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Fang AP, Edmond MC, Marsh RH, Normil M, Poola N, Michel Payant SJ, Luc PR, Strokes N, Calixte M, Rimpel L, Rouhani SA. Outcomes of Invasive and Noninvasive Ventilation in a Haitian Emergency Department. Ann Glob Health 2023; 89:72. [PMID: 37868710 PMCID: PMC10588490 DOI: 10.5334/aogh.4009] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 09/17/2023] [Indexed: 10/24/2023] Open
Abstract
Background Limited data exist on the outcomes of patients requiring invasive ventilation or noninvasive positive pressure ventilation (NIPPV) in low-income countries. To our knowledge, no study has investigated this topic in Haiti. Objectives We describe the clinical epidemiology, treatment, and outcomes of patients requiring NIPPV or intubation in an emergency department (ED) in rural Haiti. Methods This is an observational study utilizing a convenience sample of adult and pediatric patients requiring NIPPV or intubation in the ED at an academic hospital in central Haiti from January 2019-February 2021. Patients were prospectively identified at the time of clinical care. Data on demographics, clinical presentation, management, and ED disposition were extracted from patient charts using a standardized form and analyzed in SAS v9.4. The primary outcome was survival to discharge. Findings Of 46 patients, 27 (58.7%) were female, mean age was 31 years, and 14 (30.4%) were pediatric (age <18 years). Common diagnoses were cardiogenic pulmonary edema, pneumonia/pulmonary sepsis, and severe asthma. Twenty-three (50.0%) patients were initially treated with NIPPV, with 4 requiring intubation; a total of 27 (58.7%) patients were intubated. Among those for whom intubation success was documented, first-pass success was 57.7% and overall success was 100% (one record missing data); intubation was associated with few immediate complications. Twenty-two (47.8%) patients died in the ED. Of the 24 patients who survived, 4 were discharged, 19 (intubation: 12; NIPPV: 9) were admitted to the intensive care unit or general ward, and 1 was transferred. Survival to discharge was 34.8% (intubation: 22.2%; NIPPV: 52.2%); 1 patient left against medical advice following admission. Conclusions Patients with acute respiratory failure in this Haitian ED were successfully treated with both NIPPV and intubation. While overall survival to discharge remains relatively low, this study supports developing capacity for advanced respiratory interventions in low-resource settings.
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Affiliation(s)
- Anna P. Fang
- Boston Medical Center, Department of Emergency Medicine, One Boston Medical Center Place, Boston, MA, USA
| | - Marie Cassandre Edmond
- Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
- Zanmi Lasante, Port-au-Prince, Haiti
| | - Regan H. Marsh
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Manouchka Normil
- Zanmi Lasante, Port-au-Prince, Haiti
- Family Medicine, GHESKIO Centers, Port-au-Prince, Haiti
| | - Nivedita Poola
- Department of Emergency Medicine, SUNY Downstate/King’s County Hospital, Brooklyn, NY, USA
| | - Sherley Jean Michel Payant
- Zanmi Lasante, Port-au-Prince, Haiti
- Family Medicine, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Pierre Ricot Luc
- Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
- Zanmi Lasante, Port-au-Prince, Haiti
| | - Natalie Strokes
- Family Medicine, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
| | - Manise Calixte
- Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
- Zanmi Lasante, Port-au-Prince, Haiti
| | - Linda Rimpel
- Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
- Zanmi Lasante, Port-au-Prince, Haiti
| | - Shada A. Rouhani
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Connolly E, Kasomekera N, Sonenthal PD, Nyirenda M, Marsh RH, Wroe EB, Scott KW, Bukhman A, Minyaliwa T, Katete M, Banda G, Mukherjee J, Rouhani SA. Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study. BMC Health Serv Res 2023; 23:1062. [PMID: 37798681 PMCID: PMC10557270 DOI: 10.1186/s12913-023-10014-8] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. METHODS This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. RESULTS From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. CONCLUSION Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.
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Affiliation(s)
- Emilia Connolly
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi.
