Evaluating feasibility of a novel mobile emergency medical dispatch tool for lay first responder prehospital response coordination in Sierra Leone: A simulation-based study

Transportation and equipment needs for emergency medical services development in low- and middle-income countries

Prehospital emergency medical services play a vital role in reducing mortality and disease burden in low- and middle-income countries. However, the availability of adequate prehospital emergency care remains a significant challenge in many resource-limited communities, with over 91% of the African population lacking access to sufficient emergency medical services. This commentary aims to highlight the critical components of transportation infrastructure and medical supply chain challenges for emergency medical service development and propose potential solutions for future study. Transportation is a key factor influencing prehospital mortality, yet many low- and middle-income countries face issues related to timely prehospital transportation, with patients often relying on family members or private vehicles for transportation, leading to delays in reaching healthcare facilities due to poor road infrastructure. Dysfunctional and inadequate vehicles are also common barriers to timely care. Response times and transport times often exceed high-income standards, with some rural areas experiencing total prehospital time, defined as the time of injury to arrival at definitive care, exceeding 24 hours. To address these transportation challenges, some low- and middle-income countries have developed tier-1 emergency medical services programs that use existing transportation infrastructure and involve lay first responders using motorized and non-motorized vehicles. These programs prioritize rapid transportation over advanced on-scene intervention, potentially providing faster response times. A combination of tier-1 and tier-2 emergency medical services systems, as seen in some successful examples, allows for early on-scene guidance and resource allocation. In addition to transportation, the availability of medical equipment is crucial for effective prehospital interventions, particularly in tier-2 systems. However, low- and middle-income countries often face shortages of even basic supplies, limiting the scope of care that emergency medical services personnel can provide. Developing tier-2 emergency medical services upon a foundation of tier-1 prehospital care utilizing sustainable local supply chains and common household items for basic care can help alleviate these equipment challenges. The integration of tier-1 and tier-2 systems may offer a promising solution to address resource limitations and improve timely access to emergency care in low- and middle-income countries. Further research and investment are required to explore and implement these solutions, ultimately reducing mortality and enhancing healthcare services in resource-limited communities.

Emergency medical dispatch technologies: Addressing communication challenges and coordinating emergency response in low and middle-income countries

A majority of emergency response in low and middle-income countries (LMICs) without formal emergency medical services (EMS) rely on uncoordinated layperson first responders (LFRs) to respond to emergencies using readily available mobile phones and private transport. Although formally trained LFRs are an important foundation for nascent emergency medical services (EMS) development, without coordination by standardized emergency medical dispatch (EMD) systems, LFR response is limited to witnessed emergencies, which provides significant but incomplete coverage. After training and equipping LFRs, EMD implementation using telecommunications technologies is the next step in formal EMS development and is essential to coordinate response, given the impact of timely prehospital response, intervention, and transportation on reducing morbidity/mortality. In this paper, we describe the current state of dispatch technologies used for emergency response in LMICs, focusing on the role of communication technologies, current approaches, and challenges in communication, and offer potential strategies for future development.

Leveraging transportation providers to deploy lay first responder (LFR) programs in three sub-Saharan African countries without formal emergency medical services: Evaluating longitudinal impact and cost-effectiveness

INTRODUCTION

In 2019, the World Health Assembly declared emergency care essential to achieve the 2030 Sustainable Development Goals. Few sub-Saharan African (SSA) countries have developed robust approaches to sustainably deliver emergency medical services (EMS) at scale, as high-income country models are financially impractical. Innovative reassessment of EMS delivery in resource-limited settings is necessary as timely emergency care access can substantially reduce mortality.

MATERIALS AND METHODS

We developed the Lay First Responder (LFR) program by training 1,291 pre-existing motorcycle taxi drivers, a predominant form of short-distance transport in sub-Saharan Africa, to provide trauma care and transport for road traffic injuries. Three pilot programs were launched in staggered fashion between 2016 and 2019 in West, Central, and East Africa and a 5.5 h curriculum was iteratively developed to train first responders. Longitudinal data on patient impact (patient demographics, injury characteristics, and treatment rendered), emergency care knowledge acquisition/retention, and social/financial effects of LFR training were collected and pooled across three sites for collective analysis. Novel cost-effectiveness ratios were calculated based on prospective cost data from each site. Previously projected aggregate disability-adjusted life years (DALYs) addressable by LFRs were used to inform cost-effectiveness ratios($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP), following WHOCHOICE guidelines, which state ratios less than GDP per capita are "very cost-effective."

