Emergency care and health systems: consensus-based recommendations and future research priorities

Assessment of ambulance interventions; proposal of a performance measurement framework for healthcare improvement in EMS response to patient collapse

BACKGROUND

Healthcare improvement at all levels involves systematic and continuous assessment of the system's operations, efficiency, and effectiveness to ensure quality care. Likewise, in Emergency Medical Services; performance measurement and root cause analysis may aid in identifying the system inadequacies and address potential shortcomings by developing Key Performance Indicators. In this paper, we propose a tailored framework to supplement the performance measurement and healthcare improvement, primarily to monitor the quality of EMS operations and personnel for ambulance transfers, which results in patient collapses in ambulances.

METHODS

We developed a Performance Measurement Framework (PMF) based on three essential domains- Structure/System, Process, and Outcome. Each domain was further assigned with different KPIs to assess the performance of EMS operations and personnel during patient transfers. The framework was pilot-tested for one year from January to December 2023, where its use was limited to the cases of patient collapse in ambulances, also referred to as out-of-hospital deaths. To assess progress, we compared the incidence of CIA between the pre-implementation and post-implementation phases, with service operational metrics including coverage, fleet size, workforce, and response times.

RESULT

Using the PMF as a tool for quality improvement, we observed a 7% reduction in the incidence of patient collapse in ambulances and a 16% reduction in life-threatening cases resulting in CIA despite increases in service coverage (37%), ambulance workforce (32%), fleet (26%), and routine interventions (11%). A slight increases in response times indicate the greater service demands. Through pilot testing, we identified operational gaps including behavioral and communication issues, adherence to SOPs, and equipment management.

CONCLUSION

Overall, this paper proposes a performance measurement tool in the field of prehospital care for organizations to thoroughly assess and advance their operations toward healthcare improvement. The study highlights areas requiring improvement such as training guidelines, adherence to operating protocols, and resource optimization. In addition; the integration of technology and advanced training programs for the ambulance workforce may strengthen the overall EMS performance; thereby promising positive patient outcomes, and efficient service delivery and utilization.

TRIAL REGISTRATION

Not applicable.

Healthcare professionals perceptions towards the determinants of effective emergency health care services in public health centres of Addis Ababa, Ethiopia

Introduction

Emergency healthcare services enable early detection and life-saving interventions for time-sensitive acute injuries and illnesses. The aim of this paper was to assess health care professional's perception towards determinants of effective emergency healthcare services in public health centers of Addis Ababa, Ethiopia, in 2023.

Methods

A facility-based cross-sectional study was conducted at public health centers in Addis Ababa with a sample of 422 study participants. Study participants were selected using simple random sampling techniques. To identify factors associated with the outcome variable, bi-variable and multi-variable logistic regression analyses were conducted. Variables having a p-value less than 0.05 in multi-variable logistic regression analysis were declared determinants of positive perception towards emergency medical services effectiveness.

Results

Among the study participants, 76.3 % (95 % CI: 72.3, 80.6) had a positive perception towards the public health centers effectiveness in providing emergency healthcare services. Moreover, training (AOR: 4.05; 95 % CI: 1.97, 8.32), ICT service implementation (AOR: 6.55; 95 % CI: 3.37, 12.73), resource availability in the emergency department (AOR: 5.07; 95 % CI: 2.51, 10.25), and management support (AOR: 3.22; 95 % CI: 1.66, 6.25) were determinant factors associated with the perception of effectiveness in emergency medical care services.

Conclusion

Nearly three-fourths of healthcare providers in Addis Ababa perceived that the emergency healthcare services were effective. Furthermore, training on patient service delivery, ICT service implementation, availability of resources in emergency departments, and management support were independent determinants of positive perception towards effective emergency healthcare services.

Death and Dying in the Emergency Department: A New Model for End-of-Life Care

BACKGROUND

Death and dying remain taboo subjects in society today and therefore people may come to the end of their life without having thought about what death and dying might be like and what it is to have a good death. The purpose of this qualitative study was to understand the experience of death and dying in a hospital emergency department. Culturally, some individuals are unprepared for death, and when death occurs in an emergency setting it can be particularly shocking.

METHODS

A phenomenological study was undertaken, based on the existential phenomenology of Merleau-Ponty; and framed by the nurse theorist Hildegard Peplau. Bereaved relatives and registered nurses gave in-depth interviews describing their experiences and the interviews were analysed using an adaptation of the work of Thomas and Pollio (2002) and Hycner (1985), consistent with Merleau-Ponty's theories.

RESULTS

The study brings new understanding of what it is like to die in an emergency setting through new understanding of what the accompanying relatives/friends of the deceased person experience, aided by new understanding of the experiences of emergency nurses.

CONCLUSIONS

A nursing model based both on the work of Peplau (Parse et al. 2000) and on the work of the nurse theorists Ruland and Moore (1998) and Zaccara et al. (2017) was devised for use in the emergency department when death occurs. It is hoped that this model will help nurses improve the care given to this group of patients and their loved ones.

Health care workers' experiences of calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya

BACKGROUND

When caring for critically ill patients, health workers often need to 'call-for-help' to get assistance from colleagues in the hospital. Systems are required to facilitate calling-for-help and enable the timely provision of care for critically ill patients. Evidence around calling-for-help systems is mostly from high income countries and the state of calling-for-help in hospitals in Tanzania and Kenya has not been formally studied. This study aims to describe health workers' experiences about calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya.

