Applying the Three Delays Model to understand emergency care seeking and delivery in rural Bangladesh: a qualitative study

Financial toxicity and acute injury in the Kilimanjaro region: An application of the Three Delays Model

BACKGROUND

Trauma and injury present a significant global burden-one that is exacerbated in low- and middle-income settings like Tanzania. Our study aimed to describe the landscape of acute injury care and financial toxicity in the Kilimanjaro region by leveraging the Three Delays Model.

METHODS

This cross-sectional study used an ongoing injury registry and financial questionnaires collected at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania from December 2022 until March 2023. Financial toxicity measures included catastrophic expenditure and impoverishment, in accordance with World Health Organization standards. Descriptive analysis was also performed.

FINDINGS

Most acute injury patients that presented to the KCMC Emergency Department experienced financial toxicity due to their out-of-pocket (OOP) hospital expenses (catastrophic health expenditure, CHE: 62.8%; impoverishment, IMP: 85.9%). Households within our same which experienced financial toxicity had more dependents (CHE: 18.4%; IMP: 17.9% with ≥6 dependents) and lower median monthly adult-equivalent incomes (CHE: 2.53 times smaller than non-CHE; IMP: 4.27 times smaller than non-IMP). Individuals experiencing financial toxicity also underwent more facility transfers with a higher surgical burden.

INTERPRETATION

Delay 1 (decision to seek care) and Delay 2 (reaching appropriate care facility) could be significant factors for those who will experience financial toxicity. In the Tanzanian healthcare system where national health insurance is present, systematic expansions are indicated to target those who are at higher risk for financial toxicity including those who live in rural areas, experience unemployment, and have many dependents.

Root Cause Analysis of Increased Referral Rates in a Sub-district Hospital, Tamil Nadu: A Quality Improvement Initiative

Background Sub-district hospitals in Tamil Nadu are critical in providing essential healthcare services, but they face significant challenges that can lead to increased patient referrals to higher-level facilities. High referral rates can overburden tertiary care centers, delay specialized treatment, and affect patient outcomes. This study aims to identify the root causes of increased referral rates in a sub-district hospital and implement targeted interventions to reduce unnecessary referrals. Methods A descriptive study was conducted at Sriperumbudur sub-district hospital in Tamil Nadu from May to August 2023. The study utilized a root cause analysis (RCA) approach, incorporating qualitative data from brainstorming sessions with healthcare providers and administrative staff, and quantitative data from hospital records on referral rates. A fishbone (Ishikawa) diagram was employed to map causal factors, and Pareto and bar charts were used to analyze and present referral trends. Interventions were implemented using the Plan-Do-Study-Act (PDSA) cycle. Results The analysis identified several key factors contributing to high referral rates, including inadequate diagnostic services, insufficient staffing, and lack of essential resources such as CT scans and blood components. Following targeted interventions, referral rates decreased significantly from 101 cases in May-June 2023 to 52 cases in July-August 2023 highlighting a reduction of over 48%. The most notable reductions were seen in referrals for road traffic accidents with head injury (38.7%) reduction, chronic kidney disease (CKD)/hypertension (HT)/diabetes mellitus (DM) (46.2%) reduction, and crush injuries (45.5%) reduction. Conclusions The RCA revealed systemic issues that were contributing to increased referral rates at the sub-district hospital. Implementing targeted interventions based on the RCA findings led to a significant reduction in referrals, improving patient care at the local level and alleviating the burden on tertiary care centers. This study underscores the importance of continuous quality improvement initiatives in strengthening healthcare delivery at the sub-district level.

Decision-making process in seeking antenatal care: A cohort study in a poor urban and a typical rural area in Bangladesh

Background

Decision-making in choosing and using maternal health care among different care-seeking options is a complex process influenced by multilevel factors. Existing evidence on maternal health care-seeking behaviour stems primarily from cross-sectional studies with limited information. Therefore, we designed a cohort study to better understand the decision-making process in antenatal care (ANC) seeking.

Methods

We conducted this mixed-methods study among pregnant women at <27 weeks of gestation in a poor urban area (n = 1320) and a typical rural area of Bangladesh (n = 1239) whom we followed up till eight weeks after delivery. In view of quantitative methods, we interviewed all enrolled women 5-6 times four weeks apart. For the qualitative approach, we conducted 70 case studies in the urban area and 46 in the rural area by interviewing the participants and their close family members.