RESULTS

In 2,171 total patient encounters across all three pilot sites, LFRs most frequently provided hemorrhage control in 61 % of patient encounters and patient transport by motorcycle in 98.5 %. Median pre-/post-test scores improved by 34.1 percentage points (39.5% vs.73.6 %, p < 0.0001) with significant knowledge retention at six months. 75 % of initial participants remain voluntarily involved 3 years post-course, reporting increased local stature and customer acquisition(income 32.0 % greater than non-trained counterparts). Locally sourced first-aid materials cost $6.54USD/participant. Cost-effectiveness analysis demonstrated cost per DALY averted=$51.65USD.

CONCLUSION

LFR training is highly cost-effective according to WHOCHOICE guidelines and expands emergency care access. The LFR program may be an alternative approach to formal ambulance-reliant EMS that are cost-prohibitive in resource-limited, sub-Saharan African settings. A novel social/financial mechanism appears to incentivize long-term voluntary LFR involvement, which may sustain programs in resource-limited settings.

Challenges, opportunities, and priorities for tier-1 emergency medical services (EMS) development in low- and middle-income countries: A modified Delphi-based consensus study among the global prehospital consortium

INTRODUCTION

Though the disease burden addressable by prehospital and out-of-hospital emergency care(OHEC) spans communicable diseases, maternal conditions, chronic conditions and injury, the single largest disability-adjusted life year burden contributor is injury, primarily driven by road traffic injuries(RTIs). Establishing OHEC for RTIs and other common emergencies in low- and middle-income countries(LMICs) where the injury burden is disproportionately greatest is a logical first step toward more comprehensive emergency medical services(EMS). However, with limited efforts to formalize and expand existing informal bystander care networks, there is a lack of consensus on how to develop and maintain bystander-driven Tier-1 EMS systems in LMICs. Resultantly, Tier-1 EMS development is fragmented among non-governmental organizations and the public sector globally.

METHODS

A steering committee coordinated a 9-round, modified Delphi-based expert discussion to identify current challenges, opportunities, and priorities in Tier-1 EMS development globally. 11 panelists represented seven Global Prehospital Consortium(GPC) member organizations with a mean 9.57 years of organizational Tier-1 EMS development/implementation experience(median = 9 years). The consortium represents the largest collaboration between organizations directing Tier-1 EMS programs globally across 12 countries on 3 continents(Americas, sub-Saharan Africa, and South Asia) with 22,000 first responders.

RESULTS

The GPC identified seven priority areas for Tier-1 EMS development: infrastructure/operations, communication, education/training, impact evaluation, financing, governance/legal, and transportation/equipment. A high level of consensus exists regarding priorities for investigation, including Tier-1 responder density/distribution, Tier-1 patient data variable standardization for trauma registries/quality improvement, dispatch technologies/protocols, modular curricula, broader cost-effectiveness and impact evaluation indices capturing secondary impacts of EMS, standardizing legal protections for first responders, and transportation/equipment standards.

DISCUSSION

Consensus is necessary to avoid duplicative and disorganized efforts due to the fragmented nature of parallel Tier-1 EMS efforts globally. A Delphi-like multi-round expert discussion among the members of the largest collaboration between organizations directing Tier-1 EMS programs globally generated relevant priorities to direct future efforts.

Usefulness of external fixation and reverse Sural fasciocutaneous flap: Treatment of grade III B open tibial fractures in resource-limited settings

PURPOSE

Sierra Leone is a low-income country located on the west coast of Africa where the majority of the population does not have free access to emergency medical and surgical services, the principal cause of open tibia fractures is motorcycle collision. Open fractures of the middle and distal third of the tibial segments, particularly those classified as type III B, represent a challenge for orthopedic surgeons because of the loss of soft tissue coverage. The Reverse Sural Fasciocutaneous Flap (RSFF) has been shown to be an ideal and reproducible option for the treatment of soft tissue defects. The main aim of this study was to demonstrate the experience in Resource Limited Settings (RLS) by means of a short series of the efficacy of using a combination of external fixation and RSFF in the treatment of grade III B open tibia fractures where plastic surgeons were not available.

METHODS

This retrospective, descriptive, and non-experimental study included 8 patients who underwent surgical intervention between September 2020 and September 2021.

RESULTS

The skin defects were of various sizes; the smallest size was 4 × 7 cm, and the biggest size of 12 × 18 cm. We obtained a success rate in seven of the eight cases.

CONCLUSIONS

External fixation and reverse sural fasciocutaneous sural flap are excellent therapeutic options for the treatment of open grade III B diaphyseal and metaphyseal distal tibial fractures.