METHODS

Ten hospitals across Kenya and Tanzania were visited and in-depth interviews conducted with 30 health workers who had experience of caring for critically ill patients. The interviews were transcribed, translated and the data thematically analyzed.

RESULTS

The study identified three thematic areas concerning the systems for calling-for-help when taking care of critically ill patients: 1) Calling-for-help structures: there is lack of functioning structures for calling-for-help; 2) Calling-for-help processes: the calling-for-help processes are innovative and improvised; and 3) Calling-for-help outcomes: the help that is provided is not as requested.

CONCLUSION

Calling-for-help when taking care of a critically ill patient is a necessary life-saving part of care, but health workers in Tanzanian and Kenyan hospitals experience a range of significant challenges. Hospitals lack functioning structures, processes for calling-for-help are improvised and help that is provided is not as requested. These challenges likely cause delays and decrease the quality of care, potentially resulting in unnecessary mortality and morbidity.

Healthcare Worker's Satisfaction Assessment for a Healthcare Adverse Event Reporting Framework and the Management Approach for Such Reporting in the Emergency Department of Rural Government Hospitals

BACKGROUND

The healthcare adverse event (HAE) reporting framework is more than just a tool. It is a crucial pillar in our pursuit of patient safety, quality improvement, trust maintenance, regulatory compliance, and ethical standards in healthcare delivery.

AIM

To assess healthcare workers' satisfaction with the HAE reporting framework and the management approach towards such reporting in the emergency department of rural government hospitals by conducting a satisfaction survey.

MATERIALS AND METHOD

This prospective observational research was conducted in the Department of Emergency Medicine of the Uttar Pradesh University of Medical Sciences, Saifai, and adjoining district hospitals from November 2023 to January 2024. The study involved 320 healthcare professionals working in the emergency department. The quantitative survey research used a questionnaire and a quality Likert scale response. The data were analyzed on an ordinal measurement scale using nonparametric statistical methods. The sample data were analyzed using frequency tables, percentage pie charts, and comparison bar graphs. In nonparametric statistical tests, the one-sample Wilcoxon signed rank test was used to infer the population's central tendency, and the Kruskal-Wallis test was used to make inferences about the population categories.

RESULTS

The satisfaction of healthcare professionals with the HAE reporting framework and the management approach was diverse. When surveyed about the HAE reporting framework in the emergency department, out of the 320 healthcare professionals, 50% (161) expressed dissatisfaction, 47% (149) were satisfied, and 3% (10) did not comment. Paramedics were most dissatisfied (61% of 133). When asked about the management approach while dealing with such reporting, 50% (159) were satisfied, 46% (147) were unsatisfied, and 4% (14) did not comment. On comparing professions, 43% (29) of 33 doctors and 62% (83) of 133 paramedics were unsatisfied, giving a poor response. Additionally, 61% (72) of the 119 nursing staff were satisfied. The non-parametric inferential tests yielded a p-value of less than 0.001 for both questions, indicating a notable difference in the population's response to the HAE reporting framework and management approach. On pairwise comparison, there was a significant difference in perception (p<0.001) between the occupation groups, except for doctors and paramedics (p = 0.638) in the HAE reporting framework.

CONCLUSION

By encouraging reporting, standardizing processes, analyzing incidents thoroughly, and using data-driven insights to inform improvement efforts, healthcare organizations can enhance patient safety, improve quality of care, and prevent future adverse events. The management approach to HAE reporting involves fostering a culture of safety and transparency, implementing standardized reporting systems, providing education and training to healthcare staff, establishing feedback mechanisms, conducting robust analysis of reported events, promoting continuous improvement, and ensuring transparency and accountability.

Evaluation of emergency care education and triage implementation: an observational study at a hospital in rural Liberia

INTRODUCTION

In Liberia, emergency care is still in its early development. In 2019, two emergency care and triage education sessions were done at J. J. Dossen Hospital in Southeastern Liberia. The observational study objectives evaluated key process outcomes before and after the educational interventions.

METHODS

Emergency department paper records from 1 February 2019 to 31 December 2019 were retrospectively reviewed. Simple descriptive statistics were used to describe patient demographics and χ² analyses were used to test for significance. ORs were calculated for key predetermined process measures.

RESULTS

There were 8222 patient visits recorded that were included in our analysis. Patients in the post-intervention 1 group had higher odds of having a documented full set of vital signs compared with the baseline group (16% vs 3.5%, OR: 5.4 (95% CI: 4.3 to 6.7)). After triage implementation, patients who were triaged were 16 times more likely to have a full set of vitals compared with those who were not triaged. Similarly, compared with the baseline group, patients in the post-intervention 1 group had higher odds of having a glucose documented if they presented with altered mental status or a neurologic complaint (37% vs 30%, OR: 1.7 (95% CI: 1.3 to 2.2)), documented antibiotic administration if they had a presumed bacterial infection (87% vs 35%, OR: 12.8 (95% CI: 8.8 to 17.1)), documented malaria test if presenting with fever (76% vs 61%, OR: 2.05 (95% CI: 1.37 to 3.08)) or documented repeat set of vitals if presenting with shock (25% vs 6.6%, OR: 8.85 (95% CI: 1.67 to 14.06)). There was no significant difference in the above process outcomes between the education interventions.

