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Eliah D, Mashauri HL, Sadiq A, Dekker MCJ, Nyakunga G, Sakita F. A rare case of pulmonary embolism in a Mt. Kilimanjaro recreational hiker: A case report with review of literature. SAGE Open Med Case Rep 2024; 12:2050313X241254739. [PMID: 38764918 PMCID: PMC11102666 DOI: 10.1177/2050313x241254739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/25/2024] [Indexed: 05/21/2024] Open
Abstract
Pulmonary embolism is one of the rarest complications of high-altitude sickness that can coexist with high altitude pulmonary edema. The risk of developing this phenomenon increases significantly with prolonged stay in high altitudes especially above 5000 m. Given the fatality of the condition, early screening and management is crucial; however, there is no gold standard approach in diagnosis. A 44-year-old male, a Tanzanian tourist first time hiking Mt. Kilimanjaro developed difficulty in breathing on the 4th day of ascending on a route that takes 6 days to summit whereby he was saturating at 38% on room air at the height of 4775 m. He was admitted with the clinical diagnosis of high altitude pulmonary edema. However, in the course of treatment for 72 h with no improvement, further investigations including computed tomography scan were suggestive of pulmonary embolism whereby he was treated with full recovery. Pulmonary embolism case reports are increasingly rising with the difficult to notice among high altitude pulmonary edema patients given their presentation similarities. A high index of suspicion based on clinical examination and investigations should prompt a clinician to include or exclude it.
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Affiliation(s)
- Doreen Eliah
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Harold L Mashauri
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Department of Emergency Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Adnan Sadiq
- Department of Radiology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Gissela Nyakunga
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Francis Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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2
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Mloka DA, Sakita F, Minja IK, Dika H, Tarimo EAM, Sirili N, Mselle LT, Kisenge RR, Sasi P, Nsemwa L, Msanga DR, Matayan EY, Ngowi NB, Moshi MJ, Bartlett J, Macfarlane SB, Kaaya E, O’Sullivan PS. Preparing Institutions to Implement Harmonized Medicine and Nursing Curricula Through the Use of Cross-Institutional Faculty Developers. Adv Med Educ Pract 2024; 15:401-408. [PMID: 38764788 PMCID: PMC11102737 DOI: 10.2147/amep.s441090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/17/2024] [Indexed: 05/21/2024]
Abstract
Background Effective implementation of new curricula requires faculty to be knowledgeable about curriculum goals and have the appropriate pedagogical skills to implement the curriculum, even more so if the new curriculum is being deployed at multiple institutions. In this paper, we describe the process of creating a common faculty development program to train cross-institutional faculty developers to support the implementation of national harmonized medicine and nursing curricula. Methods A five-step approach was used, including a cross-institutional needs assessment survey for faculty development needs, the development of a generic faculty development program, the identification and training of cross-institutional faculty educators, and the implementation of cross-institutional faculty capacity-building workshops. Results A list of common cross-cutting faculty development needs for teaching and learning was identified from the needs assessment survey and used to develop an accredited, cross-institutional faculty development program for competency-based learning and assessment. A total of 24 cross-institutional faculty developers were identified and trained in 8 core learning and assessment workshops. A total of 18 cross-institutional and 71 institutional workshops were conducted, of which 1292 faculty members and 412 residents were trained, and three cross-institutional educational research projects were implemented. Conclusion The success attained in this study shows that the use of cross-institutional faculty developers is a viable model and sustainable resource that can be used to support the implementation of harmonized national curricula.
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Affiliation(s)
- Doreen Anna Mloka
- Department of Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Francis Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Irene Kida Minja
- Department of Restorative Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Haruna Dika
- Department of Anatomy, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Edith A M Tarimo
- Department of Nursing Management, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nathanael Sirili
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, School of Public Health and Social Sciences, Dar es Salaam, Tanzania
| | - Lillian Teddy Mselle
- Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rodrick Richard Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Philip Sasi
- Department of Pharmacology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Livuka Nsemwa
- Department of Nursing and Midwifery, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Delfina R Msanga
- Department of Pediatrics and Child Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Einoti Yohana Matayan
- Department of Ophthalmology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Mainen Julius Moshi
- Department of Biological and Preclinical Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - John Bartlett
- Department of Global Health and Medicine, Duke University, Durham, NC, USA
| | - Sarah B Macfarlane
- Department of Global Health Sciences, University of San Francisco California, San Francisco, CA, USA
| | - Ephata Kaaya
- Department of Pathology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Patricia S O’Sullivan
- Office of Research and Development in Medical Education, University of San Francisco California, San Francisco, CA, USA
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Keating EM, Sakita F, Vonderohe M, Nkini G, Amiri I, Loutzenheiser K, Young B, Rent S, Staton CA, Mmbaga BT, Watt MH. Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania. PLoS One 2023; 18:e0286836. [PMID: 38100475 PMCID: PMC10723720 DOI: 10.1371/journal.pone.0286836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/26/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge. OBJECTIVE The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania. METHODS This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis. RESULTS Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up. CONCLUSION Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.
