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Avrith N, Suh Y, Sunderwirth R, Suleman S, Akrabi AM. Introduction of WHO BEC course for nurses at Bugando Medical Center in Mwanza, Tanzania. Afr J Emerg Med 2023; 13:274-280. [PMID: 37818153 PMCID: PMC10560998 DOI: 10.1016/j.afjem.2023.09.004] [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: 03/25/2023] [Revised: 07/15/2023] [Accepted: 09/15/2023] [Indexed: 10/12/2023] Open
Abstract
Introduction The Basic Emergency Care (BEC) course is an open-access training designed for frontline providers in low resource settings which focuses on recognizing and managing emergent conditions. This study describes the implementation of the BEC course for nurses at Bugando Medical Center (BMC) in Mwanza, Tanzania in March 2020 as part of an educational initiative to improve nurses' knowledge and confidence in providing emergency care. Methods This is a 2-week educational intervention with pre-post measurements. 12 nurses (cohort 1) received BEC training from in-country facilitators over the course of 4 days. A training-of-trainers (ToT) course followed immediately and the 5 newly trained facilitators then taught the BEC course to 12 additional nurses (cohort 2). Pre- and post-BEC knowledge was assessed with a standardized 25-question multiple choice (MCQ) exam; confidence levels were evaluated using a 4-point Likert scale survey; and qualitative feedback obtained was examined by thematic analysis. Results 24 participants completed the BEC course, 5 of which completed a ToT to become BEC facilitators. For the combined group, knowledge assessment scores improved significantly from 63.8% to 85.2% with a mean difference of 21.5% (t(24)= 9.3, p<0.0001). Similar improvements were seen when cohort 1 and cohort 2 were analyzed separately. Analysis comparing the results across different demographic groups demonstrated a significant improvement in post-course score for each group. Confidence levels increased significantly across all domains. Main qualitative feedback themes were: quality of teaching; method of teaching; applicability of training to daily nursing practice; more time allotment; and the need to expand the course to other healthcare providers and to rural sites. Conclusion Implementation of the BEC course at BMC led to an improvement in nursing emergency care knowledge and self-confidence. The course was well received and the ToT model was successful, giving the nurses the ability to train additional local nurses.
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Affiliation(s)
- Nita Avrith
- Mount Sinai Morningside Hospital, New York, New York, USA
| | - Young Suh
- Mount Sinai Morningside Hospital, New York, New York, USA
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Mboya EA, Ndumwa HP, Amani DE, Nkondora PN, Mlele V, Biyengo H, Mashoka R, Haniffa R, Beane A, Mfinanga J, Sunguya BF, Sawe HR, Baker T. Critical illness at the emergency department of a Tanzanian national hospital in a three-year period 2019-2021. BMC Emerg Med 2023; 23:86. [PMID: 37553630 PMCID: PMC10408204 DOI: 10.1186/s12873-023-00858-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Critically ill patients have life-threatening conditions requiring immediate vital organ function intervention. But, critical illness in the emergency department (ED) has not been comprehensively described in resource-limited settings. Understanding the characteristics and dynamics of critical illness can help hospitals prepare for and ensure the continuum of care for critically ill patients. This study aimed to describe the pattern and outcomes of critically ill patients at the ED of the National Hospital in Tanzania from 2019 to 2021. METHODOLOGY This hospital-records-based retrospective cohort study analyzed records of all patients who attended the ED of Muhimbili National Hospital between January 2019 and December 2021. Data extracted from the ED electronic database included clinical and demographic information, diagnoses, and outcome status at the ED. Critical illness in this study was defined as either a severe derangement of one or more vital signs measured at triage or the provision of critical care intervention. Data were analyzed using Stata 17 to examine critical illnesses' burden, characteristics, first-listed diagnosis, and outcomes at the ED. RESULTS Among the 158,445 patients who visited the ED in the study period, 16,893 (10.7%) were critically ill. The burden of critical illness was 6,346 (10.3%) in 2019, 5,148 (10.9%) in 2020, and 5,400 (11.0%) in 2021. Respiratory (18.8%), cardiovascular (12.6%), infectious diseases (10.2%), and trauma (10.2%) were the leading causes of critical illness. Most (81.6%) of the critically ill patients presenting at the ED were admitted or transferred, of which 11% were admitted to the ICUs and 89% to general wards. Of the critically ill, 4.8% died at the ED. CONCLUSION More than one in ten patients attending the Tanzanian National Hospital emergency department was critically ill. The number of critically ill patients did not increase during the pandemic. The majority were admitted to general hospital wards, and about one in twenty died at the ED. This study highlights the burden of critical illness faced by hospitals and the need to ensure the availability and quality of emergency and critical care throughout hospitals.