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
- Division of Hospital Medicine, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Noel Kasomekera
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
- Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Paul D Sonenthal
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Brigham & Women's Hospital, Division of Pulmonary & Critical Care, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Mulinda Nyirenda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
- University of Malawi College of Medicine, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Regan H Marsh
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
| | - Emily B Wroe
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Division of Global Health Equity, 75 Francis St, Boston, MA, 02115, USA
| | - Kirstin W Scott
- Department of Emergency Medicine, University of Washington, Seattle, USA
| | - Alice Bukhman
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
| | - Tadala Minyaliwa
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Martha Katete
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Grace Banda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
| | - Joia Mukherjee
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Shada A Rouhani
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
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Sonenthal PD, Kasomekera N, Connolly E, Wroe EB, Katete M, Minyaliwa T, Marsh RH, Banda-Katha G, Nyirenda M, Scott KW, Bukhman A, Mukherjee J, Rouhani SA. Critical Care Units in Malawi: A Cross-Sectional Study. Ann Glob Health 2023; 89:51. [PMID: 37547484 PMCID: PMC10402812 DOI: 10.5334/aogh.4053] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
Background The global burden of critical illness falls disproportionately outside high-income countries. Despite younger patient populations with similar or lower disease severity, critical illness outcomes are poor outside high-income countries. A lack of data limits attempts to understand and address the drivers of critical care outcomes outside high-income countries. Objectives We aim to characterize the organization, available resources, and service capacity of public sector critical care units in Malawi and identify barriers to improving care. Methods We conducted a secondary analysis of the Malawi Emergency and Critical Care Survey, a cross-sectional study performed from January to February 2020 at all four central hospitals and a simple random sample of nine out of 24 public sector district hospitals in Malawi, a predominantly rural, low-income country of 19.6 million in southern Africa. Data from critical care units were used to characterize resources, processes, and barriers to care. Findings There were four HDUs and four ICUs across the 13 hospitals in the Malawi Emergency and Critical Care Survey sample. The median critical care beds per 1,000,000 catchment was 1.4 (IQR: 0.9 to 6.7). Absent equipment was the most common barrier in HDUs (46% [95% CI: 32% to 60%]). Stockouts was the most common barriers in ICUs (48% [CI: 38% to 58%]). ICUs had a median 3.0 (range: 2 to 8) functional ventilators per unit and reported an ability to perform several quality mechanical ventilation interventions. Conclusions Although significant gaps exist, Malawian critical care units report the ability to perform several complex clinical processes. Our results highlight regional inequalities in access to care and support the use of process-oriented questions to assess critical care capacity. Future efforts should focus on basic critical care capacity outside of urban areas and quantify the impact of context-specific variables on critical care mortality.
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Affiliation(s)
- Paul D. Sonenthal
- Brigham and Women’s Hospital, Division of Pulmonary and Critical Care Medicine, 75 Francis St, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St, Suite 300, Boston, MA 02199, USA
| | - Noel Kasomekera
- Ministry of Health, P.O. Box 30377, Lilongwe 3, MW
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, MW
| | - Emilia Connolly
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, MW
- University of Cincinnati College of Medicine, Division of Pediatrics, 3230 Eden Ave, Cincinnati, OH 45267, USA
- Cincinnati Children’s Hospital Medical Center, Division of Hospital Medicine, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - Emily B. Wroe
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, MW
- Brigham and Women’s Hospital, Division of Global Health Equity, 75 Francis St, Boston, MA 02115, USA
| | - Martha Katete
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, MW
| | | | - Regan H. Marsh
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St, Suite 300, Boston, MA 02199, USA
- Brigham and Women’s Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA 02115, USA
| | - Grace Banda-Katha
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Centre, P.O. Box 95, Blantyre, MW
| | - Mulinda Nyirenda
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Centre, P.O. Box 95, Blantyre, MW
- Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, MW
| | - Kirstin W. Scott
- University of Washington, Department of Emergency Medicine, 325 Ninth Street, Seattle, WA, 98104, USA
| | - Alice Bukhman
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Brigham and Women’s Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA 02115, USA
| | - Joia Mukherjee
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St, Suite 300, Boston, MA 02199, USA
| | - Shada A. Rouhani
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St, Suite 300, Boston, MA 02199, USA
- Brigham and Women’s Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA 02115, USA
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Towns K, Dolo I, Pickering AE, Ludmer N, Karanja V, Marsh RH, Horace M, Dweh D, Dalieh T, Myers S, Bukhman A, Gashi J, Sonenthal P, Ulysse P, Cook R, Rouhani SA. Evaluation of emergency care education and triage implementation: an observational study at a hospital in rural Liberia. BMJ Open 2023; 13:e067343. [PMID: 37202137 DOI: 10.1136/bmjopen-2022-067343] [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] [Indexed: 05/20/2023] Open
Abstract
INTRODUCTION In Liberia, emergency care is still in its early development. In 2019, two emergency care and triage education sessions were done at J. J. Dossen Hospital in Southeastern Liberia. The observational study objectives evaluated key process outcomes before and after the educational interventions. METHODS Emergency department paper records from 1 February 2019 to 31 December 2019 were retrospectively reviewed. Simple descriptive statistics were used to describe patient demographics and χ2 analyses were used to test for significance. ORs were calculated for key predetermined process measures. RESULTS There were 8222 patient visits recorded that were included in our analysis. Patients in the post-intervention 1 group had higher odds of having a documented full set of vital signs compared with the baseline group (16% vs 3.5%, OR: 5.4 (95% CI: 4.3 to 6.7)). After triage implementation, patients who were triaged were 16 times more likely to have a full set of vitals compared with those who were not triaged. Similarly, compared with the baseline group, patients in the post-intervention 1 group had higher odds of having a glucose documented if they presented with altered mental status or a neurologic complaint (37% vs 30%, OR: 1.7 (95% CI: 1.3 to 2.2)), documented antibiotic administration if they had a presumed bacterial infection (87% vs 35%, OR: 12.8 (95% CI: 8.8 to 17.1)), documented malaria test if presenting with fever (76% vs 61%, OR: 2.05 (95% CI: 1.37 to 3.08)) or documented repeat set of vitals if presenting with shock (25% vs 6.6%, OR: 8.85 (95% CI: 1.67 to 14.06)). There was no significant difference in the above process outcomes between the education interventions. CONCLUSION This study showed improvement in most process measures between the baseline and post-intervention 1 groups, benefits that persisted post-intervention 2, thus supporting the importance of short-course education interventions to durably improve facility-based care.
