Inter-hospital transfer of trauma patients in a developing country: a prospective descriptive study

Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review

AIM(S)

To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients.

DESIGN

Scoping review of international, peer-reviewed research studies.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023.

REPORTING METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

RESULTS

Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies).

CONCLUSION

Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Left behind: Exploring the concerns of emergency department staff when personnel are utilised for inter-hospital transfer

BACKGROUND

Inter-Hospital Transfer (IHT) may require an escort from the referring hospital, either a Registered Nurse (RN), physician or both, leading to a sudden drop in staffing levels within the referring department potentially increasing risk to patients and staff.

AIMS

To explore the perspectives of RNs and physicians of differing experience levels when left behind due to an escorted IHT, and the decision-making protocols for IHT.

METHOD

A qualitative exploratory approach of 5 RNs and 4 physicians selected using purposeful sampling. Data were collected through semi-structured interviews and thematically analysed.

FINDINGS

Five themes were identified: the impact of being left behind; the burden of transfer; missed care; a triangulation of competing needs upon the decision-making process; and the effect of inter-hospital transfers on staff with different experience levels.

CONCLUSION

IHT is described differently by less experienced RNs compared to their more experienced counterparts especially concerning safety and risk. Physicians described the department as vulnerable with ad-hoc decision-making protocols surrounding IHT the norm.

Surgical ambulance referrals in sub-Saharan Africa - financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia

BACKGROUND

An estimated nine out of ten persons in sub-Saharan Africa (SSA) are unable to access timely, safe and affordable surgery. District hospitals (DHs) which are strategically located to provide basic (non-specialist) surgical care for rural populations have in many instances been compromised by resource inadequacies, resulting in unduly frequent patient referrals to specialist hospitals. This study aimed to quantify the financial burdens of surgical ambulance referrals on DHs and explore the coping strategies employed by these facilities in navigating the challenges.

METHODS

We employed a multi-methods descriptive case study approach, across a total of 14 purposively selected DHs; seven, three, and four in Tanzania, Malawi and Zambia, respectively. Three recurrent cost elements were identified: fuel, ambulance maintenance and staff allowances. Qualitative data related to coping mechanisms were obtained through in-depth interviews of hospital managers while quantitative data related to costs of surgical referrals were obtained from existing records (such as referral registers, ward registers, annual financial reports, and other administrative records) and expert estimates. Interview notes were analysed by manual thematic coding while referral statistics and finance data were processed and analysed using Microsoft Office Excel 2016.

RESULTS

At all but one of the hospitals, respondents reported inadequacies in numbers and functional states of the ambulances: four centres indicated employing non-ambulance vehicles to convey patients occassionally. No statistically significant correlation was found between referral trip distances and total annual numbers of referral trips, but hospital managers reported considering costs in referral practices. For instance, ten of the study hospitals reported combining patients to minimize trip frequencies. The total cost of ambulance use for patient transportation ranged from I$2 k to I$58 k per year. Between 34% and 79% of all patient referrals were surgical, with total costs ranging from I$1 k to I$32 k per year.

CONCLUSION

Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case - besides equitable access to healthcare - for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.

Quantitative systematic review: Sources of inaccuracy in manually measured adult respiratory rate data

AIMS

To identify the potential sources of inaccuracy in manually measured adult respiratory rate (RR) data and quantify their effects.

DESIGN

Quantitative systematic review with meta-analyses where appropriate.

DATA SOURCES

Medline, CINAHL, and Cochrane Library (from database inception to 31 July 2019).

REVIEW METHODS

Studies presenting data on individual sources of inaccuracy in the manual measurement of adult RR were analysed, assessed for quality, and grouped according to the source of inaccuracy investigated. Quantitative data were extracted and synthesized and meta-analyses performed where appropriate.

RESULTS

Included studies (N = 49) identified five sources of inaccuracy. The awareness effect creates an artefactual reduction in actual RR, and observation methods involving shorter counts cause systematic underscoring. Individual RR measurements can differ substantially in either direction between observations due to inter- or intra-observer variability. Value bias, where particular RRs are over-represented (suggesting estimation), is a widespread problem. Recording omission is also widespread, with higher average rates in inpatient versus triage/admission contexts.

CONCLUSION

This review demonstrates that manually measured RR data are subject to several potential sources of inaccuracy.

IMPACT

RR is an important indicator of clinical deterioration and commonly included in track-and-trigger systems. However, the usefulness of RR data depends on the accuracy of the observations and documentation, which are subject to five potential sources of inaccuracy identified in this review. A single measurement may be affected by several factors. Hence, clinicians should interpret recorded RR data cautiously unless systems are in place to ensure its accuracy. For nurses, this includes counting rather than estimating RRs, employing 60-s counts whenever possible, ensuring patients are unaware that their RR is being measured, and documenting the resulting value. For any given site, interventions to improve measurement should take into account the local organizational and cultural context, available resources, and the specific measurement issues that need to be addressed.

Surgical referral systems in low- and middle-income countries: A review of the evidence

BACKGROUND

Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions.

METHODS

MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach.

RESULTS

Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities.

DISCUSSION

The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.

