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Bani Odeh AA, Wallis LA, Hamdan M, Stassen W. Consensus-based quality standards for emergency departments in Palestine. BMJ Open Qual 2024; 13:e002598. [PMID: 38519089 PMCID: PMC10961511 DOI: 10.1136/bmjoq-2023-002598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/29/2024] [Indexed: 03/24/2024] Open
Abstract
OBJECTIVES The present study aimed to establish appropriate quality standards for emergency departments (EDQS) in Palestine. METHODS The study comprised four phases. First, a comprehensive literature review was conducted to develop a framework for assessing healthcare services in EDs. Second, the initial set of EDQS was developed based on the review findings. Third, local experts provided feedback on the EDQS, suggesting additional standards, and giving recommendations. This feedback was analysed to create a preliminary set of EDQS. Finally, an expanded group of local emergency care experts evaluated the preliminary set, providing feedback on content and structure to contribute to the final set of EDQS. FINDINGS We identified quality domains in EDs and categorised them into clinical and administrative pathways. The clinical pathway comprises 39 standards across 7 subdomains: triage, treatment, transportation, medication safety, patient flow and medical diagnostic services. Expert consensus was achieved on 87.5% of these standards. The administrative domain includes 64 consensus-based standards across 9 subdomains: documentation, information management systems, access-location, design, leadership, management, workforce staffing, training, equipment, supplies, capacity-resuscitation rooms, resources for a safe working environment, performance indicators and patient safety-infection prevention and control programmes. CONCLUSION This study employed a rigorous approach to identify QS for EDs in Palestine. The multiphase consensus process ensured the appropriateness of the developed EDQS. Inclusion of diverse perspectives enriched the content. Future studies will validate and refine the standards based on feedback. The EDQS has potential to enhance emergency care in Palestine and serve as a model for other regions facing similar challenges.
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Affiliation(s)
| | - Lee A Wallis
- Emergency Medicince, University of Cape Town, Cape Town, Western Cape, South Africa
| | | | - Willem Stassen
- University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
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Pusateri AE, Morgan CG, Neidert LE, Tiller MM, Glaser JJ, Weiskopf RB, Ebrahim I, Stassen W, Rambharose S, Mahoney SH, Wallis LA, Hollis EM, Delong GT, Cardin S. Safety of Bioplasma FDP and Hemopure in rhesus macaques after 30% hemorrhage. Trauma Surg Acute Care Open 2024; 9:e001147. [PMID: 38196929 PMCID: PMC10773430 DOI: 10.1136/tsaco-2023-001147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/03/2023] [Indexed: 01/11/2024] Open
Abstract
Objectives Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM). Methods After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology. Results Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP. Conclusion There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function. Level of evidence Not applicable.
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Affiliation(s)
| | - Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Michael M Tiller
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Jacob J Glaser
- Providence Regional Medical Center, Everett, Washington, USA
| | - Richard B Weiskopf
- Department of Anesthesia and Perioperative Medcine, University of California San Francisco, San Francisco, California, USA
| | - Ismaeel Ebrahim
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Willem Stassen
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Sanjeev Rambharose
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Scott H Mahoney
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Lee A Wallis
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Ewell M Hollis
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Gerald T Delong
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Sylvain Cardin
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Binks F, Hardy A, Wallis LA, Stassen W. The variables predictive of ambulance non-conveyance of patients in the Western Cape, South Africa. Afr J Emerg Med 2023; 13:293-299. [PMID: 37807978 PMCID: PMC10551619 DOI: 10.1016/j.afjem.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/13/2023] [Accepted: 09/17/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Emergency medical service (EMS) resources are limited and should be reserved for incidents of appropriate acuity. Over-triage in dispatching of EMS resources is a global problem. Analysing patients that are not transported to hospital is valuable in contributing to decision-making models/algorithms to better inform dispatching of resources. The aim is to determine variables associated with patients receiving an emergency response but result in non-conveyance to hospital. Methods A retrospective cross-sectional study was performed on data for the period October 2018 to September 2019. EMS records were reviewed for instances where a patient received an emergency response but the patient was not transported to hospital. Data were subjected to univariate and multivariate regression analysis to determine variables predictive of non-transport to hospital. Results A total of 245 954 responses were analysed, 240 730 (97.88 %) were patients that were transported to hospital and 5 224 (2.12 %) were not transported. Of all patients that received an emergency response, 203 450 (82.72 %) patients did not receive any medical interventions. Notable variables predictive of non-transport were green (OR 4.33 (95 % CI: 3.55-5.28; p<0.01)) and yellow on-scene (OR 1.95 (95 % CI: 1.60-2.37; p<0.01).Incident types most predictive of non-transport were electrocutions (OR 4.55 (95 % CI: 1.36-15.23; p=0.014)), diabetes (OR 2.978 (95 % CI: 2.10-3.68; p<0.01)), motor vehicle accidents (OR 1.92 (95 % CI: 1.51-2.43; p<0.01)), and unresponsive patients (OR 1.98 (95 % CI: 1.54-2.55; p<0.01)). The highest treatment predictors for non-transport of patients were nebulisation (OR 1.45 (95 % CI: 1.21-1.74; p<0.01)) and the administration of glucose (OR 4.47 (95 % CI: 3.11-6.41; p<0.01)). Conclusion This study provided factors that predict ambulance non-conveyance to hospital. The prediction of patients not transported to hospital may aid in the development of dispatch algorithms that reduce over-triage of patients, on-scene discharge protocols, and treat and refer guidelines in EMS.
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Affiliation(s)
- Faisal Binks
- Division of Emergency Medicine, University of Cape Town, Private Bag X3, Rondebosch 7701, South Africa
| | | | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Private Bag X3, Rondebosch 7701, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Private Bag X3, Rondebosch 7701, South Africa
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Stassen W, Wylie C, Craig W, Ebrahim I, Mahoney SH, Pusateri AE, Rambharose S, van Koningsbruggen C, Weiskopf RB, Wallis LA. The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study. PREHOSP EMERG CARE 2023:1-7. [PMID: 37713658 DOI: 10.1080/10903127.2023.2259998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.
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Affiliation(s)
- Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Craig Wylie
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Wesley Craig
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Ismaeel Ebrahim
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Scott H Mahoney
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Anthony E Pusateri
- Naval Medical Research Unit-San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Sanjeev Rambharose
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | | | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
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Marincowitz C, Sbaffi L, Hasan M, Hodkinson P, McAlpine D, Fuller G, Goodacre S, Bath PA, Omer Y, Wallis LA. External validation of triage tools for adults with suspected COVID-19 in a middle-income setting: an observational cohort study. Emerg Med J 2023; 40:509-517. [PMID: 37217302 PMCID: PMC10359554 DOI: 10.1136/emermed-2022-212827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa. METHODS An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days. RESULTS Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage. CONCLUSION No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy.
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Affiliation(s)
- Carl Marincowitz
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Laura Sbaffi
- Information School, The University of Sheffield, Sheffield, UK
| | - Madina Hasan
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Peter Hodkinson
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - David McAlpine
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Gordon Fuller
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Peter A Bath
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
- Information School, The University of Sheffield, Sheffield, UK
| | - Yasein Omer
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
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Cunningham C, Vosloo M, Wallis LA. Interprofessional sense-making in the emergency department: A SenseMaker study. PLoS One 2023; 18:e0282307. [PMID: 36893158 PMCID: PMC9997966 DOI: 10.1371/journal.pone.0282307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Emergency Departments serve as a main entry point for patients into hospitals, and the team, the core of which is formed by doctors and nurses needs to make sense of and respond to the constant flux of information. This requires sense-making, communication, and collaborative operational decision-making. The study's main aim was to explore how collective, interprofessional sense-making occurs in the emergency department. Collective sense-making is deemed a precursor for adaptive capability, which, in turn, promotes coping in a dynamically changing environment. METHOD Doctors and nurses working in five large state emergency departments in Cape Town, South Africa, were invited to participate. Using the SenseMaker® tool, a total of 84 stories were captured over eight weeks between June and August 2018. Doctors and nurses were equally represented. Once participants shared their stories, they self-analysed these stories within a specially designed framework. The stories and self-codified data were analysed separately. Each self-codified data point was plotted in R-studio and inspected for patterns, after which the patterns were further explored. The stories were analysed using content analysis. The SenseMaker® software allows switching between quantitative (signifier) and qualitative (descriptive story) data during interpretation, enabling more deeply nuanced analyses. RESULTS The results focused on four aspects of sense-making, namely views on the availability of information, the consequences of decisions (actions), assumptions regarding appropriate action, and preferred communication methods. There was a noticeable difference in what doctors and nurses felt would constitute appropriate action. The nurses were more likely to act according to rules and policies, whereas the doctors were more likely to act according to the situation. More than half of the doctors indicated that they found it best to communicate informally, whereas the nurses indicated that formal communication worked best for them. CONCLUSION This study was the first to explore the ED's interprofessional team's adaptive capability to respond to situations from a sense-making perspective. We found an operational disconnect between doctors and nurses caused by asymmetric information, disjointed decision-making approaches, differences in habitual communication styles, and a lack of shared feedback loops. By cultivating their varied sense-making experiences into one integrated operational foundation with stronger feedback loops, interprofessional teams' adaptive capability and operational effectiveness in Cape Town EDs can be improved.
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Affiliation(s)
- Charmaine Cunningham
- Division of Emergency Medicine, The University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Marietjie Vosloo
- Department of Mathematics and Actuarial Science, University of Stellenbosch, Stellenbosch, South Africa
| | - Lee A. Wallis
- Division of Emergency Medicine, The University of Cape Town, Cape Town, South Africa
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Werner K, Risko N, Kalanzi J, Wallis LA, Reynolds TA. Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda. PLoS One 2022; 17:e0279074. [PMID: 36516176 PMCID: PMC9750003 DOI: 10.1371/journal.pone.0279074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level. METHODS A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%. RESULTS Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters. CONCLUSION Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.
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Affiliation(s)
- Kalin Werner
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | | | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Teri A. Reynolds
- Department for Clinical Services and Systems, Integrated Health Services, World Health Organization (WHO), Geneva, Switzerland
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Suresh K, Dixon JM, Patel C, Beaty B, Del Junco DJ, de Vries S, Lategan HJ, Steyn E, Verster J, Schauer SG, Becker TE, Cunningham C, Keenan S, Moore EE, Wallis LA, Baidwan N, Fosdick BK, Ginde AA, Bebarta VS, Mould-Millman NK. The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa. Scand J Trauma Resusc Emerg Med 2022; 30:55. [PMID: 36253865 PMCID: PMC9574798 DOI: 10.1186/s13049-022-01041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the “Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)” study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa. Methods The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient’s clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure). Discussion This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system. Trial Registration: Not applicable as this study is not a clinical trial.
