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Delaney PG, Moussally J, Wachira BW. Future directions for emergency medical services development in low- and middle-income countries. Surgery 2024; 176:220-222. [PMID: 38599983 DOI: 10.1016/j.surg.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/20/2024] [Accepted: 02/29/2024] [Indexed: 04/12/2024]
Abstract
The lack of prehospital care access in low- and middle-income countries is one of the greatest unmet needs and, therefore, one of the most urgent priorities in global health. Establishing emergency medical services in low- and middle-income countries poses significant challenges and complexities, requiring solutions tailored to prevailing conditions, informed by needs assessments, and adapted to meet local demands in a culturally appropriate and sustainable manner. In areas without existing emergency medical services, patients must rely on informal networks of untrained bystanders and community members to provide first aid and transport to definitive care. Since 2005, training lay first responders has been recommended by the World Health Organization as the first step toward formal emergency medical services development. However, efforts to formalize lay first responders networks have not expanded with the increasing need for prehospital emergency care in low- and middle-income countries, despite their potential. The rapid expansion of communication technologies like mobile smartphones penetrating resource-limited settings offers effective and inexpensive options for dispatching and coordinating lay first responders that were not previously available. These technologies can also be used for more advanced emergency medical services, obviating expensive communications and dispatch infrastructure. Despite disproportionately bearing the global injury burden, lay first responders frequently lack accurate and comprehensive surveillance data secondary to widespread underreporting, especially for non-fatal events. Lay first responders expand surveillance, which may inform future targeted prevention efforts, assisting in the development of tailored countermeasures suited to local hazards and diseases. Emergency medical services development in low- and middle-income countries involves a strategic approach focused on understanding the unique needs of diverse communities, requiring broad stakeholder involvement to create a sense of ownership to maintain volunteer networks and enhance sustainability. By embracing these relatively low-cost, bottom-up strategies, low- and middle-income countries can develop more accessible, efficient, and community-oriented emergency medical systems, ultimately improving public health outcomes and averting preventable deaths to address the emergency burden.
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Affiliation(s)
- Peter G Delaney
- LFR International, Makeni, Sierra Leone; Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH.
| | - Jon Moussally
- TraumaLink, Dhaka, Bangladesh; Harvard T.H. Chan School of Public Health, Boston, MA
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Werner K, Hirner S, Offorjebe OA, Hosten E, Gordon J, Geduld H, Wallis LA, Risko N. A Systematic Review of Cost-Effectiveness of Treating Out of Hospital Cardiac Arrest: Implications for Resource-limited Health Systems. RESEARCH SQUARE 2024:rs.3.rs-4402626. [PMID: 38883781 PMCID: PMC11177998 DOI: 10.21203/rs.3.rs-4402626/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources. Objective To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings. Methods The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints. Results 468 unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in TOR protocols, professional prehospital defibrillator use, and CPR training followed by distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment. Conclusion Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings.
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Delaney PG, Eisner ZJ, Pine H, Klapow M, Thullah AH, Bamuleke R, Nuur IM, Raghavendran K. 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. Injury 2024; 55:111505. [PMID: 38531720 DOI: 10.1016/j.injury.2024.111505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/17/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024]
Abstract
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.
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Affiliation(s)
| | | | - Haleigh Pine
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Max Klapow
- Oxford University, Oxford, England, United Kingdom
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Delaney PG, De Vos S, Eisner ZJ, Friesen J, Hingi M, Mirza UJ, Kharel R, Moussally J, Smith N, Slingers M, Sun J, Thullah AH. 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. Injury 2024:111522. [PMID: 38599953 DOI: 10.1016/j.injury.2024.111522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/12/2024]
Abstract
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.
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Kulkarni AJ, Batra A, Eisner ZJ, Delaney PG, Pine H, Klapow MC, Raghavendran K. Prehospital hemorrhage management in low- and middle-income countries: A scoping review. World J Surg 2024; 48:547-559. [PMID: 38265259 DOI: 10.1002/wjs.12054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Low- and middle-income countries (LMICs) account for 90% of deaths due to injury, largely due to hemorrhage. The increased hemorrhage mortality burden in LMICs is exacerbated by absent or ineffective prehospital care. Hemorrhage management (HM) is an essential component of prehospital care in LMICs, yet current practices for prehospital HM and outcomes from first responder HM training have yet to be summarized. METHODS This review describes the current literature on prehospital HM and the impact of first responder HM training in LMICs. Articles published between January 2000 and January 2023 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for HM. Relevant articles were assessed for quality using the Newcastle-Ottawa scale. RESULTS Of the initial 994 articles, 20 met inclusion criteria representing 16 countries. Studies included randomized control trials, cohort studies, case control studies, reviews, and epidemiological studies. Basic HM curricula were found in 15 studies and advanced HM curricula were found in six studies. Traumatic hemorrhage was indicated in 17 studies while obstetric hemorrhage was indicated in three studies. First responders indicated HM use in 55%-76% of encounters, the most frequent skill they reported using. Mean improvements in HM knowledge acquisition post-course ranged from 23 to 58 percentage points following training for pressure and elevation, gauze application, and tourniquet application. CONCLUSIONS Our study summarizes the current literature on prehospital HM in LMICs pertaining to epidemiology, interventions, and outcomes. HM resources should be a priority for further development.
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Affiliation(s)
- Ashwin J Kulkarni
- University of Michigan Medical School, Ann Arbor, Michigan, USA
- LFR International, Los Angeles, California, USA
- Michigan Center for Global Surgery, Ann Arbor, Michigan, USA
| | - Amber Batra
- LFR International, Los Angeles, California, USA
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Zachary J Eisner
- University of Michigan Medical School, Ann Arbor, Michigan, USA
- LFR International, Los Angeles, California, USA
- Michigan Center for Global Surgery, Ann Arbor, Michigan, USA
| | - Peter G Delaney
- LFR International, Los Angeles, California, USA
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Haleigh Pine
- LFR International, Los Angeles, California, USA
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Maxwell C Klapow
- LFR International, Los Angeles, California, USA
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Krishnan Raghavendran
- LFR International, Los Angeles, California, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Onyango OO, Willows TM, McKnight J, Schell CO, Baker T, Mkumbo E, Maiba J, Khalid K, English M, Oliwa JN. Third delay in care of critically ill patients: a qualitative investigation of public hospitals in Kenya. BMJ Open 2024; 14:e072341. [PMID: 38176878 PMCID: PMC10773318 DOI: 10.1136/bmjopen-2023-072341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVES Third delay refers to delays in delivering requisite care to patients after they arrive at a health facility. In low-resource care settings, effective triage and flow of care are difficult to guarantee. In this study, we aimed to identify delays in the delivery of care to critically ill patients and possible ways to address these delays. DESIGN This was an exploratory qualitative study using in-depth interviews and patient journeys. The qualitative data were transcribed and aggregated into themes in NVivo V.12 Plus using inductive and deductive approaches. SETTING This study was conducted in four secondary-level public Kenyan hospitals across four counties between March and December 2021. The selected hospitals were part of the Clinical Information Network. PARTICIPANTS Purposive sampling method was used to identify administrative and front-line healthcare providers and patients. We conducted 12 in-depth interviews with 11 healthcare workers and patient journeys of 7 patients. Informed consent was sought from the participants and maintained throughout the study. RESULTS We identified a cycle of suboptimal systems for care with adaptive mechanisms that prevent quality care to critically ill patients. We identified suboptimal systems for identification of critical illness, inadequate resources for continuity care and disruption of the flow of care, as the major causes of delays in identification and the initiation of essential care to critically ill patients. Our study also illuminated the contribution of inflexible bureaucratic non-clinical business-related organisational processes to third delay. CONCLUSION Eliminating or reducing delays after patients arrive at the hospital is a time-sensitive measure that could improve the care outcomes of critically ill patients. This is achievable through an essential emergency and critical care package within the hospitals. Our findings can help emphasise the need for standardised effective and reliable care priorities to maintain of care of critically ill patients.
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Affiliation(s)
| | - Tamara M Willows
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacob McKnight
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Muhimbili, Tanzania, United Republic Of
| | - Elibariki Mkumbo
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
| | - John Maiba
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
| | - Karima Khalid
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Department of Anaesthesia and Critical Care, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Mike English
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacquie N Oliwa
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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Sebakeng M, Cox M. Experiences and Interventions by Botswana police officers in providing emergency care in road traffic collisions in the greater Gaborone region. Afr J Emerg Med 2023; 13:230-234. [PMID: 37711767 PMCID: PMC10497991 DOI: 10.1016/j.afjem.2023.08.004] [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: 10/19/2021] [Revised: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023] Open
Abstract
Background Close to 500 people die annually from Road Traffic Collisions in Botswana. The country's Emergency Medical Service is limited in capacity and coverage and greatest in the region of the capital city, Gaborone. Botswana Police Service officers are often first responders to the incidents and provide first aid, however the extent of their interventions and their experiences has not been studied. Methods A questionnaire based cross-sectional survey was conducted in January 2016 on a sample of 99 officers on past pre-hospital care training, attitudes towards providing pre-hospital care for accident victims, the number of road traffic collision related deaths and injuries encountered in the last 6 months, their interventions to the victims and limitations encountered in providing care. Results The officers self-reported attending to a median of 10 injured victims (IQR = 5 - 20) and a median of 2 deaths (IQR = 0 - 4) in the preceding 6 months. The officers generally acknowledged their role and responsibility to provide pre-hospital care to the victims. Officers frequently secured accident scenes and transported injured victims to health facilities. They rarely performed haemorrhage control on victims, performed any airway manoeuvres or splint injured limbs. The major limitations to providing care were lack of first aid supplies and personal protective equipment, lack of knowledge and skills to provide care and interference from onlookers at accident scenes. Conclusion Botswana Police officers in the greater Gaborone area attend to a considerable number of traffic related injuries and fatalities. These results support many opportunities for educational interventions to add value to pre-hospital care.
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Affiliation(s)
- M. Sebakeng
- Department of Emergency Medicine; Faculty of Medicine, University of Botswana
| | - M. Cox
- University of Sydney School of Medicine and Public Health
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Diango K, Mafuta E, Wallis LA, Cunningham C, Hodkinson P. Implementation and evaluation of a pilot WHO community first aid responder training in Kinshasa, DR Congo: A mixed method study. Afr J Emerg Med 2023; 13:258-264. [PMID: 37790995 PMCID: PMC10542602 DOI: 10.1016/j.afjem.2023.09.001] [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: 05/02/2023] [Revised: 08/30/2023] [Accepted: 09/03/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction Prehospital care in many low- and middle-income countries is underdeveloped and needs strengthening for improved outcomes. Where formal prehospital care systems are under development, integration of a layperson first responder programme may help improve access for those in need. The World Health Organization recently developed the Community First Aid Responder (CFAR) learning program in support of this system, providing that it may require adaptation to be contextually suitable and sustainably implemented at country level. This study assesses a pilot WHO CFAR course in Kinshasa, Democratic Republic of Congo, to inform future rollouts and related research. Methods We conducted a 3-day in-person pilot CFAR training with 42 purposively selected community health workers. Data collection involved quantitative and qualitative phases. The first consisted of structured pre- and post-training surveys, and a course evaluation by participants. The second consisted of two focus group discussions involving purposively selected community health workers in one group, and a convenience sample of course instructors and organisers in the other. Perceptions regarding course content, perceived knowledge acquisition and self-confidence gain were analysed using descriptive statistics for the quantitative data and content analysis for qualitative data. Results Course participants were predominantly male (76.3 %) with a median age of 42 years and most (80.5 %) had no prior first aid training. Most were satisfied that the learning objectives were reached, the logistics were adequate, and that the content and teaching language were appropriately tailored to local context. The majority (94.7 %) found the 3-day duration insufficient. There was a significant self-confidence gain regarding first aid skills (average 17.9 % in pre- to 95.3 % in post-training, p < 0.001). Favourable opinions on the course structure, content, logistics and teaching methods were noted. Conclusion A CFAR course pilot was successfully conducted in Kinshasa. The course is appropriate for context and well received by participants. It can form a key component of developing prehospital care systems in resource-constrained settings.