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Affiliation(s)
- Kathleen Towns
- Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Isaac Dolo
- Partners In Health Liberia, Harper, Liberia
| | - Ashley E Pickering
- Emergency Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Nicholas Ludmer
- Partners In Health, Boston, Massachusetts, USA
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | | | - Regan H Marsh
- Partners In Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Denny Dweh
- Partners In Health Liberia, Harper, Liberia
| | | | | | - Alice Bukhman
- Partners In Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Gashi
- Boston University, Boston, Massachusetts, USA
| | - Paul Sonenthal
- Partners In Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Patrick Ulysse
- Partners In Health, Boston, Massachusetts, USA
- Partners In Health Liberia, Harper, Liberia
| | - Rebecca Cook
- Partners In Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Shada A Rouhani
- Partners In Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Sonenthal PD, Kachimanga C, Komba D, Bangura M, Ludmer N, Lado M, Patino M, Gerrard RB, Vandy MJ, Marsh RH, Mukherjee J, Rouhani SA. Applying the WHO-ICRC BEC course to train emergency and inpatient healthcare workers in Sierra Leone early in the COVID-19 outbreak. BMC Health Serv Res 2022; 22:197. [PMID: 35164753 PMCID: PMC8842917 DOI: 10.1186/s12913-022-07556-8] [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: 10/20/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Treating critical illness in resource-limited settings during disease outbreaks is feasible and can save lives. Lack of trained healthcare workers is a major barrier to COVID-19 response. There is an urgent need to train healthcare workers to manage COVID-19. The World Health Organization and International Committee of the Red Cross’s Basic Emergency Care course could provide a framework to cross-train personnel for COVID-19 care while strengthening essential health services. Methods We conducted a prospective cohort study evaluating the Basic Emergency Care course for healthcare workers from emergency and inpatient units at two hospitals in Sierra Leone, a low-income country in West Africa. Baseline, post-course, and six month assessments of knowledge and confidence were completed. Questions on COVID-19 were added at six months. We compared change from baseline in knowledge scores and proportions of participants “very comfortable” with course skills using paired Student’s t-tests and McNemar’s exact tests, respectively. Results We enrolled 32 participants of whom 31 completed pre- and post-course assessments. Six month knowledge and confidence assessments were completed by 15 and 20 participants, respectively. Mean knowledge score post-course was 85% (95% CI: 82% to 88%), which was increased from baseline (53%, 48% to 57%, p-value < 0.001). There was sustained improvement from baseline at six months (73%, 67% to 80%, p-value 0.001). The percentage of participants who were “very comfortable” performing skills increased from baseline for 27 of 34 skills post-training and 13 skills at six months. Half of respondents strongly agreed the course improved ability to manage COVID-19. Conclusions This study demonstrates the feasibility of the Basic Emergency Care course to train emergency and inpatient healthcare workers with lasting impact. The timing of the study, at the beginning of the COVID-19 pandemic, provided an opportunity to illustrate the strategic overlap between building human resource capacity for long-term health systems strengthening and COVID-19. Future efforts should focus on integration with national training curricula and training of the trainers for broader dissemination and implementation at scale. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07556-8.
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Affiliation(s)
- Paul D Sonenthal
- Brigham and Womens Hospital, Division of Pulmonary and Critical Care Medicine, 75 Francis Street Massachusetts, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA. .,Partners In Health, Boston, MA, USA.
| | | | - Doris Komba
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Nicholas Ludmer
- University of Chicago, Section of Emergency Medicine, Chicago, IL, USA
| | - Marta Lado
- Partners In Health-Sierra Leone, Kono, Sierra Leone
| | - Marta Patino
- Partners In Health-Sierra Leone, Kono, Sierra Leone
| | | | | | - Regan H Marsh
- Harvard Medical School, Boston, MA, USA.,Partners In Health, Boston, MA, USA.,Brigham and Womens Hospital, Department of Emergency Medicine, Boston, MA, USA
| | - Joia Mukherjee
- Harvard Medical School, Boston, MA, USA.,Partners In Health, Boston, MA, USA
| | - Shada A Rouhani
- Harvard Medical School, Boston, MA, USA.,Partners In Health, Boston, MA, USA.,Brigham and Womens Hospital, Department of Emergency Medicine, Boston, MA, USA
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Sonenthal PD, Nyirenda M, Kasomekera N, Marsh RH, Wroe EB, Scott KW, Bukhman A, Connolly E, Minyaliwa T, Katete M, Banda-Katha G, Mukherjee JS, Rouhani SA. The Malawi emergency and critical care survey: A cross-sectional national facility assessment. EClinicalMedicine 2022; 44:101245. [PMID: 35072017 PMCID: PMC8762065 DOI: 10.1016/j.eclinm.2021.101245] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/16/2021] [Accepted: 12/08/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage. METHODS We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility. FINDINGS A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021). INTERPRETATION This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts. FUNDING Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.
