Patient Profiles and Factors Associated with Escalated Care in a Southeast Ethiopian Pediatric Emergency Department: A Three-Year Retrospective Analysis

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Evidence regarding treatment outcomes and predictors of escalated care in Ethiopian pediatric emergency settings are limited. Objective To assess patient profiles, treatment outcomes, and factors associated with escalated care among children presenting to the pediatric emergency department of Asella Referral and Teaching Hospital (ARTH), Southeast Ethiopia. Methods A retrospective cross-sectional study was conducted among pediatric emergency visits between 10 September 2022 and 10 September 2025. A total of 407 medical records were systematically sampled. Data were entered into KoboCollect and analyzed using SPSS version 27. Variables with p < 0.25 in bivariable analysis were entered into multivariable logistic regression. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. Statistical significance was declared at p < 0.05. Results Of 407 visits, 63.9% were male and 75.9% were under five years of age. Rural residents constituted 55.3% of cases. Pneumonia (19.2%) was the leading diagnosis. Nearly half (49.6%) required escalated care (admission, referral, ICU transfer, or death). Independent predictors included malnutrition (AOR = 13.25; 95% CI: 3.40–51.61), true emergency presentation (AOR = 7.59; 95% CI: 2.59–22.20), comorbidity (AOR = 7.30; 95% CI: 1.30–40.94), altered mental status (AOR = 5.75; 95% CI: 1.67–19.83), delayed presentation > 3 days (AOR = 5.66; 95% CI: 2.22–14.40), diarrhea complaint (AOR = 5.99; 95% CI: 1.09–39.30), presence of danger signs (AOR = 2.06; 95% CI: 1.09–3.86), and referral status (AOR = 1.91; 95% CI: 1.05–3.46). Conclusion Nearly half of pediatric emergency visits required escalated care. Clinical severity indicators, malnutrition, comorbidity, and delayed presentation were strong predictors. Strengthening triage systems and early risk identification is critical to improving pediatric emergency outcomes in resource-limited settings. Pediatric emergency escalated care treatment outcome malnutrition Asella Ethiopia Figures Figure 1 Introduction Globally, emergency care contributes substantially to child survival. Despite major reductions in under-five mortality, preventable conditions such as pneumonia, diarrhea, sepsis, and malnutrition remain leading causes of pediatric morbidity and mortality, particularly in sub-Saharan Africa [ 1 – 4 ]. Pediatric emergency departments (PEDs) are often the first point of contact for critically ill children and serve as a key determinant of outcomes. In LMICs, pediatric emergency utilization has increased due to infectious diseases, trauma, urbanization, and gaps in primary healthcare access [ 5 – 8 ]. However, emergency units frequently operate under constraints including workforce shortages, limited diagnostic capacity, and delayed presentation of severe cases [ 9 , 10 ]. In Ethiopia, infectious diseases remain predominant among pediatric emergency admissions [ 11 – 14 ]. Studies from Addis Ababa, Dilla, and Tikur Anbessa have shown high admission rates and identified malnutrition, delayed care-seeking, comorbidity, and clinical severity as predictors of unfavourable outcomes [ 12 – 15 ]. Evidence from other African contexts similarly demonstrates high admission and mortality rates in pediatric emergency settings [ 16 – 18 ]. The World Health Organization (WHO) emphasizes standardized pediatric emergency triage through the Emergency Triage, Assessment and Treatment (ETAT) guidelines to reduce preventable mortality [ 19 ]. Identifying predictors of escalated care—defined as admission, referral, ICU transfer, or death—is crucial for strengthening triage systems and resource allocation. Despite increasing demand for pediatric emergency services in Ethiopia, evidence from south eastern regions remains scarce. This study therefore aimed to determine patient profiles, treatment outcomes, and factors associated with escalated care among pediatric patients attending the PED of ARTH. Methods Study design and setting Institution-based retrospective cross-sectional study conducted at Asella Referral and Teaching Hospital (ARTH), located in Asella town, Oromia Regional State. The hospital features a capacity of 321 beds and operates as a multidisciplinary hub for surgical, medical, and pediatric care. The institutional framework of ARTH is reflective of the broader Ethiopian health system’s tier-based model. As a tertiary facility, it is expected to handle complex cases referred from primary and secondary tiers; however, the reality of health utilization in Ethiopia often involves a "bypass" phenomenon where patients seek care directly at referral centers due to perceived or actual resource gaps at lower-level facilities [ 5 ]. The pediatric emergency unit at ARTH is staffed by a dedicated team of pediatricians, residents, general practitioners, and specialized nurses, yet it operates under significant pressure from high patient volumes and a limited supply of advanced diagnostic tools [ 9 ]. In comparison to other leading medical institutions such as Adama Comprehensive Specialized Hospital (ACSH), which maintains 75 pediatric beds, ARTH’s infrastructure must absorb a diveARTH serves as a tertiary referral center for the Arsi Zone and surrounding areas, providing inpatient and outpatient pediatric services. The pediatric department itself is organized into specialized units, including a neonatal intensive care unit (NICU), pediatric wards, and a 24-hour functional pediatric emergency department [ 9 ]. Medical records of pediatric patients who visited the pediatric emergency department between September 10, 2022, and September 10, 2025, were reviewed. Study population The source population included all pediatric patients who attended the pediatric emergency department at ARTH during the study period. The study population consisted of systematically sampled pediatric emergency visits that met the eligibility criteria. Children aged 29 days to 14 years were included. Patients younger than 29 days or older than 14 years, and those with incomplete documentation or lost medical charts were excluded. Incomplete charts were defined as absence of essential clinical information, consistent with previous evidence on barriers to administrative health data quality [ 8 ]. Sample size determination and sampling procedure The sample size was calculated using a single population proportion formula with a 95% confidence level, a 5% margin of error, and an expected proportion (p) of 39.6% based on a previous Ethiopian retrospective study [ 12 ]. After adding a 10% allowance for incomplete records, the final sample size was 407. The sample size calculation formula follows here under: A systematic random sampling technique was employed to select 407 patient records from the total number of children aged 29 days to 14 years attended the pediatric emergency department between September 10, 2022, and September 10, 2025. The sampling process began by generating a sampling frame—consisting of a chronological list of all eligible cases—from the pediatric emergency unit registration book. With an estimated 12,750 pediatric emergency visits during the three-year period, the sampling interval (k) was determined by dividing the total number of eligible patients (N = 12, 750) by the required sample size (n = 407) as K = 31. With an estimated 12,750 pediatric emergency visits during the three-year period, the sampling interval was calculated as K = 31. The first chart was selected by lottery from the first 31 records, and every 31th chart was included until the required sample size was achieved. Variables and operational definitions The primary outcome variable was treatment outcome of pediatric emergency visits, categorized as stable/good outcome (discharge with improvement) or escalated care outcome (admission, referral, ICU transfer, or death), similar to definitions used in prior pediatric emergency outcome studies [ 6 ]. True pediatric emergency was defined as presentation with at least one WHO emergency sign such as airway compromise, shock, coma, convulsions, severe dehydration, or severe respiratory distress [ 7 ]. Avoidable visits were defined as non-urgent pediatric emergency visits that could have been managed at primary care level without risk to the child’s health [ 10 ]. Data collection tools and procedure Data were extracted using a structured checklist adapted from the WHO emergency care assessment tool [ 7 ]. Data collectors received training prior to data extraction, and a pretest was conducted on 5% of records before the main data collection. Data were entered using Kobo Collect and exported to IBM SPSS Statistics version 27 for analysis. Data were collected using a structured abstraction form adapted from the WHO pediatric hospital care manual [ 7 ]. The tool was digitized using the Kobo Toolbox mobile application, which facilitated real-time data validation. The procedure involved a retrospective review of pediatric ward registers and individual medical charts. Two trained BSc nurses served as data collectors, and the principal investigator provided daily on-site supervision. Data Quality Assurance The data