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Michaeli N, De Luca G, Gitau M, Myers J, Ojuka D, Ouma D, Wieland T, Wanjiku G. Evaluation of the World Health Organization-International Committee of the Red Cross Basic Emergency Care course for senior medical students. Int J Emerg Med 2023; 16:29. [PMID: 37085780 PMCID: PMC10120185 DOI: 10.1186/s12245-023-00487-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 02/12/2023] [Indexed: 04/23/2023] Open
Abstract
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.
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Affiliation(s)
- Nichole Michaeli
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 55 Claverick St., Providence, RI, 02903, USA.
| | - Giovanna De Luca
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 55 Claverick St., Providence, RI, 02903, USA
| | - Mary Gitau
- P.C.E.A. Chogoria Hospital, Chogoria, Kenya
| | - Justin Myers
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel Ojuka
- Department of Surgery, University Of Nairobi, College of Health Science, Nairobi, Kenya
| | | | - Travis Wieland
- Department of Emergency Medicine, University of Wisconsin, Madison, WI, USA
| | - Grace Wanjiku
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 55 Claverick St., Providence, RI, 02903, USA
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Pickering AE, Dreifuss HM, Ndyamwijuka C, Nichter M, Dreifuss BA. Getting to the Emergency Department in time: Interviews with patients and their caregivers on the challenges to emergency care utilization in rural Uganda. PLoS One 2022; 17:e0272334. [PMID: 35926069 PMCID: PMC9352071 DOI: 10.1371/journal.pone.0272334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives Karoli Lwanga Hospital and Global Emergency Care, a 501(c)(3) nongovernmental organization, operate an Emergency Department (ED) in Uganda’s rural Rukungiri District. Despite available emergency care (EC), preventable death and disability persist due to delayed patient presentations. This study seeks to understand the emergency care seeking behavior of community members utilizing the established ED. Methods We purposefully sampled and interviewed patients and caregivers presenting to the ED more than 12 hours after onset of chief complaint in January-March 2017 to include various ages, genders, and complaints. Semistructured interviews addressing actions taken before seeking EC and delays to presentation once the need for EC was recognized were conducted until a diverse sample and theoretical saturation were obtained. An interdisciplinary and multicultural research team conducted thematic analysis based on descriptive phenomenology. Results The 50 ED patients for whom care was sought (mean age 33) had approximately even distribution of gender, as well as occupation (none, subsistence farmers and small business owner). Interviews were conducted with 13 ED patients and 37 caregivers, on the behalf of patients when unavailable. The median duration of patients’ chief complaint on ED presentation was 5.5 days. On average, participants identified severe symptoms necessitating EC 1 day before presentation. Four themes of treatment delay before and after severity were recognized were identified: 1) Cultural factors and limited knowledge of emergency signs and initial actions to take; 2) Use of local health facilities despite perception of inadequate services; 3) Lack of resources to cover the anticipated cost of obtaining EC; 4) Inadequate transportation options. Conclusions Interventions are warranted to address each of the four major reasons for treatment delay. The next stage of formative research will generate intervention strategies and assess the opportunities and challenges to implementation with community and health system stakeholders.
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Affiliation(s)
- Ashley E. Pickering
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD, United States of America
- Global Emergency Care, Shrewsbury, MA, United States of America
- * E-mail:
| | - Heather M. Dreifuss
- Department of Health Sciences, Northern Arizona University, Flagstaff, AZ, United States of America
| | | | - Mark Nichter
- School of Anthropology, University of Arizona, Tucson, AZ, United States of America
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States of America
| | - Bradley A. Dreifuss
- Global Emergency Care, Shrewsbury, MA, United States of America
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States of America
- Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ, United States of America
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Rice B, Pickering A, Laurence C, Kizito PM, Leff R, Kisingiri SJ, Ndyamwijuka C, Nakato S, Adriko LF, Bisanzo M. Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme. BMJ Open 2022; 12:e059859. [PMID: 35768107 PMCID: PMC9244677 DOI: 10.1136/bmjopen-2021-059859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda. DESIGN Retrospective cohort analysis with multivariable logistic regression. SETTING Single rural Ugandan emergency unit. PARTICIPANTS All patients presenting for care from 2009 to 2019. INTERVENTIONS Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: 'Direct Supervision' (2009-2010) emergency medicine physicians directly supervised all care; 'Indirect Supervision' (2010-2015) emergency medicine physicians were consulted as needed; 'Independent Care' (2015-2019) no emergency medicine physician supervision. PRIMARY OUTCOME MEASURE Three-day mortality. RESULTS 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts ('Direct' 3.8%, 'Indirect' 3.3%, 'Independent' 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals ('Direct' 32%, 'Indirect' 19%, 'Independent' 13%, p<0.001). After controlling for vital sign abnormalities, 'Direct' and 'Indirect' supervision were both significantly associated with reduced OR for mortality ('Direct': 0.57 (0.37 to 0.90), 'Indirect': 0.71 (0.55 to 0.92)) when compared with 'Independent Care'. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals ('Direct': 0.44 (0.22 to 0.85), 'Indirect': 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals ('Direct': 0.81 (0.44 to 1.49), 'Indirect': 0.82 (0.58 to 1.16)). CONCLUSIONS Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.