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Affiliation(s)
- Elizabeth M. Keating
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Maddy Vonderohe
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Getrude Nkini
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Ismail Amiri
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Kelly Loutzenheiser
- College of Nursing, University of Utah, Salt Lake City, UT, United States of America
| | - Bryan Young
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Sharla Rent
- Department of Pediatrics, Duke School of Medicine, Durham, North Carolina, United States of America
| | - Catherine A. Staton
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Medical Center, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
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O’Leary P, Domeracki A, Raymond J, Kozhumam A, Macha V, Sakita F, Krym V, Riccardo Nickenig Vissoci J, Staton C. A feasibility assessment of a traumatic brain injury predictive modelling tool at Kilimanjaro Christian Medical Center and Duke University Hospital. PLOS Glob Public Health 2023; 3:e0002154. [PMID: 38016001 PMCID: PMC10684081 DOI: 10.1371/journal.pgph.0002154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/18/2023] [Indexed: 11/30/2023]
Abstract
Traumatic brain injury (TBI) is the most common cause of death and disability globally. TBI, which disproportionately affects low middle-income countries (LMIC), uses significant amounts of health system resources in costly care and management. Innovative solutions are required to address this high burden of TBI. One possible solution is prognostic models which enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a TBI prognostic model developed in Tanzania for use by Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke-affiliated healthcare providers using human centered design methodology. Duke participants were included to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows, co-design interviews were conducted with emergency physicians and nursing staff at KCMC and Duke. Qualitatively, the TBI tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Our knowledge translation method was guided using the knowledge-to-action framework. Of the 21 participants interviewed, 12 were associated with Duke Hospital, and 9 from Kilimanjaro Christian Medical Centre. Emerging from the data were 6 themes that impacted the implementation of the TBI tool: access, barriers, facilitators, use of the TBI tool, outer setting, and inner setting. To our knowledge, this is the first study to investigate the pre-implementation of a sub-Saharan Africa (SSA) data- based TBI prediction tool using human centered design methodology. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC.
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Affiliation(s)
- Paige O’Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Alexis Domeracki
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Arthi Kozhumam
- Northwestern University Feinburg School of Medicine, Chicago, Illinois, United States of America
| | | | | | - Valerie Krym
- Department of Emergency Medicine, University of Toronto Medical School, Toronto, Ontario, Canada
| | - Joao Riccardo Nickenig Vissoci
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Catherine Staton
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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Keating EM, Sakita F, Vlasic K, Amiri I, Nkini G, Nkoronko M, Young B, Birchall J, Watt MH, Staton CA, Mmbaga BT. Healthcare provider perspective on barriers and facilitators in the care of pediatric injury patients at a tertiary hospital in Northern Tanzania: A qualitative study. PLOS Glob Public Health 2023; 3:e0002599. [PMID: 37983210 PMCID: PMC10659160 DOI: 10.1371/journal.pgph.0002599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023]
Abstract
Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). The recovery of injured children in LMICs is often impeded by barriers in accessing and receiving timely and quality care at healthcare facilities. The purpose of this study was to identify the barriers and the facilitators in pediatric injury care at Kilimanjaro Christian Medical Center (KCMC), a tertiary zonal referral hospital in Northern Tanzania. In this study, focus group discussions (FGDs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the barriers and facilitators in pediatric injury care. Five FGDs were completed from February 2021 to July 2021. Participants (n = 30) were healthcare providers from the emergency department, burn ward, surgical ward, and pediatric ward. De-identified transcripts were analyzed with team-based, applied thematic analysis using qualitative memo writing and consensus discussions. Our study found barriers that impeded pediatric injury care were: lack of pediatric-specific injury training and care guidelines, lack of appropriate pediatric-specific equipment, staffing shortages, lack of specialist care, and complexity of cases due to pre-hospital delays in patients presenting for care due to cultural and financial barriers. Facilitators that improved pediatric injury care were: team cooperation and commitment, strong priority and triage processes, benefits of a tertiary care facility, and flexibility of healthcare providers to provide specialized care if needed. The data highlights barriers and facilitators that could inform interventions to improve the care of pediatric injury patients in Northern Tanzania such as: increasing specialized provider training in pediatric injury management, the development of pediatric injury care guidelines, and improving access to pediatric-specific technologies and equipment.
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Affiliation(s)
- Elizabeth M. Keating
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Kajsa Vlasic
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Ismail Amiri
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Getrude Nkini
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Mugisha Nkoronko
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Bryan Young
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Jenna Birchall
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
| | - Catherine A. Staton
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
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Vissoci JRN, Friedman K, Caruzzo NM, de Oliveira LP, Pauley A, Zadey S, Menegassi V, Sakita F, Boshe J, Staton CA, Mmbaga B. Clinical evaluation of the alcohol use disorders identification test (AUDIT) in Moshi, Tanzania. PLoS One 2023; 18:e0287835. [PMID: 37939063 PMCID: PMC10631671 DOI: 10.1371/journal.pone.0287835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/14/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Alcohol use disorder is a major cause of morbidity and mortality in low- and middle-income countries. Alcohol screening using a validated tool is a useful way to capture high-risk patients and engage them in early harm reduction interventions. Our objectives were to 1) evaluate the psychometric evidence the Alcohol Use Disorders Identification Test (AUDIT) and its subscales in the general population of Moshi, Tanzania, and 2) evaluate the usefulness of the tool at predicting alcohol-related harms. METHODS Two hundred and fifty-nine adults living in Moshi, Tanzania were included in the study. We used the AUDIT and its subscales to determine the classification of harmful and hazardous drinking. To analyze the internal structure of AUDIT and the model adequacy we used Confirmatory Factor Analysis (CFA). The reliability of AUDIT was analyzed for Cronbach's alpha, Omega 6 and Composite Reliability. The optimal cut off point for the AUDIT was determined by the receiver operating characteristic (ROC) curve, using the Youden approach to maximize sensitivity and specificity. RESULTS The median score of the AUDIT was 1 (inter-quartile range: 0-7). The internal structure of the AUDIT showed factor loadings ranging from 0.420 to 0.873. Cronbach's alpha, Omega and Composite Reliability produced values above 0.70. The Average Variance Extracted was 0.530. For the AUDIT, a score of 8 was identified as the ideal cut-off value in our population. CONCLUSIONS This study validates AUDIT in the general population of Moshi and is one of the only studies in Africa to include measures of the internal structure of the AUDIT and its subscales.
