Developing emergency care systems: a human rights-based approach

Governance and legal considerations supporting prehospital emergency care in low and middle-income countries-For the Special Series on Prehospital Care in LMICs

The global imperative to expand prehospital emergency care in low and middle-income countries to reduce health disparities and improve outcomes for time-sensitive health conditions is well established in academic literature and public policy discussions. However, the governance and legal frameworks essential for the strategic development of prehospital systems remain understudied and inadequately addressed. This paper delves into the critical role of governance in prehospital systems, emphasizing its impact on equity, human rights, and the provision of timely, quality emergency care. Health system governance, defined as a complex interplay of mechanisms, processes, and institutions, is a neglected yet pivotal component of prehospital care. By highlighting previously described barriers, we underscore the opportunity to strengthen prehospital care through improved governance, particularly in leadership and legislative standards. Drawing on the World Health Organization's Health System Building Blocks and the Emergency Care System Framework, we elucidate the multifaceted nature of governance in the prehospital context, including the coordination of diverse stakeholders, the establishment of standards, and the creation of accountability mechanisms. We emphasize the importance of applying a human rights perspective to governance, ensuring non-discriminatory and timely access to emergency care. Through the application of an established governance framework of 10 principles to assess prehospital system governance, we offer policymakers and stakeholders a structured approach to identify weaknesses, propose solutions, and evaluate progress in the prehospital system. To provide practical insights, we present a contemporary case study of Ghana's National Ambulance Service Act and the Health Institutions and Facilities Act of 2011, which establish a structured approach to governance and oversight while reflecting Ghana's commitment to advancing emergency care yet faces common challenges to operationalizing the laws. We advocate for a renewed focus on governance as an essential building block for effective prehospital emergency care. By providing a comprehensive framework and case study analysis, the paper offers actionable insights to guide policymakers and stakeholders in developing and evaluating governance initiatives that improve the availability, accessibility, acceptability, and quality of prehospital care globally.

Mortality and its determinants among patients attending in emergency departments

BACKGROUND

Due to the high burden of mortality from acute communicable and non-communicable diseases, emergency department's mortality has become one of the major health indices in Ethiopia that should be evaluated regularly in every health institution. However, there are inconsistencies between studies, and there is no systematic review or meta-analysis study about the prevalence of mortality in the emergency department. Therefore, this study aimed to determine the pooled prevalence of mortality and identify its determinants in the emergency departments of Ethiopian hospitals.

METHODS

This systematic review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and has been registered with PROSPERO. A structured search of databases (Medline/PubMed, Google Scholar, CINAHL, EMBASE, HINARI, and Web of Science) was undertaken. All observational studies reporting the prevalence of mortality of patients in emergency departments of Ethiopian hospitals, and published in English up to December 16, 2023, were considered for this review. Two reviewers independently assess the quality of the studies using the Joanna Briggs Institute (JBI) critical appraisal tool. A meta-analysis using a random-effects model was performed to estimate the pooled prevalence. The heterogeneity of studies was assessed using I2 statistics, and to identify the possible causes of heterogeneity, subgroup analysis and meta-regression were used. Egger's test and funnel plots were used to assess publication bias. STATA version 17.0 software was used for all the statistical analyses. A p-value less than 0.05 was used to declare statistical significance.

RESULTS

A total of 1363 articles were retrieved through electronic search databases. Subsequently, eighteen studies comprised 21,582 study participants were included for analysis. The pooled prevalence of mortality among patients in the Emergency Department (ED) was 7.71% (95% CI: 3.62, 11.80). Regional subgroup analysis showed that the pooled prevalence of mortality was 16.7%, 12.89%, 10.28%, and 4.35% in Dire Dawa, Amhara, Oromia, and Addis Ababa, respectively. Moreover, subgroup analysis based on patients' age revealed that the pooled prevalence of mortality among adults and children was 8.23% (95% CI: 3.51, 12.94) and 4.48% (95% CI: 2.88, 6.08), respectively. Being a rural resident (OR; 2.30, 95% CI: 1.48, 3.58), unconsciousness (OR; 3.86, 95% CI: 1.35, 11.04), comorbidity (OR; 2.82, 95% CI: 1.56, 5.09), and time to reach a nearby health facility (OR; 4.73, 95% CI: 2.19, 10.21) were determinants of mortality for patients in the emergency departments.

CONCLUSION AND RECOMMENDATIONS

This study found that the overall prevalence of mortality among patients in emergency departments of Ethiopian hospitals was high, which requires collaboration between all stakeholders to improve outcomes. Being a rural resident, unconsciousness, comorbidity, and time elapsed to reach health facilities were determinants of mortality. Improving pre-hospital care, training healthcare providers, early referral, and improving first-line management at referral hospitals will help to reduce the high mortality in our country.