CONCLUSION

This study showed improvement in most process measures between the baseline and post-intervention 1 groups, benefits that persisted post-intervention 2, thus supporting the importance of short-course education interventions to durably improve facility-based care.

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

BACKGROUND

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

OBJECTIVES

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

ELIGIBILITY CRITERIA

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

SOURCE OF EVIDENCE

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

CHARTING METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality emergency care (QEC) in resource limited settings: A concept analysis

INTRODUCTION

Providing appropriate high-quality emergency care (QEC) commensurate with patients' needs is critical for continuity of care, patient safety, optimal clinical outcomes, reduced mortality, and patient satisfaction. This concept analysis aims to define and assist in understanding the concept of QEC in resource-limited settings.

METHODS

Quality emergency care concept analysis was conducted using Walker and Avant's approach. Several literature review methods and dictionaries were used to explore the QEC concept.

RESULTS

Immediate assessment, rapid diagnosis, and critical interventions are the attributes of QEC for life-threatening and time-sensitive conditions, leading to timely and safe care provision.

DISCUSSION

Nurses serve as the backbone for most emergency care centers such as primary care, emergency department, and even prehospital care. The first few hours following a potential life- or limb-threatening condition are vital. The emergency care rendered to patients can significantly affect treatment's overall outcome; therefore, quality emergency care is critical.

CONCLUSION

Strengthening emergency care knowledge and skills in Uganda and Tanzania with the WHO-ICRC Basic Emergency Care Course

BACKGROUND

There is a pressing need for emergency care (EC) training in low-resource settings. We assessed the feasibility and acceptability of training frontline healthcare providers in emergency care with the World Health Organization (WHO)-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) Course using a training-of-trainers (ToT) model with local providers.

METHODS

Quasiexperimental pretest and post-test study of an educational intervention at four first-level district hospitals in Tanzania and Uganda conducted in March and April of 2017. A 2-day ToT course was held in both Tanzania and Uganda. These were immediately followed by a 5-day BEC Course, taught by the newly trained trainers, at two hospitals in each country. Both prior to and immediately following each training, participants took assessments on EC knowledge and rated their confidence level in using a variety of EC skills to treat patients. Qualitative feedback from participants was collected and summarised.

RESULTS

Fifty-nine participants completed the four BEC Courses. All participants were current healthcare workers at the selected hospitals. An additional 10 participants completed a ToT course. EC knowledge scores were significantly higher for participants immediately following the training compared with their scores just prior to the training when assessed across all study sites (Z=6.23, p<0.001). Across all study sites, mean EC confidence ratings increased by 0.74 points on a 4-point Likert scale (95% CI 0.63 to 0.84, p<0.001). Main qualitative feedback included: positive reception of the sessions, especially hands-on skills; request for additional BEC trainings; request for obstetric topics; and need for more allotted training time.

CONCLUSIONS

Implementation of the WHO-ICRC BEC Course by locally trained providers was feasible, acceptable and well received at four sites in East Africa. Participation in the training course was associated with a significant increase in EC knowledge and confidence at all four study sites. The BEC is a low-cost intervention that can improve EC knowledge and skill confidence across provider cadres.

Optimization for Locating Emergency Medical Service Facilities: A Case Study for Health Planning from China

Purpose

Rational location of emergency medical service (EMS) facilities could improve access to EMS, and thus assist in saving patients’ lives and improving their health outcomes. A considerable amount of spatial optimization research has been devoted to the development of models to support location planning in the context of EMS, with extensive applications in policy making around the world. However, in China, studies on the location of EMS facilities have not been paid enough attention to, let alone their practical applications. This paper conducted location optimization for EMS facilities in Chengdu, one of the biggest cities in southwest China with more than 16.5 million population, aiming to optimize the EMS system by adding (upgrading) a minimum number of EMS facilities to achieve a given population coverage.

Methods

Location optimization was conducted according to regional health policy goal for the EMS system in Chengdu, China, 2017. The nearest-neighbor approach was used to calculate the shortest travel time based on geographical information system (GIS). The location set covering model was used to formulate the optimization problem under China’s context, and genetic algorithm (GA) was employed to determine the optimized locations.

Results

The results showed that a minimum number of 55 new facilities were required to upgrade to EMS facilities to achieve the policy goal of 90% population coverage of EMS within 15 minutes. Access to EMS also improved substantially in terms of shortest travel time after facility upgrading. The weighted median shortest travel time to EMS facilities in Chengdu decreased by 14.57%, from 6.45 minutes to 5.51 minutes.

Conclusion

Our study showed that the solution could effectively achieve the policy goal of population coverage with a minimum number of new EMS facilities. Our findings would support evidence-based decision-making in future EMS planning in China.

Epidemiological Comparisons and Risk Factors for Pre-hospital and In-Hospital Mortality Following Traumatic Injury in Malawi

BACKGROUND

In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years. Injury mechanism and cause of death are difficult to characterize in the absence of pre-hospital care and a trauma surveillance database. Pre-hospital deaths (PHD) and in-hospital deaths (IHD) of trauma patient were compared to elucidate comprehensive injury characteristics associated with mortality.