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Affiliation(s)
- Ken Diango
- Division of Emergency Medicine, Department of Family, Community and Emergency Care, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
| | - Eric Mafuta
- Kinshasa School of Public Health, University of Kinshasa, Commune Lemba, Kinshasa, DR Congo
| | - Lee A. Wallis
- Clinical Services and Systems, Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Charmaine Cunningham
- Division of Emergency Medicine, Department of Family, Community and Emergency Care, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
| | - Peter Hodkinson
- Division of Emergency Medicine, Department of Family, Community and Emergency Care, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
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Koranda NW, Knettel BA, Mabula P, Joshi R, Kisigo G, Klein C, Bunting A, Lauritsen M, O'Tool J, Dunlop SJ. Evaluating the impact of a training program in prehospital trauma care and mental health for traffic police in Arusha, Tanzania. Int Emerg Nurs 2023; 70:101346. [PMID: 37708788 DOI: 10.1016/j.ienj.2023.101346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/03/2023] [Accepted: 08/12/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Tanzania does not have a formalized prehospital Emergency Medical Services (EMS) response. As a result, traffic police play an integral role in the emergency response system. This study examines the potential impact of a brief training program in prehospital trauma care and mental health to improve knowledge, self-efficacy, and practice intentions related to trauma care among police officers. METHOD A cohort of 45 police officers were enrolled to participate in the training and accompanying evaluation. The training was 12 h long, held over 3 days, and included education on how to manage traumatic injuries in a prehospital environment. The course included classroom instruction, hands on skills practice, and a training simulation. Officers received instruction on conducting a primary survey, managing common airway, spinal cord, and bleeding emergencies, as well as coping strategies for their own mental health. Before and after the course, a 26-item assessment was administered to measure knowledge, self-efficacy, and practice intentions specific to the training. The study used paired-samples t-tests to compare scores in each of the three domains before and after the training. RESULTS Participants demonstrated significantly improved knowledge (M = 0.30, SD = 0.27; t(34) = 6.67, p <.001), greater self-efficacy (M = 0.44, SD = 0.53; t(34) = 4.97, p <.001), and more evidence-informed practice intentions (M = 0.12, SD = 0.28; t(34) = 2.55, p <.05) at the conclusion of the course. CONCLUSION Police officers who received the 12-hour training focused on trauma management were better prepared to respond to emergencies and demonstrated a greater understanding of prehospital trauma care. Further studies are required to assess real world impact of the training and to determine how to increase support for traffic police as emergency medical responders in low-resource settings.
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Affiliation(s)
- Nathan W Koranda
- Koranda O'Tool Paramedics Incorporated (KOPI Medical), United States; PrairieCare, United States.
| | - Brandon A Knettel
- Duke University, School of Nursing, United States; Duke Global Health Institute, United States
| | - Peter Mabula
- Koranda O'Tool Paramedics Incorporated (KOPI Medical), United States; Same Qualities Foundation, United Republic of Tanzania
| | - Rupa Joshi
- Koranda O'Tool Paramedics Incorporated (KOPI Medical), United States
| | - Godfrey Kisigo
- The London School of Hygiene & Tropical Medicine, United Kingdom
| | - Christine Klein
- Koranda O'Tool Paramedics Incorporated (KOPI Medical), United States; PrairieCare, United States
| | - Alec Bunting
- Koranda O'Tool Paramedics Incorporated (KOPI Medical), United States; Hennepin Healthcare, United States
| | | | | | - Stephen J Dunlop
- Koranda O'Tool Paramedics Incorporated (KOPI Medical), United States; Hennepin Healthcare, United States
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Hosaka L, Tupetz A, Sakita FM, Shayo F, Staton C, Mmbaga BT, Joiner AP. A qualitative assessment of stakeholder perspectives on barriers and facilitators to emergency care delays in Northern Tanzania through the Three Delays. Afr J Emerg Med 2023; 13:191-198. [PMID: 37456586 PMCID: PMC10344688 DOI: 10.1016/j.afjem.2023.06.007] [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: 11/15/2022] [Revised: 06/09/2023] [Accepted: 06/25/2023] [Indexed: 07/18/2023] Open
Abstract
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.
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Affiliation(s)
- Leah Hosaka
- University of Hawaii at Manoa School of Nursing, Honolulu, HI, United States
| | - Anna Tupetz
- Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Francis M. Sakita
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Durham, NC, United States
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Frida Shayo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Catherine Staton
- Duke Global Health Institute, Duke University, Durham, NC, United States
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Durham, NC, United States
- Department of Emergency Medicine, Duke University Medical Center, Durham, NC, United States
| | - Blandina T. Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, United States
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Durham, NC, United States
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Anjni Patel Joiner
- Duke Global Health Institute, Duke University, Durham, NC, United States
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Durham, NC, United States
- Department of Emergency Medicine, Duke University Medical Center, Durham, NC, United States
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Dworkin M, Agarwal-Harding KJ, Joseph M, Cahill G, Konadu-Yeboah D, Makasa E, Mock C. Indicators for the evaluation of musculoskeletal trauma systems: A scoping review and Delphi study. PLoS One 2023; 18:e0290816. [PMID: 37651448 PMCID: PMC10470913 DOI: 10.1371/journal.pone.0290816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 08/16/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Trauma is a leading cause of mortality and morbidity, disproportionately affecting low- and middle-income countries. Musculoskeletal trauma results in the majority of post-traumatic morbidity and disability globally. The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries. STUDY OBJECTIVES The purpose of this study was to establish a practical list of performance indicators to evaluate and monitor the quality and equity of musculoskeletal trauma care delivery in health systems worldwide. METHODS A scoping review was performed that identified performance indicators related to musculoskeletal trauma care. Indicators were organized by phase of care (general, prevention, pre-hospital, hospital, post-hospital) within a modified Donabedian model (structure, process, outcome, equity). A panel of 21 experts representing 45 countries was assembled to identify priority indicators utilizing a modified Delphi approach. RESULTS The scoping review identified 1,206 articles and 114 underwent full text review. We included 95 articles which reported 498 unique performance indicators. Most indicators related to the hospital phase of care (n = 303, 60%) and structural characteristics (n = 221, 44%). Mortality (n = 50 articles) and presence of trauma registries (n = 16 articles) were the most frequently reported indicators. After 3 rounds of surveys our panel reached consensus on a parsimonious list of priority performance indicators. These focused on access to trauma care; processes and key resources for polytrauma triage, patient stabilization, and hemorrhage control; reduction and immobilization of fractures and dislocations; and management of compartment syndrome and open fractures. CONCLUSIONS The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries. To create quality and equitable trauma systems, musculoskeletal care must be incorporated into development plans with continuous monitoring and improvement. The performance indicators identified by our expert panel and organized in a modified Donabedian model can serve as a method for evaluating musculoskeletal trauma care.
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Affiliation(s)
- M. Dworkin
- Department of Orthopaedic Surgery, The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, United States of America
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts, United States of America
| | - K. J. Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts, United States of America
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - M. Joseph
- Global Health and Social Medicine Department, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - G. Cahill
- Global Health and Social Medicine Department, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - D. Konadu-Yeboah
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - E. Makasa
- Wits-SADC Regional Collaboration Centre for Surgical Healthcare, Department of Surgery, Faculty of Health Sciences, School of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa
- Department of Surgery, School of Medicine, University of Zambia, Lusaka, Zambia
- Department of Surgery, Ministry of Health, University Teaching Hospitals (UTHs), Lusaka, Republic of Zambia
| | - C. Mock
- Department of Surgery, University of Washington, Seattle, Washington, United States of America
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Fanai S, Mohammadnezhad M. "Road traffic injury could be minimized when individual road users take more responsibility for their safety and the safety of others": Perception of healthcare workers in Vanuatu. Heliyon 2023; 9:e18580. [PMID: 37520998 PMCID: PMC10374962 DOI: 10.1016/j.heliyon.2023.e18580] [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: 05/23/2022] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Around 1.35 million deaths are caused by Road Traffic Injuries (RTIs) each year. This study aimed to explore the perceptions of Vanuatu's Health Care Workers (HCWs) regarding the existing preventative strategies for RTI. Materials and methods In 2020, this study used qualitative approaches to collect data from HCWs using Focus Group Discussions (FGDs). Study participants were self-identified Ni-Vanuatu HCWs who had been serving for more than 6 months in three main hospitals where the study was conducted and purposive sampling was used to gather the study participants. To guide the FGDs, a semi-structured open-ended questionnaire was created. Thematic analysis was used to processed the data obtained, based on predetermined themes that were based on theory while also enabling the data to determine new themes. Result From 5 FGDs with 22 HCWs who were emergency nurses, doctors and public health officers, data saturation was reached. The study yielded five main themes and sixteen subthemes. The relevance and trends of RTI, barriers to effective care, pre-hospital management capacity, barriers to pre-hospital care and addressing RTI were among the key subjects. The findings suggest that addressing health institutional leadership and resources will improve prevention of RTIs. Conclusion Prevention of RTIs is hindered by the lack of health institutional capacities in terms of leadership and resources that include emergency equipment, financial and trained human resources. The health sector should consider developing stronger leadership in road safety to be an essential part of its core business.