Utilization of emergency medical service and its associated factors among patients visited public hospitals at Hawassa City, Sidama Region, Ethiopia, 2023

Background

The burden of emergency medical conditions is borne mostly by poorer nations, with a 6 % increase in deaths of adults and children due to emergency conditions between 1990 and 2015. Emergency medical service is crucial to improve outcomes of those injuries and other time-sensitive illnesses. However, access to emergency medical services in Hawassa City is still limited and its' utilization is influenced by different factors.

Methods

A facility-based cross-sectional study was conducted among 422 randomly selected clients who visited the emergency service in public hospitals of Hawassa City. A structured interviewer-administered questionnaire adapted by reviewing previous literature was used. The collected data by using the Kobo toolbox was exported into a statical package for social science software for analysis. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used. A binary logistic regression model at a 95 % confidence interval was used to declare an association between dependent and independent variables using the odds ratio.

Results

All 422 participants completed the interview with a response rate of 100 %. The mean age of the study participants was 33.73 years with a 14.67 standard deviation. One quarter (24.9 % (95 % CI: 21.1-29.4)) of the study participants have utilized emergency medical services. Urban residence (AOR = 3.48, 95 % CI: 1.69-7.16), ever utilized ambulance service (AOR = 2.37, 95%CI: 1.21-4.67), having Red Cross Association ambulance number (AOR = 2.64, 95%CI: 1.20-5.83) and awareness on presence of free government ambulance (AOR = 3.74, 95%CI: 1.46-9.59) were the predictors of the outcome variable.

Conclusion

utilization of emergency medical services in the study area was relatively low when compared with other studies. urban residence, ever utilization of ambulance service, awareness of the presence of free government ambulances, and having a Red Cross Association ambulance number were predictors of utilization of emergency medical service.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Consensus-based recommendations for strengthening emergency care at primary health care level: a Delphi study

BACKGROUND

Emergency care at a primary health care (PHC) level must be strengthened to reduce overall mortality and morbidity in any country. Developing recommendations for improvement in this area should take into consideration the context and nuances of the current emergency care system and primary health care context. Contribution to policy from the experts in the cross-cutting fields of PHC and emergency care is lacking.

OBJECTIVES

This study aims to evaluate the strengths and weaknesses of emergency care in primary health settings and develop consensus-based recommendations for the strengthening of emergency care at this level.

METHODS

Using a modified Delphi technique, data were collected from various data sources to evaluate the strengths and weaknesses of emergency care at PHC level, from which recommendation statements were developed. These recommendations were proposed to a panel of experts using a Delphi survey to build consensus on 14 recommendations to strengthen emergency care at PHC level.

RESULTS

Ten experts were recruited to participate (n = 10) with a response rate of 90% in round II and 80% in round III of Delphi. Recommendations broadly addressed the areas of education and training in emergency care, the role and placement of various actors, leadership in emergency care and the development of a national plan for emergency care. Consensus was reached in round II for 97.61% of the statements and after modification based on open-ended comments, 98.21% consensus was reached in round III.

CONCLUSION

Strengthening emergency care at primary and subsequent levels of health care requires a coordinated effort and mandate from authority in order to effect real change.

A Global Survey of Emergency Care Clinical Networks: Discussion and Implications for Canadian Learning Health Systems

Clinical networks (CNs) can promote innovation and collaboration across providers and stakeholders. However, little is known about the structure and operations of CNs, particularly in emergency care. As Canada advances learning health systems (LHSs), foundational research is essential to enable future comparisons across CNs to identify those that contribute to positive system change. Drawing from the results of our international survey, we provide a description of 32 emergency care CNs worldwide, including their structure, operations and sustainability. Future research should consider the context of such networks, how they may contribute to an LHS and how they impact patient outcomes.

Defining measures of emergency care access in low-income and middle-income countries: a scoping review

BACKGROUND

Over 50% of annual deaths in low-income and middle-income countries (LMICs) could be averted through access to high-quality emergency care.

OBJECTIVES

We performed a scoping review of the literature that described at least one measure of emergency care access in LMICs in order to understand relevant barriers to emergency care systems.

ELIGIBILITY CRITERIA

English language studies published between 1 January 1990 and 30 December 2020, with one or more discrete measure(s) of access to emergency health services in LMICs described.

SOURCE OF EVIDENCE

PubMed, Embase, Web of Science, CINAHL and the grey literature.

CHARTING METHODS

A structured data extraction tool was used to identify and classify the number of 'unique' measures, and the number of times each unique measure was studied in the literature ('total' measures). Measures of access were categorised by access type, defined by Thomas and Penchansky, with further categorisation according to the 'Three Delay' model of seeking, reaching and receiving care, and the WHO's Emergency Care Systems Framework (ECSF).