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Affiliation(s)
- Erick A. Mboya
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Harrieth P. Ndumwa
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Davis E. Amani
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Paulina N. Nkondora
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Victoria Mlele
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Happines Biyengo
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ramadhan Mashoka
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Rashan Haniffa
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- University College London Hospitals, London, UK
| | - Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Juma Mfinanga
- Emergency Medicine Department, Dar es Salaam, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Bruno F. Sunguya
- School of Public Health and Social Sciences, Dar es Salaam, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hendry R. Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Tim Baker
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Jiang LG, Greenwald PW, Alfonzo MJ, Torres-Lavoro J, Garg M, Munir Akrabi A, Sylvanus E, Suleman S, Sundararajan R. An International Virtual Classroom: The Emergency Department Experience at Weill Cornell Medicine and Weill Bugando Medical Center in Tanzania. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:690-697. [PMID: 34593591 PMCID: PMC8514026 DOI: 10.9745/ghsp-d-21-00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 07/20/2021] [Indexed: 11/15/2022]
Abstract
Emergency medicine (EM) is rapidly being recognized as a specialty around the globe. This has particular promise for low- and middle-income countries (LMICs) that experience the largest burden of disease for emergency conditions. Specialty education and training in EM remain essentially an apprenticeship model. Finding the required expertise to educate graduate learners can be challenging in regions where there are low densities of specialty providers.We describe an initiative to implement a sustainable, bidirectional partnership between the Emergency Medicine Departments of Weill Cornell Medicine (WCM) in New York, NY, USA, and Bugando Medical Center (BMC) in Mwanza, Tanzania. We used synchronous and asynchronous telecommunication technology to enhance an ongoing emergency medicine education collaboration.The Internet infrastructure for this collaboration was created by bolstering 4G services available in Mwanza, Tanzania. By maximizing the 4G signal, sufficient bandwidth could be created to allow for live 2-way audio/video communication. Using synchronous and asynchronous applications such as Zoom and WhatsApp, providers at WCM and BMC can attend real-time didactic lectures, participate in discussion forums on clinical topics, and collaborate on the development of clinical protocols. Proof of concept exercises demonstrated that this system can be used for real-time mentoring in EKG interpretation and ultrasound technique, for example. This system was also used to share information and develop operations flows during the COVID-19 pandemic. The use of telecommunication technology and e-learning in a format that promotes long-term, sustainable interaction is practical and innovative, provides benefit to all partners, and should be considered as a mechanism by which global partnerships can assist with training in emergency medicine in LMICs.
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Affiliation(s)
- Lynn G Jiang
- Department of Emergency Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY.