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Affiliation(s)
- Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Duke Emergency Medicine, Duke University Medical Center, Durham, NC, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Durham, NC, United States of America
| | - Kaitlyn Friedman
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | | | | | - Alena Pauley
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Durham, NC, United States of America
| | - Siddhesh Zadey
- Duke Emergency Medicine, Duke University Medical Center, Durham, NC, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Durham, NC, United States of America
| | | | | | - Judith Boshe
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Duke Emergency Medicine, Duke University Medical Center, Durham, NC, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Durham, NC, United States of America
| | - Blandina Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Pauley A, Thatcher EC, Sarafian JT, Zadey S, Shayo F, Mmbaga BT, Sakita F, Boshe J, Vissoci JRN, Staton CA. Alcohol use among emergency medicine department patients in Tanzania: A comparative analysis of injury versus non-injury patients. PLOS Glob Public Health 2023; 3:e0001900. [PMID: 37910469 PMCID: PMC10619788 DOI: 10.1371/journal.pgph.0001900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Alcohol is a leading behavioral risk factor for death and disability worldwide. Tanzania has few trained personnel and resources for treating unhealthy alcohol use. In Emergency Medicine Departments (EMDs), alcohol is a well-known risk factor for injury patients. At Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania, 30% of EMD injury patients (IP) test positive for alcohol upon arrival to the ED. While the IP population is prime for EMD-based interventions, there is limited data on if non-injury patients (NIP) have similar alcohol use behavior and potentially benefit from screening and intervention as well. METHODS This was a secondary analysis of a systematic random sampling of adult (≥18 years old), KiSwahili speaking, KCMC EMD patients surveyed between October 2021 and May 2022. When medically stable and clinically sober, participants provided informed consent. Information on demographics (sex, age, years of education, type of employment, income, marital status, tribe, and religion), injury status, self-reported alcohol use, and Alcohol Use Disorder (AUD) Identification Test (AUDIT) scores were collected. Descriptive statistics were analyzed in RStudio using frequencies and proportions. RESULTS Of the 376 patients enrolled, 59 (15.7%) presented with an injury. The IP and NIP groups did not differ in any demographics except sex, an expected difference as females were intentionally oversampled in the original study design. The mean [SD] AUDIT score (IP: 5.8 [6.6]; NIP: 3.9 [6.1]), drinks per week, and proportion of AUDIT ≥8 was higher for IP (IP:37%; NIP: 21%). However, alcohol preferences, drinking quantity, weekly expenditure on alcohol, perceptions of unhealthy alcohol use, attempts and reasons to quit, and treatment seeking were comparable between IPs and NIPs. CONCLUSION Our data suggests 37% of injury and 20% of non-injury patients screen positive for harmful or hazardous drinking in our setting. An EMD-based alcohol treatment and referral process could be beneficial to reduce this growing behavioral risk factor in non-injury as well as injury populations.
