/p\\u003e\"},{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003ePediatric critical care is an essential pillar of pediatric healthcare. However, in low- and middle-income countries, pediatric critical care is limited due to constrained healthcare resources in most hospitals [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Access to critical care is a life-changing intervention and can drastically improve patient outcomes, as has been seen in high-income countries [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. However, in LMICs, the pediatric intensive care unit (PICU) and pediatric emergency department (PED) access is limited due to a lack of infrastructure and trained healthcare providers [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eUnfortunately, we face a dilemma here, as many LMICs face a heavy burden of pediatric illnesses, including infectious diseases, respiratory distress, sepsis, and dehydration. Lack of immediate medical intervention causes many preventable deaths [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. LMICs have much higher mortality rates than High-Income Countries (HICs) due to a lack of resources and availability of healthcare [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. A recent study in Pakistan revealed that children die from preventable causes, such as infections and injuries, due to inadequate treatment [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Abdelatif et al. examined structural differences\\u0026mdash;specifically in human and physical resources\\u0026mdash;between two pediatric intensive care units (PICUs), one in Egypt (a low- and middle-income country, LMIC) and the other in Japan (a high-income country, HIC). They reported a mortality rate of 41.6% in the LMIC PICU compared to 2.4% in the HIC PICU [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eResource-limited settings, such as sub-Saharan Africa and Latin America, have found that bed and healthcare staff shortages created significant challenges in the PICU [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. This leads to critical patients having to be managed in the ED for several hours. A study found that patients in the emergency department who experienced a delay of six hours or more before being transferred to the ICU tended to remain hospitalized longer and had a higher risk of dying in the ICU or during their hospital stay [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. This exacerbates the pre-existing burnout among ED physicians and nursing staff. One of the top-most contributing factors is shift work, which is made more challenging by increased workload from delayed transfers from the ED to the ICU [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eMathews et al. conducted a study in the US regarding transfers from ED to ICU for critically ill patients, showing that the transfers are solely dependent on bed availability. Additionally, extended boarding times in the ED were associated with poorer patient outcomes, suggesting that focused care may be needed for those awaiting ICU placement [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Unfortunately, in LMICs, bed availability is much more limited than HICs [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e However, there is still a need for evidence-based guidelines to optimize patient outcomes from PED to PICU, recognizing which patients can best be treated in the ED versus the PICU. It is essential to identify patients who are likely to survive with only brief ICU support to maximize the effectiveness of triage allocation during prolonged emergencies. However, no validated tool currently exists for either children or adults [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. Additionally, there is a need to identify the patient population in the PED with the highest resource utilization and facilitate early transfers to reduce and redirect the limited ED resources.\\u003c/p\\u003e\"},{\"header\":\"METHODS\",\"content\":\"\\n\\u003ch3\\u003eMaterials and Methods\\u003c/h3\\u003e\\n\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEthical Considerations\\u003c/h2\\u003e \\u003cp\\u003e The study was approved by the Institutional Ethical Review Committee (ERC) in 2021. Informed consent was waived due to the retrospective design, and patient confidentiality was maintained. ERC # 2020579915319.\\u003c/p\\u003e \\u003cp\\u003eClinical trial number: not applicable.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStudy Design and Setting\\u003c/h3\\u003e\\n\\u003cp\\u003e This retrospective chart review was conducted in the pediatric emergency department (ED) of a tertiary care hospital in 2021. The ED has 23 beds (3 resuscitation, 8 monitored, 12 non-monitored) and uses the Emergency Severity Index (ESI) for triage. The hospital has an 8-bed pediatric intensive care unit (PICU) managed by intensivists and fellows, who also attend ED patients when required. PICU admission was limited by bed availability and financial clearance; in their absence, patients remained in the ED or were referred elsewhere.\\u003c/p\\u003e\\n\\u003ch3\\u003eStudy Population\\u003c/h3\\u003e\\n\\u003cp\\u003eAll patients aged 1 month to 18 years admitted from the ED to the PICU during the study period were eligible. Both sexes were included. Race/ethnicity was not consistently documented and, therefore, not analyzed.\\u003c/p\\u003e\\n\\u003ch3\\u003eInclusion Criteria\\u003c/h3\\u003e\\n\\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eAge 1 month\\u0026ndash;18 years\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eAdmission from ED to PICU\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eExclusion Criteria\\u003c/h2\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eAge\\u0026thinsp;\\u0026lt;\\u0026thinsp;1 month\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eDirect outpatient admissions\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eReferrals already intubated\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003ePatients receiving CPR in the ED\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eSampling Strategy\\u003c/h3\\u003e\\n\\u003cp\\u003eNon-probability convenience sampling was used.\\u003c/p\\u003e\\n\\u003ch3\\u003eData Collection and Variables\\u003c/h3\\u003e\\n\\u003cp\\u003eData extracted from electronic records included demographics (age, sex), triage category, ED management, PICU admission, and outcomes.