Admission delays' magnitude of traumatized patients in the emergency department of a hospital in Egypt: a cross-sectional study

BACKGROUND

Injury is an escalating public health problem, representing about 9% of global mortality, which disproportionately impacts lower- and middle-income countries. There are approximately 12,000 annual fatalities from road traffic injuries in Egypt, but a little information about delays in seeking emergent care is available.

OBJECTIVES

To measure the time interval between sustaining an injury and presentation to the emergency department of Ain Shams University Surgery Hospital and to identify possible causes of these delays.

METHODS

We conducted a cross-sectional, facilitated survey of a convenience sample of trauma patients presenting to the emergency department of Ain Shams University Surgery Hospital from 1 February to 31 May 2014. Data obtained included: demographic information, trauma incident details, and injury assessment.

RESULTS

The average reported transport time for patients from injury to hospital arrival was 3.8 h, while the mean ambulance response time was 45 min. Referral from other hospitals was revealed to be a significant cause of delay (P = 0.004), while ignorance of the local ambulance phone number could not be confirmed as a cause (P = 0.2).

CONCLUSION

This study demonstrated that trauma patients at our hospital experience more than 3 h of delay until they reach the ED. It also identified the possible causes accounting for that delay. However, additional nationwide research is needed to establish the clear causation or association of these causes with the delay intervals.

The Birth and Growth of the National Ambulance Service in Ghana

Introduction This study aimed to document the growth and challenges encountered in the decade since inception of the National Ambulance Service (NAS) in Ghana, West Africa. By doing so, potentially instructive examples for other low- and middle-income countries (LMICs) planning a formal prehospital care system or attempting to identify ways to improve existing emergency services could be identified.

METHODS

Data routinely collected by the Ghana NAS from 2004-2014 were described, including: patient demographics, reason for the call, response location, target destination, and ti1mes of service. Additionally, the organizational structure and challenges encountered during the development and maturation of the NAS were reported.

RESULTS

In 2004, the NAS piloted operations with 69 newly trained emergency medical technicians (EMTs), nine ambulances, and seven stations. The NAS expanded service delivery with 199 ambulances at 128 stations operated by 1,651 EMTs and 47 administrative and maintenance staff in 2014. In 2004, nine percent of the country was covered by NAS services; in 2014, 81% of Ghana was covered. Health care transfers and roadside responses comprised the majority of services (43%-80% and 10%-57% by year, respectively). Increased mean response time, stable case holding time, and shorter vehicle engaged time reflect greater response ranges due to increased service uptake and improved efficiency of ambulance usage. Specific internal and external challenges with regard to NAS operations also were described.

CONCLUSION

The steady growth of the NAS is evidence of the need for Emergency Medical Services and the effects of sound planning and timely responses to changes in program indicators. The way forward includes further capacity building to increase the number of scene responses, strengthening ties with local health facilities to ensure timely emergency medical care and appropriateness of transfers, assuring a more stable funding stream, and improving public awareness of NAS services. Zakariah A , Stewart BT , Boateng E , Achena C , Tansley G , Mock C . The birth and growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017;32(1):83-93.

Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda

BACKGROUND

In developing countries, 9 out of 10 patients lack access to timely operative care. Most patients seek care at district hospitals that often lack operative capacity, creating a need for referral. Delays in referrals contribute to substantial disability and death. This study assessed the predictors of delayed referrals for injured patients.

METHODS

This retrospective cohort study included injured patients, recommended for referral between January 1, 2013, and December 31, 2013, from 3 rural district hospitals in Rwanda. We defined delay as nonexecution of referral 2 days after referral recommendation. We performed a multivariate logistic regression using stepwise backward selection to identify the predictors of delayed referral.

RESULTS

Of the 1,227 injured patients, 23.0% (n = 282) were recommended for referral. Of these, 36.5% (n = 103) had road traffic injuries and 53.6% (n = 151) were diagnosed with closed fractures/dislocation. Among 231 patients, 108 (46.8%) had a delay in referral execution. The predictors of delay included age >35 years (odds ratio = 2.45, 95% confidence interval: 1.09-5.50), closed fractures/dislocation (odds ratio = 16.37, 95% confidence interval: 3.13-85.78), admission to surgical wards (odds ratio = 10.25, 95% confidence interval: 2.70-38.82), and a duration ≥7 days from admission to referral recommendation (odds ratio = 4.80, 95% confidence interval: 1.38-16.63).

CONCLUSION

Over 50% of referrals were completed in a timely fashion due to a strong referral system and a patient support program. Empowering district hospitals with trained staff and appropriate equipment could reduce the need for referral, and increasing surgeons at referral hospitals could reduce referral delays.

Anaesthesia in underdeveloped world: Present scenario and future challenges

The overall mortality and morbidity in underdeveloped countries are still unchanged and preventable risks factors constitute the main burden. Among these, anaesthesia-related mortality is largely preventable. Various contributory factors related to human resources, technical resources, education/teaching system and other utilities needs further attention in poor income group countries. Therefore, we have made an attempt to address all these issues in this educational article and have given special reference to those factors that might gain importance in (near) future. Proper understanding of anaesthesia-related resources, their overall impact on health care system and their improvisation methods should be thoroughly evaluated for providing safer anaesthesia care in these countries which would certainly direct better outcome and consequently influence mortality.