Defining quality indicators for emergency care delivery: findings of an expert consensus process by emergency care practitioners in Africa

Facility-based emergency care delivery in low-income and middle- income countries is expanding rapidly, particularly in Africa. Unfortunately, these efforts rarely include measurement of the quality or the impact of care provided, which is essential for improvement of care provision. Our aim was to determine context-appropriate quality indicators that will allow uniform and objective data collection to enhance emergency care delivery throughout Africa. We undertook a multiphase expert consensus process to identify, rank and refine quality indicators. A comprehensive review of the literature identified existing indicators; those associated with a substantial burden of disease in Africa were categorised and presented to consensus conference delegates. Participants selected indicators based on inclusion criteria and priority clinical conditions. The indicators were then presented to a group of expert clinicians via on-line survey; all meeting agreements were refined in-person by a separate panel and ranked according to validity, feasibility and value. The consensus working group selected seven conditions addressing nearly 75% of mortality in the African region to prioritise during indicator development, and the final product at the end of the multiphase study was a list of 76 indicators. This comprehensive process produced a robust set of quality indicators for emergency care that are appropriate for use in the African setting. The adaptation of a standardised set of indicators will enhance the quality of care provided and allow for comparison of system strengthening efforts and resource distribution.

Developing prehospital clinical practice guidelines for resource limited settings: why re-invent the wheel?

OBJECTIVES

Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, the volume of literature is not matched by research into alternative methods of CPG development using existing CPG documents-a specific issue for guideline development groups in low- and middle-income countries. We report on how we developed a context specific prehospital CPG using an alternative guideline development method. Difficulties experienced and lessons learnt in applying existing global guidelines' recommendations to a national context are highlighted.

RESULTS

The project produced the first emergency care CPG for prehospital providers in Africa. It included > 270 CPGs and produced over 1000 recommendations for prehospital emergency care. We encountered various difficulties, including (1) applicability issues: few pre-hospital CPGs applicable to Africa, (2) evidence synthesis: heterogeneous levels of evidence classifications and (3) guideline quality. Learning points included (1) focusing on key CPGs and evidence mapping, (2) searching other resources for CPGs, (3) broad representation on CPG advisory boards and (4) transparency and knowledge translation. Re-inventing the wheel to produce CPGs is not always feasible. We hope this paper will encourage further projects to use existing CPGs in developing guidance to improve patient care in resource-limited settings.

Adapting the emergency first aid responder course for Zambia through curriculum mapping and blueprinting

OBJECTIVES

Community members are often the first to witness and respond to medical and traumatic emergencies, making them an essential first link to emergency care systems. The Emergency First Aid Responder (EFAR) programme is short course originally developed to help South Africans manage emergencies at the community level, pending arrival of formal care providers. EFAR was implemented in two rural regions of Zambia in 2015, but no changes were originally made to tailor the course to the new setting. We undertook this study to identify potential refinements in the original EFAR curriculum, and to adapt it to the local context in Zambia.

DESIGN

The EFAR curriculum was mapped against available chief complaint data. An expert group used information from the map, in tandem with personal knowledge, to rank each course topic for potential impact on patient outcomes and frequency of use in practice. Individual blueprints were compiled to generate a refined EFAR curriculum, the time breakdown of which reflects the relative weight of each topic.

SETTING

This study was conducted based on data collected in Kasama, a rural region of Zambia's Northern Province.

PARTICIPANTS

An expert group of five physicians practising emergency medicine was selected; all reviewers have expertise in the Zambian context, EFAR programme and/or curriculum development.

RESULTS

The range of emergencies that Zambian EFARs encounter indicates that the course must be broad in scope. The refined curriculum covers 54 topics (seven new) and 25 practical skills (five new). Practical and didactic time devoted to general patient care and scene management increased significantly, while time devoted to most other clinical, presentation-based categories (eg, trauma care) decreased.

CONCLUSIONS

Discrepancies between original and refined curricula highlight a mismatch between the external curriculum and local context. Even with limited data and resources, curriculum mapping and blueprinting are possible means of resolving these contextual issues.

