Morbidity of patients in emergency situations:

Frequency: During the study period from January 1 to April 30, 2020, 10,598 patients were seen in consultation at the SAU. Among these 388 were hospitalized, representing a proportion of 3.66% hospitalization. Emergency rooms accounted for 225 patients among those hospitalized: 57.98%.

Distribution of patients according to emergency:

Emergencies accounted for 57.98% of SAU admissions through urgency and 42, 02% are not urgent ( Figure 1 ).

The age of our patients is between 0 and 15 years (minimum 0.23 months, maximum 191 months, average 47 months and standard deviation 54). Children under 5 years old represent 70.67%.

In our study, there was a male predominance with 121 boys (53.8%) and 104 girls (46.2%). Sex ratio was 1.16.

In our study, 40.3% of our patients resided in the suburbs.

Patients according to sociodemographic characteristics: Fifty percent point two percent (50.2%) of the patients came from families with an average and low socioeconomic level in 28% and satisfactory in 21.3% ( Table 1 ).

The majority of our patients (64.9%) consulted the HEAR directly without going through a health facility compared to 35.1% who were referred ( Table 2 ).

Most of our patients: 45.6% were referred by university hospitals (other pediatric services) and 32.9% by the health center ( Table 3 ).

The majority of our patients (39.24%) were referred because of the complication of their pathology, 31.65% had a diagnostic or therapeutic problem and 13.5% due to lack of places ( Table 4 ).

Forty point eight percent (40.8%) of patients were admitted between 2 p.m. and 8 p.m.; 30.6% between 8 a.m. and 2 p.m.; 17.7% between 8 p.m. and 12 a.m. and 10.9% between 12 a.m. and 8 a.m.

Only 21.00% of our patients were referred by ambulance compared to 79.00% by public transport ( Figure 2 ).

Patients according to type of transport ( Table 5 ).

A little more than half (42.2%) of the patients consulted within 24 hours following the appearance of symptoms, in 27.8% more than 24 hours and 48 hours and in 20% 48 hours later.

Nearly 80% of patients were consulted within an hour of their arrival and 55.88% within 30 minutes.

More than half of our patients (55.88%) were treated within 30 minutes of their arrival ( Table 6 ).

The main manifestations were dominated by respiratory disorders 26%, neurological 15.11%, hemato-oncological 14.67%, cardiac 14.22%, digestive 12% and infectious 7.11% ( Figure 3 ).

The duration of follow-up in the structure was dominated by the segment of less than one day: 61.70%, with extremes of 1 and 30 days, i.e. on average 2.70 days with a standard deviation of 4.14 ( Table 7 ).

More than half, 57.4% of our referred patients had received care before being referred, however, 42.6% of those referred had received nothing before their referral ( Table 8 ).

Half of our patients (50%) had received oxygen before being referred and 14.30% were infused ( Figure 4 ).

Most of the patients (30.5%) were brought directly to HEAR because of supposed better care, 26% because they had felt the urgency, 17.6%: not enough material and technical resources for their support ( Figure 5 ).

Distribution of patients according to diagnosis ( Table 9 ).

The main causes of morbidity were represented by:

Respiratory pathologies 26%, neurological 15.11%, hemato-oncological 14.67%, cardiac 14.22%, digestive 12% and infectious 7.11% ( Figure 6 ).

Most of our patients (67.1%) had received treatment upon arrival at the HEAR emergency room ( Table 10 ).

We had recorded 12 deaths, representing a lethality of 5.3% ( Table 11 ).

The majority of cases of deaths (66.67%) occurred between 24 and 48 hours, 25% of cases after 48 hours and 8.33% of cases within 24 hours ( Table 12 ).

Most of our patients (43.11%) had benefited from executives and the others transferred to the different pavilions ( Figure 7 ).

The majority of our patients (33.30%) died due to cardiac pathologies and 25.00% due to severe sepsis ( Figure 8 ).

Excess male mortality was observed in 83.3% and a statistically significant difference with P = 0.032 ( Table 13 ).