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Affiliation(s)
- Alena Pauley
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Emily C. Thatcher
- Duke Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joshua T. Sarafian
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Siddhesh Zadey
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Duke Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Frida Shayo
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Judith Boshe
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - João Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Duke Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Duke Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
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8
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Zimmerman A, Elahi C, Hernandes Rocha TA, Sakita F, Mmbaga BT, Staton CA, Vissoci JRN. Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors. PLOS Glob Public Health 2023; 3:e0002156. [PMID: 37856444 PMCID: PMC10586611 DOI: 10.1371/journal.pgph.0002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/13/2023] [Indexed: 10/21/2023]
Abstract
Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Cyrus Elahi
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
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Rahim FO, Jain B, Bloomfield GS, Jain P, Rugakingira A, Thielman NM, Sakita F, Hertz JT. A holistic framework to integrate HIV and cardiovascular disease care in sub-Saharan Africa. AIDS 2023; 37:1497-1502. [PMID: 37199570 DOI: 10.1097/qad.0000000000003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Faraan O Rahim
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, Massachusetts
- Stanford University School of Medicine, Stanford, California
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pankaj Jain
- Highmark Health, Pittsburgh
- Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | | | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Stanford University School of Medicine, Stanford, California
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Mduma E, Chugulu S, Msuya D, Sakita F, Fabrice LM. Pattern, Management, and Outcomes of Chest Injury At Kilimanjaro Christian Medical Centre. East Afr Health Res J 2023; 7:94-102. [PMID: 37529494 PMCID: PMC10388638 DOI: 10.24248/eahrj.v7i1.714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 05/07/2023] [Indexed: 08/03/2023] Open
Abstract
Background Chest trauma is a major cause of morbidity and mortality in the region. Lacking data in our environment has been a challenging part of knowing the burden of the problem. Long hospital stays and associated injuries are an essential measure of morbidity. The study results will provide a basis for planning prevention strategies and establishment of treatment protocols. Objectives To determine the prevalence, pattern, and management outcomes of chest injury patients at Kilimanjaro Christian Medical Center (KCMC), a Tertiary Hospital in Northern zone Tanzania from October 2021 to April 2022. Methodology A hospital-based cross-sectional study was conducted among patients with chest injuries who were admitted and managed at Tertiary Hospital Northern Zone (Kilimanjaro Christian Medical Center-KCMC) in the Emergency medicine and General Surgery departments. Using a designated data collection tool, details of the mechanism of injury, radiological and laboratory investigations, management, and outcomes were recorded. Results A total of 114 chest injury patients were studied. Males outnumbered females by a ratio of 7.14:1. Their ages ranged from 2 to 83 years (mean = 36.18 years). The Majority of patients (95.58%) sustained blunt injuries. Road traffic crush was the most common cause of injuries affecting 65.79% of patients. Lung contusion, hemothorax, and rib fractures were the most common type of injuries accounting for 54.4%, 27.2%, and 21.1%, respectively. Associated injuries were noted in 85.7% of patients, and head injury (60.5%) was found in most patients. The Majority of patients (60.5%) were treated successfully with a non-operative approach. Underwater seal drainage was performed at (38.9%). One Patient (0.9%) underwent a thoracotomy. 14% of patients had complications of surgical site infection, and 69% were found in the Majority of patients. The median length of hospital stay was 4.5 days. The mortality rate was 21. Conclusion Motor traffic crash was the principal cause of chest trauma. Young male patients were most affected by chest trauma and the majority of patients were treated conservatively. Chest X-ray remains to be the main imaging modality for diagnosing thoracic trauma lesions. Associated injuries such as head injuries, were found to contribute to a high mortality rate.
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Affiliation(s)
- Elias Mduma
- General Surgery, Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College
| | - Samwel Chugulu
- General Surgery, Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College
| | - David Msuya
- General Surgery, Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College
| | - Francis Sakita
- Emergency Medicine Department, Kilimanjaro Christian Medical Centre
- Kilimanjaro Christian Medical University College
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Barcenas LK, Appenteng R, Sakita F, O’Leary P, Rice H, Mmbaga BT, Vissoci JRN, Staton CA. The epidemiology of pediatric traumatic brain injury presenting at a referral center in Moshi, Tanzania. PLoS One 2022; 17:e0273991. [PMID: 36197935 PMCID: PMC9534435 DOI: 10.1371/journal.pone.0273991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/19/2022] [Indexed: 11/05/2022] Open
Abstract
Background Over 95% of childhood injury deaths occur in low- and middle-income countries (LMICs). Patients with severe traumatic brain injury (TBI) have twice the likelihood of dying in LMICs than in high-income countries (HICs). In Africa, TBI estimates are projected to increase to upwards of 14 million new cases in 2050; however, these estimates are based on sparse data, which underscores the need for robust injury surveillance systems. We aim to describe the clinical factors associated with morbidity and mortality in pediatric TBI at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania to guide future prevention efforts. Methods We conducted a secondary analysis of a TBI registry of all pediatric (0–18 years of age) TBI patients presenting to the KCMC emergency department (ED) between May 2013 and April 2014. The variables included demographics, acute treatment and diagnostics, Glasgow Coma Scores (GCSs, severe 3–8, moderate 9–13, and mild 14–15), morbidity at discharge as measured by the Glasgow Outcome Scale (GOS, worse functional status 1–3, better functional status 4–6), and mortality status at discharge. The analysis included descriptive statistics, bivariable analysis and multivariable logistic regression to report the predictors of mortality and morbidity. The variables used in the multivariable logistic regression were selected according to their clinical validity in predicting outcomes. Results Of the total 419 pediatric TBI patients, 286 (69.3%) were male with an average age of 10.12 years (SD = 5.7). Road traffic injury (RTI) accounted for most TBIs (269, 64.4%), followed by falls (82, 19.62%). Of the 23 patients (5.58%) who had alcohol-involved injuries, most were male (3.6:1). Severe TBI occurred in 54 (13.0%) patients. In total, 90 (24.9%) patients underwent TBI surgery. Of the 21 (5.8%) patients who died, 11 (55.0%) had severe TBI, 6 (30.0%) had moderate TBI (GCS 9–13) and 3 (15.0%) presented with mild TBI (GCS>13). The variables most strongly associated with worse functional status included having severe TBI (OR = 9.45) and waiting on the surgery floor before being moved to the intensive care unit (ICU) (OR = 14.37). Conclusions Most pediatric TBI patients were males who suffered RTIs or falls. Even among children under 18 years of age, alcohol was consumed by at least 5% of patients who suffered injuries, and more commonly among boys. Patients becoming unstable and having to be transferred from the surgery floor to the ICU could reflect poor risk identification in the ED or progression of injury severity. The next steps include designing interventions to reduce RTI, mitigate irresponsible alcohol use, and improve risk identification and stratification in the ED.