Operational demands on pre-hospital emergency care for burn injuries in a middle-income setting: a study in the Western Cape, South Africa

BACKGROUND

Burns occur disproportionately within low-socioeconomic populations. The Western Cape Province of South Africa represents a middle-income setting with a high rate of burns, few specialists and few burn centres, yet a well-developed pre-hospital system. This paper describes the burn cases from a viewpoint of operational factors important to pre-hospital emergency medical services.

METHODS

A retrospective, cross-sectional study of administrative and patient records was conducted. Data were captured for all pre-hospital burn patients treated by public Emergency Medical Services over a continuous 12-month period. Data were captured separately at each site using a standardised data collection tool. Described categories included location (rural or urban), transport decision (transported or remained on scene), age (child or adult) and urgency (triage colour).

RESULTS

EMS treated 1198 patients with confirmed burns representing 0.6% of the total EMS caseload; an additional 819 potential burn cases could not be confirmed. Of the confirmed cases, 625 (52.2%) were located outside the City of Cape Town and 1058 (88.3%) were transported to a medical facility. Patients from urban areas had longer mission times. Children accounted for 37.5% (n = 449) of all burns. The majority of transported patients that were triaged were yellow (n = 238, 41.6% rural and n = 182, 37.4% urban).

CONCLUSIONS

Burns make up a small portion of the EMS caseload. More burns occurred in areas far from urban hospitals and burn centres. The majority of burn cases met the burn centre referral criteria.

Major incident triage and the implementation of a new triage tool, the MPTT-24

Introduction

The Modified Physiological Triage Tool (MPTT) is a recently developed primary triage tool and in comparison with existing tools demonstrates the greatest sensitivity at predicting need for life-saving intervention (LSI) within both military and civilian populations. To improve its applicability, we proposed to increase the upper respiratory rate (RR) threshold to 24 breaths per minute (bpm) to produce the MPTT-24. Our aim was to conduct a feasibility analysis of the proposed MPTT-24, comparing its performance with the existing UK Military Sieve.

Method

A retrospective review of the Joint Theatre Trauma Registry (JTTR) and Trauma Audit Research Network (TARN) databases was performed for all adult (>18 years) patients presenting between 2006–2013 (JTTR) and 2014 (TARN). Patients were defined as priority one (P1) if they received one or more LSIs. Using first recorded hospital RR in isolation, sensitivity and specificity of the ≥24 bpm threshold was compared with the existing threshold (≥22 bpm) at predicting P1 status. Patients were then categorised as P1 or not-P1 by the MPTT, MPTT-24 and the UK Military Sieve.

Results

The MPTT and MPTT-24 outperformed existing UK methods of triage with a statistically significant (p<0.001) increase in sensitivity of between 25.5% and 29.5%. In both populations, the MPTT-24 demonstrated an absolute reduction in sensitivity with an increase in specificity when compared with the MPTT. A statistically significant difference was observed between the MPTT and MPTT-24 in the way they categorised TARN and JTTR cases as P1 (p<0.001).

Conclusions

When compared with the existing MPTT, the MPTT-24 allows for a more rapid triage assessment. Both continue to outperform existing methods of primary major incident triage and within the military setting, the slight increase in undertriage is offset by a reduction in overtriage. We recommend that the MPTT-24 be considered as a replacement to the existing UK Military Sieve.

Trauma burden in Tanzania: a one-day survey of all district and regional public hospitals

Background

Trauma contributes significantly to the burden of disease and mortality throughout the world, but particularly in developing countries. In Tanzania, there is an enormous research gap on trauma; the limited data available reflects realities in cities and areas with moderately- to highly-resourced treatment centers. Our aim was to provide a description of the injury epidemiology across all of Tanzania. Our data will serve as a basis for future larger studies.

Methods

This is a subgroup analysis of a cross-sectional, prospective study of the clinical epidemiology of patients presenting at all public district and regional hospitals in Tanzania. The study was conducted between May 2012 and December 2012. A team of emergency doctors used a purpose-designed data collection sheet to gather the demographic and clinical information of all patients presenting during the day-site visit to each hospital. Descriptive statistics, including means, standard deviations, medians, and ranges are reported.