RESULTS

A total of 3103 articles were screened. 75 met full study inclusion. Articles were uniformly descriptive (n=75, 100%). 137 discrete measures of access were reported. Unique measures of accommodation (n=42, 30.7%) and availability (n=40, 29.2%) were most common. Measures of seeking, reaching and receiving care were 22 (16.0%), 46 (33.6%) and 69 (50.4%), respectively. According to the ECSF slightly more measures focused on prehospital care-inclusive of care at the scene and through transport to a facility (n=76, 55.4%) as compared with facility-based care (n=57, 41.6%).

CONCLUSIONS

Numerous measures of emergency care access are described in the literature, but many measures are overaddressed. Development of a core set of access measures with associated minimum standards are necessary to aid in ensuring universal access to high-quality emergency care in all settings.

Current patterns of care at adult emergency department in Ethiopian tertiary university hospital

BACKGROUND

The complexity and demands of emergency healthcare service are continuously increasing, and it is important to regularly track the patterns of care at the emergency department (ED).

METHODOLOGY

A retrospective study was conducted at the ED of the University of Gondar Comprehensive Specialized Hospital (UoGCSH) from April 1 to June 30, 2021. Ethical approval was obtained from the Emergency and Critical Care Directorate of UoGCSH. Data was collected from the emergency registry and descriptive analysis was performed.

RESULTS

A total of 5232 patients have visited and triaged at the ED. All patients who visited the ED have received triage service within 5 min of arrival. The average length of stay at the ED was 3 days. About 79.1% of patients have stayed at the ED beyond 24 h, and the unavailability of beds at admission areas was responsible for 62% of delays. Mortality rate at the ED was 1.4%, and male to female ratio of death was 1.2 to 1. Shock (all types combined), pneumonia with/without COVID-19, and poisoning were the leading causes of death at the ED which were responsible for 32.5%, 15.5%, and 12.7% of deaths respectively.

CONCLUSIONS

Triage has been done within the recommended time after patient arrival. However, many patients were staying at the ED for an unacceptably prolonged time. Unavailability of beds at the admission areas, waiting long for senior clinicians' decisions, delays in investigation results, and lack of medical equipment were the causes of delayed discharge from the ED. Shock, pneumonia, and poisoning were the leading causes of death. Healthcare administrators should address the lack of medical resources, and clinicians should provide timely clinical decision and investigation results.

The accuracy of the National Early Warning Score 2 in predicting early death in prehospital and emergency department settings: a systematic review and meta-analysis

Background

Many studies have explored the accuracy of the National Early Warning Score 2 (NEWS2) in predicting mortality in prehospital and emergency settings, but their findings are inconsistent. Whether NEWS2 is reliable for the pre-examination and triage of patients in prehospital settings and emergency departments remains debatable. Hence, this study aimed to evaluate the accuracy of NEWS2 in predicting mortality in prehospital settings and emergency departments.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wan Fang Data, Vip Database and SinoMed from the inception of each database to January 2023. The inclusion criteria: (I) patients in the prehospital settings or emergency departments; (II) the NEWS2 for predicting 2-day mortality, 30-day mortality, and in-hospital mortality; (III) sufficient data, such as sensitivity, specificity, overall survival, and deaths, were provided for the study; (IV) the type of study was accuracy prediction study. Two authors independently extracted data, including authors, year of publication, country of origin, study design, sample size, threshold cutoff values of NEWS2, and mortality. The PROBAST was used to assess the risk of bias in the included studies.

Results

Thirty studies with 185,835 participants were included. Among the 30 included studies, 13 have a high risk of bias, and 17 have a low risk of bias. The pooled sensitivity, specificity and AUC of 2-day mortality (early mortality), 30-day mortality and in-hospital mortality were 0.81 vs. 0.76 vs. 0.72 (95% CI: 0.61, 0.80), 0.81 vs. 0.69 vs. 0.78 (95% CI: 0.49, 0.93) and 0.88 vs. 0.80 vs. 0.78 (95% CI: 0.74, 0.82), respectively.

Conclusions

NEWS2 has excellent sensitivity and specificity in predicting early mortality in patients in the prehospitals setting and emergency departments. Nonetheless, it has poor performance in predicting in-hospital mortality and 30-day mortality. Our findings underpin the use of NEWS2 as a pre-examination and triage tool to predict early death in the prehospital settings and emergency departments. To improve the predictive accuracy, it should be used to monitor patients continuously rather than at a single point-in-time.