abstraction tool was pre-tested on 5% of the total sample size (20 records). Data collectors underwent a one-day intensive training session. During the data collection phase, the principal investigator performed daily audits of uploaded electronic forms. Before final analysis, data underwent a cleaning process to identify and manage outliers. Statistical Analysis The collected data were cleaned, coded, and entered into Epi-Data version 4.6 and subsequently exported to SPSS version 27.0 for analysis. Descriptive statistics were utilized to summarize categorical and continuous variables. A Binary Logistic Regression model was employed to identify predictors. Variables with a p-value < 0.25 in the bivariable analysis were entered into the multivariable model. The fitness of the final model was verified using the Hosmer-Lemeshow test. Strength of associations was expressed through Adjusted Odds Ratios (AOR) with 95% Confidence Intervals (CI). Results A total of 407 pediatric patient records were reviewed from visits to the PED of ARTH between September 10, 2022, and September 10, 2025. Baseline Sociodemographic and Clinical Characteristics A total of 407 PED records were reviewed for the period between September 2022 and September 2025. The study population was predominantly male 259 (63.9%) and under five years of age 309 (75.9%), with more than half 225 (55.3%) of the patients residing in rural areas. Regarding health service utilization and contextual factors, self-referred visits 237 (58.2%) were more frequent than institutional referrals 170 (41.8%). Peak arrival times occurred during the evening hours 150 (36.9%), and a significant majority of visits 287 (70.5%) took place during the dry season. Clinically, while most children presented in an alert mental state 351(86.2%), approximately 56 (13.8%) presented with altered consciousness, including lethargy or coma. The prevalence of malnutrition was 63 (15.5%), and nearly one in ten children 39 (9.6%) had at least one comorbid condition. Notably, 246 (60.4%) of the patients presented with at least one WHO-defined danger sign, reflecting a high burden of clinical severity among the visits. These comprehensive baseline sociodemographic, clinical, and health service characteristics are detailed in Table 1 . Table 1 Sociodemographic, clinical, and health service characteristics of pediatric patients attending the PED at ARTH, Ethiopia, 2025 (n = 407) Characteristic Category n % Sex Male 260 63.9 Female 147 36.1 Age group < 5 years 309 75.9 ≥ 5 years 98 24.1 Residence Rural 225 55.3 Urban 182 44.7 Referral status Self-referred 237 58.2 Referred 170 41.8 Season of visit Dry season 287 70.5 Rainy season 120 29.5 Time of arrival Morning 104 25.6 Daytime 118 29.0 Evening 150 36.9 Night 35 8.6 Mental status Alert 351 86.2 Lethargic 52 12.8 Comatose 4 1.0 Comorbidity Yes 39 9.6 No 368 90.4 Nutritional status Well nourished 344 84.5 Malnourished 63 15.5 Danger signs present Yes 246 60.4 No 161 39.6 Presenting Complaints and Primary Diagnoses The most frequently reported presenting complaints were cough 115 (28.3%), fever 81 (19.9%), trauma-related injuries 37 (9.1%), vomiting 28 (6.9%), diarrhea 26 (6.4%), and fast breathing 21(5.2%). When categorized by organ system, respiratory-related issues accounted for approximately one-third of all presentations. Consistent with these complaints, pneumonia was identified as the leading primary diagnosis, accounting for 78 (19.2%) of pediatric emergency visits. Other prevalent diagnoses included trauma 40 (9.8%), acute gastroenteritis 39 (9.6%), and malnutrition 28 (6.9%). These findings underscore the continued predominance of infectious diseases and injury-related conditions as the major drivers of pediatric emergency utilization in this setting. Treatment Outcomes and Predictors of Escalated Care Regarding treatment outcomes, approximately half of the pediatric emergency visits resulted in discharge with clinical improvement 205 (50.4%). The remaining 202(49.6%) of cases required escalated care, which included hospital admission 185 (45.5%), intensive care unit transfer 8(2%), referral to other facilities 6 (1.5%), or resulted in death 9 (2.2%). As shown on Fig. 1 , overall, a substantial proportion of children required escalated care beyond basic emergency treatment, demonstrating the high acuity of presentations to the PED. Multivariable logistic regression analysis identified several independent predictors of escalated care. Malnutrition was the strongest predictor, with malnourished children having more than thirteen-fold higher odds of requiring escalated care compared to well-nourished children (AOR = 13.25; 95% CI: 3.40–51.61). Other significant clinical predictors included true emergency presentations (AOR = 7.59; 95% CI: 2.59–22.20), the presence of comorbid illness (AOR = 7.30; 95% CI: 1.30–40.94), diarrhea complaints (AOR = 5.99; 95% CI: 1.09–39.30), and altered mental status at presentation (AOR = 5.75; 95% CI: 1.67–19.83). Furthermore, delayed presentation of more than three days (AOR = 5.66; 95% CI: 2.22–14.40), the presence of danger signs (AOR = 2.06; 95% CI: 1.09–3.86), and referred status (AOR = 1.91; 95% CI: 1.05–3.46) were also independently associated with an increased likelihood of escalated care. These associations are summarized in Table 2 . Table 2 Factors associated with escalated care outcome among pediatric emergency patients at ARTH, Ethiopia, 2025 (n = 407) Variable Category AOR 95% CI Mental status Altered vs alert 5.75 1.67–19.83* Comorbidity Yes vs no 7.30 1.30–40.94* Malnutrition Yes vs no 13.25 3.40–51.61 *** Danger signs Present vs absent 2.06 1.09–3.86* Referral status Referred vs self 1.91 1.05–3.46* True emergency Yes vs no 7.59 2.59–22.20 *** Delayed presentation > 3 days vs ≤ 3 days 5.66 2.22–14.40 *** Diarrhea complaint Yes vs no 5.99 1.09–39.30* Note: CI = Confidence Interval; COR = Crude Odds Ratio; AOR = Adjusted Odds Ratio; 1 = Reference group. Escalated care outcome includes admission, ICU transfer, referral, or death. Statistical significance is indicated as follows: *p < 0.05; **p < 0.01; and ***p < 0.001. Discussion The present study assessed the epidemiologic profile, treatment outcomes, and predictors of escalated care among pediatric patients at Asella Referral and Teaching Hospital over a three-year period. Our findings demonstrate that pediatric emergency utilization is largely driven by children under five years of age, rural residents, and infectious disease presentations, with a substantial proportion (49.6%) requiring escalated care beyond basic emergency management. Patient Profiles and Utilization Patterns The observed male predominance (63.9%) and the high proportion of patients under five years of age (75.9%) align with findings from other African and Ethiopian pediatric emergency studies [ 11 , 12 ]. This demographic is particularly susceptible to pneumonia, diarrhea, and malnutrition, which were the leading diagnoses in this study. Furthermore, the majority of visits (55.3%) originated from rural areas, suggesting that tertiary centers like ARTH continue to serve as a critical safety net for rural populations with limited access to primary healthcare [ 13 ]. Treatment Outcomes and Predictors of Escalated Care While nearly half of the children were discharged with improvement, the 2.2% mortality rate and the high admission rate (45.5%) underscore the severity of cases presenting to the PED [ 6 , 9 ]. Clinical severity indicators were the strongest predictors of these outcomes. Most notably, malnutrition was the strongest independent predictor identified, with malnourished children having more than thirteen-fold higher odds of requiring escalated care (AOR = 13.25) [ 6 , 17 ]. The study also highlighted the critical role of timely care-seeking; children presenting more than three days after symptom onset had nearly six-fold higher odds of escalated care (AOR = 5.66) [ 6 , 18 ]. This, combined with the significant associations found for altered mental status, comorbidities, and the presence of WHO-defined danger signs, emphasizes the urgent need for standardized triage systems to ensure early identification and stabilization of high-risk children [ 7 , 16 ]. Strengths and Limitations This study provides three years of pediatric emergency department data from a tertiary hospital in southeastern Ethiopia, a region where published emergency care outcome evidence remains limited [ 12 – 14 ]. By incorporating demographic, clinical, and system-related predictors into a multivariable logistic regression framework, the study strengthens inference regarding independent determinants of escalated care, consistent with methodological approaches used in comparable pediatric emergency research [ 16 , 17 , 31 ]. The operational definition of escalated care—comprising admission, referral, intensive care transfer, or death—aligns with internationally recognized pediatric emergency outcome frameworks [ 31 , 32 ], thereby enhancing comparability with global literature. Furthermore, the integration of the World Health Organization’s Emergency Triage, Assessment and Treatment (ETAT) criteria increases the policy relevance of the findings and supports applicability to emergency care strengthening initiatives recommended for low-resource settings [ 19 , 33 ]. However, several limitations should be considered. The retrospective design relied on secondary chart review, which may be affected by incomplete documentation, missing variables, or potential misclassification bias, challenges commonly reported in administrative health data systems in LMICs [ 6 , 34 ]. Important socioeconomic determinants such as caregiver education, household income, and transportation access were unavailable in the medical records, although these factors are known to influence healthcare-seeking behavior and delayed presentation in sub-Saharan Africa [ 24 , 26 , 35 ]. Additionally, as the study was conducted at a single tertiary referral center, the findings may not be fully generalizable to primary-level facilities or other Ethiopian regions, given documented variations in health system performance and quality of care across settings [ 28 , 36 ]. Finally, the outcome measure focused on short-term emergency disposition rather than long-term clinical outcomes, preventing assessment of post-discharge morbidity or mortality, which are increasingly emphasized in global pediatric critical care evaluations [ 31 , 39 ]. Conclusions and implications Conclusions This study demonstrates that nearly half of pediatric emergency department (PED) visits at Asella Referral and Teaching Hospital (ARTH) resulted in escalated care outcomes, including admission, referral, intensive care unit transfer, or death, reflecting a substantial burden of severe childhood illness in this tertiary setting. The patient profile was dominated by under-five children and infectious conditions, consistent with national and regional epidemiologic patterns in Ethiopia and sub-Saharan Africa [ 12 – 14 , 29 ]. Clinical severity indicators—particularly malnutrition, altered mental status, comorbidity, presence of World Health Organization (WHO) danger signs, and delayed presentation—were strong independent predictors of escalated care. These findings underscore the importance of systematic early risk identification through strengthened Pediatric Emergency Department (PED) triage systems and full implementation of Emergency Triage, Assessment and Treatment (ETAT) guidelines [ 19 , 27 , 33 ]. Addressing modifiable risk factors such as delayed care-seeking and malnutrition, while strengthening referral coordination and rural primary healthcare capacity, is essential to improving pediatric emergency outcomes in Ethiopia and comparable low-resource settings [ 21 , 24 , 28 , 36 ]. Recommendations and Policy Implications Based on these findings, several actionable recommendations emerge: 1. Strengthen ETAT Implementation Full implementation of the World Health Organization Emergency Triage, Assessment and Treatment (ETAT) guidelines should be reinforced to improve early identification and stabilization of high-risk children in pediatric emergency settings [ 19 , 33 ]. 2. Integrate Malnutrition Screening at Triage Given its strong association with escalated care, routine nutritional assessment should be incorporated into emergency triage protocols, consistent with global child survival and nutrition strategies [ 21 , 37 ]. 3. Promote Community-Level Education to Reduce Delays Public health interventions targeting early care-seeking behavior are critical, as delayed presentation significantly increased the likelihood of escalated care in this study [ 24 , 26 , 35 ]. 4. Strengthen Referral Pathways and Rural Primary Care Capacity The high proportion of rural patients highlights persistent inequities in access to quality primary healthcare. Strengthening district-level pediatric services and improving referral coordination may reduce unnecessary tertiary-level overload and improve system efficiency [ 28 , 36 , 38 ]. 5. Invest in Emergency Care System Strengthening Broader health system investments—including workforce training, pediatric intensive care expansion, and emergency transport infrastructure—are aligned with global recommendations for strengthening emergency care systems in low- and middle-income countries [ 9 , 39 , 40 ]. Abbreviations Abbreviation Full Term AGE Acute gastroenteritis AOR Adjusted odds ratio ARTH Asella Referral and Teaching Hospital CI Confidence interval CoHS College of Health Sciences COR Crude odds ratio ED Emergency department EDHS Ethiopian Demographic and Health Survey ETAT Emergency Triage, Assessment and Treatment ICU Intensive care unit LMICs Low- and middle-income countries LRI Lower respiratory infection OR Odds ratio PED Pediatric emergency department PI Principal investigator SDGs Sustainable Development Goals SPSS Statistical Package for the Social Sciences SSA Sub-Saharan Africa U5MR Under-five mortality rate WHO World Health Organization UNICEF United Nations Children’s Fund Declarations Ethics approval and consent to participate Ethical clearance was obtained from the Ethical Review Committee (ERC) of Arsi University, College of Health Sciences (Protocol Number: COHS/R/227/2025). A formal letter of cooperation was submitted to the management of Asella Referral and Teaching Hospital to secure access to the pediatric medical records. Given the retrospective nature of the study and the use of de-identified secondary data, the ERC granted a waiver of informed consent. All data were anonymized using unique identification codes to ensure patient confidentiality in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Data availability statement Findings from this study are based on hospital medical records from ARTH. The raw data set is attached to this submission; further inquiries regarding data usage may be directed to the corresponding author, subject to Arsi University guidelines. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. Authors’ contributions TN conceived the study, collected the data, performed the analysis, and drafted the manuscript. AM and AD supervised the study, AM, AD, TG and AB validation, contributed to interpretation of results, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgments The authors would like to thank Arsi University College of Health Sciences and ARTH for providing access to pediatric emergency records. We also acknowledge the data collectors and hospital staff for their cooperation and support during data extraction. References Gowa M, Habib I, Tahir A, Khan M, Shahid M. Disease spectrum and frequency of illness in pediatric emergency: a retrospective analysis from Karachi, Pakistan. Ochsner J. 2019;19(4):340–6. Guckert L, Reutter H, Saleh N, et al. Nonurgent visits to the pediatric emergency department before and during the first peak of the COVID-19 pandemic. Int J Pediatr. 2022;2022:7580546. Brugnolaro V, Fovino LN, Calgaro S, et al. Pediatric emergency care in a low-income country: characteristics and outcomes of presentations to a tertiary-care emergency department in Mozambique. PLoS ONE. 2020;15(11):e0242159. UNICEF. Levels and Trends in Child Mortality 2024 Report. New York: United Nations Children’s Fund; 2024. Hsia RY, Niedzwiecki M. Avoidable emergency department visits: a starting point. Int J Qual Health Care. 2017;29(5):642–5. Lucyk K, Tang K, Quan H. Barriers to data quality resulting from the process of coding health information to administrative data: a qualitative study. BMC Health Serv Res. 2017;17:766. Kaiser SV, Hall M, Bettenhausen JL, et al. Neighborhood child opportunity and emergency department utilization. Pediatrics. 2022;150(3):e2021056098. Borensztajn DM, Hagedoorn NN, Carrol ED, et al. Febrile children with comorbidities at the emergency department: a multicentre observational study. Eur J Pediatr. 2022;181(9):3491–500. World Health Organization. Emergency Care Systems Framework. Geneva: WHO; 2019. Reynolds TA, Sawe H, Rubiano AM, Shin SD, Wallis L, Mock CN. Strengthening health systems to provide emergency care. BMJ Glob Health. 2017;2(2):e000419. Asinakew T, Habte T. Emergency admissions and associated factors among children admitted to the pediatric emergency unit at selected public hospitals in Addis Ababa, Ethiopia: a retrospective cross-sectional study. J Emerg Med Open Access. 2024;2(1):01–11. Dube SJ, Seboka BT, Demeke AD, et al. Admission outcomes and associated factors among children admitted to the paediatric emergency unit within 24 hours of Dilla University Referral Hospital, Ethiopia: a cross-sectional study. BMJ Open. 2025;15:e091359. Zeleke TA, Nora WT, Denberu MT, et al. Length of stay and associated factors among pediatric patients in the pediatric emergency unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. BMC Emerg Med. 2024;24:170. Tsegaye H, Demelash A, Aklilu D, et al. Determinants of pediatrics emergency mortality at comprehensive specialized hospitals of Southern Nations, Nationalities, and Peoples’ Region, Ethiopia: unmatched case-control study. BMC Pediatr. 2023;23:192. Bekele M, Urgessa M, Kumsa K, et al. Contributing factors of delay in seeking treatment for childhood diarrheal diseases in Berbere Woreda, Ethiopia: an unmatched case–control study. J Health Popul Nutr. 2023;42:1–8. Agbesanwa TA, Babatola AO, Fatunla OA, et al. Pattern of admissions and outcomes in the children emergency department of a tertiary health institution in Southwestern Nigeria: a four-year review. Afr J Emerg Med. 2023;13(1):45–51. Jbari S, Lahmini W, Eddabbah M, et al. Characterization of a hospitalized population at the pediatric emergency service of Mother and Child Hospital, Marrakech, Morocco. Pan Afr Med J. 2022;43:104. Thiongane A, Ndongo AA, Sow A, et al. Epidemiology of admissions in a pediatric emergency department in Albert Royer Hospital Dakar. Open J Pediatr. 