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Affiliation(s)
- Paul D. Sonenthal
- Brigham and Women's Hospital, Division of Pulmonary and Critical Care Medicine, 75 Francis St, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
- Corresponding author at: Brigham and Women's Hospital, Division of Pulmonary and Critical Care Medicine, 75 Francis St, Boston, MA 02115, USA.
| | - Mulinda Nyirenda
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Centre, P.O. Box 95, Blantyre, Malawi
- University of Malawi College of Medicine, Private Bag 360 Blantyre 3, Chichiri, Malawi
| | - Noel Kasomekera
- Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Regan H. Marsh
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Emily B. Wroe
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
- Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis St, Boston, MA 02115, USA
| | - Kirstin W. Scott
- University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Alice Bukhman
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Emilia Connolly
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | | | - Martha Katete
- Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Grace Banda-Katha
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Centre, P.O. Box 95, Blantyre, Malawi
| | - Joia S. Mukherjee
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
| | - Shada A. Rouhani
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Partners In Health, 800 Boylston St Suite 300, Boston, MA 02199, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
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7
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Cohen CL, Walker KH, Hsiang M, Sonenthal PD, Riviello ED, Rouhani SA, Lipnick MS, Merriam LT, Kim EY. Combating information chaos: a case for collaborative clinical guidelines in a pandemic. Cell Rep Med 2021; 2:100375. [PMID: 34337553 PMCID: PMC8313756 DOI: 10.1016/j.xcrm.2021.100375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The speed and scale of new information during the COVID-19 pandemic required a new approach toward developing best practices and evidence-based clinical guidance. To address this need, we produced COVIDProtocols.org, a collaborative, evidence-based, digital platform for the development and dissemination of COVID-19 clinical guidelines that has been used by over 500,000 people from 196 countries. We use a Collaborative Writing Application (CWA) to facilitate an expedited expert review process and a web platform that deploys content directly from the CWA to minimize any delays. Over 200 contributors have volunteered to create open creative-commons content that spans over 30 specialties and medical disciplines. Multiple local and national governments, hospitals, and clinics have used the site as a key resource for their own clinical guideline development. COVIDprotocols.org represents a model for efficiently launching open-access clinical guidelines during crisis situations to share expertise and combat misinformation.
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Affiliation(s)
- C Lee Cohen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Katherine H Walker
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Mina Hsiang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Paul D Sonenthal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA.,Partners In Health, Boston, MA 02115, USA
| | - Elisabeth D Riviello
- Harvard Medical School, Boston, MA 02115, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
| | - Shada A Rouhani
- Harvard Medical School, Boston, MA 02115, USA.,Partners In Health, Boston, MA 02115, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Michael S Lipnick
- Center for Health Equity in Surgery and Anesthesia, University of California, San Francisco, CA 94110, USA
| | - Louis T Merriam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Edy Y Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
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Rybarczyk MM, Ludmer N, Broccoli MC, Kivlehan SM, Niescierenko M, Bisanzo M, Checkett KA, Rouhani SA, Tenner AG, Geduld H, Reynolds T. Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review. Ann Glob Health 2020; 86:60. [PMID: 32587810 PMCID: PMC7304456 DOI: 10.5334/aogh.2681] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings. Objective To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships. Methods An electronic search was conducted using four databases for manuscripts on EM training programs - defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care - developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted. Findings Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding. Conclusions Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.
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Affiliation(s)
- Megan M. Rybarczyk
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, US
| | - Nicholas Ludmer
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, US
| | | | - Sean M. Kivlehan
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, US
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, US
| | - Mark Bisanzo
- Division of Emergency Medicine, Department of Surgery, University of Vermont, US
| | - Keegan A. Checkett
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, US
| | - Shada A. Rouhani
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, US
| | - Andrea G. Tenner
- Department of Emergency Medicine, University of California, San Francisco, US
| | - Heike Geduld
- University of Cape Town/Stellenbosch University, College of Emergency Medicine of South Africa, ZA
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Sonenthal PD, Masiye J, Kasomekera N, Marsh RH, Wroe EB, Scott KW, Li R, Murray MB, Bukhman A, Connolly E, Minyaliwa T, Katete M, Banda G, Nyirenda M, Rouhani SA. COVID-19 preparedness in Malawi: a national facility-based critical care assessment. Lancet Glob Health 2020; 8:e890-e892. [PMID: 32464111 PMCID: PMC7247792 DOI: 10.1016/s2214-109x(20)30250-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Paul D Sonenthal
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA.