METHODS

A retrospective, descriptive analysis of adults (≥ 13 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from February 2008 to May 2018 was performed. Utilizing an emergency department-based trauma surveillance database, univariate and bivariate analysis was performed to compare patient and injury characteristics of pre-hospital and in-hospital deaths. A Poisson multivariate regression was performed, predicting the relative risk of PHD.

RESULTS

Between February 2008 and May 2018, 131,020 adult trauma patients presented to KCH, with 2007 fatalities. Of those patients, 1130 (56.3%) and 877 (43.7%) were PHD and IHD, respectively. The majority were men, with a mean age of 33.4 years (SD 12.1) for PHD and 37.4 years (SD 15.5) for IHD, (p < 0.001). Head injuries (n = 545, 49.2% vs. n = 435, 49.7%) due to assaults (n = 255, 24.7% vs. n = 178, 21.8%) and motor vehicle collisions (MVC) (n = 188, 18.2% vs. n = 173, 21.2%) were the leading cause of both groups (PHD vs. IHD). Transportation to the hospital was primarily police (n = 663, 60.1%) for PHD and ambulance (n = 401, 46.4%) for IHD. Patients who were transported to KCH by the police (RR 1.97, 95% 1.52-2.55, p < 0.001) when compared to transport via minibus had an increased relative risk of PHD. Patients with a head or spine (RR 1.32, 95% CI 1.34-1.53, p < 0.001), chest (RR 1.34, 95% CI 1.11-1.62, p = 0.002) or abdomen and pelvis (RR 1.30, 95% CI 1.14-1.53, p = 0.004) when compared to extremity injury had an increased relative risk of PHD.

CONCLUSIONS

Head injury from assaults and MVC is the leading cause of PHD and IHD in Malawi. The majority of patients are transported via police if PHD. Of IHD patients, the majority are transported by ambulance, most often from outside hospitals. Both are consistent with the absence of a pre-hospital system in Malawi. Improving pre-hospital care, with a particular focus on head injury and strategies for vehicular injury prevention within a trauma system, will reduce adult trauma mortality in Malawi.

Spatial accessibility to emergency care in Sichuan province in China

Timely access to emergency care can substantially improve overall population's health outcomes. However, currently existed evidence focusing on access to emergency care in China remains insufficient. A better understanding of emergency care from the perspective of spatial accessibility is therefore essential to assist in future healthcare planning. This study provided a brief introduction to the emergency medical service system of China, and assessed the spatial accessibility of emergency care as well as its associated social-economic characteristics based on Sichuan province. Based on populational and hospital administrative data in 2018, we employed the nearest-neighbor method to measure the spatial accessibility while identifying its associated social-economic factors via conventional Ordinary Least Square (OLS) model. The shortest travel time analysis reported a relatively high level of overall spatial accessibility to emergency care in Sichuan. However, substantial geographical disparity in accessibility could nevertheless be observed throughout the province, with the eastern area presenting much higher accessibility than the western area. Regression results suggested that county-level discrepancies in accessibility could be significantly attributed to the variance in local economic development, urbanization level and administrative area. These findings indicated that long-term efforts need to be made by central government on optimizing the allocation of healthcare resources, as well as on fortifying financial support and providing preferential policies for economically disadvantaged regions.

What every emergency physician should know about research: Introduction to a research primer for low- and middle-income countries

Research is the search for new, generalisable knowledge (Truth in the Universe) to improve our collective ability to correctly diagnose and treat human suffering. In the formal sense, medical research implies both creating new knowledge, and also disseminating that new knowledge as well as putting it into practice. This is the first paper in this Research Primer. It briefly covers why each emergency physician should know and care about research. The paper reminds us that it does not take a physician to do research, but that it is the practicing physician who best knows what new knowledge is needed at the bedside. It introduces the scope of the other papers included in this special issue. The paper reviews the definitions of research and the scope of research practice in emergency medicine; overviews the hows and whys of research, as well as discusses the research question, study justification, literature search and touching on research design.

Management of supply chains with attribute-sensitive products: a comprehensive literature review and future research agenda

Purpose

Mismanagement of supply chain operations may lead to waste of products and incur substantial monetary losses. This is particularly true for products with attributes that hasten deterioration, e.g. time, temperature, humidity and barometric pressure. Attribute-sensitive products must be carefully monitored throughout all supply chain processes to ensure acceptable quality to the end customers. This paper presents a comprehensive review of the scientific literature on attribute sensitive products and on attribute sensitive supply chains. The collected studies were reviewed using the content analysis method, focusing on the following aspects of attribute sensitive products: (1) industries; (2) product categories; (3) decisions involved; (4) processes; (5) current issues; (6) sustainability concerns; (7) research methods used; (8) objectives of decision makers; (9) solution approaches used; (10) incentives driving management and (11) future research issues. Based on the analysis of findings, gaps are identified, and future research directions are proposed.

Design/methodology/approach

Literature review and content analysis.

Findings

The authors discovered that, while the importance of product attributes vary from one industry to the other, overall the time attribute was critical in all of the industries considered in this literature review. Coordination, customer satisfaction, reliability and safety were key issues in attribute sensitive product supply chains (asp-SCs). Similar to the typical supply chains, asp-SCs face economic, social and environmental sustainability issues. However, the majority of the studies in our analysis emphasized importance of the social sustainability. The majority of the papers were reviewed and analyzed and adopted the modeling approach as a research method. Furthermore, it was found that asp-SCs were mostly driven with customer demands and social pressure.