2022;12:188–95. World Health Organization. Updated guideline: paediatric emergency triage, assessment and treatment (ETAT): care of critically ill children. Geneva: WHO; 2016. Pines JM, Hilton JA, Weber EJ, et al. International perspectives on emergency department crowding. Acad Emerg Med. 2013;20(6):619–31. Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427–51. Victora CG, Christian P, Vidaletti LP, et al. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet. 2021;397(10282):1388–99. Dibisa KE, Mengesha G, Kenea G, et al. Prevalence and factors associated with acute malnutrition among children aged 6–59 months in West Wollega, Oromia, Ethiopia. J Health Popul Nutr. 2025;44:28. Ahmed S, Sobhan F, Islam A. Barkat-e-Khuda. Neonatal morbidity and care-seeking behaviour in rural Bangladesh. Glob Health Action. 2010;3:4612. Rutherford ME, Mulholland K, Hill PC. How access to healthcare relates to under-five mortality in sub-Saharan Africa: systematic review. Trop Med Int Health. 2016;21(4):509–22. Geldsetzer P, Williams TC, Kirolos A, et al. Delays in care-seeking for fatal childhood illness in sub-Saharan Africa: systematic review and meta-analysis. Lancet Glob Health. 2019;7(10):e1318–28. Molyneux E, Ahmad S, Robertson A. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained hospital in Malawi. Arch Dis Child. 2006;91(4):314–9. Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era. Lancet Glob Health. 2018;6(11):e1196–252. GBD 2023 Child Mortality Collaborators. Global, regional, and national causes of under-five mortality in 2023. Lancet. 2024;403:105–23. World Bank. World Development Indicators 2024. Washington DC: World Bank; 2024. Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference definitions. Pediatr Crit Care Med. 2005;6:2–8. Odetola FO, et al. Outcomes of pediatric critical illness in resource-limited settings. Pediatr Crit Care Med. 2007;8:415–22. WHO. Emergency care systems framework. Geneva: World Health Organization; 2019. Mutale W, et al. Improving health information systems in sub-Saharan Africa. Health Res Policy Syst. 2013;11:35. Geldsetzer P, et al. Delays in care seeking for child illness in sub-Saharan Africa. Lancet Glob Health. 2019;7:e1318–25. Kruk ME, et al. High-quality health systems in the SDG era. Lancet Glob Health. 2018;6:e1196–252. Black RE, et al. Maternal and child undernutrition and overweight. Lancet. 2013;382:427–51. World Bank. Improving primary healthcare service delivery in Ethiopia. 2023. Reynolds TA, et al. Strengthening emergency care systems globally. BMJ Glob Health. 2017;2:e000419. Razzak JA, Kellermann AL. Emergency medical care in developing countries. Bull World Health Organ. 2002;80:900–5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8935922","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594990580,"identity":"4d10bfeb-2462-4aa6-b62a-51b73f3d8c28","order_by":0,"name":"Tufa Nugusu","email":"","orcid":"","institution":"Arsi University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tufa","middleName":"","lastName":"Nugusu","suffix":""},{"id":594990581,"identity":"7bb4edb3-2e0b-40b4-8bfe-d1f96a3df153","order_by":1,"name":"Achalu Mekuria","email":"","orcid":"","institution":"Arsi University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Achalu","middleName":"","lastName":"Mekuria","suffix":""},{"id":594990582,"identity":"2796fbdc-5fab-4441-8532-25cf374391af","order_by":2,"name":"Tesfa Gebremeskel","email":"","orcid":"","institution":"Arsi University College of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tesfa","middleName":"","lastName":"Gebremeskel","suffix":""},{"id":594990583,"identity":"160165a3-57c9-46a2-8806-3572454ab64a","order_by":3,"name":"Andinet Beyene","email":"","orcid":"","institution":"Haramaya University, College of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Andinet","middleName":"","lastName":"Beyene","suffix":""},{"id":594990584,"identity":"6b1fe0ae-ecd4-4f8f-a600-713e56200588","order_by":4,"name":"Ayalneh Demissie","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYHACxgMMDAcYGxiAiMGAQQ4kdOABAT0oWozBIgnEaYGARDADnxb+GckPDhdU3JHtFzvc/PFHQV36/LDDD4G22MnpNmDXInEjzeDwjDPPjGfOTmyT5jE4nLvxdpoBUEuysdkBHNbcSDA4zNt2OHHD7cQ2ZgaDA7kbZyeAtBxI3IZDi/yN9A+Hef8dTtx/OxHoMIO6dMPZ6R/wajG4kQO0pQFoi3RigwSPAXOCvHQOflsMz7wpOMxz7LDxjNsQvxhukM4pOJBggNsvcsfTNz7mqTks2z87/fHHH3/q5OVnp2/+8KHCTg6n9wUS0J0KVmmAQzkI8KObJd+AR/UoGAWjYBSMSAAAigNwE/rQXSwAAAAASUVORK5CYII=","orcid":"","institution":"Arsi University College of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Ayalneh","middleName":"","lastName":"Demissie","suffix":""}],"badges":[],"createdAt":"2026-02-21 22:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8935922/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8935922/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103440759,"identity":"d030237b-5a46-45c6-a75e-04b678ae5c57","added_by":"auto","created_at":"2026-02-25 17:14:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38420,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart showing treatment outcomes of pediatric emergency visits at ARTH, Ethiopia, 2025 (n = 407)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8935922/v1/65a18a99052aefa12b1a14bd.png"},{"id":107185964,"identity":"dc5d8c43-64a4-46f1-b2b1-0f78723873a0","added_by":"auto","created_at":"2026-04-17 18:55:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":515539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8935922/v1/1cf941e3-bcf6-4685-87a9-afd3a0960891.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient Profiles and Factors Associated with Escalated Care in a Southeast Ethiopian Pediatric Emergency Department: A Three-Year Retrospective Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlobally, emergency care contributes substantially to child survival. Despite major reductions in under-five mortality, preventable conditions such as pneumonia, diarrhea, sepsis, and malnutrition remain leading causes of pediatric morbidity and mortality, particularly in sub-Saharan Africa [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Pediatric emergency departments (PEDs) are often the first point of contact for critically ill children and serve as a key determinant of outcomes.\u003c/p\u003e \u003cp\u003eIn LMICs, pediatric emergency utilization has increased due to infectious diseases, trauma, urbanization, and gaps in primary healthcare access [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, emergency units frequently operate under constraints including workforce shortages, limited diagnostic capacity, and delayed presentation of severe cases [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Ethiopia, infectious diseases remain predominant among pediatric emergency admissions [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Studies from Addis Ababa, Dilla, and Tikur Anbessa have shown high admission rates and identified malnutrition, delayed care-seeking, comorbidity, and clinical severity as predictors of unfavourable outcomes [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Evidence from other African contexts similarly demonstrates high admission and mortality rates in pediatric emergency settings [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) emphasizes standardized pediatric emergency triage through the Emergency Triage, Assessment and Treatment (ETAT) guidelines to reduce preventable mortality [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Identifying predictors of escalated care\u0026mdash;defined as admission, referral, ICU transfer, or death\u0026mdash;is crucial for strengthening triage systems and resource allocation.\u003c/p\u003e \u003cp\u003eDespite increasing demand for pediatric emergency services in Ethiopia, evidence from south eastern regions remains scarce. This study therefore aimed to determine patient profiles, treatment outcomes, and factors associated with escalated care among pediatric patients attending the PED of ARTH.