Cross-sectional evaluation of emergency care capacity at public hospitals in Zambia

Emergency care capacity in Sierra Leone: A multicentre analysis

Background

The Disease Control Priorities Project estimates that over 50 % of annual mortality in low- and middle-income countries can be addressed by improved emergency care. Sierra Leone's Ministry of Health and Sanitation has highlighted emergency care as a national priority. We conducted the first multicentre analysis of emergency care capacity in Sierra Leone, using the Hospital Emergency Unit Assessment Tool (HEAT) to analyse 14 government hospitals across the country.

Methods

HEAT is a standardised assessment that is recommended in the World Health Organisation Emergency Care Toolkit. It has been used comparably elsewhere. To analyse Sierra Leone's emergency care capacity with the HEAT data, we created the HEAT-adjusted Emergency Care Capacity Score. Purposeful sampling was used to select 14 government facilities nationwide. A multidisciplinary team was interviewed over a 2-day in-person visit to each facility.

Results

Human Resources was the strongest parameter, scoring 49 %. All hospitals provided emergency cover 24/7. Emergency Diagnostic Services was the most severely limited parameter, scoring 29 %. 3 hospitals had no access to basic radiography. Infrastructure scored 47 %. 2 hospitals had adequate electricity supply; 5 had adequate clean, running water. No hospitals had adequate oxygen supply. Clinical services scored 39 %. 10 hospitals had no designated Emergency Unit, only 2 triaged to stratify severity. Signal functions scored 38 %. No hospitals had reliable access to emergency drugs such as adrenaline. The total HEAT-adjusted Emergency Care Capacity Score across all hospitals was 40 %.

Conclusions

These data identify gaps that have already led to local interventions, including focussing emergency resources to a resuscitation area, and training multidisciplinary teams in emergency care skills. This facility-level analysis could feed into wider assessment of Sierra Leone's emergency care systems at every level, which may help prioritise government strategy to target sustainable strengthening of national emergency care.

A health systems approach to critical care delivery in low-resource settings: a narrative review

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Provider-identified barriers to performance at seven Nigerian accident & emergency units: A cross-sectional study

BACKGROUND

Nigeria hosts much of Africa's morbidity and mortality from emergency medical conditions. We surveyed providers at seven Nigerian Accident & Emergency (A&E) units about (i) their unit's ability to manage six major types of emergency medical condition (sentinel conditions) and (ii) barriers to performing key functions (signal functions) to manage sentinel conditions. Here, we present our analysis of provider-reported barriers to signal function performance.

METHODS

503 Health Providers at 7 A&E units, across 7 states, were surveyed using a modified African Federation of Emergency Medicine (AFEM) Emergency Care Assessment Tool (ECAT). Providers indicating suboptimal performance ascribed this performance to any of eight multiple-choice barriers [infrastructural issues, absent and broken equipment, inadequate training, inadequate personnel, requirement of out-of-pocket payment, non-indication of that signal function for the sentinel condition, and hospital-specific policies barring signal function performance] or an open-ended "other" response. The average number of endorsements for each barrier was obtained for each sentinel condition. Differences in barrier endorsement were compared across site, barrier type and sentinel condition using a three-way ANOVA test. Open-ended responses were evaluated using inductive thematic analysis. Sentinel conditions were Shock, Respiratory Failure, Altered Mental Status, Pain, Trauma, and Maternal & Child Health. Study sites were the University of Calabar Teaching Hospital, the Lagos University Teaching Hospital, the Federal Medical Center, Katsina, the National Hospital Abuja, the Federal Teaching Hospital Gombe, the University of Ilorin Teaching Hospital (Kwara), and the Federal Medical Center Owerri (Imo).

FINDINGS

Barrier distribution varied widely by study site. Just three study sites shared any one barrier to signal function performance as their most common. The two barriers most commonly endorsed were (i) non-indication of, and (ii) insufficient infrastructure to perform signal functions. A three-way ANOVA test found significant differences in barrier endorsement by barrier type, study site and sentinel condition (p<0.05). Thematic analysis of open-ended responses highlighted (i) considerations disfavoring signal function performance and (ii) lack of experience with signal functions as barriers to signal function performance. Interrater reliability, calculated using Fleiss' Kappa, was found to be 0.5 across 11 initial codes and 0.51 for our two final themes.

INTERPRETATION

Provider perspective varied with regards to barriers to care. Despite these differences, the trends seen for infrastructure reflect the importance of sustained investment in Nigerian health infrastructure. The high level of endorsement seen for the non-indication barrier may signal need for better ECAT adaptation for local practice & education, and for improved Nigerian emergency medical education and training. A low endorsement was seen for patient-facing costs, despite the high burden of Nigerian private expenditure on healthcare, indicating limited representation of patient-facing barriers. Analysis of open-ended responses was limited by the brevity and ambiguity of these responses on the ECAT. Further investigation is needed towards better representation of patient-facing barriers and qualitative approaches to evaluating Nigerian emergency care provision.