Research limitations/implications

Based on the literature review and content analysis, there are a number of directions for the work conducted in this study to be extended in several directions. First, the literature search could be expanded by relaxing some of the restrictions (e.g. include the conference papers and articles from on-line business journals). Second, additional scientific publishers can be considered (e.g. Emerald Insight–www.emeraldinsight.com; Inderscience–www.inderscience.com). The latter two extensions would allow a more precise assessment of published to date work on asp-SC operations. Third, our findings could be validated based on interviews with professionals and executives from companies dealing with asp-SCs. Such validation will allow identification of the differences between the state of the art and the state of practice.

Practical implications

Supply chains that handle attribute sensitive products (asps) must consider the complexity of products that significantly change their properties due to factors such as time, temperature, barometric pressure, humidity. Mismanagement of operations within such supply chains may lead to significant product waste, as well as substantial monetary losses.

Originality/value

This study presented a comprehensive literature review and content analysis of studies dealing with asps in the following industries: fashion, food, healthcare, humanitarian and pharmaceutical industries

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise

BACKGROUND

More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions.

METHODS

The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings.

RESULTS

The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs.

CONCLUSIONS

Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

An integrated approach for designing in-time and economically sustainable emergency care networks: A case study in the public sector

Emergency Care Networks (ECNs) were created as a response to the increased demand for emergency services and the ever-increasing waiting times experienced by patients in emergency rooms. In this sense, ECNs are called to provide a rapid diagnosis and early intervention so that poor patient outcomes, patient dissatisfaction, and cost overruns can be avoided. Nevertheless, ECNs, as nodal systems, are often inefficient due to the lack of coordination between emergency departments (EDs) and the presence of non-value added activities within each ED. This situation is even more complex in the public healthcare sector of low-income countries where emergency care is provided under constraint resources and limited innovation. Notwithstanding the tremendous efforts made by healthcare clusters and government agencies to tackle this problem, most of ECNs do not yet provide nimble and efficient care to patients. Additionally, little progress has been evidenced regarding the creation of methodological approaches that assist policymakers in solving this problem. In an attempt to address these shortcomings, this paper presents a three-phase methodology based on Discrete-event simulation, payment collateral models, and lean six sigma to support the design of in-time and economically sustainable ECNs. The proposed approach is validated in a public ECN consisting of 2 hospitals and 8 POCs (Point of Care). The results of this study evidenced that the average waiting time in an ECN can be substantially diminished by optimizing the cooperation flows between EDs.

Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review

Background

Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings.

Objective

To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships.

Methods

An electronic search was conducted using four databases for manuscripts on EM training programs - defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care - developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted.

Findings

Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding.

Conclusions

Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.

Developing a research question: A research primer for low- and middle-income countries

As demand for emergency care (EC) systems in low- and middle-income countries (LMICs) grows, there is an urgent need to expand the evidence base for clinical and systems interventions in resource limited EC settings. Clinicians are well placed to identify, define and address unanswered research questions using both quantitative and qualitative approaches. This paper summarises established research priorities for global EC and provides a step-wise approach to developing a research question.

Research priorities for global EC broadly fall into two categories: systems-based research and research with a clinical care focus. Systems research is integral to understanding the essential components of safe and effective EC delivery, while clinical research aims to answer questions related to particular disease states, presentations or population groups.

Developing a specific research question requires an enquiring, questioning and critical approach to EC delivery. In quantitative research, use of the PECO formula (Population, Exposure, Comparator, Outcome) can help frame a research question. Qualitative research, which aims to understand, explore and examine, often requires application of a theoretical framework. Writing a brief purpose statement can be a helpful tool to clarify the objectives of a qualitative study.

This paper includes lists of tips, pitfalls and resources to assist EC clinical researchers in developing research questions. Application of these tools and frameworks will assist EC clinicians in resource limited settings to perform impactful research and improve outcomes for patients with acute illness and injury.

Cost-effectiveness of emergency care interventions in low and middle-income countries: a systematic review

OBJECTIVE

To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries.

METHODS

Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies.

RESULTS

Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied.

CONCLUSION

We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.

Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems

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.

Safety of the patient in an emergency situation: perceptions of the nursing team

OBJECTIVE

To know the perception of nursing professionals about the essential aspects to provide safe care to polytraumatized patients in emergency services.

METHOD

Descriptive and mixed study, performed with a focus group and projective techniques. The sample was made of seven nursing professionals. Data analysis took place through the Interface de R pour Analyses Multidimensionnelles de Textes et de Questionneires and SPSS 22.0 softwares.

RESULTS

Based on the analysis of participants' speeches, three content partitions emerged in the Descending Hierarchical Classification. 1) Structure: need for changes; 2) The process: safe actions by the nursing team; and 3) Care free from damage as the sought result.

CONCLUSION

Patient safety in emergency situations must rely on a proper environment and an organized sector, good conditions to transport patients, use of routines and protocols, identification and organization of the beds.

Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings

INTRODUCTION

Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings.

METHODOLOGY

This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays.