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003e Institution-based retrospective cross-sectional study conducted at Asella Referral and Teaching Hospital (ARTH), located in Asella town, Oromia Regional State. The hospital features a capacity of 321 beds and operates as a multidisciplinary hub for surgical, medical, and pediatric care. The institutional framework of ARTH is reflective of the broader Ethiopian health system\u0026rsquo;s tier-based model. As a tertiary facility, it is expected to handle complex cases referred from primary and secondary tiers; however, the reality of health utilization in Ethiopia often involves a \"bypass\" phenomenon where patients seek care directly at referral centers due to perceived or actual resource gaps at lower-level facilities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The pediatric emergency unit at ARTH is staffed by a dedicated team of pediatricians, residents, general practitioners, and specialized nurses, yet it operates under significant pressure from high patient volumes and a limited supply of advanced diagnostic tools [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In comparison to other leading medical institutions such as Adama Comprehensive Specialized Hospital (ACSH), which maintains 75 pediatric beds, ARTH\u0026rsquo;s infrastructure must absorb a diveARTH serves as a tertiary referral center for the Arsi Zone and surrounding areas, providing inpatient and outpatient pediatric services. The pediatric department itself is organized into specialized units, including a neonatal intensive care unit (NICU), pediatric wards, and a 24-hour functional pediatric emergency department [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Medical records of pediatric patients who visited the pediatric emergency department between September 10, 2022, and September 10, 2025, were reviewed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe source population included all pediatric patients who attended the pediatric emergency department at ARTH during the study period. The study population consisted of systematically sampled pediatric emergency visits that met the eligibility criteria.\u003c/p\u003e \u003cp\u003eChildren aged 29 days to 14 years were included. Patients younger than 29 days or older than 14 years, and those with incomplete documentation or lost medical charts were excluded. Incomplete charts were defined as absence of essential clinical information, consistent with previous evidence on barriers to administrative health data quality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSample size determination and sampling procedure\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated using a single population proportion formula with a 95% confidence level, a 5% margin of error, and an expected proportion (p) of 39.6% based on a previous Ethiopian retrospective study [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. After adding a 10% allowance for incomplete records, the final sample size was 407.\u003c/p\u003e \u003cp\u003eThe sample size calculation formula follows here under:\u003c/p\u003e\u003cp\u003e\u003cimg 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\" width=\"213\" height=\"91\"\u003e\u003c/p\u003e\u003cp\u003eA systematic random sampling technique was employed to select 407 patient records from the total number of children aged 29 days to 14 years attended the pediatric emergency department between September 10, 2022, and September 10, 2025. The sampling process began by generating a sampling frame\u0026mdash;consisting of a chronological list of all eligible cases\u0026mdash;from the pediatric emergency unit registration book. With an estimated 12,750 pediatric emergency visits during the three-year period, the sampling interval (k) was determined by dividing the total number of eligible patients (N\u0026thinsp;=\u0026thinsp;12, 750) by the required sample size (n\u0026thinsp;=\u0026thinsp;407) as K\u0026thinsp;=\u0026thinsp;31. With an estimated 12,750 pediatric emergency visits during the three-year period, the sampling interval was calculated as K\u0026thinsp;=\u0026thinsp;31. The first chart was selected by lottery from the first 31 records, and every 31th chart was included until the required sample size was achieved.\u003c/p\u003e\n\u003ch3\u003eVariables and operational definitions\u003c/h3\u003e\n\u003cp\u003eThe primary outcome variable was treatment outcome of pediatric emergency visits, categorized as stable/good outcome (discharge with improvement) or escalated care outcome (admission, referral, ICU transfer, or death), similar to definitions used in prior pediatric emergency outcome studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTrue pediatric emergency was defined as presentation with at least one WHO emergency sign such as airway compromise, shock, coma, convulsions, severe dehydration, or severe respiratory distress [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Avoidable visits were defined as non-urgent pediatric emergency visits that could have been managed at primary care level without risk to the child\u0026rsquo;s health [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData collection tools and procedure\u003c/h3\u003e\n\u003cp\u003eData were extracted using a structured checklist adapted from the WHO emergency care assessment tool [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Data collectors received training prior to data extraction, and a pretest was conducted on 5% of records before the main data collection. Data were entered using Kobo Collect and exported to IBM SPSS Statistics version 27 for analysis.\u003c/p\u003e \u003cp\u003eData were collected using a structured abstraction form adapted from the WHO pediatric hospital care manual [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The tool was digitized using the Kobo Toolbox mobile application, which facilitated real-time data validation. The procedure involved a retrospective review of pediatric ward registers and individual medical charts. Two trained BSc nurses served as data collectors, and the principal investigator provided daily on-site supervision.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Quality Assurance\u003c/h2\u003e \u003cp\u003eThe data abstraction tool was pre-tested on 5% of the total sample size (20 records). Data collectors underwent a one-day intensive training session. During the data collection phase, the principal investigator performed daily audits of uploaded electronic forms. Before final analysis, data underwent a cleaning process to identify and manage outliers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe collected data were cleaned, coded, and entered into Epi-Data version 4.6 and subsequently exported to SPSS version 27.0 for analysis. Descriptive statistics were utilized to summarize categorical and continuous variables. A Binary Logistic Regression model was employed to identify predictors. Variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in the bivariable analysis were entered into the multivariable model. The fitness of the final model was verified using the Hosmer-Lemeshow test. Strength of associations was expressed through Adjusted Odds Ratios (AOR) with 95% Confidence Intervals (CI).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 407 pediatric patient records were reviewed from visits to the PED of ARTH between September 10, 2022, and September 10, 2025.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Sociodemographic and Clinical Characteristics\u003c/h2\u003e \u003cp\u003eA total of 407 PED records were reviewed for the period between September 2022 and September 2025. The study population was predominantly male 259 (63.9%) and under five years of age 309 (75.9%), with more than half 225 (55.3%) of the patients residing in rural areas. Regarding health service utilization and contextual factors, self-referred visits 237 (58.2%) were more frequent than institutional referrals 170 (41.8%). Peak arrival times occurred during the evening hours 150 (36.9%), and a significant majority of visits 287 (70.5%) took place during the dry season.\u003c/p\u003e \u003cp\u003eClinically, while most children presented in an alert mental state 351(86.2%), approximately 56 (13.8%) presented with altered consciousness, including lethargy or coma. The prevalence of malnutrition was 63 (15.5%), and nearly one in ten children 39 (9.6%) had at least one comorbid condition. Notably, 246 (60.4%) of the patients presented with at least one WHO-defined danger sign, reflecting a high burden of clinical severity among the visits. These comprehensive baseline sociodemographic, clinical, and health service characteristics are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic, clinical, and health service characteristics of pediatric patients attending the PED at ARTH, Ethiopia, 2025 (n\u0026thinsp;=\u0026thinsp;407)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferral status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-referred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSeason of visit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDry season\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRainy season\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime of arrival\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMorning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDaytime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlert\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLethargic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComatose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNutritional status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWell nourished\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMalnourished\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDanger signs present\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePresenting Complaints and Primary Diagnoses\u003c/h2\u003e \u003cp\u003eThe most frequently reported presenting complaints were cough 115 (28.3%), fever 81 (19.9%), trauma-related injuries 37 (9.1%), vomiting 28 (6.9%), diarrhea 26 (6.4%), and fast breathing 21(5.2%). When categorized by organ system, respiratory-related issues accounted for approximately one-third of all presentations. Consistent with these complaints, pneumonia was identified as the leading primary diagnosis, accounting for 78 (19.2%) of pediatric emergency visits. Other prevalent diagnoses included trauma 40 (9.8%), acute gastroenteritis 39 (9.6%), and malnutrition 28 (6.9%). These findings underscore the continued predominance of infectious diseases and injury-related conditions as the major drivers of pediatric emergency utilization in this setting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Outcomes and Predictors of Escalated Care\u003c/h2\u003e \u003cp\u003eRegarding treatment outcomes, approximately half of the pediatric emergency visits resulted in discharge with clinical improvement 205 (50.4%). The remaining 202(49.6%) of cases required escalated care, which included hospital admission 185 (45.5%), intensive care unit transfer 8(2%), referral to other facilities 6 (1.5%), or resulted in death 9 (2.2%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAs shown on Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, overall, a substantial proportion of children required escalated care beyond basic emergency treatment, demonstrating the high acuity of presentations to the PED.