Human resources for emergency care systems in Ethiopia: Challenges and triumphs

Developing emergency medical care policy across Kenya: A framework for policy development

Background and objectives

The Kenya Emergency Medical Care (EMC) Policy 2020-2030 was created to guide the advancement of EMC throughout Kenya. This report describes and maps the ongoing EMC policy development process across Kenya's 47 counties, serving as a real-world example of EMC policy development within a decentralized healthcare system in a low-or middle-income country (LMIC).

Methods

This report evaluates the development of county-specific EMC policies using the Kenya Institute for Public Policy Research and Analysis (KIPPRA) six stages for policy development: 1) problem identification, 2) agenda setting, 3) policy design, 4) approval, 5) implementation, and 6) monitoring and evaluation. Meeting minutes, workshop proceedings, and draft and final EMC policy documents were used to analyze the policy development process and provide a snapshot of current EMC policy statuses by county.

Results

As of August 2024, 23 counties have engaged in EMC policy development. Thirteen have finalized and are implementing their EMC policies, while 10 await approval. The remaining 24 counties are still in the planning stages. This process included gathering baseline emergency medical care standards to identify areas for improvement in each county. A core vision, mission, and goal aligned with the national policy were established and tailored to the county's needs. County-specific strategies were developed to address gaps between the existing system and national objectives. EMC policies were drafted, collaboratively reviewed, revised, and finalized before official approval. The next steps will be implementation, monitoring, and evaluation. Growth and improvement will be measured post-implementation based on baseline EMC metrics.

Conclusion

Kenya's strategy for EMC policy development across the 47 counties, utilizing KIPPRA's guidelines for public policy formulation, established a structured approach that included engaging stakeholders, conducting situational analyses, and aligning policy objectives with national goals. It is a comprehensive example of developing EMC policies for LMICs within decentralized healthcare systems.

Incidence and predictors of mortality among patients admitted to adult intensive care unit at public hospitals in Western Ethiopia: a retrospective cohort study

Introduction

In resource-constrained countries, the incidence of mortality among patients admitted to adult intensive care units is higher than that in developed countries, which has a physical, economic, and emotional impact on the lives of patients and their families. However, there is limited evidence on factors related to nursing care that can potentially contribute to predicting and reducing mortality rates in intensive care units. Therefore, this study aimed to assess the incidence of mortality and its predictors in patients admitted to an adult intensive care unit.

Methods

A retrospective cohort study was conducted among 403 patients admitted to the adult intensive care unit from 1 January 2021 to 31 December 2021. The collected data were entered into Epi Data Manager v4.6.0.6 and exported to SPSS version 24 for analysis. Binary logistic regression was used to identify the predictors of mortality. Variables with a p-value less than 0.25 in bivariable logistic regression were selected for multivariable logistic regression. A p-value <0.05 was used to indicate a significant association in multivariable analysis. Finally, the adjusted relative risk (RR) with 95% CI was calculated.

Results

A total of 403 patients were included in the analysis. The cumulative incidence of death was 40.9% (95% CI 36, 45.9%). Mortality was significantly associated with the need for mechanical ventilation (adjusted RR = 1.45; 95% CI: 1.04, 1.85), the Glasgow Coma Scale score < 8 (adjusted RR, 3.52; 95% CI: 2.90, 4.05), presence of comorbidity (adjusted RR, 1.47; 95% CI: 1.09, 1.83), length of stay in ICU < 24 h (adjusted RR, 1.84; 95% CI: 1.37, 2.04), oxygen saturation level, and Feeding, Analgesia, Sedation, Thrombosis prophylaxis, Head elevation, Ulcer prophylaxis, and Glucose control (FASTHUG) treatment received were significantly associated with mortality.

Conclusion

The study found a high incidence proportion of death. The need for mechanical ventilation, length of stay, comorbidity, and the Glasgow Coma Scale score were significantly associated with mortality. Therefore, close monitoring and evaluation of patients are essential to improve treatment outcomes.

Prolonged length of stay and associated factors among emergency department patients in Ethiopia: systematic review and meta-analysis

BACKGROUND

The duration between a patient's arrival at the Emergency Department (ED) and their actual departure, known as the Emergency Department Length of Stay (EDLOS), can have significant implications for a patient's health. In Ethiopia, various studies have investigated EDLOS, but a comprehensive nationwide pooled prevalence of prolonged EDLOS, which varies across different locations, is currently lacking. Therefore, the objective of this systematic review and meta-analysis is to provide nationally representative pooled prevalence of prolonged EDLOS and identify associated factors.