Results

In the urban area, about one-third of the pregnant women (38.4%) sought ANC at non-governmental organisations, and nearly an equal proportion went to public facilities (36.6%). In both the situations, women preferred facilities with one-stop services at a reasonable cost. In contrast, the lack of readiness in public facilities of the rural area pushed women (77.8%) toward private facilities for ANC. The reputation of the facilities, availability of skilled care providers, diagnostic tests, and ultrasonography services therein were the key influencing factors in the participants' decisions to seek ANC services from specific facilities.

Conclusions

The availability of one-stop services was a key factor for participants' choosing of a facility for ANC. For the urban setting, there is a need to establish large public facilities with one-stop service provision in different zones, along with supporting non-governmental organisations in poor areas. For the rural setting, there is an urgent need to strengthen ANC service provision in public facilities at the community- and the sub-district level to redirect women from the private to the public sector to ensure low cost, quality services.

Timing the clinical onset of epileptic spasms in infantile epileptic spasms syndrome: A tertiary health center's experience

OBJECTIVE

Lead time to treatment (clinical onset of epileptic spasms [ES] to initiation of appropriate treatment) is known to predict outcomes in infantile epileptic spasms syndrome (IESS). Timing the clinical onset of ES is crucial to establish lead time. We investigated how often ES onset could be established to the nearest week. We aimed to (1) ascertain the exact date or estimate the nearest week of ES onset and (2) compare clinical/demographic factors between patients where date of ES onset was determined or estimated to the nearest week and patients whose date of ES onset could not be estimated to the nearest week. Reasons for difficulties in estimating date of ES onset were explored.

METHODS

Retrospective chart review of new onset IESS patients (January 2019-May 2022) extracted the date or week of the clinical onset of ES. Predictors of difficulty in date of ES onset estimation to the nearest week were examined by regression analysis. Sources contributing to difficulties determining date of ES onset were assessed after grouping into categories (provider-, caregiver-, disease-related).

RESULTS

Among 100 patients, date of ES onset was estimated to the nearest week in 47%. On univariable analysis, age at diagnosis (p = .021), development delay (p = .007), developmental regression/stagnation (p = .021), ES intermixed with other seizures (p = .011), and nonclustered ES at onset (p = .005) were associated with difficulties estimating date of ES onset. On multivariable analysis, failure to establish date of ES onset was related to ES intermixed with other seizures (p = .004) and nonclustered ES at onset (p = .003). Sources contributing to difficulties determining date of ES onset included disease-related factors (ES characteristics, challenges interpreting electroencephalograms) and provider/caregiver-related factors (delayed diagnosis).

SIGNIFICANCE

Difficulties with estimation of lead time (due to difficulties timing ES onset) can impact clinical care (prognostication), as even small increments in lead time duration can have adverse developmental consequences.

"It is because the treatment of this lady is a cascade": Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania

OBJECTIVE

To explore healthcare workers' and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania.

DESIGN

A qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis.

SETTING

This study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care.

PARTICIPANTS

Six frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility.

FINDINGS

Delays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility.

KEY CONCLUSIONS

The study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities.

IMPLICATIONS FOR PRACTICE

Our findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision.

TRIAL REGISTRATION NUMBER

NCT04685668 Date of initial trial registration: December 28th, 2020.

Identifying delays in healthcare seeking and provision: The Three Delays-in-Healthcare and mortality among infants and children aged 1-59 months