\u003c/p\u003e \u003cp\u003eMultivariable logistic regression analysis identified several independent predictors of escalated care. Malnutrition was the strongest predictor, with malnourished children having more than thirteen-fold higher odds of requiring escalated care compared to well-nourished children (AOR\u0026thinsp;=\u0026thinsp;13.25; 95% CI: 3.40\u0026ndash;51.61). Other significant clinical predictors included true emergency presentations (AOR\u0026thinsp;=\u0026thinsp;7.59; 95% CI: 2.59\u0026ndash;22.20), the presence of comorbid illness (AOR\u0026thinsp;=\u0026thinsp;7.30; 95% CI: 1.30\u0026ndash;40.94), diarrhea complaints (AOR\u0026thinsp;=\u0026thinsp;5.99; 95% CI: 1.09\u0026ndash;39.30), and altered mental status at presentation (AOR\u0026thinsp;=\u0026thinsp;5.75; 95% CI: 1.67\u0026ndash;19.83). Furthermore, delayed presentation of more than three days (AOR\u0026thinsp;=\u0026thinsp;5.66; 95% CI: 2.22\u0026ndash;14.40), the presence of danger signs (AOR\u0026thinsp;=\u0026thinsp;2.06; 95% CI: 1.09\u0026ndash;3.86), and referred status (AOR\u0026thinsp;=\u0026thinsp;1.91; 95% CI: 1.05\u0026ndash;3.46) were also independently associated with an increased likelihood of escalated care. These associations are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with escalated care outcome among pediatric emergency patients at ARTH, Ethiopia, 2025 (n\u0026thinsp;=\u0026thinsp;407)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAltered vs alert\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.67\u0026ndash;19.83*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes vs no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.30\u0026ndash;40.94*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMalnutrition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes vs no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.40\u0026ndash;51.61 ***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDanger signs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent vs absent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.09\u0026ndash;3.86*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferral status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferred vs self\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.05\u0026ndash;3.46*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrue emergency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes vs no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.59\u0026ndash;22.20 ***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDelayed presentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 days vs\u0026thinsp;\u0026le;\u0026thinsp;3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.22\u0026ndash;14.40 ***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiarrhea complaint\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes vs no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.09\u0026ndash;39.30*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote: CI\u0026thinsp;=\u0026thinsp;Confidence Interval; COR\u0026thinsp;=\u0026thinsp;Crude Odds Ratio; AOR\u0026thinsp;=\u0026thinsp;Adjusted Odds Ratio; 1\u0026thinsp;=\u0026thinsp;Reference group. Escalated care outcome includes admission, ICU transfer, referral, or death. Statistical significance is indicated as follows: *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; and ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e The present study assessed the epidemiologic profile, treatment outcomes, and predictors of escalated care among pediatric patients at Asella Referral and Teaching Hospital over a three-year period. Our findings demonstrate that pediatric emergency utilization is largely driven by children under five years of age, rural residents, and infectious disease presentations, with a substantial proportion (49.6%) requiring escalated care beyond basic emergency management.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePatient Profiles and Utilization Patterns\u003c/h2\u003e \u003cp\u003eThe observed male predominance (63.9%) and the high proportion of patients under five years of age (75.9%) align with findings from other African and Ethiopian pediatric emergency studies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This demographic is particularly susceptible to pneumonia, diarrhea, and malnutrition, which were the leading diagnoses in this study. Furthermore, the majority of visits (55.3%) originated from rural areas, suggesting that tertiary centers like ARTH continue to serve as a critical safety net for rural populations with limited access to primary healthcare [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Outcomes and Predictors of Escalated Care\u003c/h2\u003e \u003cp\u003eWhile nearly half of the children were discharged with improvement, the 2.2% mortality rate and the high admission rate (45.5%) underscore the severity of cases presenting to the PED [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Clinical severity indicators were the strongest predictors of these outcomes. Most notably, malnutrition was the strongest independent predictor identified, with malnourished children having more than thirteen-fold higher odds of requiring escalated care (AOR\u0026thinsp;=\u0026thinsp;13.25) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study also highlighted the critical role of timely care-seeking; children presenting more than three days after symptom onset had nearly six-fold higher odds of escalated care (AOR\u0026thinsp;=\u0026thinsp;5.66) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This, combined with the significant associations found for altered mental status, comorbidities, and the presence of WHO-defined danger signs, emphasizes the urgent need for standardized triage systems to ensure early identification and stabilization of high-risk children [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study provides three years of pediatric emergency department data from a tertiary hospital in southeastern Ethiopia, a region where published emergency care outcome evidence remains limited [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. By incorporating demographic, clinical, and system-related predictors into a multivariable logistic regression framework, the study strengthens inference regarding independent determinants of escalated care, consistent with methodological approaches used in comparable pediatric emergency research [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The operational definition of escalated care\u0026mdash;comprising admission, referral, intensive care transfer, or death\u0026mdash;aligns with internationally recognized pediatric emergency outcome frameworks [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], thereby enhancing comparability with global literature. Furthermore, the integration of the World Health Organization\u0026rsquo;s Emergency Triage, Assessment and Treatment (ETAT) criteria increases the policy relevance of the findings and supports applicability to emergency care strengthening initiatives recommended for low-resource settings [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, several limitations should be considered. The retrospective design relied on secondary chart review, which may be affected by incomplete documentation, missing variables, or potential misclassification bias, challenges commonly reported in administrative health data systems in LMICs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Important socioeconomic determinants such as caregiver education, household income, and transportation access were unavailable in the medical records, although these factors are known to influence healthcare-seeking behavior and delayed presentation in sub-Saharan Africa [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Additionally, as the study was conducted at a single tertiary referral center, the findings may not be fully generalizable to primary-level facilities or other Ethiopian regions, given documented variations in health system performance and quality of care across