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Affiliation(s)
- Saen Fanai
- Department of Public Health, Ministry of Health, Port Vila, Vanuatu
| | - Masoud Mohammadnezhad
- School of Nursing and Healthcare Leadership, University of Bradford, Bradford, West Yorkshire, United Kingdom
- Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Nakhon Pathom, Thailand
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13
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Tupper H, Oke R, Juillard C, Dissak-DeLon F, Chichom-Mefire A, Mbianyor MA, Etoundi-Mballa GA, Kinge T, Njock LR, Nkusu DN, Tsiagadigui JG, Carvalho M, Yost M, Christie SA. The CBS test: Development, evaluation & cross-validation of a community-based injury severity scoring system in Cameroon. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002110. [PMID: 37494346 PMCID: PMC10370767 DOI: 10.1371/journal.pgph.0002110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/06/2023] [Indexed: 07/28/2023]
Abstract
Injury-related deaths overwhelmingly occur in low and middle-income countries (LMICs). Community-based injury surveillance is essential to accurately capture trauma epidemiology in LMICs, where one-third of injured individuals never present to formal care. However, community-based studies are constrained by the lack of a validated surrogate injury severity metric. The primary objective of this bipartite study was to cross-validate a novel community-based injury severity (CBS) scoring system with previously-validated injury severity metrics using multi-center trauma registry data. A set of targeted questions to ascertain injury severity in non-medical settings-the CBS test-was iteratively developed with Cameroonian physicians and laypeople. The CBS test was first evaluated in the community-setting in a large household-based injury surveillance survey in southwest Cameroon. The CBS test was subsequently incorporated into the Cameroon Trauma Registry, a prospective multi-site national hospital-based trauma registry, and cross-validated in the hospital setting using objective injury metrics in patients presenting to four trauma hospitals. Among 8065 surveyed household members with 503 injury events, individuals with CBS indicators (CBS+) were more likely to report ongoing disability after injury compared to CBS- individuals (OR 1.9, p = 0.004), suggesting the CBS test is a promising injury severity proxy. In 9575 injured patients presenting for formal evaluation, the CBS test strongly predicted death in patients after controlling for age, sex, socioeconomic status, and injury type (OR 30.26, p<0.0001). Compared to established injury severity scoring systems, the CBS test comparably predicts mortality (AUC: 0.8029), but is more feasible to calculate in both the community and clinical contexts. The CBS test is a simple, valid surrogate metric of injury severity that can be deployed widely in community-based surveys to improve estimates of injury severity in under-resourced settings.
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Affiliation(s)
- Haley Tupper
- Department of Surgery, Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, California, United States of America
| | - Rasheedat Oke
- Department of Surgery, Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, California, United States of America
| | - Catherine Juillard
- Department of Surgery, Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, California, United States of America
| | | | | | - Mbiarikai Agbor Mbianyor
- Department of Surgery, Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, California, United States of America
| | | | - Thompson Kinge
- Hospital Administration, The Limbe Regional Hospital, Lime, Cameroon
| | - Louis Richard Njock
- Hospital Administration, The Laquintinie Hospital of Douala, Douala, Cameroon
| | - Daniel N Nkusu
- Hospital Administration, The Catholic Hospital of Pouma, Pouma, Cameroon
| | | | - Melissa Carvalho
- Department of Surgery, Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, California, United States of America
| | - Mark Yost
- Department of Surgery, Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, California, United States of America
| | - S Ariane Christie
- Department of Surgery, Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, California, United States of America
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Clinical Practices Following Train-The-Trainer Trauma Course Completion in Uganda: A Parallel-Convergent Mixed-Methods Study. World J Surg 2023; 47:1399-1408. [PMID: 36872370 PMCID: PMC10156777 DOI: 10.1007/s00268-023-06935-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Despite the growth of trauma training courses worldwide, evidence for their impact on clinical practice in low- and middle-income countries (LMICs) is sparse. We investigated trauma practices by trained providers in Uganda using clinical observation, surveys, and interviews. METHODS Ugandan providers participated in the Kampala Advanced Trauma Course (KATC) from 2018 to 2019. Between July and September of 2019, we directly evaluated guideline-concordant behaviors in KATC-exposed facilities using a structured real-time observation tool. We conducted 27 semi-structured interviews with course-trained providers to elucidate experiences of trauma care and factors that impact adoption of guideline-concordant behaviors. We assessed perceptions of trauma resource availability through a validated survey. RESULTS Of 23 resuscitations, 83% were managed without course-trained providers. Frontline providers inconsistently performed universally applicable assessments: pulse checks (61%), pulse oximetry (39%), lung auscultation (52%), blood pressure (65%), pupil examination (52%). We did not observe skill transference between trained and untrained providers. In interviews, respondents found KATC personally transformative but not sufficient for facility-wide improvement due to issues with retention, lack of trained peers, and resource shortages. Resource perception surveys similarly demonstrated profound resource shortages and variation across facilities. CONCLUSIONS Trained providers view short-term trauma training interventions positively, but these courses may lack long-term impact due to barriers to adopting best practices. Trauma courses should include more frontline providers, target skill transference and retention, and increase the proportion of trained providers at each facility to promote communities of practice. Essential supplies and infrastructure in facilities must be consistent for providers to practice what they have learned.
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Kendall I, Borra V, Laermans J, McCaul M, Aertgeerts B, De Buck E. First aid training for laypeople. Hippokratia 2022. [DOI: 10.1002/14651858.cd015538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Irvin Kendall
- Centre for Evidence-Based Practice; Belgian Red Cross; Mechelen Belgium
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care; KU Leuven; Leuven Belgium
| | - Vere Borra
- Centre for Evidence-Based Practice; Belgian Red Cross; Mechelen Belgium
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care; KU Leuven; Leuven Belgium
- Cochrane First Aid; Mechelen Belgium
| | - Jorien Laermans
- Centre for Evidence-Based Practice; Belgian Red Cross; Mechelen Belgium
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care; KU Leuven; Leuven Belgium
- Cochrane First Aid; Mechelen Belgium
| | - Michael McCaul
- Centre for Evidence-Based Health Care, Department of Global Health, Division of Epidemiology and Biostatistics; Stellenbosch University; Cape Town South Africa
| | - Bert Aertgeerts
- Centre for Evidence-Based Medicine; Cochrane Belgium; Leuven Belgium
- Academic Center for General Practice, Department of Public Health and Primary Care; KU Leuven; Leuven Belgium
| | - Emmy De Buck
- Centre for Evidence-Based Practice; Belgian Red Cross; Mechelen Belgium
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care; KU Leuven; Leuven Belgium
- Cochrane First Aid; Mechelen Belgium
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16
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Slingers M, De Vos S, Sun JH. Ten years of the community-based emergency first aid responder (EFAR) system in the Western Cape of South Africa: What has happened, what has changed, and what has been learned. Afr J Emerg Med 2022; 12:299-306. [PMID: 35892007 PMCID: PMC9307512 DOI: 10.1016/j.afjem.2022.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 05/10/2022] [Accepted: 06/20/2022] [Indexed: 11/02/2022] Open
Abstract
The emergency first aid responder (EFAR) system was designed as a low-cost and adaptable community-based prehospital emergency care system, and was first published after conducting a study in the township of Manenberg, South Africa, in 2010. EFARs are laypersons who are trained to respond to emergencies in their communities, and can provide support to the emergency medical services (EMS) by providing early clinical care, reporting back about the scene, and assisting with local scene management and logistics. Over the past ten years in South Africa, the Western Cape Government Health (WCGH) EMS and the Western Cape Government (WCG) College of Emergency Care have implemented the EFAR system in multiple communities and have trained over 10,000 community members across the Western Cape. This report is a ten-year update on what has happened since the EFAR system started, and to candidly show how the system has evolved, what has been learned, and what challenges remain so that others could look ahead and plan accordingly as they develop similar community-based first aid responder systems in resource-constrained areas. Core pillars to the EFAR system's success have included community involvement and adaptation, collaboration with the WCGH EMS and WCG College of Emergency Care, opportunities for community and EMS development, and emphasis on the sustainability of local EFAR systems. Multiple challenges also remain that others may likely face.
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Affiliation(s)
- Marcus Slingers
- Western Cape Government College of Emergency Care.,Western Cape Government Health Emergency Medical Services
| | - Simonay De Vos
- Western Cape Government College of Emergency Care.,Western Cape Government Health Emergency Medical Services
| | - Jared H Sun
- University of Cape Town, Division of Emergency Medicine
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17
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Moussally J, Saha AC, Madden S. TraumaLink: A Community-Based First-Responder System for Traffic Injury Victims in Bangladesh. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100537. [PMID: 36041838 PMCID: PMC9426980 DOI: 10.9745/ghsp-d-21-00537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 06/01/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Road traffic injuries are a rapidly growing epidemic in low- and middle-income countries (LMICs). However, many countries lack formal prehospital emergency medical services, often leaving victims without access to first aid when it can be most effective in preventing death or disability. METHODS To address the lack of a dedicated prehospital emergency medical system in Bangladesh, we developed TraumaLink, a community-based network of volunteer first responders for traffic injury victims. The service uses an emergency hotline number and 24-hour call center with local first responders who are trained in basic trauma first aid, given essential medical supplies, and dispatched to crash scenes through mobile phone text message notifications. We designed the training curriculum to teach simple lifesaving skills that people with any level of education and no prior medical background could learn and perform. We retrospectively analyzed data originally collected for quality monitoring and evaluation to provide a descriptive analysis of the program's impact. RESULTS During the first 6 years, operations were expanded from a 14-km section of 1 highway to 135 km on 3 national highways, and free care was provided to 3,119 patients involved in 1,544 crashes. All calls to the service received a response, and in 88% of cases, first responders were at the scene in 5 minutes or less. Most patients were young adult men, and 76% of victims transported to the hospital arrived there within 30 minutes of the crash. Assessments of injury severity at the accident scene aligned closely with patient dispositions, reflecting the accuracy of these triage decisions. CONCLUSION The strong community support and rapid, reliable volunteer responses suggest that this flexible and scalable model could be expanded throughout Bangladesh and adapted for other LMICs that face similar challenges with traffic injury victims.
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Affiliation(s)
- Jon Moussally
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, MA, USA.
- TraumaLink, Dhaka, Bangladesh
| | | | - Susan Madden
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, MA, USA
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18
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Alayande B, Chu KM, Jumbam DT, Kimto OE, Musa Danladi G, Niyukuri A, Anderson GA, El-Gabri D, Miranda E, Taye M, Tertong N, Yempabe T, Ntirenganya F, Byiringiro JC, Sule AZ, Kobusingye OC, Bekele A, Riviello RR. Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. CURRENT TRAUMA REPORTS 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
Purpose of Review Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information The online version contains supplementary material available at 10.1007/s40719-022-00229-1.
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Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Alliance Niyukuri
- Hope Africa University, Bujumbura, Burundi
- Mercy Surgeons-Burundi, Research Department, Bujumbura, Burundi
- Mercy James Center for Paediatric Surgery and Intensive Care-Blantyre, Blantyre, Malawi
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Deena El-Gabri
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Mulat Taye
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ngyal Tertong
- International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK
| | - Tolgou Yempabe
- Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali, Rwanda
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Olive C. Kobusingye
- Makerere University School of Public Health, Kampala, Uganda
- George Institute for Global Health, Sydney, Australia
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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Holler JT, Cortez A, Challa S, Eliezer E, Hoanga B, Morshed S, Shearer DW. Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania. J Bone Joint Surg Am 2022; 104:716-722. [PMID: 35442248 DOI: 10.2106/jbjs.21.00727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. METHODS We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures. RESULTS Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission. CONCLUSIONS Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jordan T Holler
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Abigail Cortez
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Sravya Challa
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Edmund Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Billy Hoanga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - David W Shearer
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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20
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Pine H, Eisner ZJ, Delaney PG, Ogana SO, Okwiri DA, Raghavendran K. Prehospital Airway Management for Trauma Patients by First Responders in Six Sub-Saharan African Countries and Five Other Low- and Middle-Income Countries: A Scoping Review. World J Surg 2022; 46:1396-1407. [PMID: 35217888 DOI: 10.1007/s00268-022-06481-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
Abstract
The global injury burden disproportionately affecting low- and middle-income countries (LMICs) is exacerbated by a lack of robust emergency medical services. Though airway management (AM) is an essential component of prehospital emergency care, the current standard of prehospital AM training and resources for first responders in LMICs is unknown. This scoping review includes articles published between January 2000 and June 2021, identified using PMC, MEDLINE, and SCOPUS databases, following PRISMA-ScR guidelines. Inclusion criteria spanned programs training formal or informal prehospital first responders. Included articles were assessed for quality using the Newcastle-Ottawa scale. Relevant characteristics were extracted by multiple authors to assess prehospital AM training. Of the initial 713 articles, 17 met inclusion criteria, representing 11 countries. Basic AM curricula were found in 11 studies and advanced AM curricula were found in nine studies. 35.3% (n = 6) of first responder programs provided no equipment to basic life support (BLS) AM training participants, reporting a median cost of $7.00USD per responder trained. Median frequency of prehospital AM intervention was reported in 31.0% (IQR: 6.0, 50.0) of patient encounters (advanced life support trainees: 12.1%, BLS trainees: 32.0%). In three studies, adverse event frequencies during intubation occurred with a median frequency of 22.0% (IQR: 21.0, 22.0). The training deficit in advanced AM interventions in LMICs suggests BLS AM courses should be prioritized, especially in sub-Saharan Africa. Prehospital AM resources are sparse and should be a priority for future development.