| | | | - Noel Kasomekera
- Ministry of Health, Lilongwe, Malawi; Abwenzi Pa Za Umoyo/Partners In Health, Neno, Malawi
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA
| | - Emily B Wroe
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA; Abwenzi Pa Za Umoyo/Partners In Health, Neno, Malawi
| | | | - Ruoran Li
- Harvard University T.H. Chan School of Public Health, Center for Communicable Disease Dynamics, Boston, MA, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Alice Bukhman
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA
| | - Emilia Connolly
- Abwenzi Pa Za Umoyo/Partners In Health, Neno, Malawi; Division of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Martha Katete
- Abwenzi Pa Za Umoyo/Partners In Health, Neno, Malawi
| | - Grace Banda
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Center, Blantyre, Malawi
| | - Mulinda Nyirenda
- Queen Elizabeth Central Hospital, Adult Emergency and Trauma Center, Blantyre, Malawi; University of Malawi College of Medicine, Blantyre, Malawi
| | - Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA
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10
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Affiliation(s)
- Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Partners In Health, Boston, Massachusetts, USA
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Partners In Health, Boston, Massachusetts, USA
| | - Linda Rimpel
- Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
| | | | - Marc Julmisse
- Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Partners In Health, Boston, Massachusetts, USA
| | - Keegan A Checkett
- Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Partners In Health, Boston, Massachusetts, USA.,Department of Emergency Medicine, University of Chicago, Chicago, Ilinois, USA
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11
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Rouhani SA, Eliacin HC, Edmond MC, Checkett KA, Rimpel L, Marsh RH. Epidemiology of traumatic injuries presenting to an ED in Central Haiti: a retrospective cohort study. Emerg Med J 2019; 36:389-394. [PMID: 30877264 DOI: 10.1136/emermed-2018-207559] [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] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 01/12/2019] [Accepted: 02/10/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND In Haiti, like many low-income countries, traumatic injuries are leading causes of morbidity and mortality. Yet, little is known about the epidemiology of traumatic injuries in Haitian EDs. Improved understanding of injury patterns is necessary to strengthen emergency services and improve emergency provider education. METHODS This was a retrospective cohort study of trauma patients at an academic hospital in central Haiti over 6 months. Visits were identified from the electronic medical record, and paper charts were manually reviewed. Data, including demographics, timing of presentation, injuries sustained, treatments received and ED disposition were extracted using a standardised form and later analysed in SAS V.9.3. RESULTS Of 1401 patients, 66% were male, and the average age was 26.8 years. Most visits were due to road traffic injuries (RTIs; 48%) followed by falls (22%). Trauma mechanism varied significantly by age (p<0.001): falls predominated in children under 5 years (56%) versus RTIs for adults (59%). Only 14% of patients injured on motorcycles used helmets and 30% of those injured in motor vehicles used seatbelts. Only 18% of patients arrived within 1 hour of the trauma. Skin or soft tissue injuries were the most common (58%), followed by extremity or pelvic fractures or dislocations (23%). Most patients (81%) were discharged, 14% were admitted or stayed over 24 hours in the ED and 0.8% died in the ED. Of the admitted patients, 61% had surgery, 79% of which were orthopaedic. Patients using helmets or seatbelts were more likely to be discharged than those not using protective equipment (p=0.008). CONCLUSIONS In this trauma population, RTIs and falls were the most common trauma mechanisms, safety feature use was rare, and most injuries were musculoskeletal. Presentation was delayed and mortality was low, but many patients required surgery. These findings have significant clinical, public health, operational and training implications.
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Affiliation(s)
- Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Partners In Health, Boston, Massachusetts, USA
| | - Henry Claude Eliacin
- Department of Surgery, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Zanmi Lasante, Port-au-Prince, Haiti
| | - Marie Cassandre Edmond
- Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Zanmi Lasante, Port-au-Prince, Haiti
| | - Keegan A Checkett
- Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Partners In Health, Boston, Massachusetts, USA.,Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Linda Rimpel
- Emergency Department, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Zanmi Lasante, Port-au-Prince, Haiti
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Partners In Health, Boston, Massachusetts, USA
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12
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Affiliation(s)
- Andrés M Patiño
- From the Department of Emergency Medicine, Brigham and Women's Hospital (A.M.P., R.H.M., E.J.N., C.W.B., S.A.R., S.K.), the Department of Emergency Medicine, Massachusetts General Hospital (A.M.P.), and Partners in Health (R.H.M., S.A.R.) - all in Boston; and the Harvard Humanitarian Initiative, Cambridge (E.J.N., S.K.) - all in Massachusetts
| | - Regan H Marsh
- From the Department of Emergency Medicine, Brigham and Women's Hospital (A.M.P., R.H.M., E.J.N., C.W.B., S.A.R., S.K.), the Department of Emergency Medicine, Massachusetts General Hospital (A.M.P.), and Partners in Health (R.H.M., S.A.R.) - all in Boston; and the Harvard Humanitarian Initiative, Cambridge (E.J.N., S.K.) - all in Massachusetts
| | - Eric J Nilles
- From the Department of Emergency Medicine, Brigham and Women's Hospital (A.M.P., R.H.M., E.J.N., C.W.B., S.A.R., S.K.), the Department of Emergency Medicine, Massachusetts General Hospital (A.M.P.), and Partners in Health (R.H.M., S.A.R.) - all in Boston; and the Harvard Humanitarian Initiative, Cambridge (E.J.N., S.K.) - all in Massachusetts