Not only COVID-19 disease impacts ambulance emergency demands but also lockdowns and quarantines

BACKGROUND

The pandemic has impacted both patients infected by the SARS-CoV-2 virus and patients who seek emergency assistance due to other health issues. Changes in emergency demands are expected to have occurred during the pandemic, the objective of this investigation is to characterize the changes in ambulance emergency demands during the first year of the COVID-19 pandemic in the Vaud State of Switzerland. The goal of this research is to identify the collateral effects of the COVID-19 pandemic on emergency demands. To do so, this study quantifies the differences in health issues, level of severity, and patients' sociodemographic characteristics (age, location, gender) prior to and during the outbreak.

METHOD

This is a retrospective, descriptive and comparative statistical analysis of all ambulance emergency missions from 2018 to 2020 (n = 107,150) in the State of Vaud in Switzerland. Variables analyzed were the number of ambulance missions, patient age and gender, health issues, severity (NACA scores), number of non-transports, mission times and locations. Variables were compared between prepandemic and pandemic situations across years and months. Comparative analysis used bivariate analysis, χ2 test, Student's t test, and Mann‒Whitney U test.

RESULTS

The pandemic has had two major impacts on the population's emergency demands. The first appears to be due to COVID-19, with an increase in respiratory distress cases that doubled in November 2020. The second relates to the implementation of lockdown and quarantine measures for the population and the closures of restaurants and bars. These might explain the decrease in both the number of traumas and intoxications, reaching more than 25% and 28%, respectively. An increase in prehospital emergency demands by the older population, which accounted for 53% of all demands in 2020, is measured.

CONCLUSION

Collateral effects occurred during 2020 and were not only due to the pandemic but also due to protective measures deployed relative to the population. This work suggests that more targeted reflections and interventions concerning the most vulnerable group, the population of people 65 and older, should be of high priority. Gaining generalizable knowledge from the COVID-19 pandemic in prehospital settings is critical for the management of future pandemics or other unexpected disasters.

Exploring Primary Care Streaming Pathway in Emergency Departments in Saudi Arabia: A Qualitative Study

Background

Due to significant emergency department overcrowding, some hospitals implemented a system of directing certain patients who were deemed not in need of emergency care to other facilities called triage away. Pathways were developed as ways to stream patient from emergency departments to primary healthcare who is presenting with less urgent or nonurgent conditions. Thus, the purpose of this study was to explore the pathways (process) for streaming patients from emergency department to primary healthcare at three different sites across Western Region of Saudi Arabia and to identify the streaming criteria and guidance.

Materials and Methods

This study used a qualitative observational design. Data were collected through an unstructured observational approach, with an in-depth case study observation involving three emergency departments in the Western Region. Data were collected over three months until data saturated and recorded in the form of filed notes.

Results

The results of this study explored that all CTAS-5 were streamed away either (off-site) or (on-site) from emergency department. The average of the sorting/triage cases were around 200 to 250 per shift, and about third to half of them were streamed to Primary Health Centre or Urgent Care Clinic. The total streamed patients were ranging from 50 to 60 per shift, which mean 15-20 case per hour. The study highlighted many factors that influence the practice and decision of streaming.

Conclusions

In general, the term "streaming" was not as widely known among emergency clinicians, as was the term "triage." However, streaming was performed as an evidence-based practice, and clinicians routinely acted to direct patients based on hospital policies. Although, in one hospital, some nurses hack the system to manage the flow of patients based on their intuition. In contrast, the nurses in another hospital emphasised the importance of experience and confidence in streaming improvement.

Prehospital emergency medical service utilization and associated factors among critically ill COVID-19 patients treated at centers in Addis Ababa, Ethiopia

The majority of populations in developing countries are living in areas of no access or limited access to prehospital emergency medical services (EMS). In Addis Ababa, the reported prehospital EMS utilization were ranging from zero to thirty-eight percent. However, there is limited research on reasons for the low utilization of prehospital resources in Ethiopia. This study aimed to assess factors associated with prehospital EMS utilization among critically ill COVID-19 patients in Addis Ababa, Ethiopia. A hospital-based cross-sectional study was conducted to collect primary data from 421 COVID-19 patients in Addis Ababa between May and July 2021. Logistic regression was used to identify factors associated with prehospital service utilization. Andersen's Behavioral Model was implemented to address independent variables, including predisposing, enabling, need, and health behaviors-related variables. The level of prehospital care utilization was 87.6%. Being married [AOR 2.6(95%; CI:1.24-5.58)], belief that self-transport is quicker than the ambulance [AOR 0.13(95%; CI: 0.05-0.34)], and perceptions that ambulance provides transportation service only [AOR 0.14(95%; CI:0.04-0.45)] were predisposing factors associated with prehospital service utilization while the source of referrals [AOR 6.9(95%; CI: 2.78-17.30)], and prior knowledge on the availability of toll-free ambulance calling numbers [AOR 0.14(95%; CI: 0.04-0.45)] were identified as enabling factors. Substantial proportions of critically ill COVID-19 patients used prehospital services to access treatment centers. Prehospital EMS utilization in this study varies by predisposing and enabling factors, particularly: marital status, source of referral, prior knowledge on the availability of toll-free ambulances, belief that self-transport is quicker than ambulances, and perceptions that ambulance provides transportation service only. Our findings call for further actions to be taken by policymakers including physical and media campaigns focusing on the identified factors.

