Srinivasa Janagama

All Publications

• Utility of Prehospital Call-Center Ambulance-Dispatch Data for COVID-19 Cluster-Surveillance: A Retrospective Analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Janagama, S. R., Strehlow, M. C., Rao, R. G., Kohn, M. A., Newberry, J. A. 2022

  Abstract

  INTRODUCTION: Cluster surveillance, identification, and containment are primary outbreak management techniques, however, adapting these for low- and middle-income countries is an ongoing challenge. We aimed to evaluate the utility of prehospital call-center ambulance dispatch (CCAD) data for surveillance by examining the correlation between influenza-like illness-related (ILI) dispatch calls and COVID-19 cases.METHODS: We performed a retrospective analysis of state-level CCAD and COVID-19 data recorded between January 1 and April 30, 2020, in Telangana, India. The primary outcome was a time-series correlation between ILI calls in CCAD and COVID-19 case counts. Secondarily, we looked for a year-to-year correlation of ILI calls in the same period over 2018, 2019, and 2020.RESULTS: On average, ILI calls comprised 12.9% (95%CI: 11.7%-14.1%) of total daily calls in 2020, compared to 7.8% (95%CI: 7.6-8.0%) in 2018, and 7.7% (95%CI: 7.5-7.7%) in 2019. ILI call counts from 2018, 2019, and 2020 aligned closely until March 19, when 2020 ILI calls increased, representing 16% of all calls by March 23 and 27.5% by April 7. In contrast to the significant correlation observed between 2020 and previous years' January-February calls (2020&2019: DW=0.749, p<0.001; 2020&2018: DW=1.232, p<0.001), no correlation was observed for March-April calls (2020&19: DW=2.012, p=0.476; 2020&2018: DW=1.820, p=0.208). In March-April 2020, the daily reported COVID-19 cases by time series significantly correlated with the ILI calls (DW=0.977, p<0.001). The ILI calls on a specific day significantly correlated with the COVID-19 cases reported seven days prior and up to 14days after (cross-correlation >0.251, the 95% upper confidence limit).CONCLUSIONS: The statistically significant time-series correlation between ILI calls and COVID-19 cases suggests prehospital CCAD can be part of early warning systems aiding outbreak cluster surveillance, identification, and containment.

  View details for DOI 10.1111/acem.14612

  View details for PubMedID 36271649

• Paediatric use of emergency medical services in India: A retrospective cohort study of one million children. Journal of global health Newberry, J. A., Rao, S. J., Matheson, L., Anurudran, A. S., Acker, P., Darmstadt, G. L., Mahadevan, S. V., Rao, G. V., Strehlow, M. 2022; 12: 04080

  Abstract

  Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness.We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory.Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection.EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.

  View details for DOI 10.7189/jogh.12.04080

  View details for PubMedID 36243953

• Is AVPU comparable to GCS in critical prehospital decisions? - A cross-sectional study. The American journal of emergency medicine Janagama, S. R., Newberry, J. A., Kohn, M. A., Rao, G. V., Strehlow, M. C., Mahadevan, S. V. 2022; 59: 106-110

  Abstract

  BACKGROUND: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS.METHODS: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU.RESULTS: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable.CONCLUSION: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care.

  View details for DOI 10.1016/j.ajem.2022.06.042

  View details for PubMedID 35820277

• Acute respiratory illness among a prospective cohort of pediatric patients using emergency medical services in India: Demographic and prehospital clinical predictors of mortality. PloS one Bills, C. B., Newberry, J. A., Rao, G. V., Matheson, L. W., Rao, S. n., Mahadevan, S. V., Strehlow, M. C. 2020; 15 (4): e0230911

  Abstract

  In India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India's public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint.Pediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of "shortness of breath", or a "fever" with associated "difficulty breathing" or "cough", were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality.A total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0-28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation <95% (OR: 3.18 CI: 1.77-5.71) and respiratory distress (OR: 3.72 CI: 2.17-6.36) were the strongest predictors of mortality at 30 days.This is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population.