METHODS

In this study, we conducted a comprehensive systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. We conducted a thorough search of numerous international databases, including PubMed/Medline, SCOPUS, Web of Science, and Google Scholar. The primary outcome was the prevalence of prolonged EDLOS. The secondary outcome was factors affecting the EDLOS. Random-effects model was used to since there was high heterogeneity. We also conducted subgroup analysis and meta-regression to investigate heterogeneity within the included studies. To assess publication bias, we used Egger's regression test and funnel plots. All statistical analyses were performed using STATA version 17.0 software to ensure accurate and reliable findings.

RESULT

We have identified eight articles that met our inclusion criteria with a total sample size of 8,612 participants. The findings of this systematic review and meta-analysis indicate that the pooled estimate for the prevalence of prolonged EDLOS is 63.67% (95% CI = 45.18, 82.16, I2 = 99.56%, P = 0.0001). The study identified several significant factors associated with prolonged EDLOS, including patients admitted to overcrowded emergency departments (OR = 5.25, 95% CI = 1.77, 15.58), delays in receiving laboratory findings (OR = 3.12, 95% CI = 2.16, 4.49), and delays in receiving radiological results (OR = 3.00, 95% CI = 2.16, 4.16).

CONCLUSION

In this review, the EDLOS was found to be very high. Overcrowding, delays in laboratory test findings, and delays in radiology test results make up the factors that have a statistically significant association with prolonged EDLOS. Given the high prevalence of prolonged EDLOS in this review, stakeholders should work to increase the timeliness of ED services in Ethiopia by proper disposition of non-emergency palliative patients to the appropriate destination, and implementing point-of-care testing and imaging.

Mapping the evidence of emergency nursing research in who Afro-region states: A Scoping Review

Introduction

The introduction of emergency nursing in Africa has resulted in the establishment of several training schools across the continent. This has translated into a growing body of emergency care research being carried out by nurses; however, the breadth and extent of evidence remains unclear. The aim of the review was to map and collate the available literature on emergency nursing research in WHO Afro-region states.

Methods

The review adopted the methodology of the Joanna Briggs Institute (JBI) scoping reviews. The review protocol was registered on 27 June 2022 (osf.io/5wz3x). The Population (nurse), Concept (emergency nursing research), Context (WHO Afro-region) (PCC) elements guided the development of the inclusion and exclusion criteria. Papers were searched across seven electronic data bases and two search engines using a three-search strategy. The screening was performed initially on the abstract and title and lastly on full text. The reporting for the review was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

Results

One hundred and thirteen papers were included in the review. Publication of emergency nursing research occurred from 2000 to 2022. The year 2017 and 2019 recorded the highest number of publications (n = 14). The country with the most publications was South Africa (n=50). Emergency nursing research used predominantly quantitative methodologies (n=58). The professional groups involved in research were nurses (n=69) as well as nurses and doctors (n=26). The identified papers focused primarily on emergency nursing education (n=23) and epidemiology (n=24).

Conclusion

There is a notable increase in the number of publications on emergency nursing research in WHO Afro-region states, however from only 11 countries. Since most of the research is still at descriptive level, there is need to encourage emergency nursing research on interventions and measuring outcomes and impact in the emergency care system.

Injury characteristics and mortality in an emergency department in Ethiopia: a single-center observational study

INTRODUCTION

An injury is described as any damage to the body that impairs health, and its severity can span from mild to life-threatening. On a global scale, injuries account for approximately 4.4 million deaths annually and are anticipated to become the seventh leading cause of death by 2030. In Ethiopia, injuries account for 7% of all deaths, with one of the world's highest rates of road traffic injuries. This study, undertaken at a primary trauma centre in the capital of Ethiopia, aimed to explore the characteristics of injured patients and emergency department mortality as the patient outcome. Understanding the patterns and outcomes of injuries helps to anticipate needs, prioritize patients, and allocate resources effectively.

METHODS

A retrospective single-center observational study utilised patient records from September 2020 to August 2021 at Addis Ababa Burn Emergency and Trauma Hospital, located in Ethiopia. A structured checklist facilitated the data collection. All patients arriving in the ED from September 2020 to August 2021 were eligible for the study while incomplete records (missing > 20% of wanted data elements) were excluded.

RESULT

Of the 3502 injured patients recorded during the study period, 317 were selected. The mean patient age was 30 years, with 78.5% being male. About 8% arrived the emergency department within an hour after the injury. Ambulances transported 38.8% of patients; 58.5% of these were referred from other facilities. The predominant mechanism of injury both in and outside Addis Ababa was pedestrian road traffic injuries (31.4% and 38%). The predominant injury type was fractures (33.8%). The mortality rate was 5%, of which half were pedestrian road traffic incidents.