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Affiliation(s)
- Brian Rice
- Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Ashley Pickering
- Emergency Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Colleen Laurence
- Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Prisca Mary Kizito
- Emergency Medicine, Mbarara University of Science and Technology, Mbarara, Mbarara, Uganda
- Emergency Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Rebecca Leff
- Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Steven Jonathan Kisingiri
- Emergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USA
- Public Health, Liverpool John Moores University, Liverpool, Merseyside, UK
| | | | - Serena Nakato
- Emergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USA
- Emergency Medicine, Karoli Lwanga Hospital, Rukungiri, Rukungiri, Uganda
| | - Lema Felix Adriko
- Emergency Medicine, Karoli Lwanga Hospital, Rukungiri, Rukungiri, Uganda
| | - Mark Bisanzo
- Emergency Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
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Rice B, Calo S, Kamugisha JB, Kamara N, Chamberlain S. Emergency care of sepsis in sub-Saharan Africa: Mortality and non-physician clinician management of sepsis in rural Uganda from 2010 to 2019. PLoS One 2022; 17:e0264517. [PMID: 35544466 PMCID: PMC9094533 DOI: 10.1371/journal.pone.0264517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 02/12/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Little data exists from sub-Saharan Africa describing incidence and outcomes of sepsis in emergency units and uncertainty exists surrounding optimal management of sepsis in low-income settings. There exists limited data regarding quality care metrics for non-physician clinicians trained in emergency care. The objective of this study was to describe changes in septic patients over time and evaluate associations between sepsis care and mortality. Methods Secondary analysis of a prospective cohort of all consecutive patients seen from 2010–2019 in a rural Ugandan emergency unit staffed by non-physician clinicians was performed using an electronic database based on paper charts. Sepsis was defined as suspected infection with a quick Sequential Organ Failure Assessment score (qSOFA)≥1. Multi-variable logistic regression was used to analyze three-day mortality. Results Overall, 48,653 patient visits from 2010–2019 yielded 17,490 encounters for patients age≥18 who had suspected infection, including 10,437 with sepsis. The annual proportion of patients with sepsis decreased from 45.0%% to 21.3% and the proportion with malarial sepsis decreased from 17.7% to 2.1% during the study period. Rates of septic patients receiving quality care (“both fluids and anti-infectives”) increased over time (21.2% in 2012 to 32.0% in 2019, p<0.001), but mortality did not significantly improve (4.5% in 2012 to 6.4% in 2019, p = 0.50). The increasing quality of non-physician clinician care was not associated with reduced mortality, and treatment with “both fluids and antibiotics” was associated with increased mortality (RR = 1.55, 95%CI 1.10–2.00). Conclusion The largest study of sepsis management and outcomes ever published in both Uganda and sub-Saharan Africa showed sepsis and malarial sepsis decreasing from 2010 to 2019. The increasing quality of non-physician clinician care did not significantly reduce mortality and treatment with “both fluids and antibiotics” increased mortality. With causal associations between antibiotics and mortality deemed implausible, associations between sepsis mortality and interventions likely represent confounding by indication. Defining optimal sepsis care regionally will likely require randomized controlled trials.
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Affiliation(s)
- Brian Rice
- Department of Emergency Medicine, Stanford University, Palo Alto, California, United States of America
- Global Emergency Care, United States of America
| | - Sal Calo
- Department of Emergency Medicine and Center for Global Health, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute—Cleveland Clinic, Cleveland, Ohio, United States of America
- * E-mail:
| | | | | | - Stacey Chamberlain
- Global Emergency Care, United States of America
- Department of Emergency Medicine and Center for Global Health, University of Illinois at Chicago, Chicago, Illinois, United States of America
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Brown HA, Tidwell C, Prest P. Trauma training in low- and middle-income countries: A scoping review of ATLS alternatives. Afr J Emerg Med 2022; 12:53-60. [PMID: 35070655 PMCID: PMC8761604 DOI: 10.1016/j.afjem.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/12/2021] [Accepted: 11/28/2021] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Trauma training for front-line providers is a critical component of injury mitigation and trauma systems strengthening. Although the Advanced Trauma Life Support (ATLS) course is standard in much of the world, cost and administrative barriers are prohibitive to deploying the course in many low and middle income countries (LMICs). The purpose of this study was to identify alternative trauma training courses used in LMICs by scoping review and compare their effectiveness. METHODS Several peer-reviewed and grey literature databases were searched for relevant articles describing trauma training courses for front-line medical providers in LMICs. Studies were included if: performed in a LMIC; utilized a general trauma training course other than ATLS; trainees were hospital-based medical providers; study included some type of outcome measure. RESULTS A total of 34 manuscripts met inclusion criteria. The majority of courses were novel, hospital-initiated courses and ranged in length from 1 day to 1 week. Physicians were the most common target audience, followed by medical students and nurses. Courses were taught in 24 different countries throughout the Middle East, Asia, Latin America and Africa. Comparison of pre- and post-test knowledge was the most common metric used and nearly all courses demonstrated a statistically significant knowledge gain. One study demonstrated a reduction in mortality for injured patients after course implementation. The majority of courses were a collaboration between universities in a high income country and local faculty/practitioners in the LMIC where the course was taught. Reported cost per participant ranged from $10 to $232 USD. CONCLUSIONS Several trauma courses are currently being utilized in LMICs effectively with increases in knowledge gained and at a lower reported cost than ATLS. More research is needed to link trauma training courses to patient outcomes.