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Affiliation(s)
- Haleigh Pine
- Washington University in St. Louis McKelvey School of Engineering, 1 Brookings Drive, St. Louis, MO, 63130, USA. .,LFR International, Los Angeles, CA, USA.
| | - Zachary J Eisner
- LFR International, Los Angeles, CA, USA.,University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI, 48109, USA.,Michigan Center for Global Surgery, 1301 Catherine St, Ann Arbor, MI, 48109, USA
| | - Peter G Delaney
- LFR International, Los Angeles, CA, USA.,University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI, 48109, USA.,Michigan Center for Global Surgery, 1301 Catherine St, Ann Arbor, MI, 48109, USA
| | - Simon Ochieng Ogana
- Masinde Muliro University of Science and Technology, Kakamega Webuye Highway, P.O. Box 190-50100, Kakamega, Kenya
| | - Dinnah Akosa Okwiri
- Masinde Muliro University of Science and Technology, Kakamega Webuye Highway, P.O. Box 190-50100, Kakamega, Kenya
| | - Krishnan Raghavendran
- Michigan Center for Global Surgery, 1301 Catherine St, Ann Arbor, MI, 48109, USA.,University of Michigan Medicine Department of Surgery, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
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Eisner ZJ, Delaney PG, Pine H, Yeh K, Aleem IS, Raghavendran K, Widder P. Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial. Spinal Cord 2022; 60:726-732. [PMID: 35194169 DOI: 10.1038/s41393-022-00764-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Non-inferiority trial. OBJECTIVE Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels. SETTING Washington University in St. Louis. METHODS Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states. RESULTS C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CSseated = 0.89, CSsupine = 0.47). Foam neck braces are inferior (CSseated = 2.35, CSsupine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior. CONCLUSIONS Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.
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Affiliation(s)
- Zachary J Eisner
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA. .,LFR International, Los Angeles, CA, USA.
| | - Peter G Delaney
- LFR International, Los Angeles, CA, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Haleigh Pine
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.,LFR International, Los Angeles, CA, USA
| | - Kenneth Yeh
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.,LFR International, Los Angeles, CA, USA
| | - Ilyas S Aleem
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Patricia Widder
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
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Ayoola AS, Acker PC, Kalanzi J, Strehlow MC, Becker JU, Newberry JA. A qualitative study of an undergraduate online emergency medicine education program at a teaching Hospital in Kampala, Uganda. BMC MEDICAL EDUCATION 2022; 22:84. [PMID: 35135519 PMCID: PMC8822823 DOI: 10.1186/s12909-022-03157-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 02/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Globally, half of all years of life lost is due to emergency medical conditions, with low- and middle-income countries (LMICs) facing a disproportionate burden of these conditions. There is an urgent need to train the future physicians in LMICs in the identification and stabilization of patients with emergency medical conditions. Little research focuses on the development of effective emergency medicine (EM) medical education resources in LMICs and the perspectives of the students themselves. One emerging tool is the use of electronic learning (e-learning) and blended learning courses. We aimed to understand Uganda medical trainees' use of learning materials, perception of current e-learning resources, and perceived needs regarding EM skills acquisition during participation in an app-based EM course. METHODS We conducted semi-structured interviews and focus groups of medical students and EM residents. Participants were recruited using convenience sampling. All sessions were audio recorded and transcribed verbatim. The final codebook was approved by three separate investigators, transcripts were coded after reaching consensus by all members of the coding team, and coded data were thematically analyzed. RESULTS Twenty-six medical trainees were included in the study. Analysis of the transcripts revealed three major themes: [1] medical trainees want education in EM and actively seek EM training opportunities; [2] although the e-learning course supplements knowledge acquisition, medical students are most interested in hands-on EM-related training experiences; and [3] medical students want increased time with local physician educators that blended courses provide. CONCLUSIONS Our findings show that while students lack access to structured EM education, they actively seek EM knowledge and practice experiences through self-identified, unstructured learning opportunities. Students value high quality, easily accessible EM education resources and employ e-learning resources to bridge gaps in their learning opportunities. However, students desire that these resources be complemented by in-person educational sessions and executed in collaboration with local EM experts who are able to contextualize materials, offer mentorship, and help students develop their interest in EM to continue the growth of the EM specialty.
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Affiliation(s)
| | - Peter C. Acker
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joseph Kalanzi
- Department of Emergency Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Matthew C. Strehlow
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joseph U. Becker
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer A. Newberry
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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23
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Eisner ZJ, Delaney PG, Klapow MC, Raghavendran K, Klapow JC. Identifying a 'super-responder' phenomenon in three African countries: Implications for prehospital emergency care training. Injury 2022; 53:176-182. [PMID: 34645565 DOI: 10.1016/j.injury.2021.09.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 09/11/2021] [Accepted: 09/30/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The WHO recommends training lay first responders (LFRs) as the first step toward EMS development while Disease Control Priorities (DCP) suggests training 0.5%-1% of a population for adequate emergency catchment. After launching three LFR programs in Africa, this study investigated subsequent skill usage and conducted demographic analyses to inform future recruitment of high-responding LFRs. METHODS Demographic characteristics and individual LFR intervention frequencies were collected from a pooled sample of 887 of 1,291 total LFRs (68.7%) trained across programs launched in a staggered fashion between 2016-2019 in Uganda, Chad, and Sierra Leone. A Kruskal-Wallis Rank-Sum test assessed between-group differences among demographics in each location. Spearman's r was used to determine the relationship between response frequency and LFR characteristics. RESULTS Most LFRs trained did not use skills post-training (median LFR interventions=0.0 interventions/year [IQR:0.0,5.0]). Right-skewed intervention frequency distributions demonstrate high-responding outlier responder groups do exist in all locations (p<0.0001). Median LFR interventions of the top quartile of these active LFRs ("super-responders") was 26.0 interventions/year (IQR:16.7,35.0). "Super-responders" witnessed more road traffic injuries (RTIs) prior to training (p=0.033). LFRs who never responded were significantly younger (p=0.0020). Significant correlations were demonstrated between pooled RTIs witnessed and intervention frequency (r=0.13, p=0.032) and age and intervention frequency in Sierra Leone (r=-0.15, p=0.019). CONCLUSION Current DCP-recommended training of 0.5-1% of a given population for adequate emergency catchment may be an inefficient means of building emergency care capacity. Recruiting "super-responders" with select characteristics may achieve similar coverage while conserving valuable training resources in resource-limited African settings.
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Affiliation(s)
- Zachary J Eisner
- Washington University in St. Louis, Department of Biomedical Engineering, USA.
| | - Peter G Delaney
- University of Michigan Medical School, USA; Michigan Center for Global Surgery, USA
| | - Maxwell C Klapow
- Washington University in St. Louis, Department of Psychological and Brain Sciences, USA
| | - Krishnan Raghavendran
- Michigan Center for Global Surgery, USA; University of Michigan Department of Surgery, Division of Acute Care Surgery, USA
| | - Joshua C Klapow
- University of Alabama at Birmingham, School of Public Health, Department of Healthcare Organization and Policy, USA
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24
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Turner J, Duffy S. Orthopaedic and trauma care in low-resource settings: the burden and its challenges. INTERNATIONAL ORTHOPAEDICS 2021; 46:143-152. [PMID: 34655318 DOI: 10.1007/s00264-021-05236-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND BURDEN Trauma with its early and late consequences disproportionately effects those from poor countries. The availability of effective orthopaedic and trauma care varies significantly across the globe. CHALLENGES The balancing out of quality care is required to reach the health-related UN development goal set out in 2015. A multifactorial approach addressing local, national and international aspects is key to improving the discrepancy seen between high- and low-income countries.
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Affiliation(s)
- James Turner
- Bristol Royal Hospital for Children, Bristol, UK.
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25
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Delaney PG, Eisner ZJ, Bustos A, Hancock CJ, Thullah AH, Jayaraman S, Raghavendran K. Cost-Effectiveness of Lay First Responders Addressing Road Traffic Injury in Sub-Saharan Africa. J Surg Res 2021; 270:104-112. [PMID: 34649070 DOI: 10.1016/j.jss.2021.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/29/2021] [Accepted: 08/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND To investigate the cost-effectiveness of training lay first responders (LFRs) to address road traffic injury (RTI) in sub-Saharan Africa (SSA) as the first step toward formal emergency medical services (EMS) development. MATERIALS/METHODS Cost data from five LFR programs launched between 2008 and 2019 in SSA was collected for LFR cost estimation, including three prospective collections from our group. We systematically reviewed literature and projected aggregate disability-adjusted life years (DALYs) from RTI in SSA that are addressable by LFRs to inform cost-effectiveness ratios ($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP) to determine the cost-effectiveness of LFRs addressing RTIs in SSA, following WHO-CHOICE guidelines, which state cost-effectiveness ratios less than GDP per capita are considered "very cost-effective." RESULTS Average annual cost per LFR trained across five programs was calculated to be 16.32USD (training=4.04USD, supplies=12.28USD). Following WHO and Disease Control Priorities recommendations for adequate emergency catchment, initial training of 750 LFRs per 100,000 people would cost 12,239.47USD with projected total annual DALYs averted equal to 227.7 per 100,000. Cost per DALY averted would therefore be 53.75USD with appropriate LFR availability, less than sub-Saharan African GDP per capita (1,585.40USD) and the lowest sub-Saharan African GDP per capita (Burundi, 261.20USD). CONCLUSION Following WHO-CHOICE guidelines, training LFRs can be a highly cost-effective means to address RTI morbidity and mortality across sub-Saharan Africa. With EMS unavailable for 91.3% of the African population, training LFRs can be an affordable first step toward formal EMS development.
