Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda

Resuscitation following trauma & role of trauma training programmes in emergency settings: A literature review & survey

Background & objectives Traumatic injuries, especially in low- and middle- income countries (LMICs), present significant challenges in patient resuscitation and healthcare delivery. This study explores the role of trauma training programmes in improving patient outcomes and reducing preventable trauma-related deaths. Methods A dual approach was adopted, first a literature review of trauma training in LMICs over the past decade, along with a situational assessment survey. For the review of literature, we searched the PubMed database to identify key challenges and innovative practices in trauma training programmes in LMIC's. The survey, conducted among healthcare professionals in various LMICs, collected direct insights into the challenges and the status of trauma training programmes in these countries. Results The literature review analysed 68 articles, with a significant focus on the African subcontinent (36 studies), underscoring the region's emphasis on research on trauma training programmes. These studies mainly targeted physicians, clinicians, postgraduate trainees in surgical or anaesthesia fields and medical students (86.8%), highlighting innovations like simulation-based training and the cascading training model. In our survey, we received 34 responses from healthcare professionals in India, Belarus, Azerbaijan, Nepal and Pakistan. Around 52.9 per cent reported the absence of established trauma training programmes in their settings. The majority of respondents advocated for hands-on, simulation-based training (94.1%) and emphasised the need for structured training programmes (85.3%), feedback sessions (70.6%) and updated protocols (61.8%). This combined data underlined the critical gaps and potential improvements in trauma training programmes and resuscitation practices in LMICs. Interpretation & conclusions Effective trauma care in LMICs requires the establishment of comprehensive, tailored training programmes. Key interventions should include subsidization of pre-existing trauma courses and the adoption of World Health Organization Guidelines for essential trauma care, implementation of trauma quality improvement and review processes and the incorporation of focused assessment with sonography in trauma (FAST) in emergency departments. These steps are crucial for equipping healthcare workers with vital skills and knowledge, fostering a culture of continuous learning and improvement in the realm of trauma care.

The state of emergency medicine in Greece: at critical momentum

Greece is a parliamentary republic in southeastern Europe populated by over 10 million permanent residents: 9 million reside on the mainland, with almost 4 million in the greater Athens area. The remaining 1 million populate the over 1200 Greek islands. In addition, more than 160,000 asylum-seekers reached Greece in 2022, and more than 25 million tourists have visited Greece in the last two years. Modern Greek Emergency Medicine (EM) is now in its 4th decade. The Greek government has focused the last few years on enhancing the quality of emergency services provided in public hospitals. Emergency Departments (EDs) are being modernized, undergraduate medical education gradually incorporates EM, and a specialty training program in emergency nursing has been established. However, the late recognition of the critical importance of EM as a specialty in Greece has resulted in the subsequent need to create three alternative pathways to EM, none of which are direct from residency. The first is a 24-month Emergency Medicine fellowship after completing a residency in another specialty and then passing the national exam. The second is for physicians who have worked in a public hospital ED (Gr: Ethniko Systima Ygeias (ESY) ESY for at least three years and successfully passed the national exam. The third, which no longer exists, is a 'grandfather' pathway for those physicians who worked in an ESY ED for five years prior to the creation of the fellowship training program. As a result, there is a critical shortage of EM-trained physicians, resulting in most care being provided by physicians without formal training in EM. This is further confounded by the country's challenging geography, with frequent air transfers from the islands to mainland hospitals. Creating an EM Residency training program is a critical next step to overcoming many of the challenges facing EM provision in Greece today: it would address the shortage of EM-trained providers, decrease the need for costly ground and air transfers, and improve the quality of emergency care throughout Greece.

Pediatric Emergency Surgery Course in Uganda: Long-Term Follow-Up and Insights From Further Dissemination

INTRODUCTION

Approximately 170 pediatric surgeons are needed for the 24 million children in Uganda. There are only seven. Consequently, general surgeons manage many pediatric surgical conditions. In response, stakeholders created the Pediatric Emergency Surgery Course (PESC) for rural providers, given three times in 2018-2019. We sought to understand the course's long-term impact, current pediatric surgery needs, and determine measures for improvement.