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Affiliation(s)
- Heather A. Brown
- Prisma Health Midlands/University of South Carolina, Department of Emergency Medicine, Columbia, SC, USA
| | - Caitlin Tidwell
- Prisma Health Midlands/University of South Carolina, Department of Emergency Medicine, Columbia, SC, USA
| | - Phillip Prest
- Prisma Health Midlands/University of South Carolina, Department of Surgery, Columbia, SC, USA
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Chipendo PI, Shawar YR, Shiffman J, Razzak JA. Understanding factors impacting global priority of emergency care: a qualitative policy analysis. BMJ Glob Health 2021; 6:e006681. [PMID: 34969680 PMCID: PMC8718415 DOI: 10.1136/bmjgh-2021-006681] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/25/2021] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The high burden of emergency medical conditions has not been met with adequate financial and political prioritisation especially in low and middle-income countries. We examined the factors that have shaped the priority of global emergency care and highlight potential responses by emergency care advocates. METHODS We conducted semistructured interviews with key experts in global emergency care practice, public health, health policy and advocacy. We then applied a policy framework based on political ethnography and content analysis to code for underlying themes. RESULTS We identified problem definition, coalition building, paucity of data and positioning, as the main challenges faced by emergency care advocates. Problem definition remains the key issue, with divergent ideas on what emergency care is, should be and what solutions are to be prioritised. Proponents have struggled to portray the urgency of the issue in a way that commands action from decision-makers. The lack of data further limits their effectiveness. However, there is much reason for optimism given the network's commitment to the issue, the emerging leadership and the existence of policy windows. CONCLUSION To improve global priority for emergency care, proponents should take advantage of the emerging governance structure and build consensus on definitions, generate data-driven solutions, find strategic framings and engage with non-traditional allies.
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Affiliation(s)
- Portia I Chipendo
- Emergency Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Yusra R Shawar
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeremy Shiffman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Junaid Abdul Razzak
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
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Ku BC, Zonfrillo MR, Periyanayagam U, Bisanzo M, Rice B, Maling S, Cohn KA. The Association of Malnutrition and Disease Conditions in Mortality of Pediatric Patients Presenting to a Rural Emergency Department in Uganda. Pediatr Emerg Care 2021; 37:e1515-e1520. [PMID: 32398596 DOI: 10.1097/pec.0000000000002102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The main objectives of this study were to determine the effect of concurrent malnutrition on disease condition and the primary outcome of mortality in children younger than 5 years hospitalized after presenting to a rural emergency department (ED) in Uganda and to identify a high-risk patient population who may benefit from acute ED intervention. METHODS A retrospective, observational study was performed to examine the effect of any form of malnutrition on the primary disease conditions of lower-respiratory tract infection (LRTI), malaria, and diarrheal illness. This study was conducted via review of a quality assurance database between January 2010 and July 2014. RESULTS Of 3428 hospitalized children, the mean age (SD) was 19.8 months (13.9 months) and 56% were boys. Children diagnosed with malaria, an LRTI, or diarrheal illness all had a higher rate of mortality with concurrent malnutrition versus those without malnutrition (malaria, 6.2% [3.6-8.8%] vs 2.8% [2.0-3.7%]; P < 0.01; LRTI, 8.7% [5.0-12.4%] vs. 3.7% [2.6-4.9%], P < 0.01; and diarrheal illness, 10.9% [1.9-19.9%] vs 1.7% [0.1-3.4%], P < 0.01). In children with an LRTI or malaria with concurrent malnutrition, they were statistically significantly less likely to have abnormal temperature and heart rate during the ED encounter than those without concurrent malnutrition. CONCLUSIONS Based on these results, children with malnutrition and concurrent diseases with known high morbidity may not present with abnormal vital signs. This may have clinical relevance in patient management to the acute care provider in identifying and triaging children with malnutrition and acute disease conditions.
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Affiliation(s)
| | | | | | | | | | - Samuel Maling
- College of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
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Abstract
This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient—these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single “best” care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country’s current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient’s geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.