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Affiliation(s)
- Peter G Delaney
- University of Michigan Medical School,Ann Arbor, Michigan; LFR International, Los Angeles, California; Michigan Center for Global Surgery, Ann Arbor, Michigan.
| | - Zachary J Eisner
- LFR International, Los Angeles, California; Washington University in St. Louis, St. Louis, Missouri
| | - Aiza Bustos
- LFR International, Los Angeles, California; Washington University in St. Louis, St. Louis, Missouri
| | - Canaan J Hancock
- LFR International, Los Angeles, California; Washington University in St. Louis, St. Louis, Missouri
| | | | - Sudha Jayaraman
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Krishnan Raghavendran
- Michigan Center for Global Surgery, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
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26
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Tobias J, Cunningham A, Krakauer K, Nacharaju D, Moss L, Galindo C, Roberts M, Hamilton NA, Olsen K, Emmons M, Quackenbush J, Schreiber MA, Burns BS, Sheridan D, Hoffman B, Gallardo A, Jafri MA. Protect Our Kids: a novel program bringing hemorrhage control to schools. Inj Epidemiol 2021; 8:31. [PMID: 34517905 PMCID: PMC8436006 DOI: 10.1186/s40621-021-00318-w] [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: 02/24/2021] [Accepted: 03/09/2021] [Indexed: 11/15/2022] Open
Abstract
Background Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children. Methods The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers. Results One thousand eighteen educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent. Conclusions Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools.
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Affiliation(s)
- Joseph Tobias
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
| | - Aaron Cunningham
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Kelsi Krakauer
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Deepthi Nacharaju
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lori Moss
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
| | | | | | - Nicholas A Hamilton
- Department of Surgery, Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Kyle Olsen
- Portland Public Schools, Portland, OR, USA
| | | | | | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Beech S Burns
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA.,Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David Sheridan
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA.,Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Benjamin Hoffman
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
| | - Adrienne Gallardo
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
| | - Mubeen A Jafri
- Department of Surgery, Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.,Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA
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Evaluation of a First Responders Course in Rural North India. J Surg Res 2021; 268:485-490. [PMID: 34438189 DOI: 10.1016/j.jss.2021.07.023] [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: 03/02/2021] [Revised: 06/11/2021] [Accepted: 07/23/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Most mortality in trauma occurs in prehospital settings when the golden hour is spent accessing healthcare facilities rather than resuscitating and stabilizing. Assessments performed in the rural community of Nanakpur, India demonstrated a significant paucity of, and limited access to healthcare facilities. To address deficiencies in prehospital care, the All-India Institute of Medical Sciences (AIIMS) constructed the Basic Emergency Care Course (BECC). This study evaluated the BECCs efficacy in Nanakpur. METHODS The first responder courses took place in 2017 in Nanakpur. Local community health workers, known as Accredited Social Health Activists (ASHAs) were recruited as participants. Participants completed both a pre- and post-course evaluation to assess baseline knowledge and improvement. Participants then took a one-year post-course assessment to evaluate retention. RESULTS The course included 204 individuals, and over half (109/204) were ASHAs. Pre- and post-course test results were available for 70 participants and demonstrated a significant improvement in knowledge (P < 0.0001). The one-year knowledge retention assessment was completed by 48.6% (n = 53/109) of the original ASHAs. Comparisons between both the pre- and post-course assessment tests with the 12-mo retention assessment revealed a significant decay in knowledge (P < 0.0001). CONCLUSIONS This study demonstrates the feasibility of utilizing BECC to train ASHAs in Nanakpur as first responders. Participants demonstrated a significant improvement in knowledge immediately after the course. After one year, there was a significant loss in knowledge, highlighting the need for refresher courses. These data suggest potential for the use of BECC for training ASHAs countrywide to strengthen India's prehospital care system.
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Gwaram UA, Okoye OG, Olaomi OO. Observed benefits of a major trauma centre in a tertiary hospital in Nigeria. Afr J Emerg Med 2021; 11:311-314. [PMID: 33996421 PMCID: PMC8099736 DOI: 10.1016/j.afjem.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/21/2021] [Accepted: 04/16/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction A Trauma System or its components has been shown to improve trauma services and outcome of seriously injured patients. These organised services are non0existent or the components operate in isolation in most African countries. This study was done to identify the observed advances in trauma care service delivery, brought about by the beginning of operation of a trauma centre in the capital city of a West African country. Methodology The operation of the trauma centre was reviewed for progress in terms of organisation of care, in-hospital care, training, and referral system and injury prevention. In addition, the challenges facing the trauma centre were also reviewed and discussed. Results The trauma centre has brought about better organisation of care and specialist availability, various training in trauma surgery, advances in referral and injury prevention. Funding is an identified threat to the function of the centre. Discussion The trauma centre provided the drive for specialist training in trauma and changes in the process of care. Funding is a threat to optimal function, as was poor inter-relatedness with other local hospitals, pre-hospital services and rescue providers.
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Mulima G, Purcell LN, Maine R, Bjornstad EC, Charles A. Epidemiology of prehospital trauma deaths in Malawi: A retrospective cohort study. Afr J Emerg Med 2021; 11:258-262. [PMID: 33859929 PMCID: PMC8027520 DOI: 10.1016/j.afjem.2021.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/25/2021] [Accepted: 03/13/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Trauma is among the leading causes of death and disability in both adults and children worldwide. In Malawi, trauma patients are commonly brought in dead (BID). We aimed to describe the prevalence, sociodemographic, and injury-related characteristics of patients BID to Kamuzu Central Hospital (KCH), a referral hospital in Lilongwe, Malawi. Methods We retrospectively reviewed records of all patients BID in the trauma surveillance registry at KCH from February 2008 to September 2019. We excluded patients BID that did not present to the emergency centre, and were instead taken to the mortuary directly. We used descriptive statistics to evaluate the epidemiology of patients BID. Results We reviewed 106,198 trauma records and 1889 (1.8%) were BID patients. Most patients BID were male, in both adult (n = 1337/1528, 88.4%) and children (n = 231/360, 64.9%) cohorts. The mean age was 34.7 (SD 11.9) years in adults and 7.8 (SD 5.4) years in children. Among the adult BID patients, 33.2% were unemployed, 25.6% were construction workers, and 10.1% were small business owners or managers. The common injury mechanisms in adults were road traffic-related injuries (RTIs) (47.1%) and assaults (23.6%). In children, injuries resulted from RTIs (39.7%), with 74.4% of those were pedestrians hit by cars, drowning (22.9%), and burns (12.4%). In both groups, most injuries occurred on roads (60.2%) or at home (22.1%). Reported alcohol use at the time of trauma was present in 6.3%. The police (57.9%) and privately-owned vehicles (26.6%) transported most BID patients to KCH. Conclusion Efforts to reduce prehospital trauma mortality must focus on improving prehospital care, including training the police and community in basic life support and improving resources towards prehospital trauma care. Further efforts to reduce prehospital mortality must aim to decrease injuries on the roads and at home.
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Delaney PG, Eisner ZJ, Thullah AH, Muller BD, Sandy K, Boonstra PS, Scott JW, Raghavendran K. Evaluating a Novel Prehospital Emergency Trauma Care Assessment Tool (PETCAT) for Low- and Middle-Income Countries in Sierra Leone. World J Surg 2021; 45:2370-2377. [PMID: 33907897 DOI: 10.1007/s00268-021-06140-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND WHO recommends training lay first responders (LFRs) as the first step toward formal emergency medical services development, yet no tool exists to evaluate LFR programs. METHODS We developed Prehospital Emergency Trauma Care Assessment Tool (PETCAT), a seven-question survey administered to first-line hospital-based healthcare providers, to independently assess LFR prehospital intervention frequency and quality. PETCAT surveys were administered one month pre-LFR program launch (June 2019) in Makeni, Sierra Leone and again 14 months post-launch (August 2020). Using a difference-in-differences approach, PETCAT was also administered in a control city (Kenema) with no LFR training intervention during the study period at the same intervals to control for secular trends. PETCAT measured change in both the experimental and control locations. Cronbach's alpha, point bi-serial correlation, and inter-rater reliability using Cohen's Kappa assessed PETCAT reliability. RESULTS PETCAT administration to 90 first-line, hospital-based healthcare providers found baseline prehospital intervention were rare in Makeni and Kenema prior to LFR program launch (1.2/10 vs. 1.8/10). Fourteen months post-LFR program implementation, PETCAT demonstrated prehospital interventions increased in Makeni with LFRs (5.2/10, p < 0.0001) and not in Kenema (1.2/10) by an adjusted difference of + 4.6 points/10 (p < 0.0001) ("never/rarely" to "half the time"), indicating negligible change due to secular trends. PETCAT demonstrated high reliability (Cronbach's α = 0.93, Cohen's K = 0.62). CONCLUSIONS PETCAT measures changes in rates of prehospital care delivery by LFRs in a resource-limited African setting and may serve as a robust tool for independent EMS quality assessment.
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Affiliation(s)
- Peter G Delaney
- University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI, 48109, USA.
| | | | | | | | - Kpawuru Sandy
- Sierra Leone Red Cross Society, Freetown, Sierra Leone
| | | | - John W Scott
- University of Michigan Health System, Ann Arbor, MI, USA
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Banstola A, Smart G, Raut R, Ghimire KP, Pant PR, Joshi P, Joshi SK, Mytton J. State of Post-injury First Response Systems in Nepal-A Nationwide Survey. Front Public Health 2021; 9:607127. [PMID: 33959578 PMCID: PMC8093375 DOI: 10.3389/fpubh.2021.607127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/24/2021] [Indexed: 11/21/2022] Open
Abstract
Injuries account for 9.2% of all deaths and 9.9% of the total disability-adjusted life years in Nepal. To date, there has not been a systematic assessment of the status of first response systems in Nepal. An online survey was cascaded through government, non-governmental organisations and academic networks to identify first response providers across Nepal. Identified organisations were invited to complete a questionnaire to explore the services, personnel, equipment, and resources in these organisations, their first aid training activities and whether the organisation evaluated their first response services and training. Of 28 organisations identified, 17 (61%) completed the questionnaire. The range of services offered varied considerably; 15 (88.2%) provided first aid training, 9 (52.9%) provided treatment at the scene and 5 (29.4%) provided full emergency medical services with assessment, treatment and transport to a health facility. Only 8 (47.1%) of providers had an ambulance, with 6 (35.3%) offering transportation without an ambulance. Of 13 first aid training providers, 7 (53.8%) evaluated skill retention and 6 (46.2%) assessed health outcomes of patients. The length of a training course varied from 1 to 16 days and costs from US$4.0 to 430.0 per participant. There was a variation among training providers in who they train, how they train, and whether they evaluate that training. No standardisation existed for either first aid training or provision of care at the scene of an injury. This survey suggests that coordination and leadership will be required to develop an effective first response system across the country.