| | - Peter W Greenwald
- Department of Emergency Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Michael J Alfonzo
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Jane Torres-Lavoro
- Department of Emergency Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Manish Garg
- Department of Emergency Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Ally Munir Akrabi
- Department of Emergency Medicine, Weill Bugando Medical Center, Mwanza, Tanzania
| | - Erasto Sylvanus
- Department of Emergency Medicine, Weill Bugando Medical Center, Mwanza, Tanzania
| | - Shahzmah Suleman
- Department of Emergency Medicine, Weill Bugando Medical Center, Mwanza, Tanzania
| | - Radhika Sundararajan
- Department of Emergency Medicine, New York-Presbyterian Weill Cornell Medical Center, New York, NY.,Center for Global Health, Weill Cornell Medicine, New York, NY
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Mukhtar S, Saleem SG, Ali S, Khatri SA, Yaffee AQ. Standing at the edge of mortality; Five-year audit of an emergency department of a tertiary care hospital in a low resource setup. Pak J Med Sci 2021; 37:633-638. [PMID: 34104139 PMCID: PMC8155438 DOI: 10.12669/pjms.37.3.3680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background & Objective: Understanding the demographics of mortality and its burden in the emergency department of a tertiary care setup can lead to better planning and allocation of resources to streamline process flow. This can be achieved systematically through mortality audit that can identify the loopholes and areas of improvement. Our objective was to characterize the epidemiology of ED mortality in a tertiary care hospital of Karachi, Pakistan. Methods: A five-year retrospective chart review of 322 adult mortalities presenting between January l, 2014 – December 31, 2018 was conducted in the emergency department (ED) of The Indus Hospital (TIH), Karachi. All expiries in ED were included while those brought dead and with do not resuscitate order (DNAR) were excluded. Results: Mortality incidence of 0.076% (7.6/10,000 ED visits in five years) was reported. Amongst 507,759 adult ED visits, 322 mortalities were documented. Mean time lapse before presentation was 44±147 hours and mean length of stay before death was 3.4±2.8 hours. Acute coronary syndrome (ACS) was the predominant cause of death with 109 (33.8%) expiries. Significant association was reported between no history of prior care and high priority (P1) cases (p=0.013). Conclusions: This study identified the contributing factors to adverse outcome such as delayed presentation with systemic gaps in management and unknown disposition. The need to improve these factors at local and national level can lead to improvement in Pakistani healthcare sector.
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Affiliation(s)
- Sama Mukhtar
- Sama Mukhtar, FCPS. Consultant Emergency Department, The Indus Hospital, Karachi, Pakistan
| | - Syed Ghazanfar Saleem
- Syed Ghazanfar Saleem, FCPS. Consultant Emergency Department, The Indus Hospital, Karachi, Pakistan
| | - Saima Ali
- Saima Ali, FCPS. Consultant Emergency Department, The Indus Hospital, Karachi, Pakistan
| | - Sarfraz Ahmed Khatri
- Sarfraz Ahmed Khatri, FCPS -II Trainee. Resident Emergency Medicine, The Indus Hospital, Karachi, Pakistan
| | - Anna Q Yaffee
- Anna Q Yaffee, MD, MPH. Consultant EM, Grady Memorial Hospital, Emory University, Atlanta, USA
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DeVos E, Simon EL, Aluisio A. Funding sources for research: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S130-S134. [PMID: 33304795 PMCID: PMC7718450 DOI: 10.1016/j.afjem.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 08/30/2020] [Accepted: 09/12/2020] [Indexed: 11/25/2022] Open
Abstract
Research is a fundamental component of the development of quality emergency care systems. Developing qualified professionals and programs to conduct emergency care research is essential to understanding epidemiology in low resource settings. This leads to evaluating research outcomes, developing clinical practice guidelines and program implementation. This paper aims to introduce the reader to opportunities for research funding at various stages of one's career. We will discuss concepts necessary to obtain funding for research, a crucial step towards initiating a research program. The chapter further describes competitive funding mechanisms including governmental agencies, foundations and private industry along with organisations that offer funding for global health and emergency care research. We describe categories of grants specific to a stage of an investigator's career, developing a team for a proposal and the grant application process.