Delays in illness recognition, healthcare seeking, and in the provision of appropriate clinical care are common in resource-limited settings. Our objective was to determine the frequency of delays in the "Three Delays-in-Healthcare", and factors associated with delays, among deceased infants and children in seven countries with high childhood mortality. We conducted a retrospective, descriptive study using data from verbal autopsies and medical records for infants and children aged 1-59 months who died between December 2016 and February 2022 in six sites in sub-Saharan Africa and one in South Asia (Bangladesh) and were enrolled in Child Health and Mortality Prevention Surveillance (CHAMPS). Delays in 1) illness recognition in the home/decision to seek care, 2) transportation to healthcare facilities, and 3) the receipt of clinical care in healthcare facilities were categorized according to the "Three Delays-in-Healthcare". Comparisons in factors associated with delays were made using Chi-square testing. Information was available for 1,326 deaths among infants and under 5 children. The majority had at least one identified delay (n = 854, 64%). Waiting >72 hours after illness recognition to seek health care (n = 422, 32%) was the most common delay. Challenges in obtaining transportation occurred infrequently when seeking care (n = 51, 4%). In healthcare facilities, prescribed medications were sometimes unavailable (n = 102, 8%). Deceased children aged 12-59 months experienced more delay than infants aged 1-11 months (68% vs. 61%, P = 0.018). Delays in seeking clinical care were common among deceased infants and children. Additional study to assess the frequency of delays in seeking clinical care and its provision among children who survive is warranted.

A qualitative assessment of stakeholder perspectives on barriers and facilitators to emergency care delays in Northern Tanzania through the Three Delays

Introduction

Emergency conditions cause a significant burden of death and disability, particularly in developing countries. Prehospital and Emergency Medical Services (EMS) are largely nonexistent throughout Tanzania and little is known about the community's barriers to accessing emergency care. The objective of this study was to better understand local community stakeholder perspectives on barriers, facilitators, and potential solutions surrounding emergency care in the Kilimanjaro region through the Three Delays Model framework.

Methods

A qualitative assessment of local stakeholders was conducted through semi-structured focus group discussions (FGDs) from February to June 2021 with five separate groups: hospital administrators, emergency hospital workers, police personnel, fire brigade personnel, and community health workers. FGDs were conducted in Kiswahili, audio recorded, and translated to English verbatim. Two research analysts separately coded the first two FGDs using both inductive and deductive thematic analysis. A final codebook was then created to analyze the remaining FGDs.

Results

A total of 24 participants were interviewed. Thematic analysis revealed that participants identified significant barriers within the Three Delays Model as well as identified an additional delay centered on community members and first aid provision. Perceived delays in the decision to seek care, the first delay, were financial constraints and the lack of community education on emergency conditions. Limited infrastructure and reduced transportation access were thought to contribute to the second delay. Potential barriers to receiving timely appropriate care, the third delay, included upfront payments required by hospitals and emergency department intake delays. Suggested solutions focused on increasing education and improving communication and infrastructure.

Conclusion

The findings outline barriers to accessing emergency care from a stakeholder perspective. These themes can support recommendations for further strengthening of the prehospital and emergency care system. Due to logistical constraints, emergency care workers interviewed were all from one hospital and patients were not included.

Delays in seeking, reaching and access to quality cancer care in sub-Saharan Africa: a systematic review

OBJECTIVES

Late presentation and delays in diagnosis and treatment consistently translate into poor outcomes in sub-Saharan Africa (SSA). The aim of this study was to collate and appraise the factors influencing diagnostic and treatment delays of adult solid tumours in SSA.

DESIGN

Systematic review with assessment of bias using Risk of Bias in Non-randomised Studies of Exposures (ROBINS-E) tool.

DATA SOURCES

PubMed and Embase, for publications from January 1995 to March 2021.

ELIGIBILITY CRITERIA

Inclusion criteria: quantitative or mixed-method research, publications in English, on solid cancers in SSA countries.

EXCLUSION CRITERIA

paediatric populations, haematologic malignancies, and assessments of public perceptions and awareness of cancer (since the focus was on patients with a cancer diagnosis and treatment pathways).

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted and validated the studies. Data included year of publication; country; demographic characteristics; country-level setting; disease subsite; study design; type of delay, reasons for delay and primary outcomes.

RESULTS

57 out of 193 full-text reviews were included. 40% were from Nigeria or Ethiopia. 70% focused on breast or cervical cancer. 43 studies had a high risk of bias at preliminary stages of quality assessment. 14 studies met the criteria for full assessment and all totaled to either high or very high risk of bias across seven domains. Reasons for delays included high costs of diagnostic and treatment services; lack of coordination between primary, secondary and tertiary healthcare sectors; inadequate staffing; and continued reliance on traditional healers and complimentary medicines.