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Affiliation(s)
- Amrit Banstola
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Gary Smart
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Raju Raut
- Nepal Red Cross Society, Kathmandu, Nepal
| | | | - Puspa Raj Pant
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Prerita Joshi
- Nepal Injury Research Centre, Kathmandu Medical College Public Limited, Kathmandu, Nepal
| | - Sunil Kumar Joshi
- Department of Community Medicine, Kathmandu Medical College Public Limited, Kathmandu, Nepal
| | - Julie Mytton
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
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Robinson B, Purcell LN, Kajombo C, Gallaher J, Charles A. Outcomes of stab wounds presenting to Kamuzu Central Hospital in Malawi. Malawi Med J 2021; 33:1-6. [PMID: 34422227 PMCID: PMC8360291 DOI: 10.4314/mmj.v33i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Injuries are a leading cause of morbidity and mortality worldwide, necessitating that we understand the local burden of injury to improve injury-related trauma care and patient outcomes. The characteristics, outcomes, and risk factors for mortality following stab wounds in Malawi are poorly delineated. Methods This is a retrospective, descriptive analysis of patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, with stab wounds from February 2008 to May 2018. Univariate and bivariate analyses were performed to compare patient and injury characteristics based on mortality. We performed Poisson multivariate regression to predict the factors that increase the relative risk of mortality. Results During the study, 32,297 patients presented with assault. Of those patients, 2,352 (7.3%) presented with stab wounds resulting in a 3.2% (n=74) overall mortality. The majority of wounds were to the head or cervical spine (n=1,043, 44.6%), while injuries to the chest (n=319, 13.7%) were less frequent. We found an increased relative risk of mortality in patients who presented with an injury to the chest (RR 3.95, 95% CI 1.79-8.72, p=0.001) and who were brought in by the police (RR 33.24, 95% CI 11.23-98.35, p<0.001). Conclusion In this study, stab wounds accounted for 7.3% of all assault cases, with a 3.2% mortality. Though the commonest site of stab was the head, wounds to the chest conferred the highest relative risk of mortality. A multifaceted approach to reducing mortality is needed. Incorporating training of first responders in basic life support, including the police, may reduce stab-related mortality.
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Affiliation(s)
- Brittany Robinson
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill
| | | | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill
- Kamuzu Central Hospital, Lilongwe, Malawi
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Muthomi N, Wachira LJ, Ooko WS. Knowledge in pre-hospital emergency and risk management among outdoor adventure practitioners in East Africa afro-alpine mountains. Afr J Emerg Med 2021; 11:87-92. [PMID: 33680726 PMCID: PMC7910172 DOI: 10.1016/j.afjem.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION The enjoyment of nature and other benefits of outdoor activities happen amid inherent hazards. This calls for knowledge and competency in emergency and risk management. Practitioners in outdoor activities, such as mountaineering, thus need to be knowledgeable on how to manage risks and attend to emergencies in their practice. The study sought to establish the preparedness of East African mountaineering practitioners in prehospital emergency and risk management. It sought to establish their knowledge on prehospital emergency and risk management, based on their age, gender, level of education and refresher training. METHODS The study purposively sampled one hundred and thirty six (N = 136) outdoor adventure practitioners from the Afro-alpine mountain areas in East Africa. It was hypothesized that there would be no significant relationship between the outdoor practitioners' knowledge in prehospital emergency risk management and their age, gender, level of education, refresher training. Somers' d was used to test the hypotheses. RESULTS It was established that the knowledge scores of prehospital emergency and risk management for the mountaineering practitioners was low. It was also established that the knowledge scores of outdoor practitioners were not dependent on their age, gender, and work experience. However, there was a significant relationship between the outdoor adventure practitioners' knowledge scores and their highest level of education as well as refresher training. CONCLUSIONS The study concluded that there were gaps in the knowledge of prehospital risk management of the East African Afro-alpine mountaineering practitioners. It recommends frequent and regular training and re-certification among outdoor adventure practitioners in order to raise the knowledge in prehospital emergency risk management.
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Affiliation(s)
- Nkatha Muthomi
- Department of Recreation and Sports Management, School of Hospitality, Tourism and Leisure Studies, Kenyatta University, Nairobi, Kenya
| | - Lucy-Joy Wachira
- Department of Physical Education, Exercise and Sport Science, School of Public Health and Applied Human Sciences, Kenyatta University, Nairobi, Kenya
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Glèlè-Ahanhanzo Y, Kpade A, Kpozèhouen A, Levêque A, Ouendo EM. Can Professional Motorcyclists Be an Asset in the Immediate Post-Crash Care System in Benin? Baseline of Knowledge and Practices in the City of Cotonou (Benin). Open Access Emerg Med 2021; 13:1-11. [PMID: 33442307 PMCID: PMC7797346 DOI: 10.2147/oaem.s267828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose The situation of road crashes-related deaths remains problematic in low-income countries. The present study aims at analyzing the first-aid knowledge and practices of professional motorcyclists (PMs) in the city of Cotonou in Benin. Materials and Methods This is a cross-sectional analytical study conducted from 25 March to 19 April 2019 in Cotonou and concerned PMs registered in a fleet who gave their consent to participate in the study. The World Health Organization's two-stage adaptive cluster sampling technique was applied to select the eligible PMs while respecting the proportionality rate per fleet. A logistic regression analysis was done and the odds ratios were estimated with 95% confidence interval. Results The 430 PMs surveyed were all middle-aged men with an average age of 38.38 (±8.70). Among them, 62.56% knew at least one of the emergency phone numbers for the ambulance, police or fire services and 49.53% of the PMs knew at least one of the 3 techniques evaluated. In addition, 33.23% of PMs who had witnessed at least an RC stated that they had alerted the emergency services, and 32.27% said they had helped the victims. The main reason given for the lack of initiative in RCs was lack of knowledge of the course of action to take (19.64%). The level of knowledge was associated with the level of education (AOR: 3.11; CI 95%: 1.79-5.43) and with the length of experience (AOR: 2.56; CI 95%: 1.58-4.18). Conclusion This study reveals that the level of knowledge and practice of PMs in the field of first aid in Cotonou is low and demonstrates the relevance and the need to include this target group in the first-aid chain for road crashes in Benin.
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Affiliation(s)
- Yolaine Glèlè-Ahanhanzo
- Multidisciplinary Research Unit for Road Crashes Prevention (ReMPARt), Epidemiology and Biostatistic Department, Regional Institute of Public Health, Ouidah, Benin
| | | | - Alphonse Kpozèhouen
- Multidisciplinary Research Unit for Road Crashes Prevention (ReMPARt), Epidemiology and Biostatistic Department, Regional Institute of Public Health, Ouidah, Benin
| | - Alain Levêque
- Center for Research in Epidemiology, Biostatistics and Clinical Research, Public Health School (Université Libre de Bruxelles), Brussels, Belgium
| | - Edgard-Marius Ouendo
- Health Policies and Systems Department, Regional Institute of Public Health, Ouidah, Benin
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Barbosa E, Gulela B, Taimo MA, Lopes DM, Offorjebe OA, Risko N. A systematic review of the cost-effectiveness of emergency interventions for stroke in low- and middle-income countries. Afr J Emerg Med 2020; 10:S90-S94. [PMID: 33318909 PMCID: PMC7723908 DOI: 10.1016/j.afjem.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 04/11/2020] [Accepted: 05/20/2020] [Indexed: 11/18/2022] Open
Abstract
Background Stroke is a leading cause of death and disability globally, with an increasing incidence in low- and middle-income countries (LMICs). The successful treatment of acute stroke requires an organized, efficient and well-resourced emergency care system. However, debate exists surrounding the prioritization of stroke treatment programs given the high costs of treatment and the increased incidence of hemorrhagic stroke in LMICs. Economic data is helpful to guide evidence-based priority setting in health systems development, particularly in low-resource settings where scarcity requires careful stewardship of resources. This systematic review surveys the existing evidence surrounding the cost-effectiveness of interventions to address acute stroke in LMIC settings. Methods The authors conducted a PRISMA style systematic review of economic evaluations of interventions to address acute stroke in LMICs. Five databases were systematically searched for articles, which were then reviewed for inclusion. Results Of the 153 unique articles identified, 11 met the inclusion criteria. Four studies demonstrate the heavy economic burden on patients and households due to stroke. Two studies estimate that preventive measures are more cost-effective than acute treatments. Four studies directly examine the cost-effectiveness of thrombolysis and thrombectomy in three middle-income countries (Iran, China, and Brazil) with results ranging from roughly $2578 to $34,052 (2019 USD) per quality adjusted life-year saved. These results are similar to the cost-effectiveness ratios estimated in high-income settings. Finally, one study examined a care bundle that included acute treatment elements. Conclusions The findings reinforce the need for additional research support informed decision-making. The available evidence suggests that preventive measures should be prioritized over emergency treatment for acute stroke, particularly in settings of resource scarcity. Cost-effectiveness ratios do not compare favorably to estimates for other emergency care interventions in LMICs, such as basic emergency care training, implementation of triage systems, and basic trauma care. Cost-effectiveness is also likely to vary depending on local epidemiology. Overall, decision-makers should balance the economic evidence alongside social, political and cultural priorities when making resource allocation choices.
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Lee S, Onye A, Latif A. Emergency Anesthesia in Resource-Limited Areas. Adv Anesth 2020; 38:209-227. [PMID: 34106835 DOI: 10.1016/j.aan.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Anesthesia providers play a critical role in the gap between unmet surgical need and access to safe surgical care. Providers from high-income countries can help fill this gap, particularly during crises, but it is critical to provide care responsibly and ethically. Most unmet surgical need is in low-income and middle-income countries where limited infrastructural, human, and material resources pose significant challenges. Anesthesia providers must recognize these difficulties as they apply to the local context and plan accordingly. This article outlines some of the unique issues and provides a framework of considerations for safe and responsible anesthesia delivery in resource-limited areas.
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Affiliation(s)
- Seung Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, 6222 Charlotte R. Bloomberg, Baltimore, MD 21287, USA
| | - Azuka Onye
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, 9137 Sheikh Zayed Building, Baltimore, MD 21287, USA
| | - Asad Latif
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, 600 North Wolfe Street, Meyer 297A, Baltimore, MD 21287, USA.
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Prehospital care of trauma patients in Tanzania: medical knowledge assessment and proposal for safe transportation of neurotrauma patients. Spinal Cord Ser Cases 2020; 6:32. [DOI: 10.1038/s41394-020-0280-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 11/08/2022] Open
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Abstract
Anesthesia providers play a critical role in the gap between unmet surgical need and access to safe surgical care. Providers from high-income countries can help fill this gap, particularly during crises, but it is critical to provide care responsibly and ethically. Most unmet surgical need is in low-income and middle-income countries where limited infrastructural, human, and material resources pose significant challenges. Anesthesia providers must recognize these difficulties as they apply to the local context and plan accordingly. This article outlines some of the unique issues and provides a framework of considerations for safe and responsible anesthesia delivery in resource-limited areas.
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Affiliation(s)
- Seung Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, 6222 Charlotte R. Bloomberg, Baltimore, MD 21287, USA
| | - Azuka Onye
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, 9137 Sheikh Zayed Building, Baltimore, MD 21287, USA
| | - Asad Latif
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, 600 North Wolfe Street, Meyer 297A, Baltimore, MD 21287, USA.