Results

A total of 5227 patients were seen in 24-h period in 105 (100% response rate) district (or designated district) and regional hospitals in mainland Tanzania. Of these patients, 508 (9.7%) presented with trauma-related complaints. Among patients with trauma-related complaints, 286 (56.3%) were male, and the overall median age of 30 (interquartile range of 22–35) years. Road traffic crash was the most common mechanism of injury, accounting for 227 (44.7%) complaints. Open wounds and bone fractures were the two most frequent diagnoses, with a combined 300 (59%) cases. Most of the patients - 325 (64%) - were discharged, 11 (2.2%) went to operating theatres and 4 (0.8%) of patients died while receiving care at the acute intake areas.

Conclusions

Trauma-related complaints constitute a substantial burden among patients seeking care in acute intake areas of hospitals across Tanzania. There is a need to develop, implement and study systems that can support the improvement of trauma care and optimize outcomes of trauma patients.

SCREEN: A simple layperson administered screening algorithm in low resource international settings significantly reduces waiting time for critically ill children in primary healthcare clinics

BACKGROUND

In low resource settings, an inadequate number of trained healthcare workers and high volumes of children presenting to Primary Healthcare Centers (PHC) result in prolonged waiting times and significant delays in identifying and evaluating critically ill children. The Sick Children Require Emergency Evaluation Now (SCREEN) program, a simple six-question screening algorithm administered by lay healthcare workers, was developed in 2014 to rapidly identify critically ill children and to expedite their care at the point of entry into a clinic. We sought to determine the impact of SCREEN on waiting times for critically ill children post real world implementation in Cape Town, South Africa.

METHODS AND FINDINGS

This is a prospective, observational implementation-effectiveness hybrid study that sought to determine: (1) the impact of SCREEN implementation on waiting times as a primary outcome measure, and (2) the effectiveness of the SCREEN tool in accurately identifying critically ill children when utilised by the QM and adherence by the QM to the SCREEN algorithm as secondary outcome measures. The study was conducted in two phases, Phase I control (pre-SCREEN implementation- three months in 2014) and Phase II (post-SCREEN implementation-two distinct three month periods in 2016). In Phase I, 1600 (92.38%) of 1732 children presenting to 4 clinics, had sufficient data for analysis and comprised the control sample. In Phase II, all 3383 of the children presenting to the 26 clinics during the sampling time frame had sufficient data for analysis. The proportion of critically ill children who saw a professional nurse within 10 minutes increased tenfold from 6.4% to 64% (Phase I to Phase II) with the median time to seeing a professional nurse reduced from 100.3 minutes to 4.9 minutes, (p < .001, respectively). Overall layperson screening compared to Integrated Management of Childhood Illnesses (IMCI) designation by a nurse had a sensitivity of 94.2% and a specificity of 88.1%, despite large variance in adherence to the SCREEN algorithm across clinics.

CONCLUSIONS

The SCREEN program when implemented in a real-world setting can significantly reduce waiting times for critically ill children in PHCs, however further work is required to improve the implementation of this innovative program.

Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

BACKGROUND

Triage is a key principle in the effective management at a major incident. There are at least three different triage systems in use worldwide and previous attempts to validate them, have revealed limited sensitivity. Within a civilian adult population, there has been no work to develop an improved system.

METHODS

A retrospective database review of the UK Joint Theatre Trauma Registry was performed for all adult patients (>18years) presenting to a deployed Military Treatment Facility between 2006 and 2013. Patients were defined as Priority One if they had received one or more life-saving interventions from a previously defined list. Using first recorded hospital physiological data (HR/RR/GCS), binary logistic regression models were used to derive optimum physiological ranges to predict need for life-saving intervention. This allowed for the derivation of the Modified Physiological Triage Tool-MPTT (GCS≥14, HR≥100, 12<RR≥22). A comparison of the MPTT and existing triage tools was then performed using sensitivities and specificities with 95% confidence intervals. Differences in performance were assessed for statistical significance using a McNemar test with Bonferroni correction.