RESULTS

We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2-1.3), children <5 (OR 1.4, 95% CI 1.4-1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6-35.3) and non-trauma cases (OR 4.7, 95% CI 4.4-4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0-1.1), children <5 (OR 2.0, 95% CI 1.9-2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9-15.4) and non-trauma cases (OR 1.6, 95% CI 1.5-1.7).

CONCLUSIONS

Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.

Assessment of pre-hospital emergency medical services in low-income settings using a health systems approach

Emergency medical services (EMS) is defined as the system that organizes all aspects of care provided to patients in the pre-hospital or out-of-hospital environment. Hence, EMS is a critical component of the health systems and is necessary to improve outcomes of injuries and other time-sensitive illnesses. Still there exists a substantial need for evidence to improve our understanding of the capacity of such systems as well as their strengths, weaknesses, and priority areas for improvement in low-resource environments. The aim was to develop a tool for assessment of the pre-hospital EMS system using the World Health Organization (WHO) health system framework. Relevant literature search and expert consultation helped identify variables describing system capacity, outputs, and goals of pre-hospital EMS. Those were organized according to the health systems framework, and a multipronged approach is proposed for data collection including use of qualitative and quantitative methods with triangulation of information from important stakeholders, direct observation, and policy document review. The resultant information is expected to provide a holistic picture of the pre-hospital emergency medical services and develop key recommendations for PEMS systems strengthening.

Payment Reforms for Prehospital Care Services in a Middle Income Country: Assessing Implementation and Patient Outcomes Using a Mixed-Methods Approach

Introduction

Financing health systems constitutes a key element of well-functioning healthcare system. Prior to 2015, two new financial arrangements (direct-pay and E-claim systems) were introduced on a voluntary basis which aimed to pool more financial resources and improve cash flow of prehospital care systems. The aims of this study were to (1) assess the effects of direct-pay system in terms of (a) timeliness of reimbursement to EMS agencies, (b) changes in clinical care processes, and (c) the outcomes of patient care as compared to previous system; (2) identify the reasons for or against EMS agencies to participate in direct-pay system mechanisms; (3) identify the emerging issues with potential to significantly further the advancement of EMS systems. Using a mixed-methods approach, retrospective datasets of 3,769,399 individual records of call responses from 2015 to 2017 were analyzed which compared EMS units with the direct-pay system against those without in terms of time flow of claim data and patient outcomes. For qualitative data, in-depth interviews were conducted.

Results

EMS units participating in both systems had the highest percentages of financial claim being made in time as compared to those not participating in any (p=0.012). However, there were not any practically meaningful differences between EMS units participating and not participating in either of the payment systems in terms of patient care such as appropriateness of response time, airway management, and outcome of treatment. Analysis of data from focus-group and individual interviews ended up with a causal loop diagram demonstrating potential explanatory mechanisms for those findings.

Conclusion

It is evident that progress has been made in terms of mobilising more financial inputs and improving financial information flow. However, there is no evidence of any changes in patient outcomes and quality of care. Furthermore, whether the progress is meaningful in filling the gaps of financial demands of the prehospital care systems is still questionable. Room for future improvement of prehospital care systems was discussed with implications for other countries.

Consensus-based clinical research priorities for emergency nursing in Australia

INTRODUCTION

Research is vital to responding to contemporary challenges of providing safe, high quality emergency nursing care, yet the research priorities for emergency nursing practice in Australia are unknown. This study aimed to establish research priorities for emergency nursing in Australia.

METHODS

A two-stage descriptive, exploratory study was conducted. First, research themes were identified through a survey of 232 emergency nurses the Delphi Technique (2 rounds) was used to rank and prioritise the research themes.

RESULTS

There were five research themes with a CVI≥0.90: (i) recognising and responding to deteriorating ED patients; (ii) effect of access block on clinical care of admitted ICU patients; (iii) effects of ED overcrowding on clinical care; (iv) scope of practice of specialist emergency nurses; and (v) effect of access block on clinical care of admitted ward patients. These are reflected in four broad research priority areas: professional issues, patient safety, emergency care of vulnerable populations, and healthcare system issues.

CONCLUSION

Future research should focus on these priority areas in partnership with other emergency disciplines to enable safe, high quality emergency care, and, to inform the practice of emergency nursing in Australia.

Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis

BACKGROUND

Timely access to emergency care can substantially reduce mortality. International benchmarks for access to emergency hospital care have been established to guide ambitions for universal health care by 2030. However, no Pan-African database of where hospitals are located exists; therefore, we aimed to complete a geocoded inventory of hospital services in Africa in relation to how populations might access these services in 2015, with focus on women of child bearing age.

METHODS

We assembled a geocoded inventory of public hospitals across 48 countries and islands of sub-Saharan Africa, including Zanzibar, using data from various sources. We only included public hospitals with emergency services that were managed by governments at national or local levels and faith-based or non-governmental organisations. For hospital listings without geographical coordinates, we geocoded each facility using Microsoft Encarta (version 2009), Google Earth (version 7.3), Geonames, Fallingrain, OpenStreetMap, and other national digital gazetteers. We obtained estimates for total population and women of child bearing age (15-49 years) at a 1 km2 spatial resolution from the WorldPop database for 2015. Additionally, we assembled road network data from Google Map Maker Project and OpenStreetMap using ArcMap (version 10.5). We then combined the road network and the population locations to form a travel impedance surface. Subsequently, we formulated a cost distance algorithm based on the location of public hospitals and the travel impedance surface in AccessMod (version 5) to compute the proportion of populations living within a combined walking and motorised travel time of 2 h to emergency hospital services.