The majority of our deceased patients (91.70%) were in the age group of 1 to 59 months, a statistically significant difference with P = 0.011 ( Table 14 ).

More than half of the deceased patients (67%) had not received adequate treatment on admission but the difference is not statistically significant P = 0.06 ( Table 15 ).

The difference was statistically significant P = 0.000 ( Table 16 ).

More than half of the deceased patients (62.5%) had used public transport but the difference was not statistically significant P = 0.229 ( Table 17 ).

The vast majority of our patients (85.7%) who died had received treatment before their transfer compared to 14.3% who had received nothing. The difference was not statistically significant P = 0.112 ( Table 18 ).

Most of our deceased patients (66.7%) were referred by health structures compared to 33.3% of deceased who consulted themselves. The difference is statistically significant with P = 0.023 ( Table 19 ).

Other parents not being available, difficulty in having all the information.

Other patients did not have reference letters and sometimes they were incomplete.

Contacting reference structures by telephone is sometimes difficult given the quality of the prospective study.

Individual verbal informed consent was sought and obtained from the patient’s parents or companions before any inclusion.

Prior authorization by the head of department has been obtained.

The general consultation during our study for all HEAR was 20,062 patients. Among the 10,598 patients seen at the outpatient clinic of the HEAR Emergency Reception and Management Service, 388 patients were hospitalized, representing a hospitalization rate of 3.66%. This situation suggests that the service is very often overrun by patients presenting mainly benign pathologies relating to peripheral structures.

However, it appears from several studies that the unnecessary increase in workload is likely to alter the quality of care for patients requiring urgent and specialized care according to WHO [11] .

However, despite the low hospitalization rate (3.66%), we noted that more than half of the patients hospitalized during the period of our study were in an emergency situation (57.98%) of 388 patients, a rate similar to that found by SYLLA et al. [9] and LY Fatou [10] et al., all from Dakar, had found respectively 57% (563 patients/995 hospitalized) and 57.2% (209 patients/365 hospitalized) and DAN V. 2818 patients/184 hospitalized, i.e. 60% in Cotonou. This seems normal to us given that our service is a structure of last resort for referrals.

Age: The age of our patients is between 0 and 15 years (minimum 0.23 months, maximum 191 months, average 47 months and standard deviation 54). Children under 5 years old represent 70.67%. This predominance of children under 5 years old is found by several authors: COULIBALY B. 82.4%, AZOUMAH DK 69.3% [13] and SYLLA et al. 74% [9] . This phenomenon is naturally explained by the vulnerability of children at this age, and their sensitivity to infections (DEMBELE A) [14] .

Sex: The male gender was in the majority with 53.8%, an overall sex ratio equal to 1.16. This predominance had been noted in several previous studies: SOUNTOURA IA boys 53.5% [15] versus girls 46.5%, sex ratio of 1.15 and AIBO. IN [14] boys 56% and girls 44%, sex ratio of 1.28.

However, none of the studies were able to establish a formal link between sex and the scientifically valid reference.

Origin and residence [6] [15] : The majority of our patients came directly from home, that is to say, they consulted themselves, i.e. 64.9% compared to 35.1% of referred children. Our results are similar to those of COULIBALY B. (57.9%) and ABDOU R. O et al. (77.8%). This result is discouraging and demonstrates the population’s non-compliance with the health pyramid but also the absence of criteria for admission to the service although the overall frequency of referrals is low (35.1% of hospitalized patients). It can be improved through behavior change communication. The majority of these patients who consulted themselves, i.e. 30%, justified their consultation by supposed better care, 26% by perceived urgency, 17.6% by peripheral failure and 15.3% had already been followed at least once before. HEAR. The majority of our patients came from the suburbs of Dakar and the city of Dakar: 80% of patients resided in Dakar compared to 18.6% outside. This result is close to those of COULIBALY S. (86%) [16] S.Y. O (90%) [17] and higher than that of AIBO IN (60.4%) [16] , Contrary to popular belief, emergency cases increase with the distance that separates the patient’s home from the hospital. They come late when the child’s condition worsens. This could be explained by non-compliance with the health pyramid. Among those referred, 40.51% of our patients were referred by other pediatric services compared to 32% of health centers. The reasons for referral are: complications of their pathology 41%, and insufficient diagnosis 33.80%. This is also explained by the insufficient reception capacity in these structures and technical facilities which still remain incomplete.