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e \\u003cp\\u003eAll data were analyzed using Stata version 17.0. Descriptive statistics were used to summarize patient demographics, clinical characteristics, triage levels, resource utilization, and outcomes. Categorical variables (e.g., sex, triage category, diagnosis, and mortality) were presented as frequencies and percentages. Continuous variables (e.g., age, laboratory parameters, and length of stay were assessed for normality using the Shapiro\\u0026ndash;Wilk test. Variables with a normal distribution were reported as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation (SD), while non-normally distributed variables were summarized as median with interquartile range (IQR). Data visualizations were generated using R version 4.4.2.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eA total of 418 patients were included in this study, of which 245 (58.61%) were males and 173 (41.39%) were females. Most of our patients were categorized under Triage Category P1 upon arrival at the ED (83.1%), indicating that their conditions were critical from the onset, with the majority of patients being under 5 years of age (66.91%) \\u003cstrong\\u003e(\\u003c/strong\\u003eTable\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e\\u003cstrong\\u003e).\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eDemographics and Health-Related Characteristics of Patients Admitted in the Emergency Unit\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eVariables\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTotal\\u003c/p\\u003e\\n\\u003cp\\u003e418 (100%)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAge (in years)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026lt;1 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e138 (34.07)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1\\u0026ndash;5 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e133 (32.84)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6\\u0026ndash;10 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e48 (11.85)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026gt;10 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e86 (21.23)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eGender\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMale\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e245 (58.61)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eFemale\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e173 (41.39)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTriage\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eP1\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e342 (83.01)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eP2\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e56 (13.59)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eP3\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (3.40)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLaboratory Investigation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHemoglobin (g/dL) *\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10.20 (8.70\\u0026ndash;11.70)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTLC \\u0026ndash; Leucocytes count (10\\u0026sup3;/\\u0026micro;L) *\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e13.40 (8.20\\u0026ndash;19.60)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePlatelets (10\\u0026sup3;/\\u0026micro;L) *\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e312 (170\\u0026ndash;452)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBicarbonates *\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16.95 (8.30\\u0026ndash;21.65)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBlood Sugar *\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e117 (91\\u0026ndash;168)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e*Median (Interquartile Range)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eWe found that under the P1 Triage category, the most common systemic involvement was respiratory diseases (24.45%), followed by infectious diseases (17.85%) and central nervous system (CNS) disorders (12.47%\\u003cstrong\\u003e) (\\u003c/strong\\u003eTable\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e\\u003cstrong\\u003e).\\u003c/strong\\u003e Most of our patients that transferred from ED to PICU belonged to the P1 triage category. Patients with respiratory diseases (30.6%) were the most likely to need PICU care, followed by those with infectious diseases (21.2%) and central nervous system (CNS) conditions (15.66%).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003ePatient Characteristics by Triage Category and Associated Treatments\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eVariables\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTotal\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eP1\\u003c/p\\u003e\\n\\u003cp\\u003e342 (81.82)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eP2\\u003c/p\\u003e\\n\\u003cp\\u003e56 (13.40)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eP3\\u003c/p\\u003e\\n\\u003cp\\u003e20 (4.78)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth colspan=\\\"5\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSystemic disease\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCNS\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e65 (15.66)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e51 (12.47)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (2.93)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (0.49)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCardiovascular System\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e28 (6.75)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e24 (5.87)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (0.98)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e-\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEndocrine and Metabolic\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e23 (5.54)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e18 (4.40)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (0.98)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (0.24)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eGastro Hepatobiliary\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e23 (5.54)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e18 (4.40)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (0.73)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (0.49)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eInfectious\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e88 (21.20)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e73 (17.85)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e9 (2.20)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (0.49)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMalignancy\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e19 (5.58)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16 (3.91)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (0.73)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e-\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOthers\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (2.93)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (2.93)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e-\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e-\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eRespiratory\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e127 (30.60)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e100 (24.45)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (4.89)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7 (1.47)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTrauma and Environment\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e30 (7.23)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e27 (6.60)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (0.24)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (0.48)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLength of stay (Hours)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7.95\\u0026thinsp;+\\u0026thinsp;6.39\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7.33\\u0026thinsp;+\\u0026thinsp;0.38\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e9.55\\u0026thinsp;+\\u0026thinsp;1.07\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e9.72\\u0026thinsp;+\\u0026thinsp;1.77\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd colspan=\\\"5\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eVasoactive Medication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNone\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e235 (56.22)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e189 (55.26)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e32 (57.14)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (70.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEpinephrine\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e143 (34.21)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e122 (35.67)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16 (28.57)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (25.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd 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align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTazocin\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e15 (3.59)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (1.75)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7 (12.50)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (10.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMeropenam\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e41 (9.81)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e34 (9.94)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (8.93)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (10.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eVancomycin\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e151 (36.12)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e130 (38.01)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e13 (23.21)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e8 (40.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOther\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (0.35)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e11 (3.21)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (5.36)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e-\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd colspan=\\\"5\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eBlood Transfusion\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNone\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e370 (88.52)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e304 (88.89)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e48 (85.71)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e18 (90.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePacked Cell\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e22 (5.26)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (5.85)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (3.57)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e-\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePlatelet\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7 (1.67)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5(1.46)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (3.57)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e-\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eFFP\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e19 (4.55)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e13 (3.80)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (7.14)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (10.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd colspan=\\\"5\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEndotracheal Tube\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNo\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e341 (81.97)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e270 (79.41)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e53 (94.64)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e18 (90.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e75 (18.03)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e70 (20.59)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (5.36)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (10.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd colspan=\\\"5\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFluid Bolus\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNo\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e144 (34.87)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e111 (32.94)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e26 (46.43)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7 (35.