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Affiliation(s)
- Krithika Suresh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Julia M Dixon
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Chandni Patel
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Brenda Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Deborah J Del Junco
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa
| | - Hendrick J Lategan
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elmin Steyn
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janette Verster
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Steven G Schauer
- U.S. Army Institute of Surgical Research, San Antonio Medical Center, San Antonio, TX, USA
| | - Tyson E Becker
- Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX, USA
| | - Cord Cunningham
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA
| | - Sean Keenan
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Lee A Wallis
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa.,Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Navneet Baidwan
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Bailey K Fosdick
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.
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10
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Nutbeam T, Brandling J, Wallis LA, Stassen W. Understanding people's experiences of extrication while being trapped in motor vehicles: a qualitative interview study. BMJ Open 2022; 12:e063798. [PMID: 36127106 PMCID: PMC9490624 DOI: 10.1136/bmjopen-2022-063798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To explore patient's experience of entrapment and subsequent extrication following a motor vehicle collision and identify their priorities in optimising this experience. DESIGN Semistructured interviews exploring the experience of entrapment and extrication conducted at least 6 weeks following the event. Thematic analysis of interviews. SETTING Single air ambulance and spinal cord injury charity in the UK. PARTICIPANTS 10 patients were recruited and consented; six air ambulance patients and two spinal cord injury charity patients attended the interview. 2 air ambulance patients declined to participate following consent due to the perceived potential for psychological sequelae. RESULTS The main theme across all participants was that of the importance of communication; successful communication to the trapped patient resulted in a sense of well-being and where communication failures occurred this led to distress. The data generated three key subthemes: 'on-scene communication', 'physical needs' and 'emotional needs'. Specific practices were identified that were of use to patients during entrapment and extrication. CONCLUSIONS Extrication experience was improved by positive communication, companionship, explanations and planned postincident follow-up. Extrication experience was negatively affected by failures in communication, loss of autonomy, unmanaged pain, delayed communication with remote family and onlooker use of social media. Recommendations which will support a positive patient-centred extrication experience are the presence of an 'extrication buddy', the use of clear and accessible language, appropriate reassurance in relation to co-occupants, a supportive approach to communication with family and friends, the minimisation of onlooker photo/videography and the provision of planned (non-clinical) follow-up.
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Affiliation(s)
- Tim Nutbeam
- Department of Emergency Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
- Devon Air Ambulance, Exeter, UK
| | - Janet Brandling
- Qualitative Researcher and Psychotherapist, Unaffiliated, Bristol, UK
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
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11
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Friedman A, Wallis LA, Bullick JC, Cunningham C, Kalanzi J, Kavuma P, Osiro M, Straube S, Tenner AG. Pre-course online cases for the world health organization's basic emergency care course in Uganda: A mixed methods analysis. Afr J Emerg Med 2022; 12:148-153. [PMID: 35505667 PMCID: PMC9048077 DOI: 10.1016/j.afjem.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 02/16/2022] [Accepted: 03/24/2022] [Indexed: 11/23/2022] Open
Abstract
Short courses may address a significant gap in health worker training in basic emergency care in Sub-Saharan Africa. Online open educational resources could enhance healthcare worker education in Sub-Saharan Africa as Internet access expands and costs decrease. Nurses and doctors show differential knowledge retention in blended short courses that may require targeted educational strategies.
Introduction The Ministry of Health - Uganda implemented the World Health Organization's Basic Emergency Care course (BEC1) to improve formal emergency care training and address its high burden of acute illness and injury. The BEC is an open-access, in-person, short course that provides comprehensive basic emergency training in low-resource settings. A free, open-access series of pre-course online cases available as downloadable offline files were developed to improve knowledge acquisition and retention. We evaluated BEC participants’ knowledge and self-efficacy in emergency care provision with and without these cases and their perceptions of the cases. Methods Multiple Choice Questions (MCQs2) and Likert-scale surveys assessed 137 providers’ knowledge and self-efficacy in emergency care provision, respectively, and focus group discussions explored 74 providers’ perceptions of the BEC course with cases in Kampala in this prospective, controlled study. Data was collected pre-BEC, post-BEC and six-months post-BEC. We used liability analysis and Cronbach alpha coefficients to establish intercorrelation between categorised Likert-scale items. We used mixed model analysis of variance to interpret Likert-scale and MCQ data and thematic content analysis to explore focus group discussions. Results Participants gained and maintained significant increases in MCQ averages (15%) and Likert-scale scores over time (p < 0.001). The intervention group scored significantly higher on the pre-test MCQ than controls (p = 0.004) and insignificantly higher at all other times (p > 0.05). Nurses experienced more significant initial gains and long-term decays in MCQ and self-efficacy than doctors (p = 0.009, p < 0.05). Providers found the cases most useful pre-BEC to preview course content but did not revisit them post-course. Technological difficulties and internet costs limited case usage. Conclusion Basic emergency care courses for low-resource settings can increase frontline providers’ long-term knowledge and self-efficacy in emergency care. Nurses experienced greater initial gains and long-term losses in knowledge than doctors. Online adjuncts may enhance health professional education in low-to-middle income countries.
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12
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Bhaumik S, Hannun M, Dymond C, DeSanto K, Barrett W, Wallis LA, Mould-Millman NK. Prehospital triage tools across the world: a scoping review of the published literature. Scand J Trauma Resusc Emerg Med 2022; 30:32. [PMID: 35477474 PMCID: PMC9044621 DOI: 10.1186/s13049-022-01019-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/19/2022] [Indexed: 01/15/2023] Open
Abstract
Background Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. Methods A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. Results Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. Conclusions The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01019-z.
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Affiliation(s)
- Smitha Bhaumik
- Department of Emergency Medicine, Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA.,Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Merhej Hannun
- Department of Family Medicine, Reading Hospital - Tower Health, 420 South 5th Avenue, West Reading, PA, 19611, USA
| | - Chelsea Dymond
- Department of Emergency Medicine, Providence St Joseph Hospital, 2700 Dolbeer St, Eureka, CA, 95501, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, School of Medicine, University of Colorado Anschutz Medical Campus, 12950 E. Montview Blvd., Mail Stop A003, Aurora, CO, 80045, USA
| | - Whitney Barrett
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, 1 University of New Mexico, MSC11 6025, Albuquerque, NM, 87131, USA
| | - Lee A Wallis
- Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA. .,Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa.
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Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is well studied in high-income countries, and research has encouraged the implementation of policy to increase survival rates. On the other hand, comprehensive research on OHCA in Africa is sparse, despite the higher incidence of risk factors. In this vein, structural barriers to OHCA care in Africa must be fully recognised and understood before similar improvements in outcome may be made. The aim of this study was to describe and summarise the body of literature related to OHCA in Africa. METHODS AND ANALYSIS Using an a priori developed search strategy, electronic searches were performed in Medline via Pubmed, Web of Science, Scopus and Google Scholar databases to identify articles published in English between 2000 and 2020 relevant to OHCA in Africa. Titles, abstract and full text were reviewed by two reviewers, with discrepancies handled by an independent reviewer. A summary of the main themes contained in the literature was developed using descriptive analysis on eligible articles. RESULTS A total of 1200 articles were identified. In the screening process, 785 articles were excluded based on title, and a further 127 were excluded following abstract review. During full-text review to determine eligibility, 80 articles were excluded and one was added following references review. A total of 19 articles met the inclusion criteria. During analysis, the following three themes were found: epidemiology and underlying causes for OHCA, first aid training and bystander action, and Emergency Medical Services (EMS) resuscitation and training. CONCLUSIONS In order to begin addressing OHCA in Africa, representative research with standardised reporting that complies to data standards is required to understand the full, context-specific picture. Policies and research may then target underlying conditions, improvements in bystander and EMS training, and system improvements that are contextually relevant and ultimately result in better outcomes for OHCA victims.
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Affiliation(s)
- Juliette Thibodeau
- University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Kalin Werner
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
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14
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Mould-Millman NK, Dixon JM, van Ster B, Moreira F, Bester B, Cunningham C, de Vries S, Beaty B, Suresh K, Schauer SG, Maddry JK, Wallis LA, Bebarta VS, Ginde AA. Clinical impact of a prehospital trauma shock bundle of care in South Africa. Afr J Emerg Med 2022; 12:19-26. [PMID: 35004137 PMCID: PMC8718736 DOI: 10.1016/j.afjem.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/23/2021] [Accepted: 10/08/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction Patients experiencing traumatic shock are at a higher risk for death and complications. We previously designed a bundle of emergency medical services traumatic shock care (“EMS-TruShoC”) for prehospital providers in resource-limited settings. We assess how EMS-TruShoC changes clinical outcomes of critically injured prehospital patients. Methods This is a quasi-experimental educational implementation of a simplified bundle of care using a pre-post design with a control group. The intervention was delivered to EMS providers in Western Cape, South Africa. Delta shock index (heart rate divided by systolic blood pressure, reported as change from the scene to facility arrival) from the 13 months preceding intervention were compared to the 13 months post-implementation. A difference-in-differences analysis examined the difference in mean shock index change between the groups. Results Data were collected from 198 providers who treated 770 severe trauma patients. The patient groups had similar demographic and clinical characteristics at baseline. Over all time-points, both groups had an increase in mean delta shock index (worsening shock), with the largest difference occurring 4-months post-implementation (0.047 change in control arm, 0.004 change in intervention arm; −0.043 difference-in-differences, P = 0.27). In pre-specified subgroup analyses, there was a statistically significant improvement in delta shock index in the intervention arm in patients with penetrating trauma cared for by basic providers immediately post-implementation (−0.372 difference-in-differences, P = 0.02). Discussion Overall, there was no significant difference in delta shock index between the EMS-TruShoC intervention versus control groups. However, significant improvement in shock index in one subgroup suggests the intervention may be more likely to benefit penetrating trauma patients and basic providers.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- University of Colorado Denver, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
- Corresponding author.