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Rice B, Leanza J, Mowafi H, Thadeus Kamara N, Mugema Mulogo E, Bisanzo M, Nikam K, Kizza H, Newberry JA, Strehlow M, Kohn M. Defining High-risk Emergency Chief Complaints: Data-driven Triage for Low- and Middle-income Countries. Acad Emerg Med 2020; 27:1291-1301. [PMID: 32416022 PMCID: PMC7818254 DOI: 10.1111/acem.14013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Emergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints (CCs) are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether CCs independently predict emergency unit patient outcomes. METHODS Patient data collected in a Ugandan emergency unit between 2009 and 2018 were randomized into validation and derivation data sets. A recursive partitioning algorithm stratified CCs by 3-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, CCs were categorized as "high-risk" (>2× baseline mortality), "medium-risk" (between 2 and 0.5× baseline mortality), and "low-risk" (<0.5× baseline mortality). Risk categories were then included in a logistic regression model to determine if CCs independently predicted 3-day mortality. RESULTS Overall, the derivation data set included 21,953 individuals with 7,313 in the validation data set. In total, 43 complaints were categorized, and 12 CCs were identified as high-risk. When controlled for triage data including age, sex, HIV status, vital signs, level of consciousness, and number of complaints, high-risk CCs significantly increased 3-day mortality odds ratio (OR = 2.39, 95% confidence interval [CI] = 1.95 to 2.93, p < 0.001) while low-risk CCs significantly decreased 3-day mortality odds (OR = 0.16, 95% CI = 0.09 to 0.29, p < 0.001). CONCLUSIONS High-risk CCs were identified and found to predict increased 3-day mortality independent of vital signs and other data available at triage. This list can be used to expand local triage systems and inform emergency training programs. The methodology can be reproduced in other LMIC settings to reflect their local disease patterns.
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Affiliation(s)
- Brian Rice
- From the Department of Emergency MedicineStanford UniversityPalo AltoCAUSA
| | - Joseph Leanza
- theDepartment of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Hani Mowafi
- theDepartment of Emergency MedicineYale UniversityNew HavenCTUSA
| | | | - Edgar Mugema Mulogo
- theDepartment of Community HealthMbarara University of Science and TechnologyMbararaUganda
| | - Mark Bisanzo
- theDivision of Emergency MedicineUniversity of VermontBurlingtonVT
| | - Kian Nikam
- theSchool of MedicineUniversity of California San FranciscoSan FranciscoCA
| | | | | | - Matthew Strehlow
- From the Department of Emergency MedicineStanford UniversityPalo AltoCAUSA
| | | | - Michael Kohn
- From the Department of Emergency MedicineStanford UniversityPalo AltoCAUSA
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Bisanzo M. The underpinning of emergency care development is education. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 3:100013. [PMID: 34327379 PMCID: PMC8315342 DOI: 10.1016/j.lanwpc.2020.100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Mark Bisanzo
- Global Emergency Care Collaborative, Rukungiri, Uganda.,Division of Emergency Medicine, Department of Surgery, University of Vermont Medical Center, Burlington, VT, USA
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Rybarczyk MM, Ludmer N, Broccoli MC, Kivlehan SM, Niescierenko M, Bisanzo M, Checkett KA, Rouhani SA, Tenner AG, Geduld H, Reynolds T. Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review. Ann Glob Health 2020; 86:60. [PMID: 32587810 PMCID: PMC7304456 DOI: 10.5334/aogh.2681] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings. Objective To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships. Methods An electronic search was conducted using four databases for manuscripts on EM training programs - defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care - developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted. Findings Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding. Conclusions Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.
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Affiliation(s)
- Megan M. Rybarczyk
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, US
| | - Nicholas Ludmer
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, US
| | | | - Sean M. Kivlehan
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, US
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, US
| | - Mark Bisanzo
- Division of Emergency Medicine, Department of Surgery, University of Vermont, US
| | - Keegan A. Checkett
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, US
| | - Shada A. Rouhani
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, US
| | - Andrea G. Tenner
- Department of Emergency Medicine, University of California, San Francisco, US
| | - Heike Geduld
- University of Cape Town/Stellenbosch University, College of Emergency Medicine of South Africa, ZA
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Abstract
OBJECTIVE This study aims to describe pediatric poisonings presenting to a rural Ugandan emergency department (ED), identifying demographic factors and causative agents. METHODS This retrospective study was conducted in the ED of a rural hospital in the Rukungiri District of Uganda. A prospectively collected quality assurance database of ED visits was queried for poisonings in patients under the age of 5 who were admitted to the hospital. Cases were included if the chief complaint or final diagnosis included anything referable to poisoning, ingestion, or intoxication, or if a toxicologic antidote was administered. The database was coded by a blinded investigator, and descriptive statistics were performed. RESULTS From November 9, 2009, to July 11, 2014, 3428 patients under the age of 5 were admitted to the hospital. A total of 123 cases (3.6%) met the inclusion criteria. Seventy-two patients were male (58.5%). The average age was 2.3 (SD, 0.97) years with 45 children (36.6%) under the age of 2 years. There were 19 cases (15.4%) lost to 3-day follow-up. The top 3 documented exposures responsible for pediatric poisonings were cow tick or organophosphates (36 cases, 29.2%), general poison or drug overdose (26 cases, 21.1%), and paraffin or hydrocarbon (24 cases, 19.5%).Of the admitted patients, 1 died in the ED and 2 died at 72-hour follow-up, for an overall 72-hour mortality of 2.4%. Patients who died were exposed to iron, cow tick, and rat poison. CONCLUSIONS Pediatric poisoning affects patients in rural sub-Saharan Africa. The mortality rate at one rural Ugandan hospital was greater than 2%.