Emergency unit capacity in Northern Tanzania: a cross-sectional survey

INTRODUCTION

Emergency medicine (EM) is a growing field in Sub-Saharan Africa. Characterising the current capacity of hospitals to provide emergency care is important in identifying gaps and future directions of growth. This study aimed to characterise the ability of emergency units (EU) to provide emergency care in the Kilimanjaro region in Northern Tanzania.

METHODS

This was a cross-sectional study conducted at 11 hospitals with emergency care capacity in three districts in the Kilimanjaro region of Northern Tanzania assessed in May 2021. An exhaustive sampling approach was used, whereby all hospitals within the three-district area were surveyed. Hospital representatives were surveyed by two EM physicians using the Hospital Emergency Assessment tool developed by the WHO; data were analysed in Excel and STATA.

RESULTS

All hospitals provided emergency services 24 hours a day. Nine had a designated area for emergency care, four had a core of fixed providers assigned to the EU, two lacked a protocol for systematic triage. For Airway and Breathing interventions, oxygen administration was adequate in 10 hospitals, yet manual airway manoeuvres were only adequate in six and needle decompression in two. For Circulation interventions, fluid administration was adequate in all facilities, yet intraosseous access and external defibrillation were each only available in two. Only one facility had an ECG readily available in the EU and none was able to administer thrombolytic therapy. For trauma interventions, all facilities could immobilise fractures, yet lacked interventions such as cervical spinal immobilisation and pelvic binding. These deficiencies were primarily due to lack of training and resources.

CONCLUSION

Most facilities perform systematic triage of emergency patients, though major gaps were found in the diagnosis and treatment of acute coronary syndrome and initial stabilisation manoeuvres of patients with trauma. Resource limitations were primarily due to equipment and training deficiencies. We recommend the development of future interventions in all levels of facilities to improve the level of training.

Emergency Services Capacity of a Rural Community in Guatemala

Introduction

Access to emergency care is an essential part of the health system. Improving access to emergency services in low- and middle-income countries (LMIC) decreases mortality and reduces global disparities; however, few studies have assessed emergency services resources in LMICs. To guide future improvements in care, we performed a comprehensive assessment of the emergency services capacity of a rural community in Guatemala serving a mostly indigenous population.

Methods

We performed an exhaustively sampled cross-sectional survey of all healthcare facilities providing urgent and emergent care in the four largest cities surrounding Lake Atitlán using the Emergency Services Resource Assessment Tool (ESRAT).

Results

Of 17 identified facilities, 16 agreed to participate and were surveyed: nine private hospitals; four public clinics; and three public hospitals, including the region’s public departmental hospital. All facilities provided emergency services 24/7, and a dedicated emergency unit was available at 67% of hospitals and 75% of clinics. A dedicated physician was present in the emergency unit during the day at 67% of hospitals and 75% of clinics. Hospitals had a significantly higher percentage of available equipment compared to clinics (85% vs 54%, mean difference 31%; 95% confidence interval (CI) 23–37%; P = 0.004). There was no difference in availability of laboratory tests between public and private hospitals or between cities. Private hospitals had access to a significantly higher percentage of medications compared to clinics (56% vs 27%, mean difference 29%; 95% CI 9–49%; P = 0.024).

Conclusion

We found a high availability of emergency services and universal availability of personal protective equipment but a severe shortage of critical medications in clinics, and widespread shortage of pediatric equipment.

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

Climate change and emergency care in Africa: A scoping review

Introduction

Climate change is a global public health emergency with implications for access to care and emergency care service disruptions. The African continent is particularly vulnerable to climate-related extreme weather events due to an already overburdened health system, lack of early warning signs, poverty, inadequate infrastructure, and variable adaptive capacity. Emergency care services are not only utilized during these events but also threatened by these hazards. Considering that the effects of climate change are expected to increase in intensity and prevalence, it is increasingly important for emergency care to prepare to respond to the changes in presentation and demand. The aim of this study was to perform a scoping review of the available literature on the relationship between climate change and emergency care on the African continent.

Methods

A scoping review was completed using five databases: Pubmed, Web of Science, GreenFILE, Africa Wide Information, and Google Scholar. A 'grey' literature search was done to identify key reports and references from included articles. Two independent reviewers screened articles and a third reviewer decided conflicts. A total of 1,382 individual articles were initially screened with 17 meeting full text review. A total of six articles were included in the final analysis. Data from four countries were represented including Uganda, Ghana, Tanzania, and Nigeria.

