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

The predictive value of the Kampala Trauma Score (KTS) in the outcome of multi-traumatic patients compared to the estimated Injury Severity Score (eISS)

PURPOSE

The classification of trauma patients in emergency settings is a constant challenge for physicians. However, the Injury Severity Score (ISS) is widely used in developed countries, it may be difficult to perform it in low- and middle-income countries (LMIC). As a result, the ISS was calculated using an estimated methodology that has been described and validated in a high-income country previously. In addition, a simple scoring tool called the Kampala Trauma Score (KTS) was developed recently. The aim of this study was to compare the diagnostic accuracy of KTS and estimated ISS (eISS) in order to achieve a valid and efficient scoring system in our resource-limited setting.

METHODS

We conducted a cross-sectional study between December 2020 and March 2021 among the multi-trauma patients who presented at the emergency department of Imam Reza hospital, Tabriz, Iran. After obtaining informed consent, all data including age, sex, mechanism of injury, GCS, KTS, eISS, final outcome (including death, morbidity, or discharge), and length of hospital stay were collected and entered into SPSS version 27.0 and analyzed.

RESULTS

381 multi-trauma patients participated in the study. The area under the curve for prediction of mortality (AUC) for KTS was 0.923 (95%CI: 0.888-0.958) and for eISS was 0.910 (95% CI: 0.877-0.944). For the mortality, comparing the AUCs by the Delong test, the difference between areas was not statistically significant (p value = 0.356). The diagnostic odds ratio (DOR) for the prediction of mortality KTS and eISS were 28.27 and 32.00, respectively.

CONCLUSION

In our study population, the KTS has similar accuracy in predicting the mortality of multi-trauma patients compared to the eISS.

Geospatial methodology for determining the regional prevalence of hospital-reported childhood intussusception in patients from India

Both developed and developing countries carry a large burden of pediatric intussusception. Sentinel site surveillance-based studies have highlighted the difference in the regional incidence of intussusception. The objectives of this manuscript were to geospatially map the locations of hospital-confirmed childhood intussusception cases reported from sentinel hospitals, identify clustering and dispersion, and reveal the potential causes of the underlying pattern. Geospatial analysis revealed positive clustering patterns, i.e., a Moran's I of 0.071 at a statistically significant (p value < 0.0010) Z score of 16.14 for the intussusception cases across India (cases mapped n = 2221), with 14 hotspots in two states (Kerala = 6 and Tamil Nadu = 8) at the 95% CI. Granular analysis indicated that 67% of the reported cases resided < 50 km from the sentinel hospitals, and the average travel distance to the sentinel hospital from the patient residence was calculated as 47 km (CI 95% min 1 km-max 378 km). Easy access and facility referral preferences were identified as the main causes of the existing clustering pattern of the disease. We recommend designing community-based surveillance studies to improve the understanding of the prevalence and regional epidemiological burden of the disease.

Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments?

INTRODUCTION

Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource-limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low- and middle-income country (LMIC) emergency departments (EDs).

METHODS

Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full-text review underwent risk-of-bias assessment using the Newcastle-Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE.

RESULTS

Among 10,394 articles identified through the search strategy, 58 underwent full-text review and 16 were included in the final synthesis. All utilized pre-/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators.

CONCLUSIONS

There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.

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.

National Neurotrauma Registry Data in Low- and Middle-Income Countries - Current Status and Future Requirements Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries"

Since 1990 National Trauma Registries, - taking the form of "not for profit" small and medium enterprises - have been integral to improvementsin major injury case fatality in high-income settings. This is laudable but unsatisfactory as globally most years of life lost to injury occur in low- and middle-income countries (LMICs). International Journal of Health Policy and Management, recently published a scoping review of neurotrauma registries in LMICs by Barthelemy et al; from this the commentary reflects on the state of the art and how these LMIC registries could be taken to "the next level" as meaningful tools for improving major injury patient care.

Emergency care in post-conflict settings: a systematic literature review

BACKGROUND

Emergency care systems (ECS) organize and provide access to life-saving care both during transport and at health facilities. Not enough is known about ECS in uncertain contexts such as post-conflict settings. This review aims to systematically identify and summarize the published evidence on the delivery of emergency care in post-conflict settings and to guide health sector planning.

METHODS

We searched five databases (PubMed MEDLINE, Web of Science, Embase, Scopus, and Cochrane) in September 2021 to identify relevant articles on ECS in post-conflict settings. Included studies (1) described a context that is post-conflict, conflict-affected, or was impacted by war or crisis; (2) examined the delivery of an emergency care system function; (3) were available in English, Spanish, or French; and (4) were published between 1 and 2000 and 9 September 2021. Data were extracted and mapped using the essential system functions identified in the World Health Organization (WHO) ECS Framework to capture findings on essential emergency care functions at the scene of injury or illness, during transport, and through to the emergency unit and early inpatient care.