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Terry B, Polan DL, Nambaziira R, Mugisha J, Bisanzo M, Gaspari R. Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource limited setting. Afr J Emerg Med 2019; 9:140-144. [PMID: 31528532 PMCID: PMC6742845 DOI: 10.1016/j.afjem.2019.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/31/2019] [Accepted: 05/17/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as "task-shifting" where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs. METHODS POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated. RESULTS Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32-4.32) to 4.68 (95% CI, 4.35-5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2-83.0) and 98.5 (95% CI, 93.3-99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged. CONCLUSIONS Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs.
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Affiliation(s)
- Benjamin Terry
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | - David L. Polan
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | | | - Julius Mugisha
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark Bisanzo
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Romolo Gaspari
- University of Massachusetts Medical School, Worcester, MA, United States of America
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Suriyawongpaisal P, Atiksawedparit P, Srithamrongsawad S, Thongtan T. Assessment of nationwide emergency systems in Thailand, a middle-income country setting with UHC. Int J Health Plann Manage 2019; 34:e1346-e1355. [PMID: 30945365 DOI: 10.1002/hpm.2783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/05/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Evidence has been limited regarding broader emergency systems assessment in low- and middle-income countries. The aim of the present study was to provide the empirical evidence of Thai emergency department (ED) workforce vis-à-vis workload on a national scale, the availability of services for selected high-priority health burdens, and the governance obstacles in addressing the workforce management. METHOD One hundred thirty public Thai EDs that provide 24-hour emergency medical care were identified across Thailand as meeting the inclusion criteria. The mailed questionnaires were administered to collect data related to the objectives of the research study. RESULT Responses were received from 91 of 130 (70%) hospitals. The median number of patients visiting hospital EDs was 51 221 per year with 32.8% considered nonurgent (ESI levels 4-5). University hospital EDs were staffed with a higher number of ER professionals than EDs of service-based secondary care and tertiary care hospitals under Ministry of Public Health (MOPH). Almost all hospitals expressed concerns about the deficiency of doctors and nurses especially emergency physician (EP) and emergency nurses. The percentage of hospitals reporting the availability of coronary artery catheterization (34%) and thrombolytic infusion for acute thrombotic stroke (24%) was limited. The governance obstacles to manage emergency systems were considered. CONCLUSION ED staffing seems to positively correlate with workloads except university hospitals, in our study, which may suggest the influence of teaching status on the allocation of the human resource. Among the governance obstacles in ED management, a better response to nonurgent patients requires flexibility for hospitals to set financial disincentives or mobilization and management of human resources.
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Affiliation(s)
- Paibul Suriyawongpaisal
- Department of Community Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pongsakorn Atiksawedparit
- Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Samrit Srithamrongsawad
- Department of Community Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanita Thongtan
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, Thailand
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Rice BT, Bisanzo M, Maling S, Joseph R, Mowafi H. Derivation and validation of a chief complaint shortlist for unscheduled acute and emergency care in Uganda. BMJ Open 2018; 8:e020188. [PMID: 29950461 PMCID: PMC6020949 DOI: 10.1136/bmjopen-2017-020188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/16/2018] [Accepted: 05/22/2018] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Derive and validate a shortlist of chief complaints to describe unscheduled acute and emergency care in Uganda. SETTING A single, private, not-for profit hospital in rural, southwestern Uganda. PARTICIPANTS From 2009 to 2015, 26 996 patient visits produced 42 566 total chief complaints for the derivation dataset, and from 2015 to 2017, 10 068 visits produced 20 165 total chief complaints for the validation dataset. METHODS A retrospective review of an emergency centre quality assurance database was performed. Data were abstracted, cleaned and refined using language processing in Stata to produce a longlist of chief complaints, which was collapsed via a consensus process to produce a shortlist and turned into a web-based tool. This tool was used by two local Ugandan emergency care practitioners to categorise complaints from a second longlist produced from a separate validation dataset from the same study site. Their agreement on grouping was analysed using Cohen's kappa to determine inter-rater reliability. The chief complaints describing 80% of patient visits from automated and consensus shortlists were combined to form a candidate chief complaint shortlist. RESULTS Automated data cleaning and refining recognised 95.8% of all complaints and produced a longlist of 555 chief complaints. The consensus process yielded a shortlist of 83 grouped chief complaints. The second validation dataset was reduced in Stata to a longlist of 451 complaints. Using the shortlist tool to categorise complaints produced 71.5% agreement, yielding a kappa of 0.70 showing substantial inter-rater reliability. Only one complaint did not fit into the shortlist and required a free-text amendment. The two shortlists were identical for the most common 14 complaints and combined to form a candidate list of 24 complaints that could characterise over 80% of all emergency centre chief complaints. CONCLUSIONS Shortlists of chief complaints can be generated to improve standardisation of data entry, facilitate research efforts and be employed for paper chart usage.