Research priority setting in emergency care: A scoping review

Objective

Priority areas for emergency care research are emerging and becoming ever more important. The objectives of this scoping review were to (1) provide a comprehensive overview of published emergency care priority-setting studies by collating and comparing priority-setting methodology and (2) describe the resulting research priorities identified.

Methods

The Joanna Briggs Institute methodological framework was used. Inclusion criteria were peer-review articles available in English, published between January 1, 2008 and March 31, 2019 and used 2 or more search terms. Five databases (Scopus, AustHealth, EMBASE, CINAHL, and Ovid MEDLINE) were searched. REporting guideline for PRIority SEtting of health research (REPRISE) criteria were used to assess the quality of evidence of included articles.

Results

Forty-five studies were included. Fourteen themes for emergency care research were considered within 3 overarching research domains: emergency populations (pediatrics, geriatrics), emergency care workforce and processes (nursing, shared decision making, general workforce, and process), and emergency care clinical areas (imaging, falls, pain management, trauma care, substance misuse, infectious diseases, mental health, cardiology, general clinical care). Variation in the reporting of research priority areas was evident. Priority areas to drive the global agenda for emergency care research are limited given the country and professional group-specific context of existing studies.

Conclusion

This comprehensive summary of generated research priorities across emergency care provides insight into current and future research agendas. With the nature of emergency care being inherently broad, future priorities may warrant population (eg, children, geriatrics) or subspecialty (eg, trauma, toxicology, mental health) focus and be derived using a rigorous framework and patient engagement.

Emergency Care in the Occupied Palestinian Territory: A Scoping Review

The development of robust emergency care systems as a critical platform for addressing the global burden of disease has been increasingly recognized by global health policy makers over the past decade. A human rights-based approach to securing the right to quality emergency care is also essential to respond to the structural and political determinants of poor health outcomes. In the occupied Palestinian territory, human rights violations have contributed to significant deficiencies in health and quality of health care. In this scoping review, we identify deficiencies in the management of high-risk presentations to emergency departments in the Palestinian health care system for traumatic injury, acute myocardial infarction, and stroke. We subsequently apply a human rights-based analysis to demonstrate how structural racism in the administration of the occupation has contributed to deficiencies in emergency care. Specifically, deficiencies in resource and system organization within the Palestinian emergency care system arise due to occupation-related restrictions on freedom of movement, the procurement of essential drugs and medical equipment, and the development of a national Palestinian health care system. Further research and intervention are needed to understand gaps in emergency care for Palestinians and, in turn, to improve the management of emergency medical and traumatic conditions through capacity building of a Palestinian emergency care system. Importantly, deconstruction of the structural determinants of poor health for Palestinians in the occupied territory is needed to improve public health and ensure the protection of human rights.

Prehospital characteristics of COVID-19 patients transported by emergency medical service and the predictors of a prehospital sudden deterioration in Addis Ababa, Ethiopia

Background

Severally ill COVID-19 patients may require urgent transport to a specialized facility for advanced care. Prehospital transport is inherently risky; the patient’s health may deteriorate, and potentially fatal situations may arise. Hence, early detection of clinically worsening patients in a prehospital setting may enable selecting the best receiving facility, arranging for swift transportation, and providing the most accurate and timely therapies. The incidence and predictors of abrupt prehospital clinical deterioration among critically ill patients in Ethiopia are relatively limited.

Study objectives

This study was conducted to determine the incidence of sudden clinical deterioration during prehospital transportation and its predictors.

Methods

A prospective cohort study of 591 COVID-19 patients transported by a public EMS in Addis Ababa. For data entry, Epi data V4.2 and SPSS V 25 were used for analysis. To control the effect of confounders, the candidate variables for multivariable analysis were chosen using a p 0.25 inclusion threshold from the bivariate analysis. A statistically significant association was declared at adjusted relative risk (ARR) ≠ 1 with a 95 % confidence interval (CI) and a p value < 0.05 after adjusting for potential confounders.

Results

The incidence of prehospital sudden clinical deterioration in this study was 10.8%. The independent predictors of prehospital sudden clinical deterioration were total prehospital time [ARR 1.03 (95%; CI 1.00–1.06)], queuing delays [ARR 1.03 (95%; CI 1.00–1.06)], initial prehospital respiratory rate [ARR 1.07 (95% CI 1.01–1.13)], and diabetic mellitus [ARR 1.06 (95%; CI 1.01–1.11)].