| | - Julia M. Dixon
- University of Colorado Denver, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
| | - Bradley van Ster
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Fabio Moreira
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Beatrix Bester
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Charmaine Cunningham
- University of Cape Town, Department of Surgery, Division of Emergency Medicine, Cape Town, South Africa
| | - Shaheem de Vries
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Brenda Beaty
- University of Colorado Denver, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, USA
| | - Krithika Suresh
- University of Colorado Denver, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, USA
| | - Steven G. Schauer
- U.S. Army Institute of Surgical Research, Joint Base San Antonio-Ft Sam Houston, TX, USA
| | - Joseph K. Maddry
- U.S. Air Force En Route Care Research Center, Joint Base San Antonio-Lackland, TX, USA
| | - Lee A. Wallis
- University of Cape Town, Department of Surgery, Division of Emergency Medicine, Cape Town, South Africa
| | - Vikhyat S. Bebarta
- University of Colorado Denver, School of Medicine, Center for COMBAT Research, Aurora, CO, USA
| | - Adit A. Ginde
- University of Colorado Denver, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
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15
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Mould‐Millman N, Dixon J, Lee M, Meese H, Mata LV, Burkholder T, Moreira F, Bester B, Thomas J, de Vries S, Wallis LA, Ginde AA. Measuring quality of pre-hospital traumatic shock care-development and validation of an instrument for resource-limited settings. Health Sci Rep 2021; 4:e422. [PMID: 34693030 PMCID: PMC8516037 DOI: 10.1002/hsr2.422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/09/2021] [Accepted: 09/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIMS Improving the quality of pre-hospital traumatic shock care, especially in low- and middle-income countries, is particularly relevant to reducing the large global burden of disease from injury. What clinical interventions represent high-quality care is an actively evolving field and often dependent on the specific injury pattern. A key component of improving the quality of care is having a consistent way to assess and measure the quality of shock care in the pre-hospital setting. The objective of this study was to develop and validate a chart abstraction instrument to measure the quality of trauma care in a resource-limited, pre-hospital emergency care setting. METHODS Traumatic shock was selected as the tracer condition. The pre-hospital quality of traumatic shock care (QTSC) instrument was developed and validated in three phases. A content development phase utilized a rapid literature review and expert consensus to yield the contents of the draft instrument. In the instrument validation phase, the QTSC instrument was created and underwent end user and content validation. A pilot-testing phase collected user feedback and performance characteristics to iteratively refine draft versions into a final instrument. Accuracy and inter- and intra-rater agreement were calculated. RESULTS The final QTSC instrument contains 10 domains of quality, each with specific criteria that determine how the domain is measured and the level of quality of care rendered. The instrument is over 90% accurate and has good inter- and intra-rater reliability when used by trained pre-hospital provider users in South Africa. Pre-hospital provider user feedback indicates the tool is easy to learn and quick to use. CONCLUSION We created and validated a novel chart abstraction instrument that can reliably and accurately measure the quality of pre-hospital traumatic shock care. We provide a systematic methodology for developing and validating a quality of care tool for resource-limited care settings.
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Affiliation(s)
- Nee‐Kofi Mould‐Millman
- Department of Emergency MedicineUniversity of Colorado Denver School of MedicineAuroraColoradoUSA
| | - Julia Dixon
- Department of Emergency MedicineUniversity of Colorado Denver School of MedicineAuroraColoradoUSA
| | - Michael Lee
- Western Cape Government, Department of HealthEmergency Medical ServicesCape TownSouth Africa
| | - Halea Meese
- Department of Family and Community MedicineUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Lina V. Mata
- Department of Emergency MedicineUniversity of Colorado Denver School of MedicineAuroraColoradoUSA
| | - Taylor Burkholder
- Department of Emergency MedicineUniversity of Southern California, Keck School of MedicineCaliforniaLos AngelesUSA
| | - Fabio Moreira
- Western Cape Government, Department of HealthEmergency Medical ServicesCape TownSouth Africa
| | - Beatrix Bester
- Western Cape Government, Department of HealthEmergency Medical ServicesCape TownSouth Africa
| | - Jacob Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS)University of Colorado DenverAuroraColoradoUSA
| | - Shaheem de Vries
- Western Cape Government, Department of HealthEmergency Medical ServicesCape TownSouth Africa
| | - Lee A. Wallis
- Western Cape Government, Department of HealthEmergency Medical ServicesCape TownSouth Africa
- Division of Emergency Medicine, Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Adit A. Ginde
- Department of Emergency MedicineUniversity of Colorado Denver School of MedicineAuroraColoradoUSA
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16
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Hirner S, Pigoga JL, Naidoo AV, Calvello Hynes EJ, Omer YO, Wallis LA, Bills CB. Potential solutions for screening, triage, and severity scoring of suspected COVID-19 positive patients in low-resource settings: a scoping review. BMJ Open 2021; 11:e046130. [PMID: 34526332 PMCID: PMC8449848 DOI: 10.1136/bmjopen-2020-046130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring of patients with suspected COVID-19 on initial presentation to the healthcare system and to evaluate the utility of these tools in LRS. DESIGN A scoping review was conducted to identify studies describing acute screening, triage, and severity scoring of patients with suspected COVID-19 published between 12 December 2019 and 1 April 2021. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data. PARTICIPANT The initial search strategy yielded 15 232 articles; 124 met inclusion criteria. RESULTS Most studies were from China (n=41, 33.1%) or the United States (n=23, 18.5%). In total, 57 screening, 23 triage, and 54 severity scoring tools were described. A total of 51 tools-31 screening, 5 triage, and 15 severity scoring-were identified as feasible for use in LRS. A total of 37 studies provided validation data: 4 prospective and 33 retrospective, with none from low-income and lower middle-income countries. CONCLUSIONS This study identified a number of screening, triage, and severity scoring tools implemented and proposed for patients with suspected COVID-19. No tools were specifically designed and validated in LRS. Tools specific to resource limited contexts is crucial to reducing mortality in the current pandemic.
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Affiliation(s)
- Sarah Hirner
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jennifer Lee Pigoga
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | | | - Emilie J Calvello Hynes
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Yasein O Omer
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
- Sudan Medical Specialization Board, Khartoum, Sudan
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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17
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Schell CO, Khalid K, Wharton-Smith A, Oliwa J, Sawe HR, Roy N, Sanga A, Marshall JC, Rylance J, Hanson C, Kayambankadzanja RK, Wallis LA, Jirwe M, Baker T. Essential Emergency and Critical Care: a consensus among global clinical experts. BMJ Glob Health 2021; 6:e006585. [PMID: 34548380 PMCID: PMC8458367 DOI: 10.1136/bmjgh-2021-006585] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/19/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. METHODS In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. RESULTS The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. CONCLUSION The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.
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Affiliation(s)
- Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Internal Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Alexandra Wharton-Smith
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- The George Institute for Global Health India, New Delhi, India
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital, Mumbai, India
| | - Alex Sanga
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | - John C Marshall
- Departments of Surgery and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jamie Rylance
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
| | - Raphael K Kayambankadzanja
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Maria Jirwe
- Department of Health Sciences, The Red Cross University College, Huddinge, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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18
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Stassen W, Wylie C, Djärv T, Wallis LA. Out-of-hospital cardiac arrests in the city of Cape Town, South Africa: a retrospective, descriptive analysis of prehospital patient records. BMJ Open 2021; 11:e049141. [PMID: 34400458 PMCID: PMC8370552 DOI: 10.1136/bmjopen-2021-049141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES While prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa. DESIGN Observational study with a retrospective descriptive design. SETTING Cape Town metropole, Western Cape province, South Africa. PARTICIPANTS All patients with OHCA for the period 1 January 2018-31 December 2018 were extracted from public and private emergency medical services (EMS) and described. OUTCOME MEASURES Description of patients with OHCA in terms of demographics, treatment and short-term outcome. RESULTS A total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene. CONCLUSION To our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential.
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Affiliation(s)
- Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Craig Wylie
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Therese Djärv
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Naidoo AV, Hodkinson P, Lai King L, Wallis LA. African authorship on African papers during the COVID-19 pandemic. BMJ Glob Health 2021; 6:bmjgh-2020-004612. [PMID: 33648979 PMCID: PMC7925242 DOI: 10.1136/bmjgh-2020-004612] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 01/30/2023] Open
Affiliation(s)
| | - Peter Hodkinson
- Division of Emergency Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Lauren Lai King
- Division of Emergency Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
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Mwanza KE, Stassen W, Pigoga JL, Wallis LA. The views and experiences of Zambia's emergency medicine registrars in South Africa: Lessons for the development of emergency care in Zambia. Afr J Emerg Med 2021; 11:65-69. [PMID: 33680723 PMCID: PMC7910180 DOI: 10.1016/j.afjem.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Although low- and middle-income countries (LMICs) are beginning to integrate emergency medicine (EM) specialist physicians into their healthcare systems, they must often send these trainees to other countries with established registrar programmes. Given that retention of foreign-trained EM specialist physicians is low following repatriation, there is interest in understanding their expectations and intentions when they return. This study aimed to describe the expectations of Zambia's EM registrars regarding the development of various aspects of emergency care in Zambia. Methods In this qualitative, descriptive study, individual telephonic interviews were conducted with current Zambian EM registrars using a semi-structured interview schedule. Recorded interviews were transcribed verbatim, validated by participants, and subjected to inductive content analysis. Results Four interviews were completed, representing the entire population of interest. Two key categories emerged from these discussions: that the state of emergency care in Zambia was inadequate, and that there were numerous priority areas for further developing the emergency care system. A lack of recognition of EM as a specialty, resource and training constraints in emergency units, and the lack of a formal prehospital emergency care system were prominently identified as challenges. Priority aspects that registrars hoped to focus on when developing emergency care included expanding local training and knowledge, improving the supply chain for essential medications and equipment, increasing interprofessional collaborative practice, and advocating for emergency care. Conclusion Zambian EM registrars characterised the nascent emergency care system by challenges that are common in many LMICs and align with previous in-country assessments of emergency care. In order to ensure that registrars' strategies are ultimately implemented upon their return to Zambia, it is imperative they are communicated with stakeholders in-country. From there, mutual planning can occur between future EM specialists and government stakeholders, to ensure that there are mechanisms in place to facilitate dissemination.