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Affiliation(s)
- Brian Travis Rice
- Emergency Medicine, New York University Langone Medical Center, New York City, New York, USA
- Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark Bisanzo
- Division of Emergency Medicine, Department of Surgery, University of Vermont, Burlington, Vermont, USA
| | - Samuel Maling
- Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ryan Joseph
- Emergency Medicine, Texas A&M, Corpus Christi, Texas, USA
| | - Hani Mowafi
- Emergency Medicine, Yale University, New Haven, Connecticut, USA
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16
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Dresser C, Periyanayagam U, Dreifuss B, Wangoda R, Luyimbaazi J, Bisanzo M. Management and Outcomes of Acute Surgical Patients at a District Hospital in Uganda with Non-physician Emergency Clinicians. World J Surg 2018; 41:2193-2199. [PMID: 28405807 DOI: 10.1007/s00268-017-4014-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Acute surgical care services in rural Sub-Saharan Africa suffer from human resource and systemic constraints. Developing emergency care systems and task sharing aspects of acute surgical care addresses many of these issues. This paper investigates the degree to which specialized non-physicians practicing in a dedicated Emergency Department contribute to the effective and efficient management of acute surgical patients. METHODS This is a retrospective review of an electronic quality assurance database of patients presenting to an Emergency Department in rural Uganda staffed by non-physician clinicians trained in emergency care. Relevant de-identified clinical data on patients admitted directly to the operating theater from 2011 to 2014 were analyzed in Microsoft Excel. RESULTS Overall, 112 Emergency Department patients were included in the analysis and 96% received some form of laboratory testing, imaging, medication, or procedure in the ED, prior to surgery. 72% of surgical patients referred by ED received preoperative antibiotics, and preoperative fluid resuscitation was initiated in 65%. Disposition to operating theater was accomplished within 3 h of presentation for 73% of patients. 79% were successfully followed up to assess outcomes at 72 h. 92% of those with successful follow-up reported improvement in their clinical condition. The confirmed mortality rate was 5%. CONCLUSION Specialized non-physician clinicians practicing in a dedicated Emergency Department can perform resuscitation, bedside imaging and laboratory studies to aid in diagnosis of acute surgical patients and arrange transfer to an operating theater in an efficient fashion. This model has the potential to sustainably address structural and human resources problems inherent to Sub-Saharan Africa's current acute surgical care model and will benefit from further study and expansion.
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Affiliation(s)
- Caleb Dresser
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 120 Peterborough St Apt #4, Boston, MA, 02215, USA.
| | | | - Brad Dreifuss
- Department of Emergency Medicine, University of Arizona College of Medicine, Kampala, Uganda
| | - Robert Wangoda
- Department of Surgery, Makerere University, Kampala, Uganda
| | - Julius Luyimbaazi
- Department of Surgery, Karoli Lwanga Hospital Nyakibale, Kampala, Uganda
| | - Mark Bisanzo
- Global Emergency Care Collaborative, Kampala, Uganda.,Division of Emergency Medicine, Department of Surgery, University of Vermont Medical Center, Burlington, VT, USA
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Bitter CC, Rice B, Periyanayagam U, Dreifuss B, Hammerstedt H, Nelson SW, Bisanzo M, Maling S, Chamberlain S. What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda. BMJ Open 2018; 8:e019024. [PMID: 29478017 PMCID: PMC5855402 DOI: 10.1136/bmjopen-2017-019024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 11/09/2017] [Accepted: 11/14/2017] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients. SETTING A single emergency department (ED) of a district-level hospital in rural Uganda. PARTICIPANTS 26 710 patient visits. RESULTS Procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound. CONCLUSION This study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills.
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Affiliation(s)
- Cindy Carol Bitter
- Division of Emergency Medicine, Department of Surgery, Saint Louis University, St. Louis, Missouri, USA
- Global Emergency Care
| | - Brian Rice
- Global Emergency Care
- Department of Emergency Medicine, New York University Langone Medical Center, New York City, New York, USA
| | - Usha Periyanayagam
- Global Emergency Care
- Harvard Humanitarian Initiative, Harvard University, Boston, Massachusetts, USA
| | - Bradley Dreifuss
- Global Emergency Care
- Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Heather Hammerstedt
- Global Emergency Care
- Department of Emergency Medicine, CEPA-Idaho, Boise, Idaho, USA
| | - Sara W Nelson
- Global Emergency Care
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine, USA
| | - Mark Bisanzo
- Global Emergency Care
- Division of Emergency Medicine, Department of Surgery, University of Vermont, Burlington, Vermont, USA
| | - Samuel Maling
- College of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stacey Chamberlain
- Global Emergency Care
- Department of Emergency Medicine and the Center for Global Health, University of Illinois, Chicago, Illinois, USA
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Pigoga JL, Cunningham C, Kafwamfwa M, Wallis LA. Adapting the emergency first aid responder course for Zambia through curriculum mapping and blueprinting. BMJ Open 2017; 7:e018389. [PMID: 29229657 PMCID: PMC5778307 DOI: 10.1136/bmjopen-2017-018389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
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.