settings [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Finally, the outcome measure focused on short-term emergency disposition rather than long-term clinical outcomes, preventing assessment of post-discharge morbidity or mortality, which are increasingly emphasized in global pediatric critical care evaluations [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusions and implications","content":"\u003ch3\u003eConclusions\u003c/h3\u003e\n\u003cp\u003eThis study demonstrates that nearly half of pediatric emergency department (PED) visits at Asella Referral and Teaching Hospital (ARTH) resulted in escalated care outcomes, including admission, referral, intensive care unit transfer, or death, reflecting a substantial burden of severe childhood illness in this tertiary setting. The patient profile was dominated by under-five children and infectious conditions, consistent with national and regional epidemiologic patterns in Ethiopia and sub-Saharan Africa [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Clinical severity indicators\u0026mdash;particularly malnutrition, altered mental status, comorbidity, presence of World Health Organization (WHO) danger signs, and delayed presentation\u0026mdash;were strong independent predictors of escalated care. These findings underscore the importance of systematic early risk identification through strengthened Pediatric Emergency Department (PED) triage systems and full implementation of Emergency Triage, Assessment and Treatment (ETAT) guidelines [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Addressing modifiable risk factors such as delayed care-seeking and malnutrition, while strengthening referral coordination and rural primary healthcare capacity, is essential to improving pediatric emergency outcomes in Ethiopia and comparable low-resource settings [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations and Policy Implications\u003c/h2\u003e \u003cp\u003eBased on these findings, several actionable recommendations emerge:\u003c/p\u003e \u003cp\u003e \u003cb\u003e1. Strengthen ETAT Implementation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFull implementation of the World Health Organization Emergency Triage, Assessment and Treatment (ETAT) guidelines should be reinforced to improve early identification and stabilization of high-risk children in pediatric emergency settings [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Integrate Malnutrition Screening at Triage\u003c/b\u003e \u003c/p\u003e \u003cp\u003eGiven its strong association with escalated care, routine nutritional assessment should be incorporated into emergency triage protocols, consistent with global child survival and nutrition strategies [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. Promote Community-Level Education to Reduce Delays\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePublic health interventions targeting early care-seeking behavior are critical, as delayed presentation significantly increased the likelihood of escalated care in this study [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. Strengthen Referral Pathways and Rural Primary Care Capacity\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe high proportion of rural patients highlights persistent inequities in access to quality primary healthcare. Strengthening district-level pediatric services and improving referral coordination may reduce unnecessary tertiary-level overload and improve system efficiency [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003e5. Invest in Emergency Care System Strengthening\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBroader health system investments\u0026mdash;including workforce training, pediatric intensive care expansion, and emergency transport infrastructure\u0026mdash;are aligned with global recommendations for strengthening emergency care systems in low- and middle-income countries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFull Term\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAcute gastroenteritis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAdjusted odds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eARTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAsella Referral and Teaching Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConfidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCoHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCollege of Health Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCrude odds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEmergency department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEDHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEthiopian Demographic and Health Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eETAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEmergency Triage, Assessment and Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntensive care unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLMICs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow- and middle-income countries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLower respiratory infection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePediatric emergency department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePrincipal investigator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSDGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSustainable Development Goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSPSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eU5MR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUnder-five mortality rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUNICEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUnited Nations Children\u0026rsquo;s Fund\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical clearance was obtained from the Ethical Review Committee (ERC) of Arsi University, College of Health Sciences (Protocol Number: COHS/R/227/2025). A formal letter of cooperation was submitted to the management of Asella Referral and Teaching Hospital to secure access to the pediatric medical records. Given the retrospective nature of the study and the use of de-identified secondary data, the ERC granted a waiver of informed consent. All data were anonymized using unique identification codes to ensure patient confidentiality in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eData availability statement\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eFindings from this study are based on hospital medical records from ARTH. The raw data set is attached to this submission; further inquiries regarding data usage may be directed to the corresponding author, subject to Arsi University guidelines.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eTN conceived the study, collected the data, performed the analysis, and drafted the manuscript. AM and AD supervised the study, AM, AD, TG and AB validation, contributed to interpretation of results, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank Arsi University College of Health Sciences and ARTH for providing access to pediatric emergency records. We also acknowledge the data collectors and hospital staff for their cooperation and support during data extraction.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGowa M, Habib I, Tahir A, Khan M, Shahid M. Disease spectrum and frequency of illness in pediatric emergency: a retrospective analysis from Karachi, Pakistan. Ochsner J. 2019;19(4):340\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuckert L, Reutter H, Saleh N, et al. Nonurgent visits to the pediatric emergency department before and during the first peak of the COVID-19 pandemic. Int J Pediatr. 2022;2022:7580546.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrugnolaro V, Fovino LN, Calgaro S, et al. Pediatric emergency care in a low-income country: characteristics and outcomes of presentations to a tertiary-care emergency department in Mozambique. PLoS ONE. 2020;15(11):e0242159.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. Levels and Trends in Child Mortality 2024 Report. New York: United Nations Children\u0026rsquo;s Fund; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsia RY, Niedzwiecki M. Avoidable emergency department visits: a starting point. Int J Qual Health Care. 2017;29(5):642\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLucyk K, Tang K, Quan H. Barriers to data quality resulting from the process of coding health information to administrative data: a qualitative study. BMC Health Serv Res. 2017;17:766.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaiser SV, Hall M, Bettenhausen JL, et al. Neighborhood child opportunity and emergency department utilization. Pediatrics. 2022;150(3):e2021056098.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorensztajn DM, Hagedoorn NN, Carrol ED, et al. Febrile children with comorbidities at the emergency department: a multicentre observational study. Eur J Pediatr. 2022;181(9):3491\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Emergency Care Systems Framework. Geneva: WHO; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynolds TA, Sawe H, Rubiano AM, Shin SD, Wallis L, Mock CN. Strengthening health systems to provide emergency care. BMJ Glob Health. 