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Mould-Millman NK, Dixon JM, Burkholder T, Pigoga JL, Lee M, de Vries S, Moodley K, Meier M, Colborn K, Patel C, Wallis LA. Validity and reliability of the South African Triage Scale in prehospital providers. BMC Emerg Med 2021; 21:8. [PMID: 33451294 PMCID: PMC7811258 DOI: 10.1186/s12873-021-00406-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/10/2021] [Indexed: 12/05/2022] Open
Abstract
Background The South African Triage Scale (SATS) is a validated in-hospital triage tool that has been innovatively adopted for use in the prehospital setting by Western Cape Government (WCG) Emergency Medical Services (EMS) in South Africa. The performance of SATS by EMS providers has not been formally assessed. The study sought to assess the validity and reliability of SATS when used by WCG EMS prehospital providers for single-patient triage. Methods This is a prospective, assessment-based validation study among WCG EMS providers from March to September 2017 in Cape Town, South Africa. Participants completed an assessment containing 50 clinical vignettes by calculating the three components — triage early warning score (TEWS), discriminators (pre-defined clinical conditions), and a final SATS triage color. Responses were scored against gold standard answers. Validity was assessed by calculating over- and under-triage rates compared to gold standard. Inter-rater reliability was assessed by calculating agreement among EMS providers’ responses. Results A total of 102 EMS providers completed the assessment. The final SATS triage color was accurately determined in 56.5%, under-triaged in 29.5%, and over-triaged in 13.1% of vignette responses. TEWS was calculated correctly in 42.6% of vignettes, under-calculated in 45.0% and over-calculated in 10.9%. Discriminators were correctly identified in only 58.8% of vignettes. There was substantial inter-rater and gold standard agreement for both the TEWS component and final SATS color, but there was lower inter-rater agreement for clinical discriminators. Conclusion This is the first assessment of SATS as used by EMS providers for prehospital triage. We found that SATS generally under-performed as a triage tool, mainly due to the clinical discriminators. We found good inter-rater reliability, but poor validity. The under-triage rate of 30% was higher than previous reports from the in-hospital setting. The over-triage rate of 13% was acceptable. Further clinically-based and qualitative studies are needed. Trial registration Not applicable. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00406-6.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- Department of Emergency Medicine, University of Colorado Denver, School of Medicine, Anschutz Medical Campus, 12631 E 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA. .,Division of Emergency Medicine, University of Cape Town, Department of Surgery, Cape Town, South Africa.
| | - Julia M Dixon
- Department of Emergency Medicine, University of Colorado Denver, School of Medicine, Anschutz Medical Campus, 12631 E 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Taylor Burkholder
- University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Jennifer L Pigoga
- Division of Emergency Medicine, University of Cape Town, Department of Surgery, Cape Town, South Africa
| | - Michael Lee
- Division of Emergency Medicine, University of Cape Town, Department of Surgery, Cape Town, South Africa.,Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Shaheem de Vries
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Kubendhren Moodley
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Maxene Meier
- Department of Pediatrics, University of Colorado Denver, School of Medicine, Aurora, CO, USA
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Denver, School of Medicine, Aurora, CO, USA
| | - Chandni Patel
- Department of Emergency Medicine, University of Colorado Denver, School of Medicine, Anschutz Medical Campus, 12631 E 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Department of Surgery, Cape Town, South Africa.,Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
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Wallis LA. ILCOR's first foray into low resource settings. Resuscitation 2020; 159:178. [PMID: 33385468 DOI: 10.1016/j.resuscitation.2020.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Lee A Wallis
- University of Cape Town, Cape Town, Western Province, South Africa.
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Bergquist HB, Burkholder TW, Muhammad Ali OA, Omer Y, Wallis LA. Considerations for service delivery for emergency care in low resource settings. Afr J Emerg Med 2020; 10:S7-S11. [PMID: 33318895 PMCID: PMC7723907 DOI: 10.1016/j.afjem.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 05/12/2020] [Accepted: 07/06/2020] [Indexed: 11/25/2022] Open
Abstract
In a shift from the more traditional disease focused model of global health interventions, increasing attention is now being placed on the importance of strengthening healthcare systems as a key component for achieving improved health outcomes. As emergency care systems continue to develop and strengthen around the world, the concept of service delivery provides one way to assess how well these systems are functioning. By focusing on service delivery, a system can be evaluated based on its ability to provide patients with access to the high-quality emergency care that they deserve. While the concept of service delivery is commonly used to evaluate the effectiveness of care in high-resource settings, its use in low resource settings has previously been limited due to challenges in operationalizing the concept in a context appropriate way. This article will begin by discussing the concept of service delivery as it specifically applies to emergency care systems and then discuss some of the challenges in defining and assessing this concept in low resource settings. The article will then discuss several new tools that have been developed to specifically address ways to evaluate emergency care service delivery in low-resource settings that can be used to inform future systems strengthening activities.
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Burkholder TW, Bergquist HB, Wallis LA. Governing access to emergency care in Africa. Afr J Emerg Med 2020; 10:S2-S6. [PMID: 33318894 PMCID: PMC7723917 DOI: 10.1016/j.afjem.2020.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 11/28/2022] Open
Abstract
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.
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Risko N, Werner K, Offorjebe OA, Vecino-Ortiz AI, Wallis LA, Razzak J. Cost-effectiveness and return on investment of protecting health workers in low- and middle-income countries during the COVID-19 pandemic. PLoS One 2020; 15:e0240503. [PMID: 33035244 PMCID: PMC7546502 DOI: 10.1371/journal.pone.0240503] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/28/2020] [Indexed: 12/15/2022] Open
Abstract
Background In this paper, we predict the health and economic consequences of immediate investment in personal protective equipment (PPE) for health care workers (HCWs) in low- and middle-income countries (LMICs). Methods To account for health consequences, we estimated mortality for HCWs and present a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model with Bayesian multivariate sensitivity analysis and Monte Carlo simulation. Data sources included inputs from the World Health Organization Essential Supplies Forecasting Tool and the Imperial College of London epidemiologic model. Results An investment of $9.6 billion USD would adequately protect HCWs in all LMICs. This intervention would save 2,299,543 lives across LMICs, costing $59 USD per HCW case averted and $4,309 USD per HCW life saved. The societal ROI would be $755.3 billion USD, the equivalent of a 7,932% return. Regional and national estimates are also presented. Discussion In scenarios where PPE remains scarce, 70–100% of HCWs will get infected, irrespective of nationwide social distancing policies. Maintaining HCW infection rates below 10% and mortality below 1% requires inclusion of a PPE scale-up strategy as part of the pandemic response. In conclusion, wide-scale procurement and distribution of PPE for LMICs is an essential strategy to prevent widespread HCW morbidity and mortality. It is cost-effective and yields a large downstream return on investment.
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Affiliation(s)
- Nicholas Risko
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- * E-mail:
| | - Kalin Werner
- University of Cape Town, Cape Town, South Africa
| | - O. Agatha Offorjebe
- University of Southern California Keck School of Medicine, Los Angeles, CA, United States of America
| | - Andres I. Vecino-Ortiz
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | - Junaid Razzak
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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Sawe HR, Reynolds TA, Weber EJ, Mfinanga JA, Coats TJ, Wallis LA. Development and pilot implementation of a standardised trauma documentation form to inform a national trauma registry in a low-resource setting: lessons from Tanzania. BMJ Open 2020; 10:e038022. [PMID: 33033093 PMCID: PMC7545631 DOI: 10.1136/bmjopen-2020-038022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/16/2020] [Accepted: 09/01/2020] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Trauma registries are an integral part of a well-organised trauma system. Tanzania, like many low and middle-income countries, does not have a trauma registry. We describe the development, structure, implementation and impact of a context appropriate standardised trauma form based on the adaptation of the WHO Data Set for Injury (DSI), for clinical documentation and use in a national trauma registry. SETTING Our study was conducted in emergency units of five regional referral hospitals in Tanzania. PROCEDURES Mixed methods participatory action research was employed. After an assessment of baseline trauma documentation, we conducted semi-structured interviews with a purposefully selected sample of 33 healthcare providers from all participating hospitals to understand, develop, pilot and implement a standardised trauma form. We compared the number and types of variables captured before and after the form was implemented. OUTCOMES Change in proportion of variables of DSI captured after implementation of a standardised trauma documentation form. RESULTS Piloting and feedback informed the development of a context appropriate standardised trauma documentation paper form with carbonless copy that could be used as both the clinical chart and data capture. Among 721 patients (seen by 21 clinicians) during the initial 30-day pilot, overall variable capture was 86.4% of required variables. After modifications of the form and training of healthcare providers, the form was implemented for 7 months, during which the capture improved to 96.3% among 6302 patients (seen by 31 clinicians). The providers reported the form was user-friendly, resulted in less time documenting, and served as a guide to managing trauma patients. CONCLUSIONS The development and implementation of a contextually appropriate, standardised trauma form were successful, yielding increased capture rates of injury variables. This system will facilitate expansion of the trauma registry across the country and inform similar initiatives in Sub-Saharan Africa.
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Affiliation(s)
- Hendry R Sawe
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Teri A Reynolds
- Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Ellen J Weber
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Juma A Mfinanga
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, United Republic of Tanzania
| | - Timothy J Coats
- Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Lee A Wallis
- Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Friedman A, Werner K, Geduld HI, Wallis LA. Advanced life support courses in Africa: Certification, availability and perceptions. Afr J Emerg Med 2020; 10:S60-S64. [PMID: 33318904 PMCID: PMC7723912 DOI: 10.1016/j.afjem.2020.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/15/2020] [Accepted: 07/26/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Advanced life support (ALS) short training courses are in demand across Africa, though overwhelmingly designed and priced for non-African contexts. The continental expansion of emergency care is driving wider penetration of these courses, but their relevance and accessibility is not known. We surveyed clinicians within emergency settings to describe ALS courses' prevalence and perceived value in Africa. METHODS We conducted a cross-sectional quantitative analysis of 235 clinicians' responses to the African Federation for Emergency Medicine's online needs assessment for an open-access ALS course in Africa. Participants responded to multiple-choice and open answer questions assessing demographics, ALS course certification and availability, perceptions of ALS courses, and barriers and facilitators to undertaking such courses. RESULTS 235 clinicians working in 23 African nations responded. Most clinicians reported ALS course completion within the past three years (73%) and in-country access to ALS courses (76%). Most believed the content adequately met their region's needs (60%). Price and course availability were the most common barriers to taking an ALS course. The most common courses were cardiac and paediatric-focused, and the most common reasons to take a course included general career development, personal interest, and departmental requirements. CONCLUSION One-quarter of emergency care clinicians lack access to ALS courses in twenty-three African nations. Most clinicians believe that ALS courses have value in their clinical settings and meet the needs of their region. Our findings illustrate the need for an affordable, widely available ALS course tailored to lower-resource African settings that could reach rural and peri-urban clinicians.