Conclusion

In the current study, one in every ten COVID-19 patients experienced a clinical deterioration while an EMS provider was present. The factors that determined rapid deterioration were total prehospital time, queueing delays, the initial respiratory rate, and diabetes mellitus. Queueing delays should be managed in order to find a way to decrease overall prehospital time. According to this finding, more research on prehospital intervention and indicators of prehospital clinical deterioration in Ethiopia is warranted.

Potential Access to Emergency General Surgical Care in Ontario

Limited access to timely emergency general surgery (EGS) care is a probable driver of increased mortality and morbidity. Our objective was to estimate the portion of the Ontario population with potential access to 24/7 EGS care. Geographic information system-based network-analysis was used to model 15-, 30-, 45-, 60-, and 90-min land transport catchment areas for hospitals providing EGS care, 24/7 emergency department (ED) access, and/or 24/7 operating room (OR) access. The capabilities of hospitals to provide each service were derived from a prior survey. Population counts were based on 2016 census blocks, and the 2019 road network for Ontario was used to determine speed limits and driving restrictions. Ninety-six percent of the Ontario population (n = 12,933,892) lived within 30-min's driving time to a hospital that provides any EGS care. The availability of 24/7 EDs was somewhat more limited, with 95% (n = 12,821,747) having potential access at 30-min. Potential access to all factors, including 24/7 ORs, was only possible for 93% (n = 12,471,908) of people at 30-min. Populations with potential access were tightly clustered around metropolitan centers. Supplementation of 24/7 OR capabilities, particularly in centers with existing 24/7 ED infrastructure, is most likely to improve access without the need for new hospitals.

[Inequality in pre-hospital care in Brazil: Analysis of the efficiency and sufficiency of SAMU 192 coverage]

The scope of this article is to analyze the evolution and coverage of pre-hospital care in Brazil between 2015 and 2019 based on efficiency and sufficiency in all municipalities, according to macro-regions, population covered, situation and coverage strategy, geographic area covered, available modalities and mobile resources distributed. It is an observational, quantitative, descriptive, and exploratory census, conducted with data provided by the Ministry of Health, complemented with data from the Brazilian Institute of Geography and Statistics. Efficiency in pre-hospital coverage was analyzed according to 17 indicators linked to the population covered, distribution of mobile resources and configuration of teams by modality. Sufficiency was analyzed according to variations in these indicators between municipalities in different macro-regions of the country. In 5 years, coverage rose by 5.4%, attaining 85% of citizens and 3750 municipalities, with a predominance of the Basic Life Support modality. The meager expansion of pre-hospital care and the persistence of uncovered municipalities denote the inefficiency of coverage which, associated with the inequality in the distribution of resources and modalities, corrupts the guidelines of integrality and equality in access to health (sufficiency).

A Global Review of Provisions on Emergency Care in National Constitutions

National constitutions are important tools for the realization of the right to health, and constitutional law linking health and human rights has been associated with improved access to health resources. Meanwhile, emergency care is a lifesaving service delivery platform with the potential to address much of the death and disability in low- and middle-income countries (LMICs). Yet even where services exist, access to emergency care may be systematically limited for vulnerable populations, except where laws explicitly protect the right to emergency care. We therefore sought to catalog and describe constitutional provisions related to emergency care. Through a comprehensive review of 195 national constitutions, we searched provisions for terms related to emergency care and performed qualitative framework analysis on these provisions. Eleven provisions met inclusion criteria, representing ten LMICs with constitutions written since 1996. While seven of the eleven provisions guarantee access to emergency care to all people, three narrow this guarantee to citizens only. Only three constitutions address the affordability of emergency care. While these constitutional provisions represent an important step toward the legal guarantee of access to emergency care for all people, further attention must be paid to the impact of such laws and regulation on the accessibility of emergency care and its related reduction of death and disability globally.

Global Health in Swedish Nursing Curricula: Navigating the Desirable and the Necessary

Global health challenges are likely to be aggravated in the coming years by rapid climate change and environmental degradation. To address the resulting health inequities, nurses need an integrated understanding of environmental and social determinants of health. This study adopts an explorative inductive approach to examine how global health and sustainability are expressed the course syllabi of undergraduate nursing programmes (n = 24) in Sweden. After excluding biomedical and other unrelated content, 67 syllabi were selected for a thematic analysis. Results indicate that global health, the social determinants of health and sustainability tend to appear in a fragmented manner in the syllabi. Global health content is often limited, relegated to elective courses, or altogether missing. A theoretical framework is lacking, and focus lies on an individual rather than structural perspective. Based on international policy, earlier studies on undergraduate nursing education and theoretical work, suggestions are made for how global health and sustainability content could be integrated into nursing education, notably by using a structural competency approach.