2017;2(2):e000419.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsinakew T, Habte T. Emergency admissions and associated factors among children admitted to the pediatric emergency unit at selected public hospitals in Addis Ababa, Ethiopia: a retrospective cross-sectional study. J Emerg Med Open Access. 2024;2(1):01\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDube SJ, Seboka BT, Demeke AD, et al. Admission outcomes and associated factors among children admitted to the paediatric emergency unit within 24 hours of Dilla University Referral Hospital, Ethiopia: a cross-sectional study. BMJ Open. 2025;15:e091359.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeleke TA, Nora WT, Denberu MT, et al. Length of stay and associated factors among pediatric patients in the pediatric emergency unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. BMC Emerg Med. 2024;24:170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsegaye H, Demelash A, Aklilu D, et al. Determinants of pediatrics emergency mortality at comprehensive specialized hospitals of Southern Nations, Nationalities, and Peoples\u0026rsquo; Region, Ethiopia: unmatched case-control study. BMC Pediatr. 2023;23:192.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBekele M, Urgessa M, Kumsa K, et al. Contributing factors of delay in seeking treatment for childhood diarrheal diseases in Berbere Woreda, Ethiopia: an unmatched case\u0026ndash;control study. J Health Popul Nutr. 2023;42:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgbesanwa TA, Babatola AO, Fatunla OA, et al. Pattern of admissions and outcomes in the children emergency department of a tertiary health institution in Southwestern Nigeria: a four-year review. Afr J Emerg Med. 2023;13(1):45\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJbari S, Lahmini W, Eddabbah M, et al. Characterization of a hospitalized population at the pediatric emergency service of Mother and Child Hospital, Marrakech, Morocco. Pan Afr Med J. 2022;43:104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThiongane A, Ndongo AA, Sow A, et al. Epidemiology of admissions in a pediatric emergency department in Albert Royer Hospital Dakar. Open J Pediatr. 2022;12:188\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Updated guideline: paediatric emergency triage, assessment and treatment (ETAT): care of critically ill children. Geneva: WHO; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePines JM, Hilton JA, Weber EJ, et al. International perspectives on emergency department crowding. Acad Emerg Med. 2013;20(6):619\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictora CG, Christian P, Vidaletti LP, et al. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet. 2021;397(10282):1388\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDibisa KE, Mengesha G, Kenea G, et al. Prevalence and factors associated with acute malnutrition among children aged 6\u0026ndash;59 months in West Wollega, Oromia, Ethiopia. J Health Popul Nutr. 2025;44:28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed S, Sobhan F, Islam A. Barkat-e-Khuda. Neonatal morbidity and care-seeking behaviour in rural Bangladesh. Glob Health Action. 2010;3:4612.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRutherford ME, Mulholland K, Hill PC. How access to healthcare relates to under-five mortality in sub-Saharan Africa: systematic review. Trop Med Int Health. 2016;21(4):509\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeldsetzer P, Williams TC, Kirolos A, et al. Delays in care-seeking for fatal childhood illness in sub-Saharan Africa: systematic review and meta-analysis. Lancet Glob Health. 2019;7(10):e1318\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolyneux E, Ahmad S, Robertson A. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained hospital in Malawi. Arch Dis Child. 2006;91(4):314\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era. Lancet Glob Health. 2018;6(11):e1196\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGBD 2023 Child Mortality Collaborators. Global, regional, and national causes of under-five mortality in 2023. Lancet. 2024;403:105\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Bank. World Development Indicators 2024. Washington DC: World Bank; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference definitions. Pediatr Crit Care Med. 2005;6:2\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOdetola FO, et al. Outcomes of pediatric critical illness in resource-limited settings. Pediatr Crit Care Med. 2007;8:415\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Emergency care systems framework. Geneva: World Health Organization; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMutale W, et al. Improving health information systems in sub-Saharan Africa. Health Res Policy Syst. 2013;11:35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeldsetzer P, et al. Delays in care seeking for child illness in sub-Saharan Africa. Lancet Glob Health. 2019;7:e1318\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruk ME, et al. High-quality health systems in the SDG era. Lancet Glob Health. 2018;6:e1196\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack RE, et al. Maternal and child undernutrition and overweight. Lancet. 2013;382:427\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Bank. Improving primary healthcare service delivery in Ethiopia. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynolds TA, et al. Strengthening emergency care systems globally. BMJ Glob Health. 2017;2:e000419.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRazzak JA, Kellermann AL. Emergency medical care in developing countries. Bull World Health Organ. 2002;80:900\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric emergency, escalated care, treatment outcome, malnutrition, Asella, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-8935922/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8935922/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePediatric emergency departments (PEDs) play a critical role in reducing childhood morbidity and mortality, particularly in low- and middle-income countries (LMICs), where infectious diseases and delayed healthcare-seeking remain prevalent. Evidence regarding treatment outcomes and predictors of escalated care in Ethiopian pediatric emergency settings are limited.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess patient profiles, treatment outcomes, and factors associated with escalated care among children presenting to the pediatric emergency department of Asella Referral and Teaching Hospital (ARTH), Southeast Ethiopia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cross-sectional study was conducted among pediatric emergency visits between 10 September 2022 and 10 September 2025. A total of 407 medical records were systematically sampled. Data were entered into KoboCollect and analyzed using SPSS version 27. Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in bivariable analysis were entered into multivariable logistic regression. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. Statistical significance was declared at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 407 visits, 63.9% were male and 75.9% were under five years of age. Rural residents constituted 55.3% of cases. Pneumonia (19.2%) was the leading diagnosis. Nearly half (49.6%) required escalated care (admission, referral, ICU transfer, or death). Independent predictors included malnutrition (AOR\u0026thinsp;=\u0026thinsp;13.25; 95% CI: 3.40\u0026ndash;51.61), true emergency presentation (AOR\u0026thinsp;=\u0026thinsp;7.59; 95% CI: 2.59\u0026ndash;22.20), comorbidity (AOR\u0026thinsp;=\u0026thinsp;7.30; 95% CI: 1.30\u0026ndash;40.94), altered mental status (AOR\u0026thinsp;=\u0026thinsp;5.75; 95% CI: 1.67\u0026ndash;19.83), delayed presentation\u0026thinsp;\u0026gt;\u0026thinsp;3 days (AOR\u0026thinsp;=\u0026thinsp;5.66; 95% CI: 2.22\u0026ndash;14.40), diarrhea complaint (AOR\u0026thinsp;=\u0026thinsp;5.99; 95% CI: 1.09\u0026ndash;39.30), presence of danger signs (AOR\u0026thinsp;=\u0026thinsp;2.06; 95% CI: 1.09\u0026ndash;3.86), and referral status (AOR\u0026thinsp;=\u0026thinsp;1.91; 95% CI: 1.05\u0026ndash;3.46).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNearly half of pediatric emergency visits required escalated care. Clinical severity indicators, malnutrition, comorbidity, and delayed presentation were strong predictors. Strengthening triage systems and early risk identification is critical to improving pediatric emergency outcomes in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Patient Profiles and Factors Associated with Escalated Care in a Southeast Ethiopian Pediatric Emergency Department: A Three-Year Retrospective Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 17:14:50","doi":"10.21203/rs.3.rs-8935922/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7546bc53-331b-49b8-a7f9-7505b3720bcd","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T18:54:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 17:14:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8935922","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8935922","identity":"rs-8935922","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}