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Eisner ZJ, Delaney PG, Thullah AH, Yu AJ, Timbo SB, Koroma S, Sandy K, Sesay AD, Turay P, Scott JW, Raghavendran K. Evaluation of a Lay First Responder Program in Sierra Leone as a Scalable Model for Prehospital Trauma Care. Injury 2020; 51:2565-2573. [PMID: 32917385 DOI: 10.1016/j.injury.2020.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/20/2020] [Accepted: 09/02/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The World Health Organization (WHO) recommends scaling-up lay first responder programs as the first step toward formal EMS development. MATERIALS AND METHODS We trained and equipped 4,529 lay first responders (LFRs) between June-December 2019 in Bombali District, Sierra Leone, with a 5-hour hands-on, contextually-adapted prehospital trauma course to cover 535,000 people. Instructors trained 1,029 LFRs and 50 local trainers in a training-of-trainers (TOT) model, who then trained an additional 3,500 LFRs. A validated, 23-question pre-/post-test measured knowledge improvement, while six- and nine-month follow-up tests measured knowledge retention. Incident reports tracked patient encounters to assess longitudinal impact. RESULTS Median pre-/post-test scores improved by 43.5 percentage points (34.8% vs. 78.3%, p<0.0001). Knowledge retention was assessed at six months, with median score dropping to 60.9%, while at nine months, median score dropped to 43.5%. Lay first responders participating in courses led by TOT trainers had a pre-/post-test median score improvement of 30.4 percentage points (21.7% vs. 52.2%, p<0.0001). LFRs treated 1,850 patients over six months, most frequently utilizing hemorrhage control skills in 61.2% of encounters (1,133/1,850). The plurality of patients were young adult males (36.8%) and 48.7% of encounters were motorcycle injury-related. CONCLUSION A 5-hour first responder course targeting laypeople demonstrates significant emergency care knowledge improvement and retention. By training networks of transportation providers, lay first responder programs represent a robust and scalable prehospital emergency care alternative for low-resource settings.
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Affiliation(s)
- Zachary J Eisner
- Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, United States; LFR International Encino, California, United States
| | - Peter G Delaney
- LFR International Encino, California, United States; University of Michigan Medical School, 1301 Catherine St., Ann Arbor, Michigan, United States; Michigan Center for Global Surgery, Ann Arbor, Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, United States.
| | - Alfred H Thullah
- LFR International Encino, California, United States; Agency for Rural Community Transformation, Plot 4, Lunsar-Makeni Highway, Makeni, Sierra Leone
| | - Amanda J Yu
- Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, United States; LFR International Encino, California, United States
| | - Sallieu B Timbo
- Sierra Leone Red Cross Society, 6, Liverpool St., Freetown, Sierra Leone
| | - Sylvester Koroma
- University of Makeni, Lunsar-Makeni Highway, Makeni, Sierra Leone
| | - Kpawuru Sandy
- Sierra Leone Red Cross Society, 6, Liverpool St., Freetown, Sierra Leone
| | | | - Patrick Turay
- LFR International Encino, California, United States; Holy Spirit Hospital, Makeni, Sierra Leone
| | - John W Scott
- Michigan Center for Global Surgery, Ann Arbor, Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, United States; University of Michigan Health System, Department of Surgery, 1500 E Medical Center Dr, Ann Arbor, MI, United States
| | - Krishnan Raghavendran
- Michigan Center for Global Surgery, Ann Arbor, Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, United States; University of Michigan Health System, Department of Surgery, 1500 E Medical Center Dr, Ann Arbor, MI, United States
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Delaney PG, Eisner ZJ, Blackwell TS, Ssekalo I, Kazungu R, Lee YJ, Scott JW, Raghavendran K. Exploring the factors motivating continued Lay First Responder participation in Uganda: a mixed-methods, 3-year follow-up. Emerg Med J 2020; 38:40-46. [PMID: 33127741 DOI: 10.1136/emermed-2020-210076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/20/2020] [Accepted: 09/27/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND The WHO recommends training lay first responders (LFRs) as the first step towards establishing emergency medical services (EMS) in low-income and middle-income countries. Understanding social and financial benefits associated with responder involvement is essential for LFR programme continuity and may inform sustainable development. METHODS A mixed-methods follow-up study was conducted in July 2019 with 239 motorcycle taxi drivers, including 115 (75%) of 154 initial participants in a Ugandan LFR course from July 2016, to evaluate LFR training on participants. Semi-structured interviews and surveys were administered to samples of initial participants to assess social and economic implications of training, and non-trained motorcycle taxi drivers to gauge interest in LFR training. Themes were determined on a per-question basis and coded by extracting keywords from each response until thematic saturation was achieved. RESULTS Three years post-course, initial participants reported new knowledge and skills, the ability to help others, and confidence gain as the main benefits motivating continued programme involvement. Participant outlook was unanimously positive and 96.5% (111/115) of initial participants surveyed used skills since training. Many reported sensing an identity change, now identifying as first responders in addition to motorcycle taxi drivers. Drivers reported they believe this led to greater respect from the Ugandan public and a prevailing belief that they are responsible transportation providers, increasing subsequent customer acquisition. Motorcycle taxi drivers who participated in the course reported a median weekly income value that is 24.39% higher than non-trained motorcycle taxi counterparts (p<0.0001). CONCLUSIONS A simultaneous delivery of sustained social and perceived financial benefits to LFRs are likely to motivate continued voluntary participation. These benefits appear to be a potential mechanism that may be leveraged to contribute to the sustainability of future LFR programmes to deliver basic prehospital emergency care in resource-limited settings.
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Affiliation(s)
- Peter G Delaney
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Zachary J Eisner
- McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | | | | | - Yang Jae Lee
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - John W Scott
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Krishnan Raghavendran
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
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Koome G, Atela M, Thuita F, Egondi T. Health system factors associated with post-trauma mortality at the prehospital care level in Africa: a scoping review. Trauma Surg Acute Care Open 2020; 5:e000530. [PMID: 33083557 PMCID: PMC7528423 DOI: 10.1136/tsaco-2020-000530] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/30/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Africa accounts forabout 90% of the global trauma burden. Mapping evidence on health systemfactors associated with post-trauma mortality is essential in definingpre-hospital care research priorities and mitigation of the burden. The studyaimed to map and synthesize existing evidence and research gaps on healthsystem factors associated with post-trauma mortality at the pre-hospital carelevel in Africa. METHODS A scoping review of published studies and grey literature was conducted. The search strategy utilized electronic databases comprising of Medline, Google Scholar, Pub-Med, Hinari and Cochrane Library. Screening and extraction of eligible studies was done independently and in duplicate. RESULTS A total of 782 study titles and or abstracts were screened. Of these, 32 underwent full text review. Out of the 32, 17 met the inclusion criteria for final review. The majority of studies were literature reviews (24%) and retrospective studies (23%). Retrospective and qualitative studies comprised 6% of the included studies, systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%), systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%). Reported post-trauma mortality ranged from 13% in Ghana to 40% in Nigeria. Reported preventable mortality is as high as 70% in South Africa, 60% in Ghana and 40% in Nigeria. Transport mode is the most studied health system factor (reported in 76% of the papers). Only two studies (12%) included access to pre-hospital care interventions aspects, nine studies (53%) included care providers aspects and three studies (18%) included aspects of referral pathways. The types of transport mode and referral pathway are the only factors significantly associated with post-trauma mortality, though the findings were mixed. None of the included studies reported significant associations between pre-hospital care interventions, care providers and post-trauma mortality. DISCUSSION Although research on health system factors and its influence on post-trauma mortality at the pre-hospital care level in Africa are limited, anecdotal evidence suggests that access to pre-hospital care interventions, the level of provider skills and referral pathways are important determinants of mortality outcomes. The strength of their influence will require well designed studies that could incorporate mixed method approaches. Moreover, similar reviews incorporating other LMICs are also warranted. Key Words: Health System Factors, Emergency Medical Services [EMS], Pre-hospital Care, Post-Trauma mortality, Africa.
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Affiliation(s)
- Gilbert Koome
- School of Public Health, University of Nairobi, Nairobi, Kenya
| | - Martin Atela
- Peterhouse, University of Cambridge, Cambridge, UK
| | - Faith Thuita
- School of Public Health, University of Nairobi, Nairobi, Kenya
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Konar S, Pavlov O, Durango-Espinosa Y, Garcia-Ballestas E, Joaquim AF, Ghosh A, Pal R, Moscote-Salazar LR, Agrawal A. Critical Appraisal of Traumatic Brain Injury and Its Management. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractCritical appraisal of traumatic brain injury (TBI) management has always been marred with a conflict of differential approaches, with claims and counterclaims of outcomes among the research groups. We performed this study to review the management of TBI from risk factors to outcomes including the comorbidities and final clinical status. In conjunction with the aforesaid stabilization of TBI cases, prophylactic and definitive surgical approaches and other supporting interventions will ultimately decide the final outcomes in the long run. Improvements in the quality of care for patients with severe TBI, with the reduction in mortality, have been demonstrated in high-income areas due to improvements in the health care system and not just in one isolated intervention. In the management of TBI, a fast and high index of suspicion is the key to success, from the initial assessment to the final rehabilitation of the cases, from the victim of risk factors to the victims of situation. The research groups feel that TBI prophylactic measures and primary care mitigation models are as important as definitive care, starting from prehospital care to dedicated care.
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Affiliation(s)
- Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neuro-Sciences, Bengaluru, Karnataka, India
| | - Orlin Pavlov
- Department of Neurosurgery, Fulda Clinic, Fulda, Germany
| | - Yeider Durango-Espinosa
- Department of Neurosurgery, Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Ezequiel Garcia-Ballestas
- Department of Neurosurgery, Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Andrei Fernandes Joaquim
- Division of Neurosurgery, Department of Neurology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Amrita Ghosh
- Department of Biochemistry, Medical College, Kolkata, West Bengal, India
| | - Ranabir Pal
- Department of Community Medicine, Mata Gujri Memorial Medical College & Lion Seva Kendra Hospital, Kishanganj, Bihar, India
| | - Luis Rafael Moscote-Salazar
- Department of Neurosurgery, Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
- Department of Neurosurgery, Paracelus Medical University, Salzburg, Austria
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Ndile ML, Saveman BI, Lukumay GG, Mkoka DA, Outwater AH, Backteman-Erlanson S. Traffic police officers' use of first aid skills at work: a qualitative content analysis of focus group discussions in Dar Es Salaam, Tanzania. BMC Emerg Med 2020; 20:72. [PMID: 32912156 PMCID: PMC7488336 DOI: 10.1186/s12873-020-00368-1] [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: 03/03/2020] [Accepted: 09/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background The World Health Organisation (WHO) recommends involving lay people in prehospital care. Several training programmes have been implemented to build lay responder first aid skills. Findings show that most programmes significantly improved participants’ first aid skills. However, there is a gap in knowledge of what factors influence the use of these skills in real situations. The current study aimed to describe police officers’ views on and experiences of factors that facilitate or hinder their use of trained first aid skills at work. Methods Thirty-four police officers participated in five focus group discussions. A structured interview guide was used to collect data. Interviews were audio-recorded and transcribed verbatim. Data were analysed using qualitative content analysis. Results We identified five categories of facilitators or hindrances. Training exposure was considered a facilitator; work situation and hospital atmosphere were considered hindrances; and the physical and social environments and the resources available for providing first aid could be either facilitators or hindrances. Conclusion Practical exposure during training is perceived to improve police officers’ confidence in applying their first aid skills at work. However, contextual factors related to the working environment need to be addressed to promote this transfer of skills.