| | - Christopher W Baugh
- From the Department of Emergency Medicine, Brigham and Women's Hospital (A.M.P., R.H.M., E.J.N., C.W.B., S.A.R., S.K.), the Department of Emergency Medicine, Massachusetts General Hospital (A.M.P.), and Partners in Health (R.H.M., S.A.R.) - all in Boston; and the Harvard Humanitarian Initiative, Cambridge (E.J.N., S.K.) - all in Massachusetts
| | - Shada A Rouhani
- From the Department of Emergency Medicine, Brigham and Women's Hospital (A.M.P., R.H.M., E.J.N., C.W.B., S.A.R., S.K.), the Department of Emergency Medicine, Massachusetts General Hospital (A.M.P.), and Partners in Health (R.H.M., S.A.R.) - all in Boston; and the Harvard Humanitarian Initiative, Cambridge (E.J.N., S.K.) - all in Massachusetts
| | - Stephanie Kayden
- From the Department of Emergency Medicine, Brigham and Women's Hospital (A.M.P., R.H.M., E.J.N., C.W.B., S.A.R., S.K.), the Department of Emergency Medicine, Massachusetts General Hospital (A.M.P.), and Partners in Health (R.H.M., S.A.R.) - all in Boston; and the Harvard Humanitarian Initiative, Cambridge (E.J.N., S.K.) - all in Massachusetts
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13
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Rouhani SA, Israel K, Leandre F, Pierre S, Bollman B, Marsh RH. Addressing the immediate need for emergency providers in resource-limited settings: the model of a six-month emergency medicine curriculum in Haiti. Int J Emerg Med 2018; 11:22. [PMID: 29626265 PMCID: PMC5889369 DOI: 10.1186/s12245-018-0182-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 01/11/2018] [Accepted: 03/23/2018] [Indexed: 11/04/2022] Open
Abstract
Background In many resource-limited settings, emergency medicine (EM) is underdeveloped and formal EM training limited. Residencies and fellowships are an ideal long-term solution but cannot meet immediate needs for emergency providers, while short-term programs are often too limited in content. We describe a third method successfully implemented in Haiti: a medium-duration certificate program to meet the immediate need for emergency specialists. Methods In conjunction with the Haitian Ministry of Health and National Medical School, we developed and implemented a novel, 6-month EM certificate program to build human resources for health and emergency care capacity. The program consisted of didactic and supervised clinical components, covering core content in EM. Didactics included lectures, simulations, hands-on skill-sessions, and journal clubs. Supervised clinical time reinforced concepts and taught an EM approach to patient care. Results Fourteen physicians from around Haiti successfully completed the program; all improved from their pre-test to post-test. At the end of the program and 9-month post-program evaluations, participants rated the program highly, and most felt they used their new knowledge daily. Participants found clinical supervision and simulation particularly useful. Key components to our program’s success included collaboration with the Ministry of Health and National Medical School, supervised clinical time, and the continual presence of a course director. The program could be improved by a more flexible curriculum and by grouping participants by baseline knowledge levels. Conclusion Medium-duration certificate programs offer a viable option for addressing immediate human resource gaps in emergency care, and our program offers a model for implementation in resource-limited settings. Similar options should be considered for other emerging specialties in resource-limited settings.
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Affiliation(s)
- Shada A Rouhani
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA. .,Hôpital Universitaire de Mirebalais, Route Départmentale 11, Mirebalais, Haiti. .,Partners In Health, 800 Boylston Street, Suite 300, Boston, MA, 02199, USA.
| | - Kerling Israel
- Hôpital Universitaire de Mirebalais, Route Départmentale 11, Mirebalais, Haiti.,Zanmi Lasante, 18a Route De Santo, Croix Des Bouquets, Port Au Prince, Haiti
| | - Fernet Leandre
- Zanmi Lasante, 18a Route De Santo, Croix Des Bouquets, Port Au Prince, Haiti
| | - Sosthène Pierre
- Faculte de Medecine et de Pharmacie de l'Universite d'Etat d'Haiti, 89 Rue Oswald Durand, Port-au-Prince, Haiti
| | - Brennan Bollman
- Louisiana State University Health Sciences Center, 433 Bolivar St, New Orleans, LA, 70112, USA
| | - Regan H Marsh
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Partners In Health, 800 Boylston Street, Suite 300, Boston, MA, 02199, USA
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14
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O'Laughlin KN, Rouhani SA, Kasozi J, Greenwald KE, Perkons NR, Faustin ZM, Bassett IV, Ware NC. A qualitative approach to understand antiretroviral therapy (ART) adherence for refugees living in Nakivale Refugee Settlement in Uganda. Confl Health 2018; 12:7. [PMID: 29545828 PMCID: PMC5846232 DOI: 10.1186/s13031-018-0145-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 01/12/2018] [Indexed: 01/24/2023] Open
Abstract
Background Refugees living with HIV in sub-Saharan Africa suffer unique hardships that may increase their vulnerability to interruptions in antiretroviral therapy (ART). Methods To investigate refugees’ experiences adhering to ART, we conducted inperson interviews with refugees on ART (n = 73) and HIV clinic staff (n = 4) in Nakivale Refugee Settlement in southwest Uganda from March to July 2011. Three analysts used a conventional content analysis approach to evaluate these data. Results Refugees described profound motivation to adhere to ART and employed adherence strategies to facilitate success despite the austere setting. However, refugees spoke of specific hardships living in Nakivale that served as barriers to ART adherence, including difficulty accessing clinic when ill, food insecurity, drug stockouts, and violence and unrest in the settlement. For some refugees, need for ART inextricably linked them to the HIV clinic and prevented them from transitioning permanently away from the settlement. Conclusions By learning about refugees’ experiences we can design informed interventions to enhance ART adherence, thus minimizing morbidity and mortality, preventing transmission of HIV, and supporting refugees’ abilities to move freely toward repatriation, resettlement or integration in their host country.