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Development and Implementation of Short Courses to Support the Establishment of a Prehospital System in Sub-Saharan Africa: Lessons Learned from Tanzania. Emerg Med Int 2019; 2019:3160562. [PMID: 31871789 PMCID: PMC6913157 DOI: 10.1155/2019/3160562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 11/17/2022] Open
Abstract
Background Tanzania has no formal prehospital system. The Tanzania Ministry of Health launched a formal prehospital system to address this gap. The Muhimbili University of Health and Allied Sciences (MUHAS) was tasked by the Ministry of Health to develop and implement a multicadre/provider prehospital curriculum so as to produce necessary healthcare providers to support the prehospital system. We aim to describe the process of designing and implementing the multicadre/provider prehospital short courses. The lessons learned can help inform similar initiatives in low- and middle-income countries. Methods MUHAS collaborated with local and international Emergency Medicine and Emergency Medical Services (EMS) specialists to form the Emergency Medical Systems Team (EMST) that developed and implemented four short courses on prehospital care. The EMST used a six-step approach to develop and implement the curriculum: problem identification, general needs assessment, targeted needs assessment, goals and objectives, educational strategies, and implementation. The EMST modified current best EMS practices, protocols, and curricula to be context and resource appropriate in Tanzania. Results We developed four prehospital short courses: Basic Ambulance Provider (BAP), Basic Ambulance Attendant (BAAT), Community First Aid (CFA), and EMS Dispatcher courses. The curriculum was vetted and approved by MUHAS, and courses were launched in November 2018. By the end of July 2019, a total of 63 BAPs, 104 BAATs, 25 EMS Dispatchers, and 287 CFAs had graduated from the programs. The main lessons learned are the importance of a practical approach to EMS development and working with the existing government cadre/provider scheme to ensure sustainability of the project; clearly defining scope of practice of EMS providers before curriculum development; and concurrent development of a multicadre/provider curriculum to better address the logistical barriers of implementation. Conclusion We have provided an overview of the process of designing and implementing four short courses to train multiple cadres/providers of prehospital system providers in Tanzania. We believe this model of curricula development and implementation can be replicated in other countries across Africa.
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Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study. Afr J Emerg Med 2019; 9:14-20. [PMID: 30873346 PMCID: PMC6400013 DOI: 10.1016/j.afjem.2018.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/04/2018] [Accepted: 10/04/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Although emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K). METHODS At UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012-October 2013 (pre-training) and August 2015-July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS From 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3-7.5%), while post-training EC mortality was 1.2% (95% CI 0.7-1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03-0.17; p < 0.001). Pre-training overall hospital mortality was 12.2% (95% CI 10.9-13.8%). Post-training overall hospital mortality was 8.2% (95% CI 6.9-9.6%), resulting in a 43% reduction in mortality likelihood (aOR = 0.57, 95% CI 0.36-0.94; p = 0.016). DISCUSSION In the studied population, EM training and systems implementation was associated with significant mortality reductions demonstrating the potential patient-centered benefits of EM development in resource-limited settings.
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Muhanuzi B, Sawe HR, Kilindimo SS, Mfinanga JA, Weber EJ. Respiratory compromise in children presenting to an urban emergency department of a tertiary hospital in Tanzania: a descriptive cohort study. BMC Emerg Med 2019; 19:21. [PMID: 30819093 PMCID: PMC6393970 DOI: 10.1186/s12873-019-0235-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 02/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Respiratory compromise is the leading cause of cardiac arrest and death among paediatric patients. Emergency medicine is a new field in low-income countries (LICs); the presentation, treatment and outcomes of paediatric patients with respiratory compromise is not well studied. We describe the clinical epidemiology, management and outcomes of paediatric patients with respiratory compromise presenting to the first full-capacity Emergency Department in Tanzania. METHODS This was a prospective cohort study of paediatric patients (< 18 years) with respiratory compromise (respiratory distress, respiratory failure or respiratory arrest) presenting to the Emergency Medicine Department of Muhimibili National Hospital (EMD-MNH) in Dar es Salaam, from July-November 2017. A standardized case report form was used to record demographics, presenting clinical characteristics, management and outcomes. Primary outcomes were hospital mortality and secondary outcomes were EMD mortality, 24-h mortality, incidence of cardiac arrest in the EMD, length of stay, ICU admission, and risk factors for mortality. RESULTS We enrolled 165 children; their median age was 12 months [IQR: 4-36 months], and 90 (54.4%) were male. At presentation 92 (55.8%) children were in respiratory failure. Oxygen therapy was initiated for 143 (86.7%) children, among which 21 (14.7%) were intubated. The most common aetiologies were pneumonia followed by congenital heart disease and sepsis. The majority 147 (89.1%) of children were admitted to the hospital, with 20 (12%) going to ICU. Four (2%) children were discharged from EMD and 14 (8.5%) died in the EMD. In the EMD, 18 children developed cardiac arrest, with two surviving to hospital discharge. Overall 51 (30.9%) children died; 84% of deaths were in children under five years. Risk of mortality was increased in children presenting with decreased consciousness (RR = 2.2 (1.4-3.4)), hypoxia RR = 2.6 (1.6-4.4)) or bradypnoea (RR = 3.9 (2.9-5.0)), and those who received CPR (RR = 3.7 (2.7-5.2)) and intubation (RR = 3.1 (2.1-4.5)). CONCLUSIONS In this EMD of a LICs, respiratory compromise in children carries high mortality, with children of young age being the most vulnerable. Many children arrived in respiratory failure and few children received ICU care. Outcomes can be improved by earlier recognition to prevent cardiac arrest, and more intensive treatment, including ICU and assisted ventilation.