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Affiliation(s)
| | | | | | - Paige O’Leary
- Duke Global Health Institute, Durham, NC, United States of America
| | - Henry Rice
- Division of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Blandina T. Mmbaga
- Duke Global Health Institute, Durham, NC, United States of America
- Vanderbilt University, Nashville, TN, United States of America
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Catherine A. Staton
- Duke Global Health Institute, Durham, NC, United States of America
- Division of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
- * E-mail:
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12
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Keating EM, Sakita F, Mmbaga BT, Nkini G, Amiri I, Tsosie C, Fino N, Watt MH, Staton CA. A cohort of pediatric injury patients from a hospital-based trauma registry in Northern Tanzania. Afr J Emerg Med 2022; 12:208-215. [PMID: 35719184 PMCID: PMC9188958 DOI: 10.1016/j.afjem.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Pediatric injuries in low- and middle-income countries are a leading cause of morbidity and mortality worldwide. Implementing hospital-based trauma registries can reduce the knowledge gap in both hospital care and patient outcomes and lead to quality improvement initiatives. The goal of this study was to create a pediatric trauma registry to provide insight into the epidemiology, outcomes, and factors associated with poor outcomes in injured children. Methods This was a prospective observational study in which a pediatric trauma registry was implemented at a large zonal referral hospital in Northern Tanzania. Data included demographics, hospital-based care, and outcomes including morbidity and mortality. Data were input into REDCap© and analyzed using ANOVA and Chi-squared tests in SAS(Version 9.4)©. Results 365 patients were enrolled in the registry from November 2020 to October 2021. The majority were males (n=240, 65.8%). Most were children 0-5 years (41.7%, n=152), 34.5% (n=126) were 6-11 years, and 23.8% (n=87) were 12-17 years. The leading causes of pediatric injuries were falls (n=137, 37.5%) and road traffic injuries (n=125, 34.5%). The mortality rate was 8.2% (n=30). Of the in-hospital deaths, 43.3% were children with burn injuries who also had a higher odds of mortality than children with other injuries (OR 8.72, p<0.001). The factors associated with in-hospital mortality and morbidity were vital sign abnormalities, burn severity, abnormal Glasgow Coma Score, and ICU admission. Conclusion The mortality rate of injured children in our cohort was high, especially in children with burn injuries. In order to reduce morbidity and mortality, interventions should be prioritized that focus on pediatric injured patients that present with abnormal vital signs, altered mental status, and severe burns. These findings highlight the need for health system capacity building to improve outcomes of pediatric injury patients in Northern Tanzania.
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Affiliation(s)
- Elizabeth M. Keating
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Box 2240, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Box 2240, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Box 2236, Moshi, Tanzania
| | - Getrude Nkini
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
| | - Ismail Amiri
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
| | - Chermiqua Tsosie
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Melissa H. Watt
- Department of Population Health Sciences, Salt Lake City, University of Utah, UT, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Medical Center, Durham, NC, USA
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13
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Keating EM, Sakita F, Mmbaga BT, Amiri I, Nkini G, Rent S, Fino N, Young B, Staton CA, Watt MH. Three delays model applied to pediatric injury care seeking in Northern Tanzania: A mixed methods study. PLOS Glob Public Health 2022; 2:e0000657. [PMID: 36962759 PMCID: PMC10021368 DOI: 10.1371/journal.pgph.0000657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 07/21/2022] [Indexed: 06/18/2023]
Abstract
Pediatric injuries are a leading cause of morbidity and mortality in low-and middle-income countries. Timely presentation to care is key for favorable outcomes. The goal of this study was to identify and examine delays that children experience between injury and receiving definitive care at a zonal referral hospital in Northern Tanzania. Between November 2020 and October 2021, we enrolled 348 pediatric trauma patients, collecting quantitative data on referral and timing information. In-depth interviews (IDIs) to explain and explore delays to care were completed with a sub-set of 30 family members. Data were analyzed according to the Three Delays Model. 81.0% (n = 290) of pediatric injury patients sought care at an intermediary facility before reaching the referral hospital. Time from injury to presentation at the referral hospital was 10.2 hours [IQR 4.8, 26.5] if patients presented first to clinics, 8.0 hours [IQR 3.9, 40.0] if patients presented first to district/regional hospitals, and 1.4 hours [IQR 0.7, 3.5] if patients presented directly to the referral hospital. In-hospital mortality was 8.2% (n = 30); 86.7% (n = 26) of these children sought care at an intermediary facility prior to reaching the referral hospital. IDIs revealed themes related to each delay. For decision to seek care (Delay 1), delays included emergency recognition, applying first aid, and anticipated challenges. For reaching definitive care (Delay 2), delays included caregiver rationale for using intermediary facilities, the complex referral system, logistical challenges, and intermediary facility delays. For receiving definitive care (Delay 3), wait time and delays due to treatment cost existed at the referral hospital. Factors throughout the healthcare system contribute to delays in receipt of definitive care for pediatric injuries. To minimize delays and improve patient outcomes, interventions are needed to improve caregiver and healthcare worker education, streamline the current trauma healthcare system, and improve quality of care in the hospital setting.