RESULTS

Of 6095 patients, 3654 (60.0%) had complete data and were included in the study, with 1738 (47.6%) identified as priority one. Existing triage tools had a maximum sensitivity of 50.9% (Modified Military Sieve) and specificity of 98.4% (Careflight). The MPTT (sensitivity 69.9%, 95% CI 0.677-0.720, specificity 65.3%, 95% CI 0.632-0.675) showed an absolute increase in sensitivity over existing tools ranging from 19.0% (Modified Military Sieve) to 45.1% (Triage Sieve). There was a statistically significant difference between the performance (p<0.001) between the MPTT and the Modified Military Sieve.

DISCUSSION & CONCLUSION

The performance characteristics of the MPTT exceed existing major incident triage systems, whilst maintaining an appropriate rate of over-triage and minimising under-triage within the context of predicting the need for a life-saving intervention in a military setting. Further work is required to both prospectively validate this system and to identify its performance within a civilian environment, prior to recommending its use in the major incident setting.

Outcomes by Mode of Transport of ST Elevation MI Patients in the United Arab Emirates

INTRODUCTION

The purpose of this multicenter study was to assess differences in demographics, medical history, treatment times, and follow-up status among patients with ST-elevation myocardial infarction (STEMI), who were transported to the hospital by emergency medical services (EMS) or by private vehicle, or were transferred from other medical facilities.

METHODS

This multicenter study involved the collection of both retrospective and prospective data from 455 patients admitted to four hospitals in Abu Dhabi. We collected electronic medical records from EMS and hospitals, and conducted interviews with patients in person or via telephone. Chi-square tests and Kruskal-Wallis tests were used to examine differences in variables by mode of transportation.

RESULTS

Results indicated significant differences in modes of transportation when considering symptom-onset-to-balloon time (p < 0.001), door-to-balloon time (p < 0.001), and health status at six-month and one-year follow-up (p < 0.001). Median times (interquartile range) for patients transported by EMS, private vehicle, or transferred from an outside facility were as follows: symptom-onset-to-balloon time in hours, 3.1 (1.8-4.3), 3.2 (2.1-5.3), and 4.5 (3.0-7.5), respectively; door-to-balloon time in minutes, 70 (48-78), 81 (64-105), and 62 (46-77), respectively. In all cases, EMS transportation was associated with a shorter time to treatment than other modes of transportation. However, the EMS group experienced greater rates of in-hospital events, including cardiac arrest and mortality, than the private transport group.

CONCLUSION

Our results contribute data supporting EMS transportation for patients with acute coronary syndrome. Although a lack of follow-up data made it difficult to draw conclusions about long-term outcomes, our findings clearly indicate that EMS transportation can speed time to treatment, including time to balloon inflation, potentially reducing readmission and adverse events. We conclude that future efforts should focus on encouraging the use of EMS and improving transfer practices. Such efforts could improve outcomes for patients presenting with STEMI.

Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident

INTRODUCTION

Triage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident.

METHODS

We conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%.

RESULTS

24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus.

CONCLUSIONS

This study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool.

Community-based perceptions of emergency care in Zambian communities lacking formalised emergency medicine systems

BACKGROUND

In Zambia, an increasing burden of acute illness and injury emphasised the necessity of strengthening the national emergency care system.

OBJECTIVE

The objective of this study was to identify critical interventions necessary to improve the Zambian emergency care system by determining the current pattern of emergency care delivery as experienced by members of the community, identifying the barriers faced when trying to access emergency care and gathering community-generated solutions to improve emergency care in their setting.

METHODS

We used a qualitative research methodology to conduct focus groups with community members and healthcare providers in three Zambian provinces. Twenty-one community focus groups with 183 total participants were conducted overall, split equally between the provinces. An additional six focus groups were conducted with Zambian healthcare providers. Data were coded, aggregated and analysed using the content analysis approach.

RESULTS

Community members in Zambia experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Community-identified and provider-identified barriers to emergency care included transportation, healthcare provider deficiencies, lack of community knowledge, the national referral system and police protocols.