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Affiliation(s)
- Biita Muhanuzi
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania. .,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
| | - Said S Kilindimo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Ellen J Weber
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
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Marombwa NR, Sawe HR, George U, Kilindimo SS, Lucumay NJ, Mjema KM, Mfinanga JA, Weber EJ. Performance characteristics of a local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania. BMC Pediatr 2019; 19:44. [PMID: 30709389 PMCID: PMC6357459 DOI: 10.1186/s12887-019-1417-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/25/2019] [Indexed: 11/12/2022] Open
Abstract
Background A number of region-specific validated triage systems exist; however very little is known about their performance in resource limited settings. We compare the local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania. Methodology Prospective descriptive study of consecutive under-fives seen at Muhimbili National Hospital (MNH), ED between November 2017 to April 2018. Patients were triaged according to Local Triage System (LTS), and the information collected were used to assign acuities in the other triage scales: Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), Manchester Triage Scale (MTS) and South African Triage Scale (SATS). Patients were then followed up to determine disposition and 24 h outcome. Sensitivity, specificity, positive and negative predictive values for admission and mortality were then calculated. Results A total of 384 paediatric patients were enrolled, their median age was 17 months (IQR 7–36 months). Using LTS, 67(17.4%) patients were triaged in level one, 291(75.8%) level 2 and 26 (6.8%) in level 3 categories. Overall admission rate was 59.6% and at 24 h there were five deaths (1.3%). Using Level 1 in LTS, and Levels 1 and 2 in other systems, sensitivity and specificity for admission for all triage scales ranged between 27.1–28.4% and 95.4–98% respectively, (PPV 90.3–95.3%, NPV 47.1–47.4%). Sensitivity for mortality was 80% for LTS, and 100% for the other scales, while specificity was low, yielding a PPV for all scales between 6.9 and 8%. Conclusion All triage scales showed poor ability to predict need for admission, however all triage scales except LTS predicted mortality. The test characteristics for the other scales were similar. Future studies should focus on determining the reliability and validity of each of these triage tools in our setting. Electronic supplementary material The online version of this article (10.1186/s12887-019-1417-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nafsa R Marombwa
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar Es Salaam-Tanzania Dar es Salaam, Tanzania
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar Es Salaam-Tanzania Dar es Salaam, Tanzania. .,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
| | - Upendo George
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Said S Kilindimo
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar Es Salaam-Tanzania Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Nanyori J Lucumay
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar Es Salaam-Tanzania Dar es Salaam, Tanzania
| | - Kilalo M Mjema
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar Es Salaam-Tanzania Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Ellen J Weber
- Department of Emergency Medicine, University of California, San Francisco, California, USA
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Shao PJ, Sawe HR, Murray BL, Mfinanga JA, Mwafongo V, Runyon MS. Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania. BMC Cardiovasc Disord 2018; 18:158. [PMID: 30068315 PMCID: PMC6090910 DOI: 10.1186/s12872-018-0895-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania. METHODS This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency. RESULTS We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45-67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively. CONCLUSION In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.