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Affiliation(s)
- Kelli N O'Laughlin
- 1Division of International Emergency Medicine and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,2Medical Practice Evaluation Center, Department of Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Shada A Rouhani
- 1Division of International Emergency Medicine and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Julius Kasozi
- United Nations High Commissioner for Refugees, P.O. Box 3813, Kampala, Uganda
| | - Kelsy E Greenwald
- 3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA.,11Harvard Affiliated Emergency Medicine Residency, 75 Francis Street, Boston, MA 02115 USA
| | | | | | - Ingrid V Bassett
- 2Medical Practice Evaluation Center, Department of Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114 USA.,3Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA.,7Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA.,8Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 0213 USA
| | - Norma C Ware
- 9Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 USA.,10Department of Global Health & Social Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
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15
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Rouhani SA, Aaronson E, Jacques A, Brice S, Marsh RH. Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti. Int Emerg Nurs 2017; 33:26-31. [PMID: 28228342 DOI: 10.1016/j.ienj.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/18/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti. METHODS A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis. RESULTS Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively. CONCLUSION This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.
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Affiliation(s)
- Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States; University Teaching Hospital at Mirebalais, Mirebalais, Haiti; Partners In Health, Boston, MA, United States.
| | - Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States
| | - Angella Jacques
- University Teaching Hospital at Mirebalais, Mirebalais, Haiti
| | - Sandy Brice
- University Teaching Hospital at Mirebalais, Mirebalais, Haiti
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States; University Teaching Hospital at Mirebalais, Mirebalais, Haiti; Partners In Health, Boston, MA, United States
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16
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Johnston LG, McLaughlin KR, Rouhani SA, Bartels SA. Measuring a hidden population: A novel technique to estimate the population size of women with sexual violence-related pregnancies in South Kivu Province, Democratic Republic of Congo. J Epidemiol Glob Health 2016; 7:45-53. [PMID: 27663900 PMCID: PMC7320514 DOI: 10.1016/j.jegh.2016.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 05/02/2016] [Revised: 07/13/2016] [Accepted: 08/25/2016] [Indexed: 11/03/2022] Open
Abstract
Successive sampling (SS)-population size estimation (PSE) is a technique used to estimate the sizes of hidden populations using data collected in respondent-driven sampling (RDS) surveys. We assess past estimations and use new data from an RDS survey to calculate a new PSE. In 2012, 852 adult women in South Kivu Province, Democratic Republic of Congo, who self-identified as survivors of sexual violence, resulting in a pregnancy, since the start of the war (in 1996) were sampled using RDS. We used imputed visibility, enrollment order, and prior estimates for PSE using SS-PSE in RDS Analyst. Prior estimates varied between Congolese local experts and researchers. We calculated the PSE of women with a sexual violence-related pregnancy in South Kivu using researchers' priors to be approximately 17,400. SS-PSE is an effective method for estimating the population sizes of hidden populations, useful for providing evidence for services and resource allocation. SS-PSE is beneficial because population sizes can be calculated after conducting the survey and do not rely on separate studies or additional data (as in network scale-up, multiplier, and capture-recapture methods).
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Affiliation(s)
- Lisa G Johnston
- Tulane University School of International Public Health and Tropical Medicine, New Orleans, LA, USA
| | | | - Shada A Rouhani
- Harvard Humanitarian Initiative, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan A Bartels
- Harvard Humanitarian Initiative, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
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17
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Rouhani SA, Scott J, Burkhardt G, Onyango MA, Haider S, Greiner A, Albutt K, VanRooyen M, Bartels SA. A quantitative assessment of termination of sexual violence-related pregnancies in eastern Democratic Republic of Congo. Confl Health 2016; 10:9. [PMID: 27053946 PMCID: PMC4822240 DOI: 10.1186/s13031-016-0073-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/19/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Sexual violence is prevalent in eastern Democratic Republic of Congo (DRC), and has resulted in sexual violence-related pregnancies (SVRPs). Despite restrictive laws, women may seek to terminate SVRPs; however, there are limited data on termination of SVRPs. METHODS A mixed methods study was conducted in 2012 in Bukavu, DRC. Adult women who self-reported an SVRP and termination of that SVRP were recruited using respondent-driven sampling (RDS). Trained female interviewers verbally administered a quantitative survey to all participants and a semi-structured qualitative survey to a subset. Quantitative data on characteristics and complications of pregnancy termination, including mental health outcomes, were analyzed using SAS. RESULTS In total, 86 women completed quantitative surveys. Most SVRPs (93 %) involved two or more assailants; 73 % occurred while in captivity. Most women (82 %) terminated the SVRPs at 3 months gestation or earlier; 79 % reported one attempt at pregnancy termination and 21 % more than one attempt. The most common methods of termination were an oral medicine (55 %) or herb (35 %); cimpokolo (31 %) and quinine (18 %) were most frequently reported. These methods were accessed through friends (37 %), healthcare providers (18 %), family (16 %), or self-obtained (12 %). Following the termination, 79 % of women reported subsequent physical symptoms, including abdominal pain (74 %), bleeding (47 %), vaginal discharge (35 %) and fever (18 %); 44 % sought medical care for their symptoms. Varied emotional responses to the termination were reported and included relief (34 %), anxiety (21 %), anger (19 %), guilt (19 %), and regret (10 %). At the time of the study, many women met symptom criteria for post-traumatic stress disorder (57 %), depression (50 %), and generalized anxiety disorder (33 %). CONCLUSION Most women terminated SVRPs using medications or herbs not recognized as evidence-based methods of pregnancy termination and sought these methods outside of the formal healthcare sector. These data suggest that access to safe abortion methods is needed for women with SVRPs in DRC. Physical symptoms and emotional reactions related to the termination varied. While it is not possible to differentiate the impacts of sexual violence, SVRP, and pregnancy termination on mental health outcomes, the findings highlight the complex needs of women with SVRPs and opportunities for integrative health services.