CONCLUSIONS

Robust research to inform policy on the barriers to quality cancer care in SSA is absent. The focus of most research is on breast and cervical cancers. Research outputs are from few countries. It is imperative that we investigate the complex interaction of these factors to build resilient and effective cancer control programmes.

Community stressors and coping mechanisms in accessing the health system during a double crisis: a qualitative case study from Yangon Region, Myanmar

BACKGROUND

Due to the COVID-19 pandemic and political crisis, Myanmar's health system has suspended routine services while struggling to respond to the pandemic. Many people who need continuous care, like pregnant women and people with chronic illnesses, have been facing challenges in seeking and receiving essential health services. This study explored community health seeking practices and coping mechanisms, including their views on health system stressors.

METHODS

This was a cross-sectional qualitative study based on 12 in-depth-interviews with pregnant people and persons with pre-existing chronic health conditions in Yangon. Sampling was purposive, convenience-based and snowball sampling was also used. The 3-delays framework was used to understand how persons were interacting with and accessing health care services; community and health system stressors and coping mechanisms in relation to COVID-19 were also identified.

RESULTS

Findings showed that Yangon region was the hardest hit with both the pandemic and political crisis and its health system was greatly affected. People were unable to access essential health services on time. The health facilities were not available to see patients, with serious shortages in human resources, medicines and equipment, resulting in interruption of essential routine services. The prices of medicines and consultation fees, and transportation costs, increased during this period. Limited options for accessing care were available due to travel restrictions and curfews. It became challenging to receive quality care because of unavailable public facilities and private hospitals being costly. Despite these challenges, the Myanmar people and health system have shown resilience. Cohesive and organized family support structures and extended and deep social networks played an important role in accessing health care. At times of emergency, people relied on community-based social organizations for transportation and accessing essential medicines. The health system also showed resilience through establishing new service provision options, such as teleconsultations, mobile clinics, and sharing medical advice through social media.

CONCLUSIONS

This is the first study in Myanmar to explore peoples' perceptions on COVID-19, the health system and their healthcare experiences during political crisis. Although there is no easy way to cope with this dual hardship, the people and the health system, even in a fragile and shock-prone setting like Myanmar, stayed resilient by developing alternative pathways for seeking and providing health services.

Maternal health and maternal health service utilization among female sex workers: A scoping review

BACKGROUND

High proportions of female sex workers (FSWs) become pregnant and have children. Many FSWs are at increased risk of maternal health complications due to factors such as poverty, violence, and healthcare barriers. Despite this, FSWs' maternal health and use of maternal health services (MHS) receive limited attention.

OBJECTIVES

The objectives of this scoping review are to (1) synthesize existing data on FSWs' maternal health and MHS utilization and (2) assess the state of peer-reviewed literature on FSWs' maternal health in regard to methodological approaches and reported outcomes.

ELIGIBILITY CRITERIA

Included articles were peer-reviewed, published in English, and reported empirical data on FSWs for outcomes related to antenatal care, pregnancy, and labor complications, postnatal and delivery care, and/or barriers to MHS.

SOURCES OF EVIDENCE

Article searches were conducted in PubMed, Web of Science, Global Health, Sociological Abstracts, Sociological Index, PsychInfo, and CINAHL.

CHARTING METHODS

Information extracted from eligible articles included publication year, study design, location, sample size, outcome measures, and findings. The "Three Delays" model was used to synthesize findings on barriers to MHS as relevant to phase I, II, or III delays.

RESULTS

Eighteen publications met the eligibility criteria. Studies were conducted in 11 countries and primarily reported quantitative data from cross-sectional surveys. The most frequently reported outcome was antenatal care utilization (n = 14), whereas few studies reported findings related to postnatal care and breastfeeding counseling (n = 2). Across publications, there was a substantial range in the proportion of FSWs who reported accessing different types of MHS.

CONCLUSION

Literature on FSWs' maternal health is limited and heterogenous. More research is needed that specifically focuses on measuring outcomes related to FSWs' maternal health and examines associated factors. Such work can inform future research directions and public health interventions for FSWs-a population of marginalized women whose maternal health has been overlooked in existing efforts.