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Affiliation(s)
- Patrick J. Shao
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Hendry R. Sawe
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Brittany L. Murray
- Division of Paediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Juma A. Mfinanga
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Victor Mwafongo
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Michael S. Runyon
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina USA
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11
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Coralic Z, Sawe HR, Mfinanga JA, Cortez A, Koehl J, Siroker H, Reynolds TA. Ketamine procedural sedation in the emergency department of an urban tertiary hospital in Dar es Salaam, Tanzania. Emerg Med J 2018; 35:214-219. [PMID: 29358491 DOI: 10.1136/emermed-2017-206974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 12/01/2017] [Accepted: 12/19/2017] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVE We describe ketamine procedural sedations and associated adverse events in low-acuity and high-acuity patients in a resource-limited ED. METHODS This was a prospective observational study of ketamine procedural sedations at the Emergency Medical Department at the Muhimbili National Hospital in Dar es Salaam, Tanzania. We observed consecutive procedural sedations and recorded patient demographics, medications, vital signs, pulse oximetry, capnography and a priori defined adverse events (using standard definitions in emergency medicine sedation guidelines). All treatment decisions were at the discretion of the treating providers who were blinded to study measurements to simulate usual care. Data collection was unblinded if predefined safety parameters were met. For all significant adverse and unblinding events, ketamine causality was determined via review protocol. Additionally, providers and patients were assessed for sedation satisfaction. RESULTS We observed 54 children (median 3 years, range 11 days-15 years) and 45 adults (median 33 years, range 18-79 years). The most common indications for ketamine were burn management in children (55.6%) and orthopaedic procedures in adults (68.9%). Minor adverse events included nausea/vomiting (12%), recovery excitation (11%) and one case of transient hypertension. There were nine (9%) patients who had decreased saturation readings (SpO2 ≤92%). There were three deaths, all in severely injured patients. After review protocol, none of the desaturations or patient deaths were thought to be caused by ketamine. No patient experienced ketamine-related laryngospasm, apnoea or permanent complications. Overall, ketamine was well tolerated and resulted in high patient and provider satisfaction. CONCLUSION In this series of ketamine sedations in an urban, resource-limited ED, there were no serious adverse events attributable to ketamine.
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Affiliation(s)
- Zlatan Coralic
- Department of Pharmacy, University of California San Francisco, San Francisco, California, USA.,Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Alfredo Cortez
- Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Koehl
- Department of Pharmacy, University of Wisconsin, Madison, Wisconsin, USA
| | - Hannah Siroker
- Department of Emergency Medicine, Highland Hospital, Oakland, California, USA
| | - Teri A Reynolds
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA.,Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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12
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Young JR, Sawe HR, Mfinanga JA, Nshom E, Helm E, Moore CG, Runyon MS, Reynolds SL. Subdissociative intranasal ketamine plus standard pain therapy versus standard pain therapy in the treatment of paediatric sickle cell disease vaso-occlusive crises in resource-limited settings: study protocol for a randomised controlled trial. BMJ Open 2017; 7:e017190. [PMID: 28698351 PMCID: PMC5541700 DOI: 10.1136/bmjopen-2017-017190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Pediatric sickle cell disease, highly prevalent in sub-Saharan Africa, carries great morbidity and mortality risk. Limited resources and monitoring make management of acute vaso-occlusive crises challenging. This study aims to evaluate the efficacy and safety of subdissociative intranasal ketamine as a cheap, readily available and easily administered adjunct to standard pain therapy. We hypothesise that subdissociative, intranasal ketamine may significantly augment current approaches to pain management in resource-limited settings in a safe and cost-effective manner. METHODS AND ANALYSIS This is a multicentred, randomised, double-blind, placebo-controlled trial enrolling children 4-16 years of age with sickle cell disease and painful vaso-occlusive pain crises. Study sites include two sub-Saharan teaching and referral hospitals with acute intake areas. All patients receive standard analgesic therapy during evaluation. Patients randomised to the treatment arm receive 1 mg/kg intranasal ketamine at onset of therapy, while placebo arm participants receive volume-matched intranasal normal saline. All participants and clinical staff are blinded to the treatment allocation. Data will be analysed on an intention-to-treat basis. Primary endpoints are changes in self-report pain scales (Faces Pain Scale-Revised) at 30, 60 and 120 minutes and rates of adverse events. Secondary endpoints include hospital length of stay, total analgesia use and quality of life assessment 2-3 weeks postintervention. ETHICS AND DISSEMINATION The research methods for this study have been approved by the Cameroon Baptist Convention Health Board Institutional Review Board (IRB2015-07), the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol. IX/2299), Muhimbili National Hospital IRB (MNH/IRB/I/2015/14) and the Tanzanian Food and Drugs Authority (TFDA0015/CTR/0015/9). Data reports will be provided to the Data and Safety Monitoring Board (DSMB) periodically throughout the study as well as all reports of adverse events. All protocol amendments will also be reviewed by the DSMB. Study results, regardless of direction or amplitude, will be submitted for publication in relevant peer-reviewed journals. TRIAL REGISTRATION ClinicalTrials.Gov, NCT02573714. Date of registration: 8 October 2015. Pre-results.