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Affiliation(s)
- Alexandra Friedman
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- University of California, San Francisco, San Francisco, CA, USA
| | - Kalin Werner
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Heike I. Geduld
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
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Sawe HR, Sirili N, Weber E, Coats TJ, Wallis LA, Reynolds TA. Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania. Afr J Emerg Med 2020; 10:S23-S28. [PMID: 33318898 PMCID: PMC7723914 DOI: 10.1016/j.afjem.2020.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The burden of trauma in low and middle-income countries (LMICs) is disproportionately high: LMICs account for nearly 90% of the global trauma deaths. Lack of trauma data has been identified as one of the major challenges in addressing the quality of trauma care and informing injury-preventing strategies in LMICs. This study aimed to explore the barriers and facilitators of current trauma documentation practices towards the development of a national trauma registry (TR). METHODS An exploratory qualitative study was conducted at five regional hospitals between August 2018 and December 2018. Five focus group discussions (FGDs) were conducted with 49 participants from five regional hospitals. Participants included specialists, medical doctors, assistant medical officers, clinical officers, nurses, health clerks and information communication and technology officers. Participants came from the emergency units, surgical and orthopaedic inpatient units, and they had permanent placement to work in these units as non-rotating staff. We analysed the gathered information using a hybrid thematic analysis. RESULTS Inconsistent documentation and archiving system, the disparity in knowledge and experience of trauma documentation, attitudes towards documentation and limitations of human and infrastructural resources in facilities we found as major barriers to the implementation of trauma registry. Health facilities commitment to standardising care, Ministry of Health and medicolegal data reporting requirements, and insurance reimbursements criteria of documentation were found as major facilitators to implementing trauma registry. CONCLUSIONS Implementation of a trauma registry in regional hospitals is impacted by multiple barriers related to providers, the volume of documentation, resource availability for care, and facility care flow processes. However, financial, legal and administrative data reporting requirements exist as important facilitators in implementing the trauma registry at these hospitals. Capitalizing in the identified facilitators and investing to address the revealed barriers through contextualized interventions in Tanzania and other LMICs is recommended by this study.
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Affiliation(s)
- Hendry R. Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nathanael Sirili
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ellen Weber
- Emergency Department, University of California, San Francisco, CA, USA
| | - Timothy J. Coats
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Lee A. Wallis
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Teri A. Reynolds
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Clinical Services and Systems, Integrated Health Services, World Health Organization (WHO), Geneva, Switzerland
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van de Ruit C, Lahri S, Wallis LA. Clinical teams' experiences of crowding in public emergency centres in Cape Town, South Africa. Afr J Emerg Med 2020; 10:52-57. [PMID: 32612908 PMCID: PMC7320195 DOI: 10.1016/j.afjem.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 12/16/2019] [Accepted: 12/20/2019] [Indexed: 11/12/2022] Open
Abstract
Introduction Crowding is a significant challenge for emergency centres (ECs) globally. While South Africa is not alone in reckoning with high patient demand and insufficient resources to treat these patients; staff-to-patient ratios are generally lower than in the Global North. The study of crowding and its consequences for patient care is a key research priority for strengthening the quality and efficacy of emergency care in South Africa. The study set out to understand frontline staff's perspectives on crowding in Cape Town public ECs to learn how they cope in such high- pressure working conditions, determine what they see as the factors contributing to crowding, and obtain their recommendations for reform. Methods This research is a qualitative study from interviews and observations at five ECs in Cape Town, conducted in June and July 2017. In total 43 staff were interviewed individually or in pairs. The interviews included physicians of varying levels of experience (25), and registered or enrolled nurses (18). Data were analysed with the qualitative text-analysis software NVivo. Results Both doctors and nurses saw crowding as a consequence of three factors: 1) limited bed space in the EC, 2) insufficient health professionals to care for admitted patients, and 3) the presence of boarders. Systemic or organizational factors as well as human resource scarcity were determined to be the key reasons for crowding. Discussion With its high patient acuity and volume and its limited human and material resources, South Africa is an important case study for understanding how emergency care providers manage working in crowded conditions. The solutions to crowding recommended by interviewees were to expand the EC workforce and to add discharge lounges and examination tables.
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Pigoga JL, Joiner AP, Chowa P, Luong J, Mhlanga M, Reynolds TA, Wallis LA. Evaluating capacity at three government referral hospital emergency units in the kingdom of Eswatini using the WHO Hospital Emergency Unit Assessment Tool. BMC Emerg Med 2020; 20:33. [PMID: 32375637 PMCID: PMC7201969 DOI: 10.1186/s12873-020-00327-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Kingdom of Eswatini, a lower-middle income nation of 1.45 million in southern Africa, has recently identified emergency care as a key strategy to respond to the national disease burden. We aimed to evaluate the current capacity of hospital emergency care areas using the WHO Hospital Emergency Unit Assessment Tool (HEAT) at government referral hospitals in Eswatini. METHODS We conducted a cross-sectional study of three government referral hospital emergency care areas using HEAT in May 2018. This standardised tool assists healthcare facilities to assess the emergency care delivery capacity in facilities and support in identifying gaps and targeting interventions to strengthen care delivery within emergency care areas. Senior-level emergency care area employees, including senior medical officers and nurse matrons, were interviewed using the HEAT. RESULTS All sites provided some level of emergency care 24 h a day, 7 days a week, though most had multiple entry points for emergency care. Only one facility had a dedicated area for receiving emergencies and a dedicated resuscitation area; two had triage areas. Facilities had limited capacity to perform signal functions (life-saving procedures that require both skills and resources). Commonly reported barriers included training deficits and lack of access to supplies, medications, and equipment. Sites also lacked formal clinical management and process protocols (such as triage and clinical protocols). CONCLUSIONS The HEAT highlighted strengths and weaknesses of emergency care delivery within hospitals in Eswatini and identified specific causes of these system and service gaps. In order to improve emergency care outcomes, multiple interventions are needed, including training opportunities, improvement in supply chains, and implementation of clinical and process protocols for emergency care areas. We hope that these findings will allow hospital administrators and planners to develop effective change management plans.
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Affiliation(s)
- J L Pigoga
- Division of Emergency Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7935, South Africa.
| | - A P Joiner
- Division of Emergency Medicine, Duke University, Durham, North Carolina, USA
| | - P Chowa
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - J Luong
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - M Mhlanga
- Emergency Preparedness and Response, Eswatini Ministry of Health, Mbabane, Eswatini
| | - T A Reynolds
- Department for Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - L A Wallis
- Division of Emergency Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7935, South Africa
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Sawe HR, Sirili N, Weber E, Coats TJ, Reynolds TA, Wallis LA. Perceptions of health providers towards the use of standardised trauma form in managing trauma patients: a qualitative study from Tanzania. Inj Epidemiol 2020; 7:15. [PMID: 32354375 PMCID: PMC7193390 DOI: 10.1186/s40621-020-00244-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/02/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Trauma registries (TRs) are essential to informing the quality of trauma care within health systems. Lack of standardised trauma documentation is a major cause of inconsistent and poor availability of trauma data in most low- and middle-income countries (LMICs), hindering the development of TRs in these regions. We explored health providers' perceptions on the use of a standardised trauma form to record trauma patient information in Tanzania. METHODS An exploratory qualitative research using a semi-structured interview guide was carried out to purposefully selected key informants comprising of healthcare providers working in Emergency Units and surgical disciplines in five regional hospitals in Tanzania. Data were analysed using a thematic analysis approach to identify key themes surrounding potential implementation of the standardised trauma form. RESULTS Thirty-three healthcare providers participated, the majority of whom had no experience in the use of standardised charting. Only five respondents had prior experience with trauma forms. Responses fell into three themes: perspectives on the concept of a standardised trauma form, potential benefits of a trauma form, and concerns regarding successful and sustainable implementation. CONCLUSION Findings of this study revealed wide healthcare provider acceptance of moving towards standardised clinical documentation for trauma patients. Successful implementation likely depends on the perceived benefits of using a trauma form as a tool to guide clinical management, standardise care and standardise data reporting; however, it will be important moving forward to factor concerns brought up in this study. Potential barriers to successful and sustainable implementation of the form, including the need for training and tailoring of form to match existing resources and knowledge of providers, must be considered.
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Affiliation(s)
- Hendry R. Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nathanael Sirili
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ellen Weber
- Emergency Department, University of California, San Francisco, CA USA
| | - Timothy J. Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Teri A. Reynolds
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Unit Head, Clinical Services and Systems, Integrated Health Services, World Health Organization (WHO), Geneva, Switzerland
| | - Lee A. Wallis
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Sawe HR, Reynolds TA, Weber EJ, Mfinanga JA, Coats TJ, Wallis LA. Trauma care and capture rate of variables of World Health Organisation data set for injury at regional hospitals in Tanzania: first steps to a national trauma registry. BMC Emerg Med 2020; 20:29. [PMID: 32326896 PMCID: PMC7178583 DOI: 10.1186/s12873-020-00325-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background In Tanzania, there is no national trauma registry. The World Health Organization (WHO) has developed a data set for injury that specifies the variables necessary for documenting the burden of injury and patient-related clinical processes. As a first step in developing and implementing a national Trauma Registry, we determined how well hospitals currently capture the variables that are specified in the WHO injury set. Methods This was a prospective, observational cross-sectional study of all trauma patients conducted in the Emergency Units of five regional referral hospitals in Tanzania from February 2018 to July 2018. Research assistants observed the provision of clinical care in the EU for all patients, and documented performed assessment, clinical interventions and final disposition. Research assistants used a purposefully designed case report form to audit the injury variable capture rate, and to review Ministry of Health (MoH) issued facility Register book recording the documentation of variables. We present descriptive statistics for hospital characteristics, patient volume, facility infrastructure, and capture rate of trauma variables. Results During the study period, 2891 (9.3%) patients presented with trauma-related complaints, 70.7% were male. Overall, the capture rate of all variables was 33.6%. Documentation was most complete for demographics 71.6%, while initial clinical condition, and details of injury were documented in 20.5 and 20.8% respectively. There was no documentation for the care prior to Emergency Unit arrival in all hospitals. 1430 (49.5%) of all trauma-related visits seen were documented in the facility Health Management Information System register submitted to the MoH. Among the cases reported in the register book, the date of EU care was correctly documented in 77% cases, age 43.6%, diagnosis 66.7%, and outcome in 38.9% cases. Among the observed procedures, initial clinical condition (28.7%), interventions at Emergency Unit (52.1%), investigations (49.0%), and disposition (62.9%) were documented in the clinical charts. Conclusions In the regional hospitals of Tanzania, there is inadequate documentation of the minimum trauma variables specified in the WHO injury data set. Reasons for this are unclear, but will need to be addressed in order to improve documentation to inform a national injury registry.