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Affiliation(s)
- Jennifer L Pigoga
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Emergency Medicine, University of Cape Town, CapeTown, South Africa
| | | | - Muhumpu Kafwamfwa
- Mobile and Emergency Health Services, Zambian Ministry of Health, Lusaka, Zambia
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, CapeTown, South Africa
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A roadmap for acute care training of frontline Healthcare workers in LMICs. J Crit Care 2017; 41:313-317. [PMID: 28826944 DOI: 10.1016/j.jcrc.2017.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/13/2017] [Accepted: 07/11/2017] [Indexed: 11/21/2022]
Abstract
This 10-step roadmap outlines explicit procedures for developing, implementing and evaluating short focused training programs for acute care in low and middle income countries (LMICs). A roadmap is necessary to develop resilient training programs that achieve equivalent outcomes despite regional variability in human capacity and infrastructure. Programs based on the roadmap should address shortfalls in human capacity and access to care in the short term and establish the ground work for health systems strengthening in the long term. The primary targets for acute care training are frontline healthcare workers at the clinic level. The programs will differ from others currently available with respect to the timelines, triage method, therapeutic interventions and potential for secondary prevention. The roadmap encompasses multiple iterative cycles of the Plan-Do-Study-Act framework. Core features are integration of frontline trainees with the referral system while promoting research, quality improvement and evaluation from the bottom-up. Training programs must be evidence based, developed along action timelines and use adaptive training methods. A systems approach is essential because training programs that take cognizance of all factors that influence health care delivery have the potential to produce health systems strengthening (HSS).
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20
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Kakyo TA, Xiao LD. Nurse managers' experiences in continuous quality improvement in resource-poor healthcare settings. Nurs Health Sci 2017; 19:244-249. [PMID: 28276128 DOI: 10.1111/nhs.12338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/12/2016] [Accepted: 01/13/2017] [Indexed: 11/28/2022]
Abstract
Ensuring safe and quality care for patients in hospitals is an important part of a nurse manager's role. Continuous quality improvement has been identified as one approach that leads to the delivery of quality care services to patients and is widely used by nurse managers to improve patient care. Nurse managers' experiences in initiating continuous quality improvement activities in resource-poor healthcare settings remain largely unknown. Research evidence is highly demanded in these settings to address disease burden and evidence-based practice. This interpretive qualitative study was conducted to gain an understanding of nurse managers' Continuous Quality Improvement experiences in rural hospitals in Uganda. Nurse managers in rural healthcare settings used their role to prioritize quality improvement activities, monitor the Continuous Quality Improvement process, and utilize in-service education to support continuous quality improvement. The nurse managers in our sample encountered a number of barriers during the implementation of Continuous Quality Improvement, including: limited patient participation, lack of materials, and limited human resources. Efforts to address the challenges faced through good governance and leadership development require more attention.
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Affiliation(s)
| | - Lily Dongxia Xiao
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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21
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Chanler-Berat J, Birungi A, Dreifuss B, Mbiine R. Typhoid intestinal perforation: Point-of-care ultrasound as a diagnostic tool in a rural Ugandan Hospital. Afr J Emerg Med 2016; 6:44-46. [PMID: 30456063 PMCID: PMC6233237 DOI: 10.1016/j.afjem.2015.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 09/03/2015] [Accepted: 09/18/2015] [Indexed: 11/28/2022] Open
Abstract
Introduction Point-of-care ultrasound (POCUS) in resource-limited areas has demonstrated utility in the hands of physicians and may be useful for non-physician providers to learn as well. Case Report An 11 year old male presented with abdominal pain and diffuse abdominal tenderness to a remote Emergency Centre (EC). An Emergency Care Practitioner, a non-physician emergency care provider with limited ultrasound training, used bedside ultrasonography and alerted the on-call surgeon of complex intraperitoneal fluid representing perforated typhoid, which expedited the patient’s care. Discussion There is scant literature involving cases of non-physician use of POCUS, particularly in the emergency care setting. This case demonstrates the potential benefits of training these providers in POCUS.
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Affiliation(s)
- Jordan Chanler-Berat
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY, USA
- Correspondence to Jordan Chanler-Berat.
| | | | - Brad Dreifuss
- Global Emergency Care Collaborative, University of Arizona, Tucson, AZ, USA
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22
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Rice B, Periyanayagam U, Chamberlain S, Dreifuss B, Hammerstedt H, Nelson S, Maling S, Bisanzo M. Mortality in Children Under Five Receiving Nonphysician Clinician Emergency Care in Uganda. Pediatrics 2016; 137:e20153201. [PMID: 26921282 DOI: 10.1542/peds.2015-3201] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A nonphysician clinician (NPC) training program was started in Uganda in 2009. NPC care was initially supervised by a physician and subsequent care was independent. The mortality of children under 5 (U5) was analyzed to evaluate the impact of transitioning NPC care from physician-supervised to independent care. METHODS A retrospective review was performed of a quality assurance database including 3-day follow-up for all patients presenting to the emergency department (ED). Mortality rates were calculated and χ(2) tests used for significance of proportions. Multiple logistic regression was used to assess independent predictors of mortality. RESULTS Overall, 68.8% of 4985 U5 patients were admitted and 28.6% were "severely ill." The overall mortality was significantly lower in physician-supervised versus independent NPC care (2.90% vs 5.04%, P = .05). No significant mortality difference was seen between supervised and unsupervised care (2.17% vs 3.01%, P = .43) for the majority of patients that were not severely ill. Severely ill patients analyzed separately showed a significant mortality difference (4.07% vs 10.3%, P = .01). Logistic regression revealed physician supervision significantly reduced mortality for patients overall (odds ratio = 0.52, P = .03), but not for nonseverely ill patients analyzed separately (odds ratio = 0.73, P = .47). CONCLUSIONS Though physician supervision reduced mortality for the severely ill subset of patients, physicians are not available full-time in most EDs in Sub-Saharan Africa. Training NPCs in emergency care produced noninferior mortality outcomes for unsupervised NPC care compared with physician-supervised NPC care for the majority of U5 patients.