  View details for DOI 10.1371/journal.pone.0230911

  View details for PubMedID 32240227

• Critical Communication: A Cross-sectional Study of Signout at the Prehospital and Hospital Interface. Cureus Janagama, S. R., Strehlow, M. n., Gimkala, A. n., Rao, G. V., Matheson, L. n., Mahadevan, S. n., Newberry, J. A. 2020; 12 (2): e7114

  Abstract

  Introduction Miscommunication during patient handoff contributes to an estimated 80% of serious medical errors and, consequently, plays a key role in the estimated five million excess deaths annually from poor quality of care in low- and middle-income countries (LMICs). Objective The objective of this study was to assess signout communication during patient handoffs between prehospital personnel and hospital staff. Methods This is a cross-sectional study, with a convenience sample of 931 interfacility transfers for pregnant women across four states from November 7 to December 13, 2016. A complete signout, as defined for this study, contains all necessary signout elements for patient care exchanged verbally or in written form between an emergency medical technician (EMT) and a physician or nurse. Results Enrollment of 786 cases from 931 interfacility transfers resulted in 1572 opportunities for signout. EMTs and a physician or nurse signed out in 1549 cases (98.5%). Signout contained all elements in 135 cases (8.6%). The mean percentage of signout elements included was 45.2% (95% CI, 43.9-46.6). Physician involvement was correlated with a higher mean percent (63.4% [95% CI, 62-64.8]) compared to nurse involvement (23.6% [95% CI, 22.5-24.8]). With respect to the frequency of signout communication, 63.1% of EMTs reported often or always giving signout, and 60.5% reported often or always giving signout; they reported feeling moderately to very comfortable with signout (73.7%) and 34.1% requested further training. Conclusions Physicians, nurses, and the EMTs conducted signout 99% of the time but often fell short of including all elements required for optimal patient care. Interventions aimed at improving the quality of patient care must include strengthening signout communication.

  View details for DOI 10.7759/cureus.7114

  View details for PubMedID 32140371

  View details for PubMedCentralID PMC7047340

• A profile of traumatic injury in the prehospital setting in India: A prospective observational study across seven states. Injury Newberry, J. A., Bills, C. B., Matheson, L., Zhang, X., Gimkala, A., Ramana Rao, G. V., Janagama, S. R., Mahadevan, S. V., Strehlow, M. C. 2019

  Abstract

  BACKGROUND: Traumatic injury continues to be a leading cause of mortality and morbidity in low-income and middle-income countries (LMIC). The World Health Organization has called for a strengthening of prehospital care in order to improve outcomes from trauma. In this study we sought to profile traumatic injury seen in the prehospital setting in India and identify predictors of mortality in this patient population.METHODS: We conducted a prospective observational study of a convenience sample of patients using a single emergency medical services (EMS) system for traumatic injuries across seven states in India from November 2015 through January 2016. Any patient with a chief complaints indicative of a traumatic injury was eligible for enrollment. Our primary outcome was 30-day mortality.RESULTS: We enrolled 2905 patients. Follow-up rates were 76% at 2 days, 70% at 7 days, and 70% at 30 days. The median age was 36 years (IQR: 25-50) and were predominately male (72%, N=2088), of lower economic status (97%, N=2805 used a government issued ration card) and were from rural or tribal areas (74%, N=2162). Cumulative mortality at 2, 7, and 30 days, was 3%, 4%, and 4% respectively. Predictors of 30-day mortality were prehospital abnormal mental status (OR 7.5 (95% CI: 4-14)), presence of hypoxia or hypotension (OR 4.0 (95% CI: 2.2-7)), on-scene mobility (OR 2.8 (95% CI: 1.3-6)), and multisystem injury inclusive of head injury (OR 2.3 (95% CI: 1.1-5)).CONCLUSIONS: EMS in an LMIC can transport trauma patients from poor and rural areas that traditionally struggle to access timely trauma care to facilities in a timeframe consistent with current international recommendations. Information readily obtained by EMTs predicts 30-day mortality within this population and could be utilized for triaging patients with the potential to reduce morbidity and mortality.

  View details for DOI 10.1016/j.injury.2019.11.020

  View details for PubMedID 31761424

• Connecting Children to Emergency Care: Pediatric Utilization of the World's Largest Emergency Medical Service from 2013 to 2015 Newberry, J. A., Mahadevan, S., Matheson, L., Bills, C. B., Rao, S., Rao, R. G., Strehlow, M. C. MOSBY-ELSEVIER. 2018: S125–S126

  View details for DOI 10.1016/j.annemergmed.2018.08.324

  View details for Web of Science ID 000445690900314