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e269 (65.13)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e226 (67.06)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e30 (53.57)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e13 (65.00)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eFever (47%) was the most common presenting complaint, followed by respiratory distress (34%), cough and chest congestion (20%), with less frequent symptoms including vomiting, drowsiness, seizures, and trauma. Further details are shown in Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n\\u003cp\\u003eAmong respiratory diseases, Pneumonia (18.51%) and Acute Exacerbation of Asthma (4.57%) were the most common diagnoses requiring admission from the Pediatric Emergency Department to the PICU. Under Infectious disease, we found patients with Septic Shock (13.22%) in the ED, requiring PICU transfer. Patients diagnosed with Meningoencephalitis (9.38%) were also critical and were transferred to the PICU \\u003cstrong\\u003e(Table\\u0026nbsp;3)\\u003c/strong\\u003e. Based on this data, we conclude that patients admitted under the P1 triage category with these diagnoses are high-priority cases that cannot be managed solely in the ED and require the specialized care, highly trained staff, and advanced resources available in the PICU.\\u003c/p\\u003e\\n\\u003cp\\u003eIn terms of resource utilization, the maximum resources were used by patients with diagnoses under respiratory, infectious, and CNS disease \\u003cstrong\\u003e(\\u003c/strong\\u003eFig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e\\u003cstrong\\u003e)\\u003c/strong\\u003e. However, the majority of these patients were eventually transferred out to the PICU. This suggests that earlier transfer of high-priority patients to the PICU is crucial to save time and resources. By transferring them sooner, critical resources and ED staff time could be spared. This would allow the emergency department to better manage other patients who can be stabilized and recover without needing PICU admission.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003ePatients diagnosed with trauma, gastrointestinal and hepatobiliary diseases, as well as endocrine and metabolic disorders, made up a smaller fraction of transfers to PICU (Table\\u0026nbsp;3), suggesting effective treatment in the PED. Additionally, these patients also used fewer ED resources (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e), had shorter lengths of stay (LoS) (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e), and most had favorable (alive) outcomes (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003ctable id=\\\"Tab3\\\" style=\\\"width: 521.151px;\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable\\u0026nbsp;3\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eSystematic Diagnostic Categories of Patients Admitted to PICU.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth style=\\\"width: 148px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSystem\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDisease\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth style=\\\"width: 149px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eFrequency (Percentage)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" rowspan=\\\"4\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCNS\\u003c/p\\u003e\\n\\u003cp\\u003e65 (15.66)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMeningoencephalitis\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e39 (9.38)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eStatus Epilepticus\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e10 (2.40)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eIntracranial bleed\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e5 (1.20)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOther Neurological\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e11 (2.64)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" rowspan=\\\"7\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eRespiratory\\u003c/p\\u003e\\n\\u003cp\\u003e127 (30.60)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePneumonia\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e77 (18.51)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAcute Exacerbation of Asthma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e19 (4.57)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBronchiolitis\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e7 (1.68)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eForeign body ingestion\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e6 (1.44)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePleural Effusion\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e9 (2.16)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCroup\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e4 (0.96)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOther Diagnosis\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e5 (1.20)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" rowspan=\\\"4\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eInfectious\\u003c/p\\u003e\\n\\u003cp\\u003e88 (21.20)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSeptic Shock\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e55 (13.22)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDengue\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e11 (2.64)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEnteric Shock\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e10 (2.40)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOther infection\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e12 (2.88)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" rowspan=\\\"6\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCardiovascular\\u003c/p\\u003e\\n\\u003cp\\u003e28 (6.75)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMyocarditis\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e12 (2.88)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eArrhythmias\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3 (0.72)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTet spell\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e4 (0.96)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHypertensive emergencies\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e5 (1.20)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCongestive and Structural Diseases\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3 (0.72)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCongenital or Cyanotic Disease\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2 (0.48)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" rowspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eGastro and Hepatobiliary\\u003c/p\\u003e\\n\\u003cp\\u003e23 (5.54)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eGastroenteritis with MODS\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e10 (2.40)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAcute Liver failure\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e13 (3.13)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" rowspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTrauma and Environmental\\u003c/p\\u003e\\n\\u003cp\\u003e30 (7.23)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTrauma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e17 (4.09)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEnvironmental\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e13 (3.13)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" rowspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEndocrine and metabolic\\u003c/p\\u003e\\n\\u003cp\\u003e23 (5.54)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDKA\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e15 (3.61)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eIEM\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e8 (1.92)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMalignancy\\u003c/p\\u003e\\n\\u003cp\\u003e19 (5.58)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMalignancy\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e19 (4.57)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd style=\\\"width: 148px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOthers\\u003c/p\\u003e\\n\\u003cp\\u003e12 (2.93)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 195px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOthers\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"width: 149px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e12 (2.88)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"char\\\"\\u003e\\u0026nbsp;\\u0026nbsp;\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 4 - Mean Length of Stay (LoS) with patient mortality outcomes.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003ctable id=\\\"Taba\\\" border=\\\"1\\\"\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003cth style=\\\"height: 70px;\\\" rowspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n\\u003cth style=\\\"height: 70px;\\\" rowspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eED LOS (Hours)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth style=\\\"height: 35px;\\\" colspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOutcome\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003cth style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAlive\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDead\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCNS\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e6.84\\u0026nbsp;+\\u0026nbsp;0.55\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e51 (14.61)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (20.29)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eRespiratory\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e7.96\\u0026nbsp;+\\u0026nbsp;0.56\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e104 (29.80)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e24 (34.78)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eInfectious\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e7.59\\u0026nbsp;+\\u0026nbsp;0.63\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e78 (22.35)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10 (14.49)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCardiovascular\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e10.27\\u0026nbsp;+\\u0026nbsp;1.29\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e22 (6.30)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (8.70)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eGastro and Hepatobiliary\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e8.06\\u0026nbsp;+\\u0026nbsp;1.44\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e20 (5.73)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (5.80)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTrauma and Environmental\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e7.10\\u0026nbsp;+\\u0026nbsp;0.80\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e26 (7.45)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (5.80)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEndocrine and metabolic\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e6.84\\u0026nbsp;+\\u0026nbsp;1.15\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e19 (5.44)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (5.80)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMalignancy\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e8.14\\u0026nbsp;+\\u0026nbsp;1.65\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e16 (4.58)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (4.35)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr style=\\\"height: 35px;\\\"\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOthers\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\"+\\\"\\u003e\\n\\u003cp\\u003e10.50\\u0026nbsp;+\\u0026nbsp;2.54\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e13 (3.72)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd style=\\\"height: 35px;\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003ePatients with the longest LoS were under the P3 triage category, followed by P2 and then P1 \\u003cstrong\\u003e(\\u003c/strong\\u003eTable\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e\\u003cstrong\\u003e)\\u003c/strong\\u003e. Additionally, patients with malignancy, cardiac issues, or endocrine/metabolic issues had the longest stays by disease category. \\u003cstrong\\u003e(\\u003c/strong\\u003eFig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e, Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e\\u003cstrong\\u003e).\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eThis study represents a pioneering investigation into the clinical characteristics of pediatric patients who presented to the emergency department (ED) of a tertiary care hospital and were subsequently admitted to the Pediatric Intensive Care Unit (PICU) in a resource-limited country, such as Pakistan. Our findings provide important insights into the critical factors influencing pediatric care in emergency care settings in resource-limited environments.