Socioeconomic level of parents during our study, 49.5% of the parents of our hospitalized patients had a socio-economic level considered average. This result is similar to that of SIDIBE M. who found 45.6% in Mali [18] and LY Fatou [10] 53% patients in Senegal from families with an average socio-economic level. Contrary to what DAN V [19] had found, 99% of emergencies came from our patients who came for consultation in the first three days of progression of the disease represented 42.65%. Also to consult a hospital such as Albert Royer which is a national reference structure it also requires having a little means where the majority of patients are Dakar residents with a slightly improved standard of living than 5 years ago.

Our patients who came for consultation in the first three days of disease progression represented 42.65%. The average time taken by our patients before the consultation was 2.7 days. This study shows that the normal time and the maximum time were 1 day and 2 years respectively. Our result could be explained by its easy accessibility and by the better care assumed by those accompanying it. Ly Fatou in 2002 found around 50% of patients who had been consulted early within 24 hours. DIOUF et al. in Senegal [20] : in their series none of the patients had been consulted within 24 hours following the start of the symptoms and 66.5% of cases of pathologies had been evolving for 7 days. ABDOUL et al. in Gabon [15] : for whom 67.5% of children were brought for consultation 24 hours after the start of the symptoms. In Africa in general, delays in seeking hospital treatment are often reported. The remoteness and/or isolation of certain geographical areas that are difficult to access, transport difficulties, certain beliefs and the recourse first to traditional practitioners, partly justify the delay in consultation compared to developed countries.

The majority of our patients: 84.41% were treated within one hour of their arrival at the SAU. This result is similar to that of LY Fatou et al. [10] . This could be explained by a good organization of emergency care noted since the construction of the new buildings, the presence of TRI service, and red boxes nearby. The shorter the treatment time, the better the quality of patient care, as in the case of our study.

In our series, 57.4% of our referred patients had received care before being referred, however, 42.6% of the referred patients received nothing before their transfer. We found that 21.50% of patients were referred by ambulance compared to 78.50% by public transport. On the other hand, in Benin AKODJENOU J [21] et al. had found the motorcycle taxi (commonly called Zémidjan in Benin), as the most used means of transport in their study in 71.72% of cases followed by 24.18% by personal vehicle. 96% of referred children did not have medical assistance during their transfer. Only 1.63% were transferred by ambulance. These results are low compared to those of SIDIKI B. GUINDO in Burkina-Faso [22] which found 69.3% of patients transferred by ambulance and 19.80% benefiting from medical assistance during their transfer. This is explained by the patient transport system, set up in Bobo-Dioulasso (Burkina-Faso), from peripheral maternity wards to the hospital, and which works thanks to Burkina relief and/or the firefighters who crisscross the area. City 24 hours a day, a system that does not exist in Abomey-Calavi/Sô-Ava (AKODJENOU and GREGOIRE) [21] . Furthermore, these data are more or less similar to those of SYLLA [9] (28%) and GUEYE (36%). On the other hand, in developed countries, the ambulance is used in 80 to 92% of emergency cases, and in 50% to 60% of these cases are medically justified (LY Fatou). This low rate of ambulance use could be explained by the origin of emergency consultants who in 64.9% came from home.

The time taken to make the decision to transfer a patient was more than one hour in 61.70% of cases. Much higher than that of NDIAYE O. et al.: 35.90% [8] . Our result can be explained by the fact that most of our patients were referred by other pediatric structures which, after treatment, refer the patients due to insufficient technical facilities. The sooner the patient is referred, the more likely he or she will recover quickly in the reception structure.