METHODS

In October 2021, we distributed the same test given in 2018-2019. Student's t-test was used to compare former participants' scores to previous scores. The course was delivered again in May 2022 to new participants. We performed a quantitative needs assessment and also conducted a focus group with these participants. Finally, we interviewed Surgeon in Chiefs at previous sites.

RESULTS

Twenty three of the prior 45 course participants re-took the PESC course assessment. Alumni scored on average 71.9% ± 18% correct. This was higher from prior precourse test scores of 55.4% ± 22.4%, and almost identical to the 2018-2019 postcourse scores 71.9% ± 14%. Fifteen course participants completed the needs assessment. Participants had low confidence managing pediatric surgical disease (median Likert scale ≤ 3.0), 12 of 15 participants endorsed lack of equipment, and eight of 15 desired more educational resources. Qualitative feedback was positive: participants valued the pragmatic lessons and networking with in-country specialists. Further training was suggested, and Chiefs noted the need for more trained staff like anesthesiologists.

CONCLUSIONS

Participants favorably reviewed PESC and retained knowledge over three years later. Given participants' interest in more training, further investment in locally derived educational efforts must be prioritized.

A qualitative study of barriers and facilitators to using tenecteplase to treat acute ischemic stroke

BACKGROUND

Tenecteplase (TNK) is emerging as an alternative to alteplase (ALT) for thrombolytic treatment of acute ischemic stroke (AIS). Compared to ALT, TNK has a longer half-life, shorter administration time, lower cost, and similarly high efficacy in treating large vessel occlusion. Nevertheless, there are barriers to adopting TNK as a treatment for AIS. This study aimed to identify thematic barriers and facilitators to adopting TNK as an alternative to ALT as a thrombolytic for eligible AIS patients.

METHODS

Qualitative research methodology using hermeneutic cycling and purposive sampling was used to interview four stroke clinicians in Texas. Interviews were recorded and transcribed verbatim. Enrollment was complete when saturation was reached. All members of the research team participated in content analysis during each cycle and in thematic analysis after saturation.

RESULTS

Interviews were conducted between November 2022 and February 2023 with stroke center representatives from centers that either had successfully adopted TNK, or had not yet adopted TNK. Three themes and eight sub-themes were identified. The theme "Evidence" had three sub-themes: Pro-Con Balance, Fundamental Knowledge, and Pharmacotherapeutics. The theme "Process Flow" had four subthemes: Proactive, Reflective self-doubt, Change Process Barriers, and Parameter Barriers. The theme "Consensus" had one sub-theme: Getting Buy-In.

CONCLUSION

Clinicians experience remarkably similar barriers and facilitators to adopting TNK. The results lead to a hypothesis that providing evidence to support a practice change, and identifying key change processes, will help clinicians achieve consensus across teams that need to 'buy in' to adopting TNK for AIS treatment.

Essential human and material resources for emergency care in the district hospitals of Burundi

Introduction

Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery.

Methods

In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p<0.05 considered significant.

Results

Forty of 45 district hospitals completed the survey, of which 35 were rural (matching national demographics). The majority of district hospitals (21/40) had ready access to ≥4/5 critical drugs while few (5/40) were equipped with ≥4/5 key material. One quarter had 24/7 physician coverage and X-ray available. Only 3 had continuous access to ultrasound studies despite most district hospitals having ultrasound machines. Trained emergency room staff were almost totally absent from the field, with only 6 nurses, 4 generalists, and 1 specialist reported across 9 sites. Even a single EM-trained staff member was significantly correlated with being better equipped for emergencies (p<0.01).

Conclusion

Burundi needs a strategic investment in emergency preparedness and care. Policy initiatives and technology purchases have demonstrated reasonable penetration down to the district hospital level, however, trained personnel are essential to develop sustainable emergency capacity.