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Affiliation(s)
- Elizabeth M. Keating
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Francis Sakita
- Emergency Medical Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke-KCMC Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Ismail Amiri
- Duke-KCMC Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Getrude Nkini
- Duke-KCMC Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Sharla Rent
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Nora Fino
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Bryan Young
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Catherine A. Staton
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Melissa H. Watt
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
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Knettel BA, Knettel CT, Sakita F, Myers JG, Edward T, Minja L, Mmbaga BT, Nickenig Vissoci JR, Staton C. Predictors of ICU admission and patient outcome for traumatic brain injury in a Tanzanian referral hospital: Implications for improving treatment guidelines. Injury 2022; 53:1954-1960. [PMID: 35365345 PMCID: PMC9167761 DOI: 10.1016/j.injury.2022.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
Traumatic brain injuries (TBI) are a critical global health challenge, with disproportionate negative impact in low- and middle-income countries (LMICs). People who suffer severe TBI in LMICs are twice as likely to die than those in high-income countries, and survivors experience substantially poorer outcomes. In the hospital, patients with severe TBI are typically seen in intensive care units (ICU) to receive advanced monitoring and lifesaving treatment. However, the quality and outcomes of ICU care in LMICs are often unclear. We analyzed secondary data from a cohort of 605 adult patients who presented to the Emergency Department (ED) of a Tanzanian hospital with a moderate or severe TBI. We examined patient characteristics and performed two binary logistic regression models to assess predictors of ICU admission and patient outcome. Patients were often young (median age = 32, SD = 15), overwhelmingly male (88.9%), and experienced long delays from time of injury to presentation in the ED (median=12 h, SD = 168). A majority of patients (87.8%) underwent surgery and 55.6% ultimately had a "good recovery" with minimal disability, while 34.0% died. Patients were more likely to be seen in the ICU if they had worse baseline symptoms and were over age 60. TBI surgery conveyed a 37% risk reduction for poor TBI outcome. However, ICU patients had a 3.91 times higher risk of poor TBI outcome as compared to those not seen in the ICU, despite controlling for baseline symptoms. The findings point to the need for targeted interventions among young men, improvements in pre-hospital transportation and care, and continued efforts to increase the quality of surgical and ICU care in this setting. It is unlikely that poorer outcome among ICU patients was indicative of poorer care in the ICU; this finding was more likely due to lack of data on several factors that inform care decisions (e.g., comorbid conditions or injuries). Nevertheless, future efforts should seek to increase the capacity of ICUs in low-resource settings to monitor and treat TBI according to international guidelines, and should improve predictive modeling to identify risk for poor outcome.
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Affiliation(s)
- Brandon A. Knettel
- Duke University School of Nursing; Duke Global Health Institute, Durham, NC, USA
| | - Christine T. Knettel
- Department of Emergency Medicine, University of North Carolina School of Medicine; Raleigh Emergency Medicine Associates, UNC REX Healthcare, Raleigh, NC, USA
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Justin G. Myers
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Linda Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre; Kilimanjaro Clinical Research Institute; Kilimanjaro Christian Medical University College; Duke Global Health Institute, Moshi, Tanzania
| | | | - Catherine Staton
- Division of Emergency Medicine, Duke School of Medicine; Duke Global Health Institute, Duke University, Durham, NC, USA
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15
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Staton CA, Zadey S, O’Leary P, Phillips A, Minja L, Swahn MH, Hirshon JM, Boshe J, Sakita F, Vissoci JRN, Mmbaga BT. PRACT: a pragmatic randomized adaptive clinical trial protocol to investigate a culturally adapted brief negotiational intervention for alcohol use in the emergency department in Tanzania. Trials 2022; 23:120. [PMID: 35123566 PMCID: PMC8818146 DOI: 10.1186/s13063-022-06060-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/27/2022] [Indexed: 12/20/2022] Open
Abstract
Background Alcohol use in resource-limited settings results in significant morbidity and mortality. These settings lack the necessary specialty-trained personnel and infrastructure. Therefore, implementing evidence-based interventions from high-income settings, like a brief negotiational intervention (BNI) for alcohol, will require rapid production of evidence of effectiveness to guide implementation priorities. Thus, this study describes a clinical trial protocol to rapidly optimize and evaluate the impact of a culturally adapted BNI to reduce alcohol-related harms and alcohol consumption among injury patients. Methods Our pragmatic, adaptive, randomized controlled trial (PRACT) is designed to determine the most effective intervention approach to reduce hazardous alcohol use among adult (≥18 years old) in acute (< 24 h) injury patients. Our culturally adapted, nurse-delivered, intervention (PPKAY) has been augmented with evidence-based, culturally appropriate standards and will be evaluated as follows. Stage 1 of the trial will determine if PPKAY, either with a standard short-message-service (SMS) booster or with a personalized SMS booster is more effective than usual care (UC). While optimizing statistical efficiency, Stage 2 drops the UC arm to compare the PPKAY with a standard SMS booster to PPKAY with a personalized SMS booster. Finally, in Stage 3, the more effective arm in Stage 2 is compared to PPKAY without an SMS booster. The study population is acute injury patients who present to Kilimanjaro Christian Medical Centre, Tanzania, who (1) test alcohol positive by breathalyzer upon arrival; (2) have an Alcohol Use Disorder Identification Test of 8 or above; and/or (3) have reported drinking alcohol prior to their injury. Outcome measures will be evaluated for all arms at 3, 6, 9, 12, and 24 months. The primary outcome for the study is the reduction of the number of binge drinking days in the 4 weeks prior to follow-up. Secondary outcomes include alcohol-related consequences, measured by the Drinker Inventory of Consequences. Discussion The findings from this study will be critically important to identify alcohol harm reduction strategies where alcohol research and interventions are scarce. Our innovative and adaptive trial design can transform behavior change research and identify the most effective nurse-driven intervention to be targeted for integration into standard care. Trial registration ClinicalTrials.govNCT04535011. Registered on September 1, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06060-y.