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Affiliation(s)
- James R Young
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Hendry Robert Sawe
- Deparment of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Juma A Mfinanga
- Department of Emergency Medicine, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Ernest Nshom
- Department of Internal Medicine, CIMS, Mbingo Baptist Hospital, Cameroon Baptist Convention, Mbingo, Cameroon
| | - Ethan Helm
- Department of Pediatrics, Mbingo Baptist Hospital, Cameroon Baptist Convention, Mbingo, Cameroon
| | - Charity G Moore
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Michael S Runyon
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Stacy L Reynolds
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
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13
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Ro YS, Shin SD, Jeong J, Kim MJ, Jung YH, Kamgno J, Alain EMG, Hollong B. Evaluation of demands, usage and unmet needs for emergency care in Yaoundé, Cameroon: a cross-sectional study. BMJ Open 2017; 7:e014573. [PMID: 28167749 PMCID: PMC5293974 DOI: 10.1136/bmjopen-2016-014573] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To assess the burden of emergent illnesses and emergency care system usage by Yaoundé residents and to evaluate unmet needs for emergency care and associated barriers. DESIGN A cross-sectional study using a community-based survey. SETTING Yaoundé, Cameroon. PARTICIPANTS All residents living in Yaoundé were selected as the target population to investigate the needs and usage of emergency care in Yaoundé. 14 households in every health area (47 in total) were selected using 2-stage sampling. PRIMARY OUTCOME MEASURES Unmet needs for emergency care. RESULTS Among the 3201 participants from 619 households who completed the survey, 1113 (34.8%) with median age of 22 experienced 1 or more emergency conditions in the previous year. Respondents who experienced emergency conditions used emergency units (7.0%), outpatient clinics (46.5%) or hospitalisation (13.0%), and in overall, 68.8% of them reported unmet needs for emergency care. The primary reasons for not seeking healthcare were economic issues (37.2%) and use of complementary medicine (22.2%). Young age (adjusted OR (95% CI) 1.80 (1.23 to 2.62)), rental housing (1.50 (1.11 to 2.03)) and moderate household income (0.60 (0.36 to 0.99)) were associated with unmet needs for emergency care. CONCLUSIONS Residents of Yaoundé had a high demand for emergency care, and high unmet needs were observed due to low emergency care usage. Development of a cost-effective, universal emergency care system is urgently needed in Cameroon.
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Affiliation(s)
- Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Joongsik Jeong
- Korea International Cooperation Agency, Korea
- Department of Emergency Medicine, Centre des Urgences de Yaoundé, Yaoundé, Cameroon
| | - Min Jung Kim
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Young Hee Jung
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Joseph Kamgno
- Faculty of Medicine and Biomedical Services, Department of Epidemiology, University of Yaoundé, Yaoundé, Cameroon
| | | | - Bonaventure Hollong
- Department of Emergency Medicine, Centre des Urgences de Yaoundé, Yaoundé, Cameroon
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