Identification of new demands regarding prehospital care based on 35,188 missions in 2018

BACKGROUND

Population ageing and increased prevalence of chronic diseases result in the emergence of new demands in prehospital care. The prehospital system is facing an increase of cases without acute threat to life (so-called "non-urgent"), which generates tension due to a higher number of admissions to emergency departments and a greater use of prehospital resources. Our aim is to understand this transition in prehospital activities and to delineate the primary missions performed by paramedics in 2018 with a focus on the population concerned, the severity of cases encountered and the typology of health issues.

METHOD

The study is retrospective, and descriptive, using a statistical description of 35,188 primary missions realized in 2018 in the State of Vaud (Switzerland). The characteristics taken into consideration are the age and gender of patients, as well as the health issue, the severity of cases based on National Advisory Committee for Aeronautics score (NACA score), and the time and place of intervention.

RESULTS

The results describe the primary missions in the State of Vaud in 2018 and show that 87% of missions concern "non-urgent" situations (without acute threat to life). Over half of patients are 65 or older, the highest proportion of health issues, 49%, are medical and only 23% of missions are for traumas. Mission related to mental health issues reach 7% and those for intoxication 6%. Most missions take place between 7:00 am and 6:00 pm (67%), and around 12% of missions lead to the non-transport of the patient.

CONCLUSION

The prehospital sector is confronted with a major transition in terms of patient care. An increase of non-urgent cases is observed, associated with the care of persons aged 65 or more. Our results question the adequacy between the needs in terms of prehospital care and the paramedic profession as it is currently defined, as well as the place of this profession within the health network. Reflecting upon the role of paramedics with respect to the socio-demographic evolution of populations appears necessary, to analyse the adequacy of the paramedics' skills to respond to the current needs.

Clinical Nutrition and Human Rights. An International Position Paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Travel time to emergency care not by geographic time, but by optimal time: A nationwide cross-sectional study for establishing optimal hospital access time to emergency medical care in South Korea

Increase in travel time, beyond a critical point, to emergency care may lead to a residential disparity in the outcome of patients with acute conditions. However, few studies have evaluated the evidence of travel time benchmarks in view of the association between travel time and outcome. Thus, this study aimed to establish the optimal hospital access time (OHAT) for emergency care in South Korea. We used nationwide healthcare claims data collected by the National Health Insurance System database of South Korea. Claims data of 445,548 patients who had visited emergency centers between January 1, 2006 and December 31, 2014 were analyzed. Travel time, by vehicle from the residence of the patient, to the emergency center was calculated. Thirteen emergency care-sensitive conditions (ECSCs) were selected by a multidisciplinary expert panel. The 30-day mortality after discharge was set as the outcome measure of emergency care. A change-point analysis was performed to identify the threshold where the mortality of ECSCs changed significantly. The differences in risk-adjusted mortality between patients living outside of OHAT and those living inside OHAT were evaluated. Five ECSCs showed a significant threshold where the mortality changed according to their OHAT. These were intracranial injury, acute myocardial infarction, other acute ischemic heart disease, fracture of the femur, and sepsis. The calculated OHAT were 71-80 min, 31-40 min, 70-80 min, 41-50 min, and 61-70 min, respectively. Those who lived outside the OHAT had higher risks of death, even after adjustment (adjusted OR: 1.04-7.21; 95% CI: 1.03-26.34). In conclusion, the OHAT for emergency care with no significant increase in mortality is in the 31-80 min range. Optimal travel time to hospital should be established by optimal time for outcomes, and not by geographic time, to resolve the disparities in geographical accessibility to emergency care.

EMS operation in a female restricted university, Saudi prospective

This paper was written to explain the process and steps and to describe the experience with building a women-only operated collegiate emergency medical service (EMS) system in the largest women-only university in the world. To the best of the authors’ knowledge, the EMS system described in this report is the first collegiate EMS system in the Gulf region. The concept of the collegiate EMS system at the university, the factors that mandated the creation of this system, the process steps, the challenges faced, and, finally, the reported outcome have been evaluated. The women-only campus conferred unique challenges and additional pressure during the planning and implementation stages of this project; our system had helped in decreasing response time to medical emergency, provided back up support during mass gathering events in the university, and helped in decreasing the load on other national EMS services.

Governing access to emergency care in Africa

Emergency care not only has the potential to address a large portion of death and disability in low- and middle-income countries, it is also essential to achieving the current Universal Health Coverage agenda and fulfilling the universal human right to the highest attainable standard of health. One of six health system building blocks, governance is often neglected but nonetheless essential for guaranteeing access and strengthening emergency care systems in Africa. In this paper, we highlight key components of governance that are necessary to guaranteeing access to emergency care, describe current examples of emergency care accessibility laws and regulation in various African countries, and suggest priorities for measuring and evaluating the impact of legal guarantees for access to emergency care in Africa.