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Affiliation(s)
- Menti L Ndile
- Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences (MUHAS), P.O. Box 65001, Dar es Salaam, Tanzania.
| | | | - Gift G Lukumay
- Department of Community Nursing, MUHAS, Dar es Salaam, Tanzania
| | - Dickson A Mkoka
- Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences (MUHAS), P.O. Box 65001, Dar es Salaam, Tanzania
| | - Anne H Outwater
- Department of Community Nursing, MUHAS, Dar es Salaam, Tanzania
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Ullrich SJ, DeWane MP, Cheung M, Fleming M, Namugga MM, Fu W, Kurigamba G, Kabuye R, Mabweijano J, Galukande M, Ozgediz D, Pei KY. Development of an Operative Trauma Course in Uganda-A Report of a Three-Year Experience. J Surg Res 2020; 256:520-527. [PMID: 32799000 DOI: 10.1016/j.jss.2020.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/01/2020] [Accepted: 07/11/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Trauma is a leading cause of morbidity and mortality in low-income countries. Improved health care systems and training are potential avenues to combat this burden. We detail a collaborative and context-specific operative trauma course taught to postgraduate surgical trainees practicing in a low-resource setting and examine its effect on resident practice. METHOD Three classes of second year surgical residents participated in trainings from 2017 to 2019. The course was developed and taught in conjunction with local faculty. The most recent cohort logged cases before and after the course to assess resources used during initial patient evaluation and operative techniques used if the patient was taken to theater. RESULTS Over the study period, 52 residents participated in the course. Eighteen participated in the case log study and logged 117 cases. There was no statistically significant difference in patient demographics or injury severity precourse and postcourse. Postcourse, penetrating injuries were reported less frequently (40 to 21% P < 0.05) and road traffic crashes were reported more frequently (39 to 60%, P < 0.05). There was no change in the use of bedside interventions or diagnostic imaging, besides head CT. Of patients taken for a laparotomy, there was a nonstatistically significant increase in the use of four-quadrant packing 3.4 to 21.7%) and a decrease in liver repair (20.7 to 4.3%). CONCLUSIONS The course did not change resource utilization; however, it did influence clinical decision-making and operative techniques used during laparotomy. Additional research is indicated to evaluate sustained changes in practice patterns and clinical outcomes after operative skills training.
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Affiliation(s)
- Sarah J Ullrich
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Michael P DeWane
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Fleming
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Martha M Namugga
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Whitney Fu
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Gideon Kurigamba
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Ronald Kabuye
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Jackie Mabweijano
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Moses Galukande
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Kevin Y Pei
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
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De Buck E, Laermans J, Vanhove AC, Dockx K, Vandekerckhove P, Geduld H. An educational pathway and teaching materials for first aid training of children in sub-Saharan Africa based on the best available evidence. BMC Public Health 2020; 20:836. [PMID: 32493323 PMCID: PMC7268765 DOI: 10.1186/s12889-020-08857-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND First aid training is a cost-effective way to decrease the burden of disease and injury in low- and middle-income countries (LMIC). Since evidence from Western countries has shown that children are able to learn first aid, first aid training of children in LMIC may be a promising way forward. Hence, our project aim was to develop contextualized materials to train sub-Saharan African children in first aid, based on the best available evidence. METHODS Systematic literature searches were conducted to identify studies on first aid education to children up to 18 years old (research question one), and studies investigating different teaching approaches (broader than first aid) in LMIC (research question two). A multidisciplinary expert panel translated the evidence to the context of sub-Saharan Africa, and evidence and expert input were used to develop teaching materials. RESULTS For question one, we identified 58 studies, measuring the effect of training children in resuscitation, first aid for skin wounds, poisoning etc. For question two, two systematic reviews were included from which we selected 36 studies, revealing the effectiveness of several pedagogical methods, such as problem-solving instruction and small-group instruction. However, the certainty of the evidence was low to very low. Hence expert input was necessary to formulate training objectives and age ranges based on "good practice" whenever the quantity or quality of the evidence was limited. The experts also placed the available evidence against the African context. CONCLUSIONS The above approach resulted in an educational pathway (i.e. a scheme with educational goals concerning first aid for different age groups), a list of recommended educational approaches, and first aid teaching materials for children, based on the best available evidence and adapted to the African context.
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Affiliation(s)
- Emmy De Buck
- Centre for Evidence-Based Practice, Belgian Red Cross, Motstraat 40, 2800, Mechelen, Belgium.
- Cochrane First Aid, Motstraat 40, 2800, Mechelen, Belgium.
- Department of Public Health and Primary Care, Faculty of Medicine, Catholic University of Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium.
| | - Jorien Laermans
- Centre for Evidence-Based Practice, Belgian Red Cross, Motstraat 40, 2800, Mechelen, Belgium
| | - Anne-Catherine Vanhove
- Centre for Evidence-Based Practice, Belgian Red Cross, Motstraat 40, 2800, Mechelen, Belgium
- Cochrane First Aid, Motstraat 40, 2800, Mechelen, Belgium
- Cochrane Belgium, Center for Evidence-Based Medicine (Cebam), Kapucijnenvoer 33, 3000, Leuven, Belgium
| | - Kim Dockx
- Centre for Evidence-Based Practice, Belgian Red Cross, Motstraat 40, 2800, Mechelen, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Faculty of Medicine, Catholic University of Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium
- Belgian Red Cross, Motstraat 40, 2800, Mechelen, Belgium
| | - Heike Geduld
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
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Ndile ML, Saveman BI, Outwater AH, Mkoka DA, Backteman-Erlanson S. Implementing a layperson post-crash first aid training programme in Tanzania: a qualitative study of stakeholder perspectives. BMC Public Health 2020; 20:750. [PMID: 32448350 PMCID: PMC7245810 DOI: 10.1186/s12889-020-08692-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background In low and middle-income countries (LMICs), laypersons play a significant role in providing initial care to injured victims of traffic accidents. Post-crash first aid (PFA) training programmes for laypersons have become an important response to addressing knowledge and skills gaps in pre-hospital care. However, little is known about factors influencing effective implementation of such programmes from stakeholders’ point of view. Therefore, this study aimed to explore views of stakeholders on potential factors that may facilitate or hinder successful implementation of a PFA training programme for lay persons. Methods Twelve semi-structured qualitative interviews with leaders at a traffic police department and leaders of an association of city bus drivers, taxi drivers and motorcycle taxis in Tanzania were conducted. Interviews were audio-recorded and transcribed verbatim. A thematic analysis approach was used to identify themes and sub-themes. Results Three themes pertaining to implementation of a PFA training programme were identified: Motivation for engaging in training, Constrains for engaging in training and Training processes. They consisted of a total of six sub-themes: “perceived benefits of first aid training” and “availability of incentives” were considered as facilitators to PFA training. “Availability of time to attend training” and “accessibility of training” were reported as a potential barriers to successful training. Finally, they felt that “methods of training delivery” and “availability of first aid training materials and equipment” could either facilitate or impede delivery of PFA training. Conclusion This study highlights potential facilitators and barriers to implementing a PFA training programme for lay persons from the perspectives of leaders from police department and associations of city bus drivers, taxi drivers, and motorcycle taxis. This may be useful information for other stakeholders, and may enable government-level leaders and persons higher up in the health service hierarchy to take action to meet WHO recommendations for emergency pre-hospital care.
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Affiliation(s)
- Menti L Ndile
- Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences (MUHAS), P.O BOX 65001, Dar es Salaam, Tanzania.
| | | | - Anne H Outwater
- Department of Community Nursing, MUHAS, Dar es Salaam, Tanzania
| | - Dickson A Mkoka
- Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences (MUHAS), P.O BOX 65001, Dar es Salaam, Tanzania
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Werner K, Risko N, Burkholder T, Munge K, Wallis L, Reynolds T. Cost-effectiveness of emergency care interventions in low and middle-income countries: a systematic review. Bull World Health Organ 2020; 98:341-352. [PMID: 32514199 PMCID: PMC7265944 DOI: 10.2471/blt.19.241158] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries. METHODS Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies. RESULTS Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied. CONCLUSION We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.
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Affiliation(s)
- Kalin Werner
- Department of Surgery, Division of Emergency Medicine, F51-62, Old Main Building, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Nicholas Risko
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, United States of America (USA)
| | - Taylor Burkholder
- Department of Emergency Medicine, University of Southern California, Los Angeles, USA
| | - Kenneth Munge
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Lee Wallis
- Department of Surgery, Division of Emergency Medicine, F51-62, Old Main Building, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Teri Reynolds
- Department for Clinical Services and Systems, Integrated Health Services, World Health Organization, Geneva, Switzerland
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Ndile ML, Lukumay GG, Bolenius K, Outwater AH, Saveman BI, Backteman-Erlanson S. Impact of a postcrash first aid educational program on knowledge, perceived skills confidence, and skills utilization among traffic police officers: a single-arm before-after intervention study. BMC Emerg Med 2020; 20:21. [PMID: 32188402 PMCID: PMC7079460 DOI: 10.1186/s12873-020-00317-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background An overwhelming proportion of road traffic deaths and injuries in low- and middle-income countries (LMICs) occur in prehospital environments. Lay first responders such as police officers play an important role in providing initial assistance to victims of road traffic injuries either alone or in collaboration with others. The present study evaluated a postcrash first aid (PFA) educational program developed for police officers in Tanzania. Method A 16-h PFA educational program was conducted in Dar es Salaam, Tanzania, for 135 police officers. Participants completed training surveys before, immediately and 6 months after the training (before, N = 135; immediately after, N = 135; after 6 months, N = 102). The primary outcome measures were PFA knowledge, perceived skills confidence, and skills utilization. Parametric and nonparametric tests were used to analyse changes in outcome. Results The mean PFA knowledge score increased from 44.73% before training (SD = 20.70) to 72.92% 6 months after training (SD = 18.12), p < .001, N = 102. The mean PFA perceived skills confidence score (measured on a 1–5 Likert scale) increased from 1.96 before training (SD = 0.74) to 3.78 6 months after training (SD = 0.70), p < .001, N = 102. Following training, application of the recovery position skill (n = 42, 46%) and application of the bleeding control skill (n = 45, 49%) were reported by nearly half of the responding officers. Less than a quarter of officers reported applying head and neck immobilization skills (n = 20, 22%) following training. Conclusion A PFA educational program has shown to improve police officers’ knowledge and perceived skills confidence on provision of first aid. However qualitative research need to be conducted to shed more light regarding reasons for low utilization of trained first aid skills during follow-up.
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Affiliation(s)
- Menti L Ndile
- Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences (MUHAS), P.O BOX 65001, Dar es Salaam, Tanzania.
| | - Gift G Lukumay
- Department of Community Nursing, MUHAS, Dar es Salaam, Tanzania
| | | | - Anne H Outwater
- Department of Community Nursing, MUHAS, Dar es Salaam, Tanzania
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Ullrich SJ, Kilyewala C, Lipnick MS, Cheung M, Namugga M, Muwanguzi P, DeWane MP, Muzira A, Tumukunde J, Kabagambe M, Kebba N, Galukande M, Mabweijano J, Ozgediz D. Design, implementation and long-term follow-up of a context specific trauma training course in Uganda: Lessons learned and future directions. Am J Surg 2020; 219:263-268. [DOI: 10.1016/j.amjsurg.2019.10.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 10/08/2019] [Accepted: 10/31/2019] [Indexed: 11/16/2022]
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Varghese M. Prehospital trauma care evolution, practice and controversies: need for a review. Int J Inj Contr Saf Promot 2020; 27:69-82. [DOI: 10.1080/17457300.2019.1708409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Mathew Varghese
- Department of Orthopaedic Surgery, St Stephen’s Hospital, Delhi, India
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