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Affiliation(s)
- Brian Rice
- Department of Emergency Medicine, New York University School of Medicine, New York, New York;
| | - Usha Periyanayagam
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stacey Chamberlain
- Department of Emergency Medicine, University of Illinois-Chicago, Chicago, Illinois
| | - Bradley Dreifuss
- Department of Emergency Medicine, University of Arizona College of Medicine-Tucson, Tucson, Arizona
| | | | - Sara Nelson
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine
| | - Samuel Maling
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda; and
| | - Mark Bisanzo
- Department of Emergency Medicine, University of Massachusetts, Worchester, Massachusetts
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23
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Calvello EJB, Tenner AG, Broccoli MC, Skog AP, Muck AE, Tupesis JP, Brysiewicz P, Teklu S, Wallis L, Reynolds T. Operationalising emergency care delivery in sub-Saharan Africa: consensus-based recommendations for healthcare facilities. Emerg Med J 2015. [PMID: 26202673 DOI: 10.1136/emermed-2015-204994] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A major barrier to successful integration of acute care into health systems is the lack of consensus on the essential components of emergency care within resource-limited environments. The 2013 African Federation of Emergency Medicine Consensus Conference was convened to address the growing need for practical solutions to further implementation of emergency care in sub-Saharan Africa. Over 40 participants from 15 countries participated in the working group that focused on emergency care delivery at health facilities. Using the well-established approach developed in the WHO's Monitoring Emergency Obstetric Care, the workgroup identified the essential services delivered-signal functions-associated with each emergency care sentinel condition. Levels of emergency care were assigned based on the expected capacity of the facility to perform signal functions, and the necessary human, equipment and infrastructure resources identified. These consensus-based recommendations provide the foundation for objective facility capacity assessment in developing emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery.
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Affiliation(s)
- Emilie J B Calvello
- Department of Emergency Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Andrea G Tenner
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Morgan C Broccoli
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander P Skog
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Andrew E Muck
- Division of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Janis P Tupesis
- Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Petra Brysiewicz
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Sisay Teklu
- Department of Emergency Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Teri Reynolds
- Department of Emergency Medicine, University of California, San Francisco, California, USA
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24
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Stolz LA, Muruganandan KM, Bisanzo MC, Sebikali MJ, Dreifuss BA, Hammerstedt HS, Nelson SW, Nayabale I, Adhikari S, Shah SP. Point-of-care ultrasound education for non-physician clinicians in a resource-limited emergency department. Trop Med Int Health 2015; 20:1067-72. [PMID: 25808431 DOI: 10.1111/tmi.12511] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe the outcomes and curriculum components of an educational programme to train non-physician clinicians working in a rural, Ugandan emergency department in the use of POC ultrasound. METHODS The use of point-of-care ultrasound was taught to emergency care providers through lectures, bedsides teaching and hands-on practical sessions. Lectures were tailored to care providers' knowledge base and available therapeutic means. Every ultrasound examination performed by these providers was recorded over 4.5 years. Findings of these examinations were categorised as positive, negative, indeterminate or procedural. Other radiologic studies ordered over this same time period were also recorded. RESULTS A total of 22,639 patients were evaluated in the emergency department by emergency care providers, and 2185 point-of-care ultrasound examinations were performed on 1886 patients. Most commonly used were the focused assessment with sonography in trauma examination (53.3%) and echocardiography (16.4%). Point-of-care ultrasound studies were performed more frequently than radiology department-performed studies. Positive findings were documented in 46% of all examinations. CONCLUSIONS We describe a novel curriculum for point-of-care ultrasound education of non-physician emergency practitioners in a resource-limited setting. These non-physician clinicians integrated ultrasound into clinical practice and utilised this imaging modality more frequently than traditional radiology department imaging with a large proportion of positive findings.
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Affiliation(s)
- Lori A Stolz
- The University of Arizona, Tucson, AZ, USA.,Global Emergency Care Collaborative
| | | | - Mark C Bisanzo
- Global Emergency Care Collaborative.,University of Massachusetts, Worcester, MA, USA
| | - Mugisha J Sebikali
- Department of Radiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Bradley A Dreifuss
- The University of Arizona, Tucson, AZ, USA.,Global Emergency Care Collaborative
| | | | - Sara W Nelson
- Global Emergency Care Collaborative.,Maine Medical Center, Portland, ME, USA
| | - Irene Nayabale
- Global Emergency Care Collaborative.,Nyakibale Hospital, Rukungiri, Uganda
| | | | - Sachita P Shah
- Global Emergency Care Collaborative.,University of Washington School of Medicine, Seattle, WA, USA
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