RESULTS

We identified studies that describe the unique burden of disease and challenges in delivering to the populations in these states, pointing to particular gaps in prehospital care delivery (both during scene response and during transport). Common barriers include poor infrastructure, lingering social distrust, scarce formal emergency care training, and lack of resources and supplies.

CONCLUSION

To our knowledge, this is the first study to systematically identify the evidence on ECS in fragile and conflict-affected settings. Aligning ECS with existing global health priorities would ensure access to these critical life-saving interventions, yet there is concern over the lack of investments in frontline emergency care. An understanding of the state of ECS in post-conflict settings is emerging, although current evidence related to best practices and interventions is extremely limited. Careful attention should be paid to addressing the common barriers and context-relevant priorities in ECS, such as strengthening prehospital care delivery, triage, and referral systems and training the health workforce in emergency care principles.

Neurotrauma Registries in Low- and Middle-Income Countries for Building Organized Neurotrauma Care: The LATINO Registry Experience Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries"

Trauma registries play an important role in building capacity for trauma systems. Regularly, trauma registries exist in high-income countries (HICs) but not in low- and middle-income countries (LMICs). Neurotrauma includes common conditions, like traumatic brain injuries (TBIs) and spinal cord injuries. The development of organized neurotrauma care is crucial for improving the quality of care in less-resourced areas. The recent article published in International Journal of Health Policy and Management by Barthélemy et al entitled "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries" adds an important body of literature to improve understanding of the importance of these types of efforts by promoting organized neurotrauma care systems in LMICs. Here, we provide a short commentary based on our experience with the Latin America and the Caribbean Neurotrauma Registry (LATINO-TBI) in the Latin America (LATAM) region.

Getting to the Emergency Department in time: Interviews with patients and their caregivers on the challenges to emergency care utilization in rural Uganda

Objectives

Karoli Lwanga Hospital and Global Emergency Care, a 501(c)(3) nongovernmental organization, operate an Emergency Department (ED) in Uganda’s rural Rukungiri District. Despite available emergency care (EC), preventable death and disability persist due to delayed patient presentations. This study seeks to understand the emergency care seeking behavior of community members utilizing the established ED.

Methods

We purposefully sampled and interviewed patients and caregivers presenting to the ED more than 12 hours after onset of chief complaint in January-March 2017 to include various ages, genders, and complaints. Semistructured interviews addressing actions taken before seeking EC and delays to presentation once the need for EC was recognized were conducted until a diverse sample and theoretical saturation were obtained. An interdisciplinary and multicultural research team conducted thematic analysis based on descriptive phenomenology.

Results

The 50 ED patients for whom care was sought (mean age 33) had approximately even distribution of gender, as well as occupation (none, subsistence farmers and small business owner). Interviews were conducted with 13 ED patients and 37 caregivers, on the behalf of patients when unavailable. The median duration of patients’ chief complaint on ED presentation was 5.5 days. On average, participants identified severe symptoms necessitating EC 1 day before presentation. Four themes of treatment delay before and after severity were recognized were identified: 1) Cultural factors and limited knowledge of emergency signs and initial actions to take; 2) Use of local health facilities despite perception of inadequate services; 3) Lack of resources to cover the anticipated cost of obtaining EC; 4) Inadequate transportation options.

Conclusions

Interventions are warranted to address each of the four major reasons for treatment delay. The next stage of formative research will generate intervention strategies and assess the opportunities and challenges to implementation with community and health system stakeholders.

Lessons from the frontline: Leadership and governance experiences in the COVID-19 pandemic response across the Pacific region

Background

Universal access to safe, effective emergency care (EC) during the COVID-19 pandemic has illustrated its centrality to healthcare systems. The 'Leadership and Governance' building block provides policy, accountability and stewardship to health systems, and is essential to determining effectiveness of pandemic response. This study aimed to explore the experience of leadership and governance during the COVID-19 pandemic from frontline clinicians and stakeholders across the Pacific region.

Methods

Australian and Pacific researchers collaborated to conduct this large, qualitative research project in three phases between March 2020 and July 2021. Data was gathered from 116 Pacific regional participants through online support forums, in-depth interviews and focus groups. A phenomenological approach shaped inductive and deductive data analysis, within a previously identified Pacific EC systems building block framework.