In our series, the main causes of morbidity were respiratory pathologies (26%), followed by neurological (15.11%), hematological (14.67%), cardiac (14.22%), digestive (12%) and infectious. (7.11%) and others. Respiratory conditions occupy first place with 26.22%, and our result is similar to that of Coulibaly A. and the same constant was made by CAMARA B. DIOUF et al. Who had noticed that the Respiratory pathologies are dominated by bronchiolitis and asthma attacks which are usually most frequent during the hot and humid season of the year which corresponds to the period of our study. Children who are often away from home due to heat and crowding are more exposed to pneumallergens. For Dr Sanou Dieng Mbaye, “Senegal records 27,000 child deaths per year, including 73 deaths per day. Most deaths are preventable and 12% of deaths are due to pneumonia. Neurological conditions:15.11% occupy second place, contrary to what others found that digestive conditions occupied second place. ATANDA HL et al. [4] found neurological emergencies in the lead with 52%, followed by respiratory emergencies 21.5% then hematological 12.7% and gastroenteritis 11.5% of cases in black point 1994. Hematological conditions: 14.67%, dominated by conditions linked to sickle cell anemia and anemia. Heart diseases occupy 4th place, marked by decompensated non-cyanogenic congenital heart diseases, anoxic discomfort and rheumatic heart disease. Infectious causes: 7.11%, dominated by malaria and severe sepsis.

Among the 225 hospitalized patients, we recorded 12 deaths. The mortality rate was 5.30%. This mortality rate is lower than that of NDIAYE O. et al. in 2002 in HEAR had found a fatality rate of 26.1% and COULIBALY B. [11] in 2006 on 381 hospitalized; 74 deaths or a mortality rate of 19.4% - this rate is similar to that of OUNOGO MS (417 hospitalized patients, 19 cases of deaths or 4.55%) [23] . The HEAR improves the quality of care on a daily basis in order to meet the objectives of the WHO and SDG (3.2 by 2030). But this rate remains even higher than that of GHORBAL FS in Tunis, 2.4% [24] .

1) Sex The proportion of boys who died (83.3%) was higher than that of girls (16.7%). Confirming the excess male mortality reported by several authors: AIBO and SYLLA et al. without a scientifically valid reason. This difference observed in mortality based on sex was significant with P = 0.032.

2) Age We noted high mortality among children aged 1 to 59 months with a mortality rate of 91.7%, newborn 8.3%, and no deaths beyond 59 months were recorded. This high excess mortality in this class age could be explained by their vulnerability to complications of infectious and nutritional pathologies. And no death beyond 59 months. This confirms the WHO report which shows significant progress in improving care for this age group due to the reduction in infectious diseases.

Half of our deceased patients (58.3%) had not received the medications adapted to their emergency upon admission to the SAU compared to (42.7%). However the difference was not statistically significant P = 0.06. Our results could be explained by the fact that the hospital pharmacy does not have all kinds of essential resuscitation drugs and sometimes experiences stock shortages. The other fact is that the HEAR does not have permanent blood stocks, ward boys must go to the National Blood Transfusion Center (CNTS) to obtain blood. Our results are different from those of COULIBALY B. (18.85%) [5] .

The majority of our deceased patients came from families with a low socio-economic level (83.3%), medium (16.7%) and no cases of death observed in families with a high socio-economic level. The difference was statistically significant P = 0.000. GHORBAL in Tunis reported that the mortality rate among children experiences an evolution proportionally inverse to the socio-economic level. Low socio-economic level among parents and residence in a rural area are the main risk factors for pediatric mortality throughout the world according to several authors (Fengming Chao et al.).

The majority of our patients died between 24 hours and 48 hours followed by 25% after 48 hours and 8.33% before 24 hours. This excess mortality before between 24 and 48 hours could be explained by the delay in transfer or delay in the detection of signs of seriousness by the patients’ parents and diagnostic problems on admission. The result is contrary to that of DIACK, in 2017 in Dakar which showed that many deaths occurred between 3 and 7 days (52.1%); KOUETA et al. [25] duration of 1.6 days and GHORBAR a longer duration of 6 days [24] .

The majority of our patients died following cardiac pathologies 33.30%, followed by septic shock 25.00%.

The cost of cardiovascular surgery makes better care impossible, leading to complications and death. Recommendation for finding partners to cover intervention costs.