Barriers and enablers to emergency obstetric and newborn care services use in Wolaita Zone, Southern Ethiopia: a qualitative case study

BACKGROUND

Globally, 11.4 million untreated obstetric complications did not receive Emergency Obstetric and Newborn Care (EmONC) services yearly, with the highest burden in low and middle-income countries. Half of the Ethiopian women with obstetric complications did not receive EmONC services. However, essential aspects of the problem have not been assessed in depth. This study, therefore, explored the various aspects of barriers and enablers to women's EmONC services utilization in southern Ethiopia.

METHODOLOGY

A qualitative case study research design was used in nine districts of the Wolaita Zone. A total of 37 study participants were selected using a purposive stratified sampling technique and interviewed till data saturation. Twenty-two key informant interviews were conducted among front-line EmONC service providers, managers, community leaders, and traditional birth attendants (TBAs). Individual in-depth interviews were conducted among 15 women with obstetric complications. The trustworthiness of the research was assured by establishing credibility, transferability, conformability, and dependability. NVivo 12 was used to assist with the thematic data analysis.

RESULT

Five themes emerged from the analysis: service users' perception and experience (knowledge, perceived quality, reputation, respectful care, and gender); community-related factors (misconceptions, traditional practices, family and peer influence, and traditional birth attendants' role); access and availability of services (infrastructure and transportation); healthcare financing (drugs and supplies, out-of-pocket expenses, and fee exemption); and health facility-related factors (competency, referral system, waiting time, and leadership).

CONCLUSION

Many women and their newborns in the study area suffered severe and life-threatening complications because of the non-utilization or delayed utilization of EmONC services. A key policy priority should be given to enhancing women's awareness, eliminating misconceptions, improving women's autonomy, and ensuring traditional practices' role in EmONC service utilization. Community awareness interventions are required to enhance service uptake. Furthermore, the health systems must emphasize improving the quality of care, inequitable distribution of EmONC facilities, and essential drugs. The financial constraints need to be addressed to motivate women from low socioeconomic status. Furthermore, intersectoral collaboration is required to maintain a legal framework to control and prohibit home deliveries and empower women.

Area of focus to handle delays related to maternal death in Ethiopia

Background

Maternal delay factors, together with medical factors, have a substantial role in determining maternity outcomes. Although several studies were conducted on delay factors that contribute to maternal death in Ethiopia, the studies were mostly focused either on an individual or at a provincial level factor with a limited number of study participants. In response to this gap, this study is aimed at exploring the magnitude and factors related to delay factors that contribute to maternal death in Ethiopia.

Methods

The study used maternal death surveillance data collected from different regions of Ethiopia, compiled between 2013 and 2021. A total of 4530 maternal deaths were reviewed during the study period. A Multilevel multinomial logistic regression model was applied to examine factors associated with delays related to maternal death. An adjusted relative risk ratio with a 95% confidence interval was stated and variables with p-values less than 0.05 were declared as significant predictors of maternal delay.

Result

Delay three (delay in receiving adequate and appropriate care once reached a health facility) has contributed to 36.3% of maternal deaths followed by delay one (delay in deciding to seek care when experiencing an obstetric emergency) and delay two (delay in reaching to an appropriate obstetric facility) where each of them contributed to 36.1% and 27.6% of maternal deaths respectively. In the multivariate multilevel multinomial model, maternal age, education status, and place of death were among the individual level factors associated with both delay two and delay three. Conversely, marital status and ANC follow-up were associated with delay two alone, while the timing of maternal death was associated with delay three. Residence and type of facility were provincial-level factors linked with both delay two and delay three, while the type of region was related to delay three of maternal death.

Conclusion

Both delay one and three have a major contribution to maternal death in Ethiopia. Individual and provincial level factors played an important role in determining delays related to maternal death. Therefore, it is crucial to account for measures that provide emphasis on the area of raising awareness on the utilization of Antenatal care (ANC) service, improving facility readiness to handle obstetrics emergencies, and narrowing down inequality among regions in service provision.