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Affiliation(s)
- Hendry R Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania. .,Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Private Bag X24 • Bellville, Cape Town, 7535, South Africa.
| | - Teri A Reynolds
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Private Bag X24 • Bellville, Cape Town, 7535, South Africa.,Department for the Management of NCDs, Disability, Violence and Injury Prevention, Integrated Health Services, World Health Organization (WHO), 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Ellen J Weber
- Emergency Department, University of California San-Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Juma A Mfinanga
- Department of Emergency Medicine, Muhimbili National Hospital, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Timothy J Coats
- Department of Cardiovascular Sciences, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Lee A Wallis
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Private Bag X24 • Bellville, Cape Town, 7535, South Africa
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Affiliation(s)
- Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, South Africa.,African Federation for Emergency Medicine, Cape Town, South Africa.,African Journal of Emergency Medicine, Cape Town, South Africa
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Affiliation(s)
- Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, South Africa
- African Federation for Emergency Medicine, Cape Town, South Africa
- African Journal of Emergency Medicine, Cape Town, South Africa
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Carlson LC, Reynolds TA, Wallis LA, Calvello Hynes EJ. Reconceptualizing the role of emergency care in the context of global healthcare delivery. Health Policy Plan 2019; 34:78-82. [PMID: 30689851 DOI: 10.1093/heapol/czy111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2018] [Indexed: 12/13/2022] Open
Abstract
Since the adoption of the Sustainable Development Goals in 2015, innovation in global healthcare delivery has been recognized as a vital avenue for strengthening health systems and overcoming present implementation bottlenecks. In the recent rapid development of the science of global health-care delivery, emergency care-a critical element of the health system-has been widely overlooked. Emergency care plays a vital role in the health system through providing immediately responsive care and serving as one of the main entry points for those with symptomatic disease. We present a new perspective on emergency care's role in the health system within the context of global health-care delivery, and argue that, if properly integrated, emergency care has the potential to add significant value across the healthcare continuum. Capitalizing on emergency care as a shared delivery infrastructure presents opportunities to increase efficiency not only in treatment of time-sensitive conditions, but also for secondary prevention through its capacity to promote early disease detection and enhance coordination of care. We propose an integrated emergency care delivery value chain, demonstrating emergency care's critical position as a point of access to the greater health system and its key connections to longitudinal care delivery, which remain under-developed in low- and middle-income country health systems. As emergency care systems are created within emerging and established health systems, this role can be more effectively leveraged by policy makers and healthcare leaders globally to promote progress towards the Sustainable Development Goals.
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Affiliation(s)
- Lucas C Carlson
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Teri A Reynolds
- Department for Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Emilie J Calvello Hynes
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO, USA
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Hansoti B, Mwinnyaa G, Hahn E, Rao A, Black J, Chen V, Clark K, Clarke W, Eisenberg AL, Fernandez R, Iruedo J, Laeyendecker O, Maharaj R, Mda P, Miller J, Mvandaba N, Nyanisa Y, Reynolds SJ, Redd AD, Ryan S, Stead DF, Wallis LA, Quinn TC. Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments. EClinicalMedicine 2019; 15:14-22. [PMID: 31709410 PMCID: PMC6833451 DOI: 10.1016/j.eclinm.2019.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The Eastern Cape province of South Africa has one of the highest burdens of HIV in the world. Emergency Departments (EDs) can serve as optimal clinical sites for the identification of new HIV infections and entry into care. We sought to determine the current burden of HIV disease among ED patients in the Eastern Cape. METHODS We conducted a prospective cross-sectional observational study in the EDs of three Hospitals in the Eastern Cape province of South Africa from June 2017 to July 2018. All adult, non-critical patients presenting to the ED were systematically approached and offered a Point-Of-Care (POC) HIV test in accordance with South African guidelines. All HIV-positive individuals had their blood tested for the presence of antiretroviral therapy (ART) and the presence of viral suppression (≤ 1000 copies/ml). HIV incidence was estimated using a multi-assay algorithm, validated for a subtype C epidemic. FINDINGS Of the 2901 patients for whom HIV status was determined (either known HIV-positive or underwent POC HIV testing), 811 (28.0%) were HIV positive, of which 234 (28.9%) were newly diagnosed. HIV prevalence was higher in Mthatha [34% (388/1134) at Mthatha Regional Hospital and 28% (142/512) at Nelson Mandela Academic Hospital], compared to Port Elizabeth [22% (281/1255) at Livingstone Hospital]. HIV incidence was estimated at 4.5/100 person-years (95% CI: 2.4, 6.50) for women and 1.5 (CI 0.5, 2.5) for men. Of all HIV positive individuals tested for ART (585), 54% (316/585) tested positive for the presence of ARTs, and for all HIV positive participants with viral load data (609), 49% (299/609) were found to be virally suppressed. INTERPRETATION Our study not only observed a high prevalence and incidence of HIV among ED patients but also highlights significant attrition along the HIV care cascade for HIV positive individuals. Furthermore, despite developing an optimal testing environment, we were only able to enrol a small sub-set of the ED population. Given the high HIV prevalence and high attrition in the ED population, HIV services in the ED should also develop strategies that can accommodate large testing volumes and ART initiation.
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Affiliation(s)
- Bhakti Hansoti
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - George Mwinnyaa
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, 31 Center Dr # 7A03, Bethesda, MD 20892, USA
| | - Elizabeth Hahn
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Aditi Rao
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - John Black
- Faculty of Health Sciences, Walter Sisulu University, Umtata Part 1, Mthatha, South Africa
- Department of Medicine, Livingstone Hospital, Stanford Road, Korsten, Port Elizabeth 6020, South Africa
| | - Victoria Chen
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Kathryn Clark
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - William Clarke
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Anna L. Eisenberg
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, 31 Center Dr # 7A03, Bethesda, MD 20892, USA
| | | | - Joshua Iruedo
- Faculty of Health Sciences, Walter Sisulu University, Umtata Part 1, Mthatha, South Africa
| | - Oliver Laeyendecker
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, 31 Center Dr # 7A03, Bethesda, MD 20892, USA
| | - Roshen Maharaj
- Faculty of Health Sciences, Walter Sisulu University, Umtata Part 1, Mthatha, South Africa
- Department of Emergency Medicine, Livingstone Hospital, Stanford Road, Korsten, Port Elizabeth 6020, South Africa
| | - Pamela Mda
- Nelson Mandela Hospital Clinical Research Unit, Sisson St, Fort Gale, Mthatha 5100, South Africa
| | - Jernelle Miller
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Nomzamo Mvandaba
- Faculty of Health Sciences, Walter Sisulu University, Umtata Part 1, Mthatha, South Africa
| | - Yandisa Nyanisa
- Faculty of Health Sciences, Walter Sisulu University, Umtata Part 1, Mthatha, South Africa
| | - Steven J. Reynolds
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, 31 Center Dr # 7A03, Bethesda, MD 20892, USA
| | - Andrew D. Redd
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, 31 Center Dr # 7A03, Bethesda, MD 20892, USA
| | - Sofia Ryan
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
| | - David F. Stead
- Faculty of Health Sciences, Walter Sisulu University, Umtata Part 1, Mthatha, South Africa
- Department of Medicine, Frere Hospital, Amalinda Main Rd, Braelyn, East London 5201, South Africa
| | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, Main Rd, Observatory, Cape Town 7925, South Africa
| | - Thomas C. Quinn
- The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, 31 Center Dr # 7A03, Bethesda, MD 20892, USA
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Risko N, Chandra A, Burkholder TW, Wallis LA, Reynolds T, Calvello Hynes EJ, Razzak J. Advancing research on the economic value of emergency care. BMJ Glob Health 2019; 4:e001768. [PMID: 31406603 PMCID: PMC6666808 DOI: 10.1136/bmjgh-2019-001768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 06/25/2019] [Accepted: 06/29/2019] [Indexed: 01/08/2023] Open
Abstract
Emergency care and the emergency care system encompass an array of time-sensitive interventions to address acute illness and injury. Research has begun to clarify the enormous economic burden of acute disease, particularly in low-income and middle-income countries, but little is known about the cost-effectiveness of emergency care interventions and the performance of health financing mechanisms to protect populations against catastrophic health expenditures. We summarise existing knowledge on the economic value of emergency care in low resource settings, including interventions indicated to be highly cost-effective, linkages between emergency care financing and universal health coverage, and priority areas for future research.
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Affiliation(s)
- Nicholas Risko
- Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Amit Chandra
- Collaborative on Enhancing Emergency Care Research in Low and Middle Income Countries, Bethesda, Maryland, USA
| | - Taylor W Burkholder
- Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Lee A Wallis
- Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Teri Reynolds
- Department for Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | | | - Junaid Razzak
- Emergency Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Moresky RT, Razzak J, Reynolds T, Wallis LA, Wachira BW, Nyirenda M, Carlo WA, Lin J, Patel S, Bhoi S, Risko N, Wendle LA, Calvello Hynes EJ. Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems. BMJ Glob Health 2019; 4:e001265. [PMID: 31406599 PMCID: PMC6666806 DOI: 10.1136/bmjgh-2018-001265] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023] Open
Abstract
Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.