Disparities between Rural and Urban Areas of the Central Region of Saudi Arabia in the Utilization and Time-Centeredness of Emergency Medical Services

The purpose of this study was to explore differences in characteristics of missions dispatched by Emergency Medical Services (EMS) between rural and urban areas of Riyadh province in Saudi Arabia (SA). It also aimed at identifying weaknesses related to utilization and Response Time (RT). The study retrospectively evaluated 146,639 completed missions in 2018 by measuring the utilization rate in rural and urban areas. The study shows there are six times more ambulance crews available for rural areas compared to urban. There were 22.1 missions per 1000 urban inhabitants and 11.2 missions per 1000 in rural areas. The median RT for high urgent trauma cases was 20.2 min in rural compared to 15.2 min in urban areas (p < 0.001). In urban areas, the median RT for high urgent medical cases was 16.1 min, while it was 15.2 min for high urgent trauma cases. Around 62.3% of emergency cases in urban and 56.5% in rural areas were responded to within 20.00 min. Women utilized EMS less frequently. The RT was increased in urban areas compared to previous studies. The RT in the central region of SA has been identified as equal, or less than 20.00 min in 62.4% of all emergency cases. To further improve adherence to the 20' target, reorganizing the lowest urgent cases in the rural areas seems necessary.

A rights-based approach to public health emergencies: The case of the 'More Rights, Less Zika' campaign in Brazil

During health emergencies, the security agenda tends to impose itself over the human rights agenda. That happened when Brazil became the Zika-related PHEIC epicentre in 2016. While the federal government promoted a 'war against the mosquito' Aedes aegypti, some social actors emphasised the social determinants of health and women's rights. This article presents the United Nations Population Fund (UNFPA) led campaign 'More Rights, Less Zika' as a consistent example of the positive effects the coordination between global and local actors might have on health initiatives. We conducted field research in Recife, Northeast of Brazil, one of the campaign's target cities, where we interviewed main local actors. The campaign focussed on disseminating women's sexual and reproductive rights as an alternative to the strategy of the federal government, primarily focussed on controlling the vector, postponing pregnancies, and the use of repellent. Despite its scale limitations, the campaign demonstrates that a right-based approach can contribute to increasing the security of communities during health emergencies. The case also suggests that coordinating global actors' actions with local actors improves the quality of global health initiatives, which is particularly important when a conservative agenda opposing women's rights gains leverage in Brazil and other States.

Emergency care status, priorities and standards for the Pacific region: A multiphase survey and consensus process across 17 different Pacific Island Countries and Territories

Background

Effective emergency care (EC) reduces mortality, aids disaster and outbreak response, and is necessary for universal health coverage. Surge events frequently challenge Pacific Island Countries and Territories (PICTs), where robust routine EC is required for resilient health systems. We aimed to describe the current status, determine priority actions and set minimum standards for EC systems development across the Pacific region.

Methods

We used a prospective, multiphase, expert consensus process to collect data from PICT EC stakeholders using focus groups, electronic surveys and panel review between August 2018 and April 2019. Data were analysed using descriptive statistics, consensus agreement and graphic interpretation. We structured the research according to the World Health Organisation EC Systems and building block framework adapted for the Pacific context.

Findings

Over 200 participants from 17 PICTs engaged in at least one component of the multiphase process. Gaps in functional capacity exist in most PICTs for both facility-based and pre-hospital care. EC is a low priority across the Pacific and integrated poorly with disaster plans. Participants emphasised human resource support and government recognition of EC as priority actions, and generated 24 facility-based and 22 pre-hospital Pacific EC standards across all building blocks.

Interpretation

PICT stakeholders now have baseline indicators and a comprehensive roadmap for EC development within a globally recognised health systems framework. This study generates practical, context-appropriate tools to trigger further research, conduct evidence-based advocacy, drive future improvements and measure progress towards achieving universal health access for Pacific peoples.

Funding

Secretariat of the Pacific Community (partial)

Evolution of emergency medical services in the Kingdom of Bahrain

Emergency medical services (EMS) is crucial to any healthcare system, especially in urban countries. The Kingdom of Bahrain has always strived to develop healthcare services throughout the Kingdom including EMS. Like any other country, the Kingdom has gone through several stages in the provision of EMS. This article will focus on the development of EMS in the Kingdom and its evolution from a scattered hospital-based system to a unified system, which ensures ease of access for the population and speed of delivery to the healthcare facilities. The major focus will be the most recent national project which is the National Ambulance.