\\u003c/p\\u003e \\u003cp\\u003eOur findings indicated that a majority of patients present under the Critical Triage (P1) category. P1 category patients are the most critical and therefore need advanced interventions and more ED resources, such as mechanical ventilation or admission to the PICU, in contrast to P2 triage patients [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. The majority of the patients transferred to the PICU were males, which could indicate higher admissions of males to the Pediatric Emergency department. This pattern was also noted in a study carried out in Boston, United States. The study documented that access to healthcare is greater for males than for females in children [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. In contrast, another study noted that the overall hospitalization rate to the PICU was higher for boys than for girls [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. A study done in India reported that immunization coverage is higher in boys, as compared to girls [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eWe found that the most common systemic involvement was respiratory diseases, under the P1 triage category, eventually transferring out to the PICU. Siddiqui et al. reported a similar pattern in their study, also conducted at a tertiary center in a LMIC in Pakistan, where they found asthma, bronchiolitis, and pneumonia to be the most common diagnoses under P1 being further escalated to the PICU [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. A similar pattern was noted in a study done in the United States, where they found respiratory distress to be the most common reason for transfer from the ED to PICU in the pediatric population [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAfter respiratory diseases, a significant number of patients with infectious diseases, such as septic shock, and CNS disorders/infections, such as meningoencephalitis, required PICU care and were transferred from the ED to the PICU. Lipsett et al. found a similar pattern; however, their study also assessed seasonal trends in pediatric infectious diseases. [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eAnother way to decrease the ED and potential pediatric visits is to improve immunization practices, especially in LMICs. However, a study done in Pakistan showed that vaccinated children might still get diseases at the completion of the Expanded Program on Immunization (EPI) [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eTriage categorization in an ED can influence the length of patient stay in ED, cost of ED stays and resource utilization. Critically ill P1 triage patients put a significant burden on the ED [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. This suggests a need for a speedy PICU transfer for critical patients, especially presenting with respiratory, CNS, or infectious disease. However, in LMICs such as Karachi, Pakistan, PICU facilities are limited. A systematic review conducted on ICU capacity in LMICs found beds to be significantly reduced in contrast to their need [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. To add to this issue, some transfers to PICU are potentially avoidable, as found in a study where more than half of the transfers from the general care unit to PICU were potentially avoidable transfers (PATs) [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. We found that patients diagnosed with trauma, GI, endocrine, and metabolic disorders had the fewest transfers to PICU.\\u003c/p\\u003e \\u003cp\\u003eED overcrowding has been a growing issue internationally [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e], and due to limited PICU availability, ED stays are prolonged. Additionally, prolonged ED stays could also be due to other factors such as consultations, diagnostic tests, or the triage level. [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e] This adds to the overall ED burden, resource utilization, and ED staff burnout. We saw that certain conditions had a higher resource utilization in the ED, such as respiratory illnesses. Prompt transfer would help preserve the limited ED resources.\\u003c/p\\u003e \\u003cp\\u003eWe also found a need for a more efficient collaboration between the ED and PICU would help the physicians, nursing staff, and patients to assist in early transfer of high-priority patients. An example where this was successfully introduced was the usage of an SBAR tool. This project introduced a tailored SBAR handoff tool and trained the ED and PICU nurses in a collaborative bedside process for verifying medications and lines or drains. After implementation, PICU nurses noted more structured care transitions and greater confidence in having the information needed to safely manage critically ill patients [\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOur study also found that the significant burden placed on pediatric emergency departments in resource-limited settings is due to delays and constraints in PICU availability. Most critically ill children require PICU transfer, which is a challenge in LMICs. The majority of our PICU admissions were respiratory illnesses, followed by infectious and CNS disorders. These systems also consumed substantial ED resources. Timely triage and early transfer to the PICU can potentially help to optimize resource utilization and improve patient outcomes. Some transfers might be avoidable with clearer admission criteria or guidelines for intradepartmental transfer.\\u003c/p\\u003e \\u003cp\\u003eOur study has some limitations. As a retrospective, single-center study, the findings may not be fully generalizable. In addition, since it was conducted at a well-resourced private tertiary care center, the results may not fully reflect the realities of more resource-constrained public sector settings, such as the government-run hospitals in LMICs.\\u003c/p\\u003e \\u003cp\\u003eIn low- and middle-income countries like Pakistan, we suggest expanding pediatric critical care capacity through intermediate-level PICUs. As the majority of critically ill patients simply require respiratory support like oxygen, High-Flow Nasal Cannula (HFNC), and a very small number require intubation, vasopressors, and invasive monitoring, so in a resource-limited setting like Pakistan, we should build some intermediate-level PICUs where we can treat and manage patients with less intensive care requirements.\\u003c/p\\u003e \\u003cp\\u003eA potential solution could be a novel Emergency Department-based ICU model (EC3). Gunnerson et al. created and studied its impact on critically ill patients in Michigan, US. They found its implementation was linked to improved 30-day survival and fewer inpatient ICU admissions. Findings suggest ED-based ICUs may help alleviate ICU strain and improve outcomes [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e There is also a need for guidelines for higher priority transfers between ED and PICU teams, outlining key strategies to reduce overcrowding, preserve limited resources, and improve survival among critically ill children.