Results

Analysis of the six articles yielded three key themes that were identified: climate-related health impacts that contribute to surges in demand and resource utilization, opportunities for health sector engagement, and solutions to improve emergency preparedness. Authors used the outcomes of the review to propose 10 recommendations for decision-makers and leaders.

DXDiscussion

Incorporating these key recommendations at the local and national level could help improve preparedness and adaptation measures in highly vulnerable, populated areas on the African continent.

Potential solutions for screening, triage, and severity scoring of suspected COVID-19 positive patients in low-resource settings: a scoping review

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.

Risk Factors for Respiratory Syncytial Virus-Associated Community Deaths in Zambian Infants

BACKGROUND

Respiratory syncytial virus (RSV) is a major cause of infant deaths. Its epidemiology in low- and middle-income countries is poorly understood. Risk factors associated with RSV-associated infant deaths that occur in community settings are incompletely known.

METHODS

Community deaths for infants aged 4 days to 6 months were identified during a 3-year postmortem RSV prevalence study at the main city morgue in Lusaka, Zambia, where 80% of deaths are registered. This analysis focuses on the subset of deaths for which an abbreviated verbal autopsy was available and intended to sort deaths into respiratory or nonrespiratory causes by clinical adjudication. Posterior nasopharyngeal swab samples were collected within 48 hours of death and tested for RSV using quantitative reverse-transcription polymerase chain reaction. Associations between potential risk factors were determined as relative risks with 95% confidence intervals (CIs).

RESULTS

We prospectively enrolled 798 community infant deaths with verbal autopsies and RSV laboratory results, of which 62 results were positive. The mean age of the infants was 10 weeks, and 41.4% of them were male. Of all deaths, 44% were attributed to respiratory causes. RSV was detected in 7.8% of the community infants and was significantly associated with respiratory deaths (risk ratio, 4.0 [95% CI, 2.2-7.1]). Compared with older infants, those aged 0-8 weeks had a 2.83 (95% CI, 1.30-6.15) increased risk of dying with RSV. The risk of RSV for the 0-8-week age group increased to 5.24 (1.56-33.14) with adjustment for demographics, parental education, and geography. RSV deaths were increased with domiciliary overcrowding and were concentrated in poor and dense neighborhoods in Lusaka (risk ratio, 2.00 [95% CI, 1.22-3.27]).

CONCLUSION

RSV is a significant contributor to community respiratory deaths in this population, particularly in the first 3 months of life and in the more poor and dense parts of Lusaka.

Derivation of a Contextually-Appropriate COVID-19 Mortality Scale for Low-Resource Settings

Background

In many low- and middle-income countries, where vaccinations will be delayed and healthcare systems are underdeveloped, the COVID-19 pandemic will continue for the foreseeable future. Mortality scales can aid frontline providers in low-resource settings (LRS) in identifying those at greatest risk of death so that limited resources can be directed towards those in greatest need and unnecessary loss of life is prevented. While many prognostication tools have been developed for, or applied to, COVID-19 patients, no tools to date have been purpose-designed for, and validated in, LRS.

Objectives

This study aimed to develop a pragmatic tool to assist LRS frontline providers in evaluating in-hospital mortality risk using only easy-to-obtain demographic and clinical inputs.

Methods

Machine learning was used on data from a retrospective cohort of Sudanese COVID-19 patients at two government referral hospitals to derive contextually appropriate mortality indices for COVID-19, which were then assessed by C-indices.

Findings

Data from 467 patients were used to derive two versions of the AFEM COVID-19 Mortality Scale (AFEM-CMS), which evaluates in-hospital mortality risk using demographic and clinical inputs that are readily obtainable in hospital receiving areas. Both versions of the tool include age, sex, number of comorbidities, Glasgow Coma Scale, respiratory rate, and systolic blood pressure; in settings with pulse oximetry, oxygen saturation is included and in settings without access, heart rate is included. The AFEM-CMS showed good discrimination: the model including pulse oximetry had a C-statistic of 0.775 (95% CI: 0.737-0.813) and the model excluding it had a C-statistic of 0.719 (95% CI: 0.678-0.760).

Conclusions

In the face of an enduring pandemic in many LRS, the AFEM-CMS serves as a practical solution to aid frontline providers in effectively allocating healthcare resources. The tool's generalisability is likely narrow outside of similar extremely LRS settings, and further validation studies are essential prior to broader use.

The views and experiences of Zambia's emergency medicine registrars in South Africa: Lessons for the development of emergency care in Zambia

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.

Evaluating capacity at three government referral hospital emergency units in the kingdom of Eswatini using the WHO Hospital Emergency Unit Assessment Tool

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.

Evaluating emergency care capacity in Africa: an iterative, multicountry refinement of the Emergency Care Assessment Tool

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.