CONCLUSIONS

Creating community education initiatives, strengthening the formal prehospital emergency care system, implementing triage in healthcare facilities and training healthcare providers in emergency care were community-identified and provider-identified solutions for improving access to emergency care.

Professional needs of young Emergency Medicine specialists in Africa: Results of a South Africa, Ethiopia, Tanzania, and Ghana survey

INTRODUCTION

Emergency Medicine (EM) residency programmes are new to Africa and exist in only a handful of countries. There has been no follow up on faculty development needs nor training of these graduates since they completed their programmes. The African Federation for Emergency Medicine (AFEM) aims to explore the needs of recent EM graduates with respect to the need for resources, mentorship, and teaching in order to develop a focused African faculty development intervention.

METHODS

As part of the AFEM annual survey, all those who have graduated since 2012 from a Sub-Saharan African EM residency programme were approached. These included Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, Addis Ababa University (AAU) in Ethiopia, Komfo Anokye Teaching Hospital (KATH) in Ghana, the University of Cape Town (UCT) in South Africa, the University of Pretoria (UP) in South Africa, the University of Witswatersrand (Wits) in South Africa, and the University of KwaZulu-Natal (UKZN) in South Africa.

RESULTS

The 47 respondents rated themselves as most confident medical experts in knowledge, procedural skills, and communication. Overall graduates felt least equipped as scholars and managers, and requested more educational materials. They reported that the best way for AFEM to support them is through emergency care advocacy and support for their advocacy activities and that their most critical development need is for leadership development, including providing training materials.

CONCLUSION

Recent graduates report that the best ways for AFEM to help new EM graduates is to continue advocacy programmes and the development of leadership and mentorship programmes. However, there is also a demand from these graduates for educational materials, especially online.

Utilizations and Perceptions of Emergency Medical Services by Patients with ST-Segments Elevation Acute Myocardial Infarction in Abu Dhabi: A Multicenter Study

BACKGROUND

Data on the use of emergency medical services (EMS) by patients with cardiac conditions in the Gulf region are scarce, and prior studies have suggested underutilization. Patient perception and knowledge of EMS care is critical to proper utilization of such services.

OBJECTIVES

To estimate utilization, knowledge, and perceptions of EMS among patients with ST-elevation myocardial infarction (STEMI) in the Emirate of Abu Dhabi.

METHODS

We conducted a multicenter prospective study of consecutive patients admitted with STEMI in four government-operated hospitals in Abu Dhabi. Semi-structured interviews were conducted with patients to assess the rationale for choosing their prehospital mode of transport and their knowledge of EMS services.

RESULTS

Of 587 patients with STEMI (age 51 ± 11 years, male 95%), only 15% presented through EMS, and the remainder came via private transport. Over half of the participants (55%) stated that they did not know the telephone number for EMS. The most common reasons stated for not using EMS were that private transport was quicker (40%) or easier (11%). A small percentage of participants (7%) did not use EMS because they did not think their symptoms were cardiac-related or warranted an EMS call. Stated reasons for not using EMS did not significantly differ by age, gender, or primary language of the patients.

CONCLUSIONS

EMS care for STEMI is grossly underutilized in Abu Dhabi. Patient knowledge and perceptions may contribute to underutilization, and public education efforts are needed to raise their perception and knowledge of EMS.

Caregivers' Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation

PURPOSE

Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement.

METHODS

Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison.

RESULTS

Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism.

CONCLUSIONS

Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.

Electronic Medical Records in low to middle income countries: The case of Khayelitsha Hospital, South Africa

INTRODUCTION

Electronic Medical Records (EMRs) have shown benefit for clinical, organisational, and societal outcomes. In low-to-middle-income countries, the desire for EMRs will continue to rise as increasing trauma and infectious disease rates necessitate adequate record keeping for effective follow-up. 114 nations are currently working on national EMRs, with some using both a full EMR (Clinicom) and a paper-based system scanned to an online Enterprise Content Management (ECM) database.