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePED\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePediatric Emergency Department\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePICU\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePediatric Intensive Care Unit\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eED\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eEmergency Department\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLMIC\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLow- and Middle-Income Country\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eESI\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eEmergency Severity Index\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLoS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLength of Stay\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eCNS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eCentral Nervous System\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eERC\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eEthical Review Committee\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate:\\u0026nbsp;\\u003c/strong\\u003eThis study was approved by the Ethical Review Committee (ERC), \\u0026nbsp;Aga Khan University Hospital, Karachi, Pakistan (ERC #2020579915319).\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki.\\u003c/p\\u003e\\n\\u003cp\\u003eGiven the retrospective nature of the study, the requirement for informed consent was waived by the ERC.\\u003c/p\\u003e\\n\\u003cp\\u003eAs the study involved pediatric participants, the ERC determined that parental/legal guardian consent was not required due to the use of de-identified retrospective data.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication:\\u003c/strong\\u003e Not applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials:\\u003c/strong\\u003e The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests:\\u0026nbsp;\\u003c/strong\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding:\\u003c/strong\\u003e No funding was received for this research.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors' contributions:\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eConceptualization: Saleem Akhtar, Momal A. Wasim, Surraiya Bano\\u003c/p\\u003e\\n\\u003cp\\u003eMethodology: Surraiya Bano, Momal A. Wasim\\u003c/p\\u003e\\n\\u003cp\\u003eSoftware: Zeeshan Allana\\u003c/p\\u003e\\n\\u003cp\\u003eValidation: Surraiya Bano, Saleem Akhtar\\u003c/p\\u003e\\n\\u003cp\\u003eFormal analysis: Zeeshan Allana\\u003c/p\\u003e\\n\\u003cp\\u003eInvestigation: Sara Fatima, Ammara Hameed\\u003c/p\\u003e\\n\\u003cp\\u003eResources: Sara Fatima, Ammara Hameed\\u003c/p\\u003e\\n\\u003cp\\u003eData curation: Sara Fatima, Ammara Hameed\\u003c/p\\u003e\\n\\u003cp\\u003eWriting - original draft: Momal A. Wasim\\u003c/p\\u003e\\n\\u003cp\\u003eWriting - review \\u0026amp; editing: Momal A. Wasim, Saleem Akhtar, Surraiya Bano\\u003c/p\\u003e\\n\\u003cp\\u003eVisualization: Momal A. Wasim, Surraiya Bano\\u003c/p\\u003e\\n\\u003cp\\u003eSupervision: Surraiya Bano\\u003c/p\\u003e\\n\\u003cp\\u003eProject administration: Surraiya Bano\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements:\\u0026nbsp;\\u003c/strong\\u003eThe authors would like to acknowledge the support of the Emergency Department and Pediatric Intensive Care Unit staff at Aga Khan University Hospital for their assistance in data collection and patient care.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eSlusher TM, Kiragu AW, Day LT, Bjorklund AR, Shirk A, Johannsen C, Hagen SA. Pediatric critical care in resource-limited settings\\u0026mdash;overview and lessons learned. Front Pead. 2018;6:49.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKelly FE, Fong K, Hirsch N, Nolan JP. Intensive care medicine is 60 years old: the history and future of the intensive care unit. Clin Med. 2014;14(4):376\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHsu BS, Hill V, Frankel LR, et al. Executive summary: criteria for critical care of infants and children: PICU admission, discharge, and triage practice statement and levels of care guidance. Pediatrics. 2019;144(4):e20192433.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKortz TB, Nielsen KR, Mediratta RP, et al. The burden of critical illness in hospitalized children in low- and middle-income countries: protocol for a systematic review and meta-analysis. Front Pediatr. 2022;10:756643.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWorld Health Organization. Guideline: Updates on Paediatric Emergency Triage, Assessment and Treatment: Care of Critically-Ill Children. World Health Organization. 2016. Accessed March 19, 2025. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://pubmed.ncbi.nlm.nih.gov/27010047/\\u003c/span\\u003e\\u003cspan address=\\\"https://pubmed.ncbi.nlm.nih.gov/27010047/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFrenk J, G\\u0026oacute;mez-Dant\\u0026eacute;s O. False dichotomies in global health: the need for integrative thinking. Lancet. 2017;389(10069):667\\u0026ndash;70.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAtiq H, Siddiqui E, Bano S, et al. The pediatric disease spectrum in emergency departments across Pakistan: data from a pilot surveillance system. BMC Emerg Med. 2015;15(S2):S11.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLebet R, Vendramim P, Pires M, Kachmar A, Kabara H, Pedreira M, Curley M. March \\u003cem\\u003ePediatric Critical Care Concerns\\u003c/em\\u003e; World Federation of Critical Care Nurses: Sydney, Australia, 2018; Available online: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://wfccn.org/wp-content/uploads/2020/06/Chapter-8_pp64-74_FINAL.pdf\\u003c/span\\u003e\\u003cspan address=\\\"https://wfccn.org/wp-content/uploads/2020/06/Chapter-8_pp64-74_FINAL.pdf\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e (accessed on 5 2025).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChalfin DB, MD, MS FCCM, Trzeciak SMD, Likourezos MPH, Antonios MA, Baumann MPH, MD BM, Dellinger MSCE, Phillip R, FCCM for the DELAY-ED study group. June MD,. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit*. 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European Journal of Emergency Medicine 22(4):p 227\\u0026ndash;234, August 2015. | \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/MEJ.0000000000000194\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/MEJ.0000000000000194\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMathews KS, MD, MPH, MSCR1,2, Durst MS, MD, MS1, Vargas-Torres CMA, Olson AD. MA3; Mazumdar, Madhu PhD3; Richardson, Lynne D. MD2,3. Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients*. 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PMID: 32257435; PMCID: PMC7103036.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChristian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175:1377\\u0026ndash;81.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSiddiqui EU, Ain NU, Jamali AA, Kazi GI, Siddiqui T. Outcomes of pediatric patients prioritized as critical (P1/P2) by registered triage nurses from a tertiary care hospital in a low-middle-income country. J Med Life. 2025;18(1):48\\u0026ndash;53. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.25122/jml-2024-0228\\u003c/span\\u003e\\u003cspan address=\\\"10.25122/jml-2024-0228\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLeiter V, Rieker PP. Mind the gap: gender differences in child special health care needs. Matern Child Health J. 2012;16:1072\\u0026ndash;80.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEsteban E, Bujaldon E, Esparza M, Jordan I, Esteban ME. Sex differences in children with severe health conditions: causes of admission and mortality in a pediatric intensive care unit. Am J Hum Biol. 2015;27:613\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSingh PK. Trends in child immunization across geographical regions in India: focus on urban-rural and gender differentials. PLoS ONE. 2013;8:e73102.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJane Sibilia A, Dewan M, Gauthier A, Clover-Brown I, Pittman E, Chima RS. (2025). Characterization of Potentially Avoidable Pediatric Intensive Care Unit Transfers. Hosp Pediatr, e2025008338.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLipsett SC MD\\u0026lowast;,\\u0026dagger;;, Monuteaux MC ScD\\u0026lowast;,\\u0026dagger;;, Fine AMMD. MPH\\u0026lowast;,\\u0026dagger;,\\u0026Dagger;. Seasonality of Common Pediatric Infectious Diseases. Pediatric Emergency Care 37(2):p 82\\u0026ndash;85, February 2021. | \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/PEC.0000000000001496\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/PEC.0000000000001496\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eQazi U, Malik S, Raza UA, Saad M, Zeeshan MF, Anwar S. Compliance to timely vaccination in an expanded Program on Immunization center of Pakistan. Vaccine. 2019;37(32):4618\\u0026ndash;22.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMurthy S, Leligdowicz A, Adhikari NK. (2015). Intensive care unit capacity in low-income countries: a systematic review. PLoS ONE, 10(1), e0116949.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAmerican Academy of Pediatrics Committee on Pediatric Emergency Medicine. Overcrowding crisis in our nation's emergency departments: is our safety net unraveling? Pediatrics. 2004;114(3):878\\u0026ndash;88.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYoon P, Steiner I, Reinhardt G. Analysis of factors influencing length of stay in the emergency department. CJEM. 2003;5(3):155\\u0026ndash;61.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRoutly M, Gettis M, Thomas A, Macias J, Cherven B. Transferring critical pediatric patients from emergency department to intensive care: A quality improvement initiative. J Pediatr Nurs. 2023;72:e47\\u0026ndash;52.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGunnerson KJ, Bassin BS, Havey RA, et al. Association of an Emergency Department\\u0026ndash;Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions. JAMA Netw Open. 2019;2(7):e197584. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1001/jamanetworkopen.2019.7584\\u003c/span\\u003e\\u003cspan address=\\\"10.1001/jamanetworkopen.2019.7584\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-pediatrics\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bped\",\"sideBox\":\"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bped/default.aspx\",\"title\":\"BMC Pediatrics\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Pediatric Emergency Department (PED), Pediatric Intensive Care Unit (PICU), Triage, Resource Utilization, Critical Care, Low and Middle Income Countries (LMICs), Length of Stay (LoS)\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9042477/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9042477/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground:\\u003c/h2\\u003e \\u003cp\\u003ePediatric critical care remains a major challenge in low- and middle-income countries (LMICs) because of the limited PICU capacity. This often forces critically ill children to be managed in emergency departments (EDs) for long periods, exhausting the already scarce resources. This delays care and contributes to poor outcomes. The purpose of this study was to describe the characteristics, triage levels, and outcomes of children admitted from the ED to the PICU at a tertiary hospital in Pakistan.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eWe reviewed charts of all children between 1 month and 18 years who were admitted from the ED to the PICU during 2021. Information on age, sex, presenting symptoms, diagnosis, triage level, ED resource use, length of stay, and outcomes was collected.\\u003c/p\\u003e\\u003ch2\\u003eResults:\\u003c/h2\\u003e \\u003cp\\u003eAmong 418 patients, most were under 5 years of age (66.9%) and male (58.6%). The majority (83%) arrived in the ED as P1 (critical) triage. Respiratory diseases were the leading cause of PICU transfer (30.6%), followed by infectious illnesses (21.2%) and central nervous system disorders (15.7%). Pneumonia (18.5%), septic shock (13.2%), and meningoencephalitis (9.4%) were frequent diagnoses. These groups also consumed the greatest share of ED resources. By contrast, trauma, gastrointestinal, and endocrine/metabolic disorders required fewer transfers and shorter stays.\\u003c/p\\u003e\\u003ch2\\u003eConclusion:\\u003c/h2\\u003e \\u003cp\\u003eIn this LMIC setting, most children transferred from ED to PICU were very young and critically ill with respiratory, infectious, or CNS diseases. Earlier transfer and expansion of intermediate-level PICUs may help reduce ED strain and improve outcomes. Clearer admission and transfer guidelines are also needed to avoid unnecessary PICU use and preserve limited resources.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Prioritizing Pediatric Emergency Transfers: Identifying Clinical and Resource-Based Indicators for PICU Admission in a Tertiary Care Hospital in Karachi, Pakistan.\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-15 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