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Affiliation(s)
- Rachel T Moresky
- sidHARTe-Strengthening Emergency Systems Program, Columbia University Heilbrunn Department of Population and Family Health, New York, New York, USA.,Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Junaid Razzak
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Teri Reynolds
- Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mulinda Nyirenda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, Ministry of Health, Blantyre, Malawi.,Emergency Medicine Section, Internal Medicine Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Waldemar A Carlo
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Janet Lin
- Department of Emergency Medicine and Center for Global Health, University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
| | - Shama Patel
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lily A Wendle
- sidHARTe-Strengthening Emergency Systems Program, Columbia University Heilbrunn Department of Population and Family Health, New York, New York, USA
| | - Emilie J Calvello Hynes
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Chavula C, Pigoga JL, Kafwamfwa M, Wallis LA. Cross-sectional evaluation of emergency care capacity at public hospitals in Zambia. Emerg Med J 2019; 36:620-624. [PMID: 31292206 DOI: 10.1136/emermed-2018-207465] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The last decade has seen rapid expansion of emergency care systems across Africa, although they remain underdeveloped. In Zambia, the Ministry of Health has taken interest in improving the situation and data are needed to appropriately guide system strengthening efforts. The Emergency Care Assessment Tool (ECAT) provides a context-specific means of measuring capacity of healthcare facilities in low- and middle-income countries. We evaluated Zambian public hospitals using the ECAT to inform resource-effective improvements to the nation's healthcare system. METHODS The ECAT was administered to the lead clinician in the emergency unit at 23 randomly sampled public hospitals across seven of Zambia's 10 provinces in March 2016. Data were collected regarding hospitals' perceived abilities to perform a number of predefined signal functions - life-saving procedures that encompass the need for both skills and resources. Signal functions (36 for intermediate facilities, 51 for advanced) related to six sentinel conditions that represent a large burden of morbidity and mortality from emergencies. We report the proportion of procedures that each level of hospital was capable of, along with barriers to delivery of care. RESULTS Across all hospitals, most of the level-appropriate emergency care procedures could be performed. Intermediate level (district) hospitals were able to perform 75% (95% CI 73.2 to 76.8) of signal functions for the six conditions. Among advanced level hospitals, provincial hospitals were able to perform 68.6% (67.4% to 69.7%) and central hospitals 96.1% (95% CI 93.5 to 98.7) Main failures in delivery of care were attributed to a lack of healthcare worker training and availability of consumable resources, such as medicines or supplies. CONCLUSION Zambian public hospitals have reasonable capacity to care for acutely ill and injured patients; however, there is a need for increased training and improved supply chains.
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Affiliation(s)
- Chancy Chavula
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer L Pigoga
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.,Emory University School of Public Health, Atlanta, Georgia, USA
| | | | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Bellville, South Africa
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Geduld H, Hynes EJC, Wallis LA, Reynolds T. Hospital proximity does not guarantee access to emergency care. Lancet Glob Health 2019; 6:e731. [PMID: 29903374 DOI: 10.1016/s2214-109x(18)30235-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/25/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Heike Geduld
- African Federation for Emergency Medicine, Karl Bremer Hospital, Belville, South Africa
| | | | - Lee A Wallis
- International Federation for Emergency Medicine, Melbourne, VIC, Australia
| | - Teri Reynolds
- WHO Program on Emergency, Trauma and Acute Care, World Health Organization, Geneva, Switzerland
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Affiliation(s)
- Teri A Reynolds
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland.
| | - Sara M Hollis
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland.
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK.
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Boissin C, Wallis LA, Kleintjes W, Laflamme L. Admission factors associated with the in-hospital mortality of burns patients in resource-constrained settings: A two-year retrospective investigation in a South African adult burns centre. Burns 2019; 45:1462-1470. [PMID: 30928024 DOI: 10.1016/j.burns.2019.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/27/2019] [Accepted: 03/03/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Little is known concerning the factors associated with in-hospital mortality of trauma patients in resource-constrained settings, not least in burns centres. We investigated this question in the adult burns centre at Tygerberg Hospital in Cape Town. We further assessed whether the Abbreviated Burn Severity Index (ABSI) is an accurate predictive score of mortality in this setting. METHODS Medical records of all patients admitted with fresh burns over a two-year period (2015 and 2016) were scrutinized to obtain data on patient, injury and admission-related characteristics. Association with in-hospital mortality was investigated for flame burns using logistic regressions and expressed as odds ratios (ORs). The mortality prediction of the ABSI score was assessed using sensitivity and specificity analyses. RESULTS Overall the in-hospital mortality was 20.4%. For the 263 flame burns, while crude ORs suggested gender, burn depth, burn size, inhalation injury, and referral status were all individually significantly associated with mortality, only the association with female gender, not being referred and burn size remained significant after adjustments (adjusted ORs = 3.79, 2.86 and 1.11 (per percentage increase in size) respectively). For the ABSI score, sensitivity and specificity were 84% and 86% respectively. CONCLUSION In this specialised centre, mortality occurs in one in five patients. It is associated with a few clinical parameters, and can be predicted using the ABSI score.
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Affiliation(s)
- Constance Boissin
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Lee A Wallis
- Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Bellville, South Africa; Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Wayne Kleintjes
- Surgery Department, Faculty of Medicine and Health Sciences, Stellenbosch University, Bellville, South Africa.
| | - Lucie Laflamme
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; University of South Africa, Pretoria, South Africa.
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Mould-Millman NK, Dixon J, Burkholder TW, Sefa N, Patel H, Yaffee AQ, Osisanya A, Oyewumi T, Botchey I, Osei-Ampofo M, Sawe H, Lemery J, Cushing T, Wallis LA. Fifteen years of emergency medicine literature in Africa: A scoping review. Afr J Emerg Med 2019; 9:45-52. [PMID: 30873352 PMCID: PMC6400014 DOI: 10.1016/j.afjem.2019.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/15/2018] [Accepted: 01/04/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Emergency medicine (EM) throughout Africa exists in various stages of development. The number and types of scientific EM literature can serve as a proxy indicator of EM regional development and activity. The goal of this scoping review is a preliminary assessment of potential size and scope of available African EM literature published over 15 years. METHODS We searched five indexed international databases as well as non-indexed grey literature from 1999-2014 using key search terms including "Africa", "emergency medicine", "emergency medical services", and "disaster." Two trained physician reviewers independently assessed whether each article met one or more of five inclusion criteria, and discordant results were adjudicated by a senior reviewer. Articles were categorised by subject and country of origin. Publication number per country was normalised by 1,000,000 population. RESULTS Of 6091 identified articles, 633 (10.4%) were included. African publications increased 10-fold from 1999 to 2013 (9 to 94 articles, respectively). Western Africa had the highest number (212, 33.5%) per region. South Africa had the largest number of articles per country (171, 27.0%) followed by Nigeria, Kenya, and Ghana. 537 (84.8%) articles pertained to facility-based EM, 188 (29.7%) to out-of-hospital emergency medicine, and 109 (17.2%) to disaster medicine. Predominant content areas were epidemiology (374, 59.1%), EM systems (321, 50.7%) and clinical care (262, 41.4%). The most common study design was observational (479, 75.7%), with only 28 (4.4%) interventional studies. All-comers (382, 59.9%) and children (91, 14.1%) were the most commonly studied patient populations. Undifferentiated (313, 49.4%) and traumatic (180, 28.4%) complaints were most common. CONCLUSION Our review revealed a considerable increase in the growth of African EM literature from 1999 to 2014. Overwhelmingly, articles were observational, studied all-comers, and focused on undifferentiated complaints. The articles discovered in this scoping review are reflective of the relatively immature and growing state of African EM.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
- Corresponding author.
| | - Julia Dixon
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
| | - Taylor W. Burkholder
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Nana Sefa
- Beaumont Health System, Royal Oak, MI, USA
| | - Hiren Patel
- Harvard Medical School/Massachusetts General Hospital, Department of Emergency Medicine, MA, USA
| | - Anna Q. Yaffee
- Emory University, Department of Emergency Medicine, Atlanta, GA, USA
| | | | - Tolulope Oyewumi
- University of Colorado, School of Public Health, Department of Epidemiology, Aurora, CO, USA
| | | | - Maxwell Osei-Ampofo
- Komfo Anokye Teaching Hospital, Emergency Medicine Directorate, Kumasi, Ghana
| | - Hendry Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jay Lemery
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
| | - Tracy Cushing
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
| | - Lee A. Wallis
- University of Cape Town, Division of Emergency Medicine, Observatory, Cape Town, South Africa
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Zaidi AA, Dixon J, Lupez K, De Vries S, Wallis LA, Ginde A, Mould-Millman NK. The burden of trauma at a district hospital in the Western Cape Province of South Africa. Afr J Emerg Med 2019; 9:S14-S20. [PMID: 31073509 PMCID: PMC6497867 DOI: 10.1016/j.afjem.2019.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/19/2018] [Accepted: 01/05/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa bears a disproportionate burden of mortality from trauma. District hospitals, although not trauma centres, play a critical role in the trauma care system by serving as frontline hospitals. However, the clinical characteristics of patients receiving trauma care in African district hospitals remains under-described and is a barrier to trauma care system development. We aim to describe the burden of trauma at district hospitals by analysing trauma patients at a prototypical district hospital emergency centre. METHODS An observational study was conducted in August, 2014 at Wesfleur Hospital, a district facility in the Western Cape Province of South Africa. Data were manually collected from a paper registry for all patients visiting the emergency centre. Patients with trauma were selected for further analysis. RESULTS Of 3299 total cases, 565 (17.1%) presented with trauma, of which 348 (61.6%) were male. Of the trauma patients, 256 (47.6%) were ages 18-34 and 298 (52.7%) presented on the weekend. Intentional injuries (assault, stab wounds, and gunshot wounds) represented 251 (44.4%) cases of trauma. There were 314 (55.6%) cases of injuries that were unintentional, including road traffic injuries. There were 144 (60%) intentionally injured patients that arrived overnight (7pm-7am). Patients with intentional injuries were three times more likely to be transferred (to higher levels of care) or admitted than patients with unintentional injuries. CONCLUSION This district hospital emergency centre, with a small complement of non-EM trained physicians and no trauma surgical services, cared for a high volume of trauma with over half presenting on weekends and overnight when personnel are limited. The high volume and rate of admission/ transfer of intentional injuries suggests the need for improving prehospital trauma triage and trauma referrals. The results suggest strengthening trauma care systems at and around this resource-limited district hospital in South Africa may help alleviate the high burden of post-trauma morbidity and mortality.