FINDINGS

We consulted 100 databases from 48 sub-Saharan countries and islands, including Zanzibar, and identified 4908 public hospitals. 2701 hospitals had either full or partial information about their geographical coordinates. We estimated that 287 282 013 (29·0%) people and 64 495 526 (28·2%) women of child bearing age are located more than 2-h travel time from the nearest hospital. Marked differences were observed within and between countries, ranging from less than 25% of the population within 2-h travel time of a public hospital in South Sudan to more than 90% in Nigeria, Kenya, Cape Verde, Swaziland, South Africa, Burundi, Comoros, São Tomé and Príncipe, and Zanzibar. Only 16 countries reached the international benchmark of more than 80% of their populations living within a 2-h travel time of the nearest hospital.

INTERPRETATION

Physical access to emergency hospital care provided by the public sector in Africa remains poor and varies substantially within and between countries. Innovative targeting of emergency care services is necessary to reduce these inequities. This study provides the first spatial census of public hospital services in Africa.

FUNDING

Wellcome Trust and the UK Department for International Development.

What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda

OBJECTIVES

To determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients.

SETTING

A single emergency department (ED) of a district-level hospital in rural Uganda.

PARTICIPANTS

26 710 patient visits.

RESULTS

Procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound.

CONCLUSION

This study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills.

Validação de protocolos gráficos para avaliação da segurança do paciente politraumatizado

Resumo Objetivo: Validar o conteúdo e a aparência dos protocolos gráficos para avaliação da estrutura, processo e resultado do cuidado seguro de enfermagem ao paciente politraumatizado em situação de emergência. Métodos: Estudo metodológico e quantitativo. Para a coleta de dados, aplicou-se a técnica de Delphi em duas rodadas (Delphi I e Delphi II). A amostra do Delphi I consistiu em 15 juízes e o Delphi II arrolou 13 juízes. Considerou-se válidos aqueles itens dos protocolos com Índice de Validação de Conteúdo (IVC) maior que 0.78 e consenso de mais de 70,0% na técnica de Delphi. Os dados foram analisados por meio de estatística descritiva e inferencial (Teste de Wilcoxon e Binomial). Adotou-se o ρ-valor ≤ 0,05 para a significância estatística. Além disso, aplicou-se o Alfa de Cronbach (α) para avaliar a consistência interna dos protocolos. Considerou-se confiável aquele item que apresentasse o α ≥ 0,7. Resultados: Todos os requisitos de avaliação dos protocolos alcançaram concordância entre os juízes superior a 80,0%, bem como todos os itens alcançaram níveis de avaliação estatisticamente significativos. Ao final do Delphi II, os três protocolos se apresentaram expressivamente válidos (estrutura [IVC = 0,92]; processo [IVC = 0,96]; e, resultado [IVC = 0,96]) e confiáveis (estrutura [α = 0,95]; processo [α = 0,95]; e, resultado [α = 0,89]). Conclusão: Atingiu-se a validação de conteúdo e de aparência dos protocolos integralmente, assim como, a validação interna com exímio.

Community-based perceptions of emergency care in Zambian communities lacking formalised emergency medicine systems

BACKGROUND

In Zambia, an increasing burden of acute illness and injury emphasised the necessity of strengthening the national emergency care system.

OBJECTIVE

The objective of this study was to identify critical interventions necessary to improve the Zambian emergency care system by determining the current pattern of emergency care delivery as experienced by members of the community, identifying the barriers faced when trying to access emergency care and gathering community-generated solutions to improve emergency care in their setting.

METHODS

We used a qualitative research methodology to conduct focus groups with community members and healthcare providers in three Zambian provinces. Twenty-one community focus groups with 183 total participants were conducted overall, split equally between the provinces. An additional six focus groups were conducted with Zambian healthcare providers. Data were coded, aggregated and analysed using the content analysis approach.

RESULTS

Community members in Zambia experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Community-identified and provider-identified barriers to emergency care included transportation, healthcare provider deficiencies, lack of community knowledge, the national referral system and police protocols.

CONCLUSIONS

Creating community education initiatives, strengthening the formal prehospital emergency care system, implementing triage in healthcare facilities and training healthcare providers in emergency care were community-identified and provider-identified solutions for improving access to emergency care.

Emergency Department of a Rural Hospital in Ecuador

Introduction

There is a paucity of data studying patients and complaints presenting to emergency departments (EDs) in low- and middle-income countries. The town of Pedro Vicente Maldonado (PVM) is located in the northwestern highlands of Ecuador. Hospital PVM (HPVM) is a rural teaching hospital providing family medicine residency training. These physicians provide around-the-clock acute medical care in HPVM’s ED. This study provides a first look at a functioning ED in rural Latin America by reviewing one year of ED visits to HPVM.