CONCLUSION

Pedestrian road traffic injuries were the main cause of injury in and outside of Addis Ababa. A small proportion of patients arrived at the emergency department within the first hour after an injury event. A significant proportion of ambulance-transported patients were referred from other facilities rather than directly from the scene. The overall mortality rate was high, with pedestrian road traffic injury accounting for half of the proportion.

The practice and determinants of ambulance service utilization in pre-hospital settings, Jimma City, Ethiopia

BACKGROUND

In pre-hospital setting, ambulance provides emergency care and means of transport to arrive at appropriate health centers are as vital as in-hospital care, especially, in developing countries. Accordingly, Ethiopia has made several efforts to improve accessibility of ambulances services in prehospital care system that improves the quality of basic emergency care. Yet, being a recent phenomenon in Ethiopia, empirical studies are inadequate with regard to the practice and determinants of ambulance service utilization in pre-hospital settings. Hence, this study aimed to assess the ambulance service utilization and its determinants among patients admitted to the Emergency Departments (EDs) within the context of pre-hospital care system in public hospitals of Jimma City.

METHOD

A cross-sectional study design was used to capture quantitative data in the study area from June to July 2022. A systematic sampling technique was used to select 451 participants. Interviewer-administered questionnaire was used to collect data. Data analysis was done using SPSS version 26.0; descriptive and logistic regressions were done, where statistical significance was determined at p < 0.05.

RESULTS

Ambulance service was rendered to bring about 39.5% (of total sample, 451) patients to hospitals. The distribution of service by severity of illnesses was 48.7% among high, and 39.4% among moderately acute cases. The major determinants of ambulance service utilization were: service time (with AOR, 0.35, 95%CI, 0.2-0.6 for those admitted to ED in the morning, and AOR, 2.36, 95%CI, 1.3-4.4 for those at night); referral source (with AOR, 0.2, 95%CI, 0.1-0.4 among the self-referrals); mental status (with AOR, 1.9, 95%CI, 1-3.5 where change in the level of consciousness is observed); first responder (AOR, 6.3 95%CI, 1.5-26 where first responders were the police, and AOR, 3.4, 95%C1, 1.7-6.6 in case of bystanders); distance to hospital (with AOR,0.37, 95%CI, 0.2-0.7 among the patients within ≤15km radius); and prior experience in ambulance use (with AOR, 4.1,95%CI, 2.4-7).

CONCLUSION

Although the utilization of ambulance in pre-hospital settings was, generally, good in Jimma City; lower levels of service use among patients in more acute health conditions is problematic. Community-based emergency care should be enhanced to improve the knowledge and use of ambulance services.

A health systems approach to critical care delivery in low-resource settings: a narrative review

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Evaluation of the World Health Organization-International Committee of the Red Cross Basic Emergency Care course for senior medical students

BACKGROUND

The Basic Emergency Care: Approach to the acutely ill and injured course was developed to train health care providers to recognize, stabilize, and treat critically ill patients in resource-limited settings. This study evaluates the Basic Emergency Care course as a tool for improving the emergency medicine knowledge and skills of medical students in a lower-middle income country.

METHODS

This prospective study was conducted with senior medical students at the University of Nairobi School of Medicine in October 2021. Participants' knowledge was assessed with multiple choice pre- and post-course examinations. Pre- and post-course surveys assessed participants' confidence in managing acutely ill and injured patients using a 4-point Likert scale.

RESULTS

A total of 30 students from the graduating medical school class participated in the study. Post-course examination scores (mean 94.5%, range 80-100%) showed a significant improvement (p < 0.05) compared to pre-course examination scores (mean 82%, range 64-96%). Participants' comfort and confidence in providing emergency care and performing critical emergency skills significantly increased (p < 0.05) between the pre- and post-course surveys.

CONCLUSION

These findings suggest that the Basic Emergency Care course is effective in providing senior medical students with basic emergency medicine knowledge and increasing their confidence to identify and address life-threatening conditions prior to their intern year.

Prolonged length of stay and its associated factors at adult emergency department in amhara region comprehensive specialized hospitals, northwest Ethiopia

Background

Prolonged length of stay at the emergency department interferes with the main goal of emergency care and results in adverse patient outcomes like nosocomial infection, dissatisfaction, morbidity, and mortality. Despite this, little is known about the length of stay and the factors that influence it in Ethiopia’s emergency department.