Findings

Politics profoundly influenced pandemic response effectiveness, even at the clinical coalface. Experienced clinicians spoke authoritatively to decision-makers; focusing on safety, quality and service duty. Rapid adaptability, past surge event experience, team-focus and systems-thinking enabled EC leadership. Transparent communication, collaboration, mutual respect and trust created unity between frontline clinicians and 'top-level' administrators. Pacific cultural assets of relationship-building and community cohesion strengthened responses.

Interpretation

Effective governance occurs when political, administrative and clinical actors work collaboratively in relationships characterised by trust, transparency, altruism and evidence. Trained, supported EC leadership will enhance frontline service provision, health security preparedness and future Universal Health Coverage goals.

Funding

Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Sudanese emergency departments: a study to identify the barriers to a well-functioning triage

BACKGROUND

Triage system is a sorting system that categorizes patients on the basis of the severity of their condition and the availability of the resources in the emergency department. There has been little attention in the public literature to triage systems in Sudan. The aim of this study was to explore the triage system and identify the barriers in its application in hospitals in Sudan.

METHODS

A cross-sectional hospital based study was conducted at eight hospitals in Khartoum during December 2020. A multi-stage cluster sampling was applied. Data were obtained by interviewing emergency department staff using a structured questionnaire. The data were analyzed using statistical package for social sciences to find the association between various variables by chi-square test.

RESULTS

Most of the respondents stated that the triage system was deficient. Most of the participants of this study agreed that the role played by the administration in taking legislative decisions is crucial in improving the triage system. Among the factors found to be significant to a well-functioning triage system were, the need for substantial capital expenditure, p-value: 0.026, prudent legislative decisions, p-value: 0.026, adequate training of staff on means of performing efficient triaging, p-value: 0.007 and raising the awareness of the staff on the correct application of triage guidelines, p-value: 0.017.

CONCLUSION

Currently there is no formal triage system in the State of Khartoum and has yet to be established. Policy making by administrators will play an important role in its implementation. It is suggested that prompt executive orders on improving the current triage system in Khartoum, should be carried out sooner than later, as the ripple effects of a well-functioning triage will decrease the average length of stay, mortality and morbidity rates and will eventually increase the patient's satisfaction.

Validity and reliability of the Interagency Integrated Triage Tool in a regional emergency department in Papua New Guinea

OBJECTIVE

The Interagency Integrated Triage Tool (IITT) is a novel, three-tier triage system recommended by the World Health Organization. The present study sought to assess the validity and reliability of a pilot version of the tool in a resource-limited ED in regional Papua New Guinea.

METHODS

This pragmatic prospective observational study, conducted at Mount Hagen Provincial Hospital, commenced 1 month after IITT implementation. The facility did not have a pre-existing triage system. All ED patients presenting within a 5-month period were included. The primary outcome was sensitivity for the detection of time-critical illness, defined by 10 pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced external triage officer.

RESULTS

There were 9437 presentations during the study period and 9175 (97.2%) had a triage category recorded. Overall, 138 (1.5%) were classified as category 1 (emergency), 1438 (15.7%) as category 2 (priority) and 7599 (82.8%) as category 3 (non-urgent). When applied by a mix of community health workers, nurses, health extension officers and doctors, the tool's sensitivity for the detection of time-critical illness was 77.8% (95% confidence interval 64.4-88.0). The admission rate was 14.5% (20/138) among emergency patients, 12.0% (173/1438) among priority patients and 0.4% (30/7599) among non-urgent patients (P = 0.00). Death in the ED occurred in 13 (9.4%) of 138 emergency patients, 34 (2.4%) of 1438 priority patients and four (0.1%) of 7599 non-urgent patients (P = 0.00). The negative predictive value for these outcomes was >99.5%. Among 170 observed triage assessments, weighted κ was 0.81 (excellent agreement). On average, it took clinicians 2 min 43 s (standard deviation 1:10) to complete a triage assessment.

CONCLUSION

There is limited published data regarding the predictive validity and inter-rater reliability of the IITT. In this pragmatic study, the pilot version of the tool demonstrated adequate performance. Evaluation in other emergency care settings is recommended.

Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study

Background

The Interagency Integrated Triage Tool (IITT) is a three-tier triage system designed for resource-limited emergency care (EC) settings. This study sought to assess the validity and reliability of a pilot version of the tool in an urban emergency department (ED) in Papua New Guinea.

Methods

A pragmatic observational study was conducted at Gerehu General Hospital in Port Moresby, commencing eight weeks after IITT implementation. All ED patients presenting within the subsequent two-month period were included. Triage assessments were performed by a variety of ED clinicians, including community health workers, nurses and doctors. The primary outcome was sensitivity for the detection of time-critical illness, defined by ten pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced, external triage officer.