Methods

All ED visits between April 14, 2013, and April 13, 2014, were included and analyzed, totaling 1,239 patient visits. Data were collected from their electronic medical record and exported into a de-identified Excel® database where it was sorted and categorized. Variables included age, gender, mode of arrival, insurance type, month and day of the week of the service, chief complaint, laboratory and imaging requests, and disposition. We performed descriptive statistics, and where possible, comparisons using Student’s T or chi-square, as appropriate.

Results

Of the 1239 total ED visits, 48% were males and 52% females; 93% of the visits were ambulatory, and 7% came by ambulance. Sixty-three percent of the patients had social security insurance. The top three chief complaints were abdominal pain (25.5%), fever (15.1%) and trauma (10.8%). Healthcare providers requested labs on 71.3% of patients and imaging on 43.2%. The most frequently requested imaging studies were chest radiograph (14.9%), upper extremity radiograph (9.4%), and electrocardiogram (9.0%). There was no seasonal or day-of-week variability to number of ED patients. The chief complaint of human or animal bite made it more likely the patient would be admitted, and the chief complaint of traumatic injury made it more likely the patient would be transferred.

Conclusion

Analysis of patients presenting to a rural ED in Ecuador contributes to the global study of acute care in the developing world and also provides a self-analysis identifying disease patterns of the area, training topics for residents, areas for introducing protocols, and information to help planning for rural EDs in low- and middle-income countries.

Perceptions of emergency care in Kenyan communities lacking access to formalised emergency medical systems: a qualitative study

OBJECTIVES

We undertook this study in Kenya to understand the community's emergency care needs and barriers they face when trying to access care, and to seek community members' thoughts regarding high impact solutions to expand access to essential emergency services.

DESIGN

We used a qualitative research methodology to conduct 59 focus groups with 528 total Kenyan community member participants. Data were coded, aggregated and analysed using the content analysis approach.

SETTING

Participants were uniformly selected from all eight of the historical Kenyan provinces (Central, Coast, Eastern, Nairobi, North Eastern, Nyanza, Rift Valley and Western), with equal rural and urban community representation.

RESULTS

Socioeconomic and cultural factors play a major role both in seeking and reaching emergency care. Community members in Kenya experience a wide range of medical emergencies, and seem to understand their time-critical nature. They rely on one another for assistance in the face of substantial barriers to care-a lack of: system structure, resources, transportation, trained healthcare providers and initial care at the scene.

CONCLUSIONS

Access to emergency care in Kenya can be improved by encouraging recognition and initial treatment of emergent illness in the community, strengthening the pre-hospital care system, improving emergency care delivery at health facilities and creating new policies at a national level. These community-generated solutions likely have a wider applicability in the region.

Operationalising emergency care delivery in sub-Saharan Africa: consensus-based recommendations for healthcare facilities

A major barrier to successful integration of acute care into health systems is the lack of consensus on the essential components of emergency care within resource-limited environments. The 2013 African Federation of Emergency Medicine Consensus Conference was convened to address the growing need for practical solutions to further implementation of emergency care in sub-Saharan Africa. Over 40 participants from 15 countries participated in the working group that focused on emergency care delivery at health facilities. Using the well-established approach developed in the WHO's Monitoring Emergency Obstetric Care, the workgroup identified the essential services delivered-signal functions-associated with each emergency care sentinel condition. Levels of emergency care were assigned based on the expected capacity of the facility to perform signal functions, and the necessary human, equipment and infrastructure resources identified. These consensus-based recommendations provide the foundation for objective facility capacity assessment in developing emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery.

Applying the lessons of maternal mortality reduction to global emergency health

Over the last few decades, maternal health has been a major focus of the international community and this has resulted in a substantial decrease in maternal mortality globally. Although, compared with maternal illness, medical and surgical emergencies account for far more morbidity and mortality, there has been less focus on global efforts to improve comprehensive emergency systems. The thoughtful and specific application of the concepts used in the effort to decrease maternal mortality could lead to major improvements in global emergency health services. The so-called three-delay model that was developed for maternal mortality can be adapted to emergency service delivery. Adaptation of evaluation frameworks to include emergency sentinel conditions could allow effective monitoring of emergency facilities and further policy development. Future global emergency health efforts may benefit from incorporating strategies for the planning and evaluation of high-impact interventions.

A "three delays" model for severe sepsis in resource-limited countries

PURPOSE

The developing world carries the greatest burden of sepsis-related mortality, but success in managing severe sepsis in resource-limited countries (RLCs) remains challenging. A "three delays" model has been developed to describe factors influencing perinatal mortality in developing nations. This model has been validated across different World Health Organization regions and has provided the framework for policymakers to plan targeted interventions. Here, we propose a three delays model for severe sepsis in RLCs.

MATERIALS AND METHODS

A literature review was performed using the PubMed, Google Scholar, and Ovid databases. Additional sources were found after review of the reference lists from retrieved articles.

RESULTS

We propose a three delays model for severe sepsis in adults in RLCs. The model highlights limitations in the 3 basic pillars of sepsis management: (1) sepsis recognition and diagnosis at the time of triage, (2) initial focused resuscitation, and (3) postresuscitation clinical monitoring and reassessment.

CONCLUSIONS

Characterizing the major barriers to effective treatment of severe sepsis in RLCs frames the problem in a language common to global health circles, which may stimulate further research, streamline treatment, and reduce sepsis-related mortality in the developing world.