METHODS

The authors sought to evaluate the ability and completeness of the EMR at Khayelitsha Hospital (KH) to capture all Emergency Centre (EC) encounters classified as trauma. Based on the high trauma rates in the Khayelitsha area and equally high referral rates from KH to higher-level trauma centres, an assumption was made that its rates would mirror nationwide estimates of 40% of EC visits. Records from July 2012 to June 2013 were examined.

RESULTS

3488 patients visited the EC in the month of July 2012. 10% were noted as trauma on Clinicom and within their records were multiple sections with missing information. The remaining months of Aug 2012-June 2013 had an average trauma load of 8%. On further investigation, stacks of un-scanned patient folders were identified in the records department, contributing to the unavailability of records from January 2013 to the time of study (June 2013) on ECM.

CONCLUSION

The results highlight difficulties with implementing a dual record system, as neither the full EMR nor ECM was able to accurately capture the estimated trauma load. Hospitals looking to employ such a system should ensure that sufficient funds are in place for adequate support, from supervision and training of staff to investment in infrastructure for efficient transfer of information. In the long run, efforts should be made to convert to a complete EMR to avoid the many pitfalls associated with handling paper records.

Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi

Introduction

Physician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi.

Objectives

To describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi.

Methods

We surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS.

Results

Of 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10 years. Less than half of the responders (42%) were “Somewhat Satisfied” (35%) or “Very Satisfied” (7%) with current EMS level of care for STEMI patients. Most respondents were “Very Likely” (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. “Strongly Agree”) of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties.

Conclusions

Most physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.

Perceptions of emergency care in Kenyan communities lacking access to formalised emergency medical systems: a qualitative study

OBJECTIVES

We undertook this study in Kenya to understand the community's emergency care needs and barriers they face when trying to access care, and to seek community members' thoughts regarding high impact solutions to expand access to essential emergency services.

DESIGN

We used a qualitative research methodology to conduct 59 focus groups with 528 total Kenyan community member participants. Data were coded, aggregated and analysed using the content analysis approach.

SETTING

Participants were uniformly selected from all eight of the historical Kenyan provinces (Central, Coast, Eastern, Nairobi, North Eastern, Nyanza, Rift Valley and Western), with equal rural and urban community representation.

RESULTS

Socioeconomic and cultural factors play a major role both in seeking and reaching emergency care. Community members in Kenya experience a wide range of medical emergencies, and seem to understand their time-critical nature. They rely on one another for assistance in the face of substantial barriers to care-a lack of: system structure, resources, transportation, trained healthcare providers and initial care at the scene.

CONCLUSIONS

Access to emergency care in Kenya can be improved by encouraging recognition and initial treatment of emergent illness in the community, strengthening the pre-hospital care system, improving emergency care delivery at health facilities and creating new policies at a national level. These community-generated solutions likely have a wider applicability in the region.

Applying the lessons of maternal mortality reduction to global emergency health

Over the last few decades, maternal health has been a major focus of the international community and this has resulted in a substantial decrease in maternal mortality globally. Although, compared with maternal illness, medical and surgical emergencies account for far more morbidity and mortality, there has been less focus on global efforts to improve comprehensive emergency systems. The thoughtful and specific application of the concepts used in the effort to decrease maternal mortality could lead to major improvements in global emergency health services. The so-called three-delay model that was developed for maternal mortality can be adapted to emergency service delivery. Adaptation of evaluation frameworks to include emergency sentinel conditions could allow effective monitoring of emergency facilities and further policy development. Future global emergency health efforts may benefit from incorporating strategies for the planning and evaluation of high-impact interventions.

Emergency care in 59 low- and middle-income countries: a systematic review

Objective

To conduct a systematic review of emergency care in low- and middle-income countries (LMICs).

Methods

We searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards.

Findings

We identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2–5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3–8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5–6.3%). The median number of patients was 30 000 per year (IQR: 10 296–60 000), most of whom were young (median age: 35 years; IQR: 6.9–41.0) and male (median: 55.7%; IQR: 50.0–59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care.

Conclusion

Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.