Findings

Among 4512 presentations during the study period, 58 (1.3%) were classified as category one (emergency), 967 (21.6%) as category two (priority) and 3478 (77.1%) as category three (non-urgent). The tool's sensitivity for detecting the pre-specified set of time-sensitive conditions was 70.8% (95%CI 58.2-81.4%), with negative predictive values of 97.3% (95%CI 96.7 - 97.8%) for admission/transfer and 99.9% (95%CI 99.7 - 100.0%) for death. The admission/transfer rate was 44.8% (26/58) among emergency patients, 22.9% (223/976) among priority patients and 2.7% (94/3478) among non-urgent patients (Cramer's V=0.351, p=0.00). Four of 58 (6.9%) emergency patients, 19/976 (2.0%) priority patients and 3/3478 (0.1%) non-urgent patients died in the ED (Cramer's V=0.14, p=0.00). The under-triage rate was 2.7% (94/3477) and the over-triage rate 48.2% (28/58), both within pre-specified limits of acceptability. On average, it took staff 3 minutes 34 seconds (SD 1:06) to determine and document a triage category. Among 70 observed assessments, weighted κ was 0.84 (excellent agreement).

Interpretation

The pilot version of the IITT demonstrated acceptable performance characteristics, and validation in other EC settings is warranted.

Funding

This project was funded through a Friendship Grant from the Australian Government Department of Foreign Affairs and Trade and an International Development Fund Grant from the Australasian College for Emergency Medicine Foundation.

Emergency Care Sensitive Conditions in Brazil: A Geographic Information System Approach to Timely Hospital Access

Background

The benefits of treatment for many conditions are time dependent. The burden of these emergency care sensitive conditions (ECSCs) is especially high in low- and middle-income countries. Our objective was to analyze geospatial trends in ECSCs and characterize regional disparities in access to emergency care in Brazil.

Methods

From publicly available datasets, we extracted data on patients assigned an ECSC-related ICD-10 code and on the country's emergency facilities from 2015-2019. Using ArcGIS, OpenStreetMap, and WorldPop, we created catchment areas corresponding to 180 minutes of driving distance from each hospital. We then used ArcGIS to characterize space-time trends in ECSC admissions and to complete an Origin-Destination analysis to determine the path from household to closest hospital.

Findings

There were 1362 municipalities flagged as "hot spots," areas with a high volume of ECSCs. Of those, 69.7% were more than 180 minutes (171 km) from the closest emergency facility. These municipalities were primarily located in the states of Minas Gerais, Bahia, Espiríto Santo, Tocantins, and Amapá. In the North region, only 69.1% of the population resided within 180 minutes of an emergency hospital.

Interpretations

Significant geographical barriers to accessing emergency care exist in certain areas of Brazil, especially in peri-urban areas and the North region. One limitation of this approach is that geolocation was not possible in some areas and thus we are likely underestimating the burden of inadequate access. Subsequent work should evaluate ECSC mortality data.

Funding

This study was funded by the Duke Global Health Institute Artificial Intelligence Pilot Project.

Knowledge, Practice, and Associated Factors of Nurses in Pre-Hospital Emergency Care at a Tertiary Care Teaching Hospital

BACKGROUND

Pre-hospital emergency care is a medical care given to patients before arrival in the hospital after activation of the emergency team. Poor knowledge and practice about pre-hospital emergency care hurt the health outcomes of the patients.

OBJECTIVE

This study aimed to assess knowledge and practice nurses at the University of Gondar Compressive Specialized Hospital, Northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted from March 20 to April 10, 2020. A stratified sampling technique was used to select the study participants. Data were collected using a pretested structured self-administered questionnaire. Data were analyzed using SPSS version 20. To explain study variables, frequency tables and percentages were used. Logistic regression analysis was used to see the association between independent and dependent variables.

RESULTS

Out of the total 378 respondents, less than half (42.9%) had good knowledge; similarly, 49.5% of them had good practice about pre-hospital emergency care. Male sex and attend formal training were significant associations with both knowledge and practice of pre-hospital emergency nursing care. Male participants (adjusted odds ratio (AOR) = 6.57, 95% confidence interval (CI) (3.79-11.36)) and having training (AOR=1.74, 95% CI (1.83-3.66)) were significantly associated with knowledge of pre-hospital emergency care, whereas male sex (AOR=1.73, 95% CI (1.09-2.73)) and having training (AOR=6.16, 95% CI (2.69-14.10)) were significantly associated with the practice of pre-hospital emergency care.

CONCLUSION

Knowledge and practice of nurses regarding pre-hospital emergency care was found to be inadequate as compared to previous studies. Male sex and attend formal training showed a positive and significant association with both knowledge and practice of pre-hospital emergency nursing care. The responsible body ought to allow professional development and attending formal training for nurses.