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Affiliation(s)
- Ali A. Zaidi
- Indiana University, School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Julia Dixon
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, United States
| | - Kathryn Lupez
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, United States
| | - Shaheem De Vries
- Western Cape Government EMS, Bellville, Western Cape Province, South Africa
| | - Lee A. Wallis
- University of Cape Town, Division of Emergency Medicine, Cape Town, Western Cape Province, South Africa
- Western Cape Government EMS, Bellville, Western Cape Province, South Africa
| | - Adit Ginde
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, United States
| | - Nee-Kofi Mould-Millman
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, United States
- University of Cape Town, Division of Emergency Medicine, Cape Town, Western Cape Province, South Africa
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Burger A, Hodkinson PW, Wallis LA. Emergency Centre-based paediatric procedural sedation: current practice and challenges in Cape Town. Southern African Journal of Anaesthesia and Analgesia 2019. [DOI: 10.1080/22201181.2018.1541561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A Burger
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - PW Hodkinson
- Department of Surgery, Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - LA Wallis
- Joint Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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McCaul M, Clarke M, Bruijns SR, Hodkinson PW, de Waal B, Pigoga J, Wallis LA, Young T. Global emergency care clinical practice guidelines: A landscape analysis. Afr J Emerg Med 2018; 8:158-163. [PMID: 30534521 PMCID: PMC6277502 DOI: 10.1016/j.afjem.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION An adaptive guideline development method, as opposed to a de novo guideline development, is dependent on access to existing high-quality up-to-date clinical practice guidelines (CPGs). We described the characteristics and quality of CPGs relevant to prehospital care worldwide, in order to strengthen guideline development in low-resource settings for emergency care. METHODS We conducted a descriptive study of a database of international CPGs relevant to emergency care produced by the African Federation for Emergency Medicine (AFEM) CPG project in 2016. Guideline quality was assessed with the AGREE II tool, independently and in duplicate. End-user documents such as protocols, care pathways, and algorithms were excluded. Data were imported, managed, and analysed in STATA 14 and R. RESULTS In total, 276 guidelines were included. Less than 2% of CPGs originated from low- and middle income-countries (LMICs); only 15% (n = 38) of guidelines were prehospital specific, and there were no CPGs directly applicable to prehospital care in LMICs. Most guidelines used de novo methods (58%, n = 150) and were produced by professional societies or associations (63%, n = 164), with the minority developed by international bodies (3%, n = 7). National bodies, such as the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), produced higher quality guidelines when compared to international guidelines, professional societies, and clinician/academic-produced guidelines. Guideline quality varied across topics, subpopulations and producers. Resource-constrained guideline developers that cannot afford de novo guideline development have access to an expanding pool of high-quality prehospital guidelines to translate to their local setting. DISCUSSION Although some high-quality CPGs exist relevant to emergency care, none directly address the needs of prehospital care in LMICs, especially in Africa. Strengthening guideline development capacity, including adaptive guideline development methods that use existing high-quality CPGs, is a priority.
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Affiliation(s)
- Michael McCaul
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Stellenbosch University, South Africa
| | - Mike Clarke
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Stellenbosch University, South Africa
- Centre for Public Health, Queen’s University Belfast, Northern Ireland, United Kingdom
| | - Stevan R. Bruijns
- Division of Emergency Medicine, University of Cape Town, South Africa
| | | | - Ben de Waal
- Department of Emergency Medical Sciences, Cape Peninsula University of Technology, South Africa
| | - Jennifer Pigoga
- Division of Emergency Medicine, University of Cape Town, South Africa
| | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, South Africa
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Stellenbosch University, South Africa
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Koka PM, Sawe HR, Mbaya KR, Kilindimo SS, Mfinanga JA, Mwafongo VG, Wallis LA, Reynolds TA. Disaster preparedness and response capacity of regional hospitals in Tanzania: a descriptive cross-sectional study. BMC Health Serv Res 2018; 18:835. [PMID: 30400927 PMCID: PMC6219171 DOI: 10.1186/s12913-018-3609-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/07/2018] [Indexed: 11/27/2022] Open
Abstract
Background Tanzania has witnessed several disasters in the past decade, which resulted in substantial mortality, long-term morbidity, and significant socio-economic losses. Health care facilities and personnel are critical to disaster response. We assessed the current state of disaster preparedness and response capacity among Tanzanian regional hospitals. Methods This descriptive cross-sectional survey was conducted in all Tanzanian regional hospitals between May 2012 and December 2012. Data were prospectively collected using a structured questionnaire based on the World Health Organization National Health Sector Emergency Preparedness and Response Tool. Trained medical doctors conducted structured interviews and direct observations in each hospital. Results We surveyed 25 regional hospitals (100% capture) in mainland Tanzania, in which interviews were conducted with 13-hospital doctors incharge, 9 matrons and 4 heads of casualty. All the hospitals were found to have inadequate numbers of all cadres of health care providers to support effective disaster response. 92% of hospitals reported experiencing a disaster in the past 5 years; with the top three being large motor vehicle accidents 22 (87%), floods 7 (26%) and infectious disease outbreaks 6 (22%). Fifteen hospitals (60%) had a disaster committee, but only five (20%) had a disaster plan. No hospital had all components of surge capacity. Although all had electricity and back-up generators, only 3 (12%) had a back-up communication system. Conclusion This nationwide survey found that hospital disaster preparedness is at an early stage of development in Tanzania, and important opportunities exist to better prepare regional hospitals to respond to disasters.
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Affiliation(s)
- Philip M Koka
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania. .,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
| | - Khalid R Mbaya
- Emergency Department, Al-Zahra Hospital Sharjah, Sharjah, United Arab Emirates
| | - Said S Kilindimo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Victor G Mwafongo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Teri A Reynolds
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization (WHO), Geneva, Switzerland
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Bae C, Pigoga JL, Cox M, Hollong B, Kalanzi J, Abbas G, Wallis LA, Calvello Hynes EJ. Evaluating emergency care capacity in Africa: an iterative, multicountry refinement of the Emergency Care Assessment Tool. BMJ Glob Health 2018; 3:e001138. [PMID: 30364370 PMCID: PMC6195145 DOI: 10.1136/bmjgh-2018-001138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 11/03/2022] Open
Abstract
Healthcare facilities in low-income and middle-income countries lack an objective measurement tool to assess emergency care capacity. The African Federation for Emergency Medicine developed the Emergency Care Assessment Tool (ECAT) to fulfil this function. The ECAT assesses the provision of key medical interventions (signal functions) that emergency units (EUs) should be able to perform to adequately treat six common, life-threatening conditions (sentinel conditions). We describe the piloting and refinement of the ECAT, to improve usability and context-appropriateness. We undertook iterative, multisite refinement of the ECAT. After pilot testing at a South African referral hospital, subsequent studies occurred at district, regional and central facilities across four countries representing the major regions of Africa: Cameroon, Uganda, Egypt and Botswana. At each site, the tool was administered to three participants: one senior physician, one senior nurse and one other clinical provider. Feedback informed refinements of the ECAT, and an updated tool was used in the next-studied country. Iteratively implementing refined versions of the tool in various contexts across Africa resulted in a final ECAT that uses signal functions, categorised by sentinel conditions and evaluated against discrete barriers to emergency care service delivery, to assess EUs. It also allowed for refinement of administration and data analysis processes. The ECAT has a total of 71 items. Advanced facilities are expected to perform all 71 signal functions, while intermediate facilities should be able to perform 53. The ECAT is the first tool to provide a standardised method for assessing facility-based emergency care in the African context. It identifies where in the maturation process a hospital or system is and what gaps exist in delivery of care, so that a comprehensive roadmap for development can be established. Although validity and feasibility testing have now occurred, reliability studies must be conducted prior to amplification across the region.
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Affiliation(s)
- Crystal Bae
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer L Pigoga
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Megan Cox
- Department of Emergency Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Bonaventure Hollong
- Department of Emergency Medicine, Centre des Urgences de Yaounde, Yaounde, Cameroon
| | | | - Gamal Abbas
- Egyptian Resuscitation Council, Cairo, Egypt
- Military Production Medical Center, Cairo, Egypt
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Emilie J Calvello Hynes
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
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50
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Sawe HR, Reynolds TA, Mfinanga JA, Runyon MS, Murray BL, Wallis LA, Makani J. The clinical presentation, utilization, and outcome of individuals with sickle cell anaemia presenting to urban emergency department of a tertiary hospital in Tanzania. BMC Hematol 2018; 18:25. [PMID: 30245824 PMCID: PMC6142707 DOI: 10.1186/s12878-018-0122-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sickle cell anaemia (SCA) is prevalent in sub-Saharan Africa, with high risk of complications requiring emergency care. There is limited information about presentation of patients with SCA to hospitals for emergency care. We describe the clinical presentation, resource utilization, and outcomes of SCA patients presenting to the emergency department (ED) at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. METHODS This was a prospective cohort study of consecutive patients with SCA presenting to ED between December 2014 and July 2015. Informed consent was obtained from all patients or patients' proxies prior to being enrolled in the study. A standardized case report form was used to record study information, including demographics, relevant clinical characteristics and overall patients outcomes. Categorical variables were compared with chi-square test or Fisher's exact test; continuous variables were compared with two-sample t-test or Mann-Whitney U-test. RESULTS We enrolled 752 (2.7%) people with SCA from 28,322 patients who presented to the MNH-ED. The median age was 14 years (Interquartile range [IQR]: 6-23 years), and 395 (52.8%) were female. Pain 614 (81.6%), fever 289 (38.4%) were the most frequent presenting complaint. Patients with fever, hypoxia, altered mental status and bradycardia had statistically significant relative risk of mortality of 10.4, 153, 50 and 12.1 (p < 0.0001) respectively, compared to patients with normal vitals. Overall, 656 (87.2%) patients received Complete Blood Cell counts test, of these 342 (52.1%) had severe anaemia (haemoglobin < 7 g/dl), and a 30.3 (p = 0.02) relative risk of relative risk of mortality compare to patients with higher haemoglobin. Patients who had malaria, elevated renal function test and hypoglycemia, had relative risk of mortality of 22.9, 10.4 and 45.2 (p < 0.0001) respectively, compared to patient with normal values. Most 534 (71.0%) patients were hospitalized for in patients care, and the overall morality rate was 16 (2.1%). CONCLUSIONS We described the clinical presentation, management, and outcomes of patients with SCA presenting to the largest public ED in Tanzania, as well as information on resource utilization. This information can inform development of treatment guidelines, clinical staff education, and clinical research aimed at optimizing care for SCA patients.
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Affiliation(s)
- Hendry R. Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 54235, Dar es salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Teri A. Reynolds
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 54235, Dar es salaam, Tanzania
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA USA
| | - Juma A. Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 54235, Dar es salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Michael S. Runyon
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 54235, Dar es salaam, Tanzania
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC USA
| | - Brittany L. Murray
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 54235, Dar es salaam, Tanzania
- Division of Pediatric Emergency Medicine, Emory University School of Medicine/Children’s Hospital of Atlanta, Atlanta, GA USA
| | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town City, South Africa
| | - Julie Makani
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Haematology and blood transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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