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16
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Elahi C, Adil SM, Sakita F, Mmbaga BT, Rocha TAH, Fuller A, Haglund MM, Vissoci JRN, Staton C. Corticosteroid Randomization after Significant Head Injury and International Mission for Prognosis and Clinical Trialsin Traumatic Brain Injury Models Compared with a Machine Learning-Based Predictive Model from Tanzania. J Neurotrauma 2021; 39:151-158. [PMID: 33980030 DOI: 10.1089/neu.2020.7483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hospitals in low- and middle-income countries (LMICs) could benefit from decision support technologies to reduce time to triage, diagnosis, and surgery for patients with traumatic brain injury (TBI). Corticosteroid Randomization after Significant Head Injury (CRASH) and International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) are robust examples of TBI prognostic models, although they have yet to be validated in Sub-Saharan Africa (SSA). Moreover, machine learning and improved data quality in LMICs provide an opportunity to develop context-specific, and potentially more accurate, prognostic models. We aim to externally validate CRASH and IMPACT on our TBI registry and compare their performances to that of the locally derived model (from the Kilimanjaro Christian Medical Center [KCMC]). We developed a machine learning-based prognostic model from a TBI registry collected at a regional referral hospital in Moshi, Tanzania. We also used the core CRASH and IMPACT online risk calculators to generate risk scores for each patient. We compared the discrimination (area under the curve [AUC]) and calibration before and after Platt scaling (Brier, Hosmer-Lemeshow Test, and calibration plots) for CRASH, IMPACT, and the KCMC model. The outcome of interest was unfavorable in-hospital outcome defined as a Glasgow Outcome Scale score of 1-3. There were 2972 patients included in the TBI registry, of whom 11% had an unfavorable outcome. The AUCs for the KCMC model, CRASH, and IMPACT were 0.919, 0.876, and 0.821, respectively. Prior to Platt scaling, CRASH was the best calibrated model (χ2 = 68.1) followed by IMPACT (χ2 = 380.9) and KCMC (χ2 = 1025.6). We provide the first SSA validation of the core CRASH and IMPACT models. The KCMC model had better discrimination than either of these. CRASH had the best calibration, although all model predictions could be successfully calibrated. The top performing models, KCMC and CRASH, were both developed using LMIC data, suggesting that locally derived models may outperform imported ones from different contexts of care. Further work is needed to externally validate the KCMC model.
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Affiliation(s)
- Cyrus Elahi
- Barrow Neurological Institute, Phoenix, Arizona, USA.,Division of Neurosurgery and Neurology, Department of Neurosurgery, and Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Syed M Adil
- Division of Neurosurgery and Neurology, Department of Neurosurgery, and Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Francis Sakita
- Emergency Department, and Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Anthony Fuller
- Division of Neurosurgery and Neurology, Department of Neurosurgery, and Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Michael M Haglund
- Division of Neurosurgery and Neurology, Department of Neurosurgery, and Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - João Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Catherine Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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17
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Joiner A, Lee A, Chowa P, Kharel R, Kumar L, Caruzzo NM, Ramirez T, Reynolds L, Sakita F, Van Vleet L, von Isenburg M, Yaffee AQ, Staton C, Vissoci JRN. Access to care solutions in healthcare for obstetric care in Africa: A systematic review. PLoS One 2021; 16:e0252583. [PMID: 34086753 PMCID: PMC8177460 DOI: 10.1371/journal.pone.0252583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context. METHODS The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach. FINDINGS A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention. INTERPRETATION Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.
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Affiliation(s)
- Anjni Joiner
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Austin Lee
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Phindile Chowa
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ramu Kharel
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Lekshmi Kumar
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Nayara Malheiros Caruzzo
- Physical Education Department, State University of Maringá, Maringá, PR, United States of America
| | - Thais Ramirez
- Duke Global Health Institute, Durham, NC, United States of America
| | - Lindy Reynolds
- University of Alabama School of Public Health, Birmingham, AL, United States of America
| | - Francis Sakita
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Lee Van Vleet
- Durham County Emergency Services, Durham, NC, United States of America
| | - Megan von Isenburg
- Medical Center Library, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anna Quay Yaffee
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Catherine Staton
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
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Dekker MCJ, Mremi A, Kilonzo KG, Nyakunga G, Sakita F, Mvungi M, Urasa SJ, Masenga G, Howlett WP. Altitude-Related Disorders on Mount Kilimanjaro, Tanzania: Two-Year Survey in a Local Referral Center. Wilderness Environ Med 2021; 32:36-40. [PMID: 33431301 DOI: 10.1016/j.wem.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION A significant number of climbers on Mount Kilimanjaro are affected by altitude-related disorders. The aim of this study was to determine the main causes of morbidity and mortality in a representative cohort of climbers based on local hospital records. METHODS We conducted a 2-y retrospective chart review of all patients presenting to the main referral hospital in the region after a climb on Mount Kilimanjaro, including all relevant records and referrals for postmortem studies. RESULTS We identified 62 climbers who presented to the hospital: 47 inpatients and 15 outpatients. Fifty-six presented with high altitude illness, which included acute mountain sickness (n=8; 14%), high altitude pulmonary edema (HAPE) (n=30; 54%), high altitude cerebral edema (HACE) (n=7; 12%), and combined HAPE/HACE (n=11; 20%). The mean altitude of symptom onset ranged from 4600±750 m for HAPE to 5000±430 m for HAPE/HACE. The vast majority of inpatients (n=41; 87%) were improved on discharge. Twenty-one deceased climbers, most having died while climbing (n=17; 81%), underwent postmortem evaluation. Causes of death were HAPE (n=16; 76%), HAPE/HACE (n=3; 14%), trauma (1), and cardiopulmonary (1). CONCLUSIONS HAPE was the main cause of death during climbing as well as for hospital admissions. The vast majority of climbers who presented to hospital made a full recovery.