Three delays model applied to pediatric injury care seeking in Northern Tanzania: A mixed methods study

Pediatric injuries are a leading cause of morbidity and mortality in low-and middle-income countries. Timely presentation to care is key for favorable outcomes. The goal of this study was to identify and examine delays that children experience between injury and receiving definitive care at a zonal referral hospital in Northern Tanzania. Between November 2020 and October 2021, we enrolled 348 pediatric trauma patients, collecting quantitative data on referral and timing information. In-depth interviews (IDIs) to explain and explore delays to care were completed with a sub-set of 30 family members. Data were analyzed according to the Three Delays Model. 81.0% (n = 290) of pediatric injury patients sought care at an intermediary facility before reaching the referral hospital. Time from injury to presentation at the referral hospital was 10.2 hours [IQR 4.8, 26.5] if patients presented first to clinics, 8.0 hours [IQR 3.9, 40.0] if patients presented first to district/regional hospitals, and 1.4 hours [IQR 0.7, 3.5] if patients presented directly to the referral hospital. In-hospital mortality was 8.2% (n = 30); 86.7% (n = 26) of these children sought care at an intermediary facility prior to reaching the referral hospital. IDIs revealed themes related to each delay. For decision to seek care (Delay 1), delays included emergency recognition, applying first aid, and anticipated challenges. For reaching definitive care (Delay 2), delays included caregiver rationale for using intermediary facilities, the complex referral system, logistical challenges, and intermediary facility delays. For receiving definitive care (Delay 3), wait time and delays due to treatment cost existed at the referral hospital. Factors throughout the healthcare system contribute to delays in receipt of definitive care for pediatric injuries. To minimize delays and improve patient outcomes, interventions are needed to improve caregiver and healthcare worker education, streamline the current trauma healthcare system, and improve quality of care in the hospital setting.

Caregivers' perception and determinants of delayed presentation of children with severe malaria in an emergency room in Benin City, Nigeria

INTRODUCTION

Severe malaria is a leading cause of mortality due to late presentation to health facilities. Hence, there is a need to identify and mitigate factors promoting delayed presentation with severe malaria.

OBJECTIVE

This study aimed to evaluate determinants of delayed presentation of children with severe malaria in a tertiary referral hospital.

METHODS

This study adopted a descriptive, cross-sectional design. The participants were children with a diagnosis of severe malaria, based on WHO diagnostic criteria. Delayed presentation was defined as presentation at the referral centre at >3 days of illness. Inferential analyses were done to identify factors associated with delayed presentation. P < 0.05 was considered statistically significant.

RESULTS

A total of 126 children with severe malaria participated in the study; their mean (standard deviation) age was 4.2 (5.3) years. The prevalence of delayed presentation in this study is 37.3%. Socio-economic class (P = 0.003); marital status (P = 0.015) and the number of health facilities visited before admission in the referral centre (P = 0.008) were significantly associated with delayed presentation. Children from upper socio-economic class were thrice more likely to present late, compared to those from lower social class (odds ratio [OR] = 3.728, 95% confidence interval [CI]: 1.694-8.208; P = 0.001). Likewise, the Yorubas were more delayed than the Binis (OR = 0.408, 95% CI: 0.180-0.928; P = 0.033). There was a negative correlation between caregivers' perception of treatment (r = -0.113, P = 0.21) of convulsion in severe malaria and timing of presentation.

CONCLUSIONS

Delayed presentation is common with multifactorial determinants in the setting. Health education of caregivers on the consequences of delayed presentation in severe malaria is desirable.

Prolonged Casualty Care: Extrapolating Civilian Data to the Military Context

BACKGROUND

Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource-limitations, and system configuration to U.S. military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations.

METHODS

We conducted a 6 month analysis of an on-going, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape ('EpiC'). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using chi-squared and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models.

RESULTS

146 of 995 patients experienced PCC. The PCC group, compared to non-PCC, were more critically injured (66% vs 51%), received more critical interventions (36% vs 29%), had a greater proportionate mortality (5% vs 3%), longer hospital stays (3 vs 1 day), and higher SOFA scores (5 vs 3). The odds of 7-day mortality and a SOFA score ≥ 5 were 1.6 (OR: 1.59; 0.68, 3.74) and 3.6 (OR: 3.69; 2.11, 6.42) times higher, respectively, in PCC versus non-PCC patients.

CONCLUSIONS

EpiC enrolled critically injured patients with PCC who received resuscitative interventions. PCC patients had worse outcomes than non-PCC. EpiC will be a useful platform to provide on-going data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care.

LEVEL OF EVIDENCE

III; prospective comparative study.