Methods

An institution-based cross-sectional study was conducted on 495 patients admitted at Amhara region comprehensive specialized hospitals emergency department from May 14 to June 15/2022. A systematic random sampling was employed to select study participants. A pretested structured interview-based questionnaire was used to collect data by using Kobo toolbox software. SPSS version 25 was used for data analysis. Bi-variable logistic regression analysis was carried out to select variables with P-value < 0.25. The significance of association was interpreted using an Adjusted Odds Ratio with a 95% confidence interval. Variables with P-value < 0.05 in the multivariable logistic regression analysis were inferred to be significantly associated with length of stay.

Result

Out of 512 enrolled participants, 495 were participated with a response rate of 96.7%. The prevalence of prolonged length of stay in the adult emergency department was 46.5% (95%CI: 42.1, 51.1). Lack of insurance (AOR: 2.11; 95% CI: 1.22, 3.65), non-communicative presentation (AOR: 1.98; 95% CI: 1.07, 3.68), delayed consultation (AOR: 9.5; 95% CI: 5.00, 18.03), overcrowding (AOR: 4.98; 95% CI: 2.13, 11.68), and shift change experience (AOR: 3.67; 95% CI: 1.30, 10.37) were significantly associated with prolonged length of stay.

Conclusion

The result of this study is found to be high based on Ethiopian target emergency department patient length of stay. Lack of insurance, presentation without communication, delayed consultation, overcrowding, and shift change experience were significant factors for prolonged emergency department length of stay. Therefore, interventions like expansion of organizational setup are needed to decrease the length of stay to an acceptable level.

The Status of Facility Based Emergency Care in Public Hospitals of Ethiopia Using WHO Assessment Tool

Background

The availability of emergency care contributes to half of the total mortality burden in a low and middle income countries. The significant proportion of emergency departments in LMICs are understaffed and poorly equipped. The purpose of this study is to examine the status of emergency units and to describe the facilitators and barriers to the provision of facility-based emergency care at selected Ethiopian public hospitals.

Methods

A mixed-methods explanatory design was used. Ten hospitals were purposively selected due to their high number of patients and referral service. A WHO facility assessment tool was used to quantitatively assess the facilities, and an in-depth interview with hospital and emergency room leadership was conducted. The quantitative results were descriptively analyzed, and the qualitative data was thematically analyzed.

Result

This survey included a total of ten hospitals. Three of the facilities were general hospitals, and seven were tertiary level hospitals. They all were equipped with an emergency room. All of the studied hospitals serve a population of over one million people. In terms of infrastructure, only 3/10 (30%) have adequate water supply, and alf (5/10) have telephone access in their ED. The qualitative resultshowedthat the most common barriers to emergency care delivery were prolonged patient stays in the emergency room, inadequate equipment, and a shortage of trained professionals.

Conclusion

The status of emergency care in Ethiopia is still developing, and hospital care as a whole should improve to alleviate the high burden of care in emergency rooms and reduce morbidity and mortality.

Emergency capacity analysis in Ethiopia: Results of a baseline emergency facility assessment

INTRODUCTION

In Ethiopia, the specialty of Emergency Medicine is a relatively new discipline. In the last few decades, policymakers have made Emergency Medicine a priority for improving population health. This study aims to contribute to this strengthening of Emergency Medicine, by conducting the country's first baseline gap analysis of Emergency Medicine Capacity at the pre-hospital and hospital level in order to help identify needs and areas for intervention.

METHODS

This is a cross sectional investigation that utilized a convenience sampling of 22 primary, general and tertiary hospitals. Trained personnel visited the hospitals and conducted 4-hour interviews with hospital administrators and emergency care area personnel. The tool used in the interview was the Columbia University sidHARTe Program Emergency Services Resource Assessment Tool (ESRAT) to evaluate both emergency and trauma capacity in different regions of Ethiopia. The findings of this survey were then compared against two established standards: the World Health Organization's Essential Package of Emergency Care (EPEC), as well as those set by Ethiopia's Federal Ministry of Health.

RESULTS

The tool assessed the services provided at each hospital and evaluated the infrastructure of emergency care at the facility. Triage systems differed amongst the hospitals surveyed though triaging and emergency unit infrastructures were relatively similar amongst the hospitals. There was a marked variability in the level of training, guidelines, staffing, disaster preparedness, drug availability, procedures performed, and quality assurance measures from hospital to hospital. Most regional and district hospitals did not have nurses or doctors trained in Emergency Medicine and over 70% of the hospitals did not have written guidelines for standardized emergency care.

CONCLUSION

This gap analysis has revealed numerous inconsistencies in health care practice, resources, and infrastructure within the scope of Emergency Medicine in Ethiopia. Major gaps were identified, and the results of this assessment were used to devise action priorities for the Ministry of Health. Much remains to be done to strengthen Emergency Medicine in Ethiopia, and numerous opportunities exist to make additional short and long-term improvements.