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Affiliation(s)
- Marieke C J Dekker
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi Kilimanjaro, United Republic of Tanzania.
| | - Alex Mremi
- Department of Pathology, Moshi Kilimanjaro, United Republic of Tanzania
| | - Kajiru G Kilonzo
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi Kilimanjaro, United Republic of Tanzania
| | - Gissela Nyakunga
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi Kilimanjaro, United Republic of Tanzania
| | - Francis Sakita
- Department of Emergency Medicine, Moshi Kilimanjaro, United Republic of Tanzania
| | - Mark Mvungi
- Department of Emergency Medicine, Moshi Kilimanjaro, United Republic of Tanzania
| | - Sarah J Urasa
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi Kilimanjaro, United Republic of Tanzania; Department of Administration, Moshi Kilimanjaro, United Republic of Tanzania
| | - Gileard Masenga
- Department of Administration, Moshi Kilimanjaro, United Republic of Tanzania
| | - William P Howlett
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi Kilimanjaro, United Republic of Tanzania
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Staton CA, Zhao D, Ginalis EE, Hirshon JM, Sakita F, Swahn MH, Mmbaga BT, Vissoci JRN. Alcohol Availability, Cost, Age of First Drink, and Its Association with At-Risk Alcohol Use in Moshi, Tanzania. Alcohol Clin Exp Res 2020; 44:2266-2274. [PMID: 32944986 PMCID: PMC7680393 DOI: 10.1111/acer.14457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Kilimanjaro region has one of the highest levels of reported alcohol intake per capita in Tanzania. Age at first drink has been found to be associated with alcohol problems in adulthood, but there is less information on the age of first drink in the Kilimanjaro region and its associations with alcohol-related consequences later in life. Furthermore, local alcohol cost and availability may influence the prevalence of alcohol use and alcohol use disorders. METHODS Data on the age of first drink, alcohol use disorder identification tool (AUDIT), number and type of alcohol consequences (DrInC), and perceived alcohol at low cost and high availability for children and adolescents were collected from an alcohol and health behavior survey of injury patients (N = 242) in Moshi, Tanzania. Generalized linear models were used to test age at first drink, perceived alcohol cost and availability, and their association with the AUDIT and DrInC scores, and current alcohol use, respectively. RESULTS Consuming alcohol before age 18 was significantly associated with higher AUDIT and DrInC scores, with odds ratios of 1.22 (CI: 1.004, 1.47) and 1.72 (CI: 1.11, 2.63), respectively. Female gender is strongly associated with less alcohol use and alcohol consequences, represented by an odds ratio of 3.70 (CI: 1.72, 8.33) for an AUDIT score above 8 and an odds ratio of 3.84 (CI: 2.13, 6.67) with the DrInC score. Perceived high availability of alcohol for children is significantly related to higher alcohol use quantity, with the odds ratio of 1.6 (CI: 1.17, 2.20). CONCLUSIONS The first use of alcohol before the age of 18 is associated with higher alcohol use and alcohol-related adverse consequences. In Tanzania, age at first drink is an important target for interventions aiming to prevent negative alcohol-related consequences later in life.
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Affiliation(s)
| | - Duan Zhao
- Duke Kunshan Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu China
| | | | - Jon Mark Hirshon
- University of Maryland School of Medicine, College Park, Maryland USA
| | | | | | - Blandina Theophil Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC USA
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Zimmerman A, Fox S, Griffin R, Nelp T, Thomaz EBAF, Mvungi M, Mmbaga BT, Sakita F, Gerardo CJ, Vissoci JRN, Staton CA. An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country. PLoS One 2020; 15:e0240528. [PMID: 33045030 PMCID: PMC7549769 DOI: 10.1371/journal.pone.0240528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. Methods We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. Results Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. Conclusions Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Samara Fox
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Randi Griffin
- Department of Evolutionary Anthropology, Duke University, Durham, North Carolina, United States of America
| | - Taylor Nelp
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Mark Mvungi
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
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21
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Friedman K, Raymond J, Minnig MC, Sakita F, Vissoci JRN, Staton C. Association between alcohol use and violence-related injury in emergency department patients in Moshi, Tanzania: analysis of a prospective trauma registry. The Lancet Global Health 2020. [DOI: 10.1016/s2214-109x(20)30159-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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