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Affiliation(s)
- Shada A. Rouhani
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
- />Harvard Medical School, Boston, MA USA
| | - Jennifer Scott
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Gillian Burkhardt
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA
| | - Monica A. Onyango
- />Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Sadia Haider
- />Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA
| | - Ashley Greiner
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Katherine Albutt
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Michael VanRooyen
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
- />Harvard Medical School, Boston, MA USA
- />Harvard School of Public Health, Boston, MA USA
| | - Susan A. Bartels
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Department of Emergency Medicine, Queen’s University, Kingston, Canada
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Affiliation(s)
- Regan H Marsh
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Partners In Health, Boston, MA, USA.
| | - Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Partners In Health, Boston, MA, USA
| | | | - Paul E Farmer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Partners In Health, Boston, MA, USA
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Rouhani SA, O'Laughlin KN, Faustin ZM, Tsai AC, Kasozi J, Ware NC. The role of social support on HIV testing and treatment adherence: A qualitative study of HIV-infected refugees in southwestern Uganda. Glob Public Health 2016; 12:1051-1064. [PMID: 26783835 DOI: 10.1080/17441692.2015.1132472] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 10/22/2022]
Abstract
Little is known about the factors that encourage or discourage refugees to test for HIV, or to access and adhere to HIV care. In non-refugee populations, social support has been shown to influence HIV testing and utilisation of services. The present study enrolled HIV-infected refugees on anti-retroviral therapy (ART) in Uganda, who participated in qualitative interviews on HIV testing, treatment, and adherence. Interviews were analysed for themes about four types of social support: emotional, informational, instrumental, and appraisal support. A total of 61 interviews were analysed. Four roles for these types of social support were identified: (1) informational support encouraged refugees to test for HIV; (2) emotional support helped refugees cope with a diagnosis of HIV; (3) instrumental support facilitated adherence to ART and (4) after diagnosis, HIV-infected refugees provided informational and emotional support to encourage other refugees to test for HIV. These results suggest that social support influences HIV testing and treatment among refugees. Future interventions should capitalise on social support within a refugee settlement to facilitate testing and treatment.
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Affiliation(s)
- Shada A Rouhani
- a Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA.,b Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
| | - Kelli N O'Laughlin
- a Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA.,b Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA.,c Medical Practice Evaluation Center , Massachusetts General Hospital , Boston , MA , USA
| | | | - Alexander C Tsai
- e Massachusetts General Hospital (MGH) , MGH Global Health , Boston , MA , USA.,f Harvard Center for Population and Development Studies , Cambridge , MA , USA
| | - Julius Kasozi
- g United Nations High Commissioner for Refugees , Kampala , Uganda
| | - Norma C Ware
- h Department of Global Health and Social Medicine , Harvard Medical School , Boston , MA , USA
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Rouhani SA, Scott J, Greiner A, Albutt K, Hacker MR, Kuwert P, VanRooyen M, Bartels S. Stigma and Parenting Children Conceived From Sexual Violence. Pediatrics 2015; 136:e1195-203. [PMID: 26438704 PMCID: PMC4890150 DOI: 10.1542/peds.2014-3373] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Since armed conflict began in 1996, widespread sexual violence in eastern Democratic Republic of Congo has resulted in many sexual violence-related pregnancies (SVRPs). However, there are limited data on the relationships between mothers and their children from sexual violence. This study aimed to evaluate the nature and determinants of these maternal-child relationships. METHODS Using respondent-driven sampling, 757 women raising children from SVRPs in South Kivu Province, Democratic Republic of Congo were interviewed. A parenting index was created from questions assessing the maternal-child relationship. The influences of social stigma, family and community acceptance, and maternal mental health on the parenting index were assessed in univariate and multivariable analyses. RESULTS The majority of mothers reported positive attitudes toward their children from SVRPs. Prevalence of perceived family or community stigma toward the women or their children ranged from 31.8% to 42.9%, and prevalence of perceived family or community acceptance ranged from 45.2% to 73.5%. In multivariable analyses, stigma toward the child, as well as maternal anxiety and depression, were associated with lower parenting indexes, whereas acceptance of the mother or child and presence of a spouse were associated with higher parenting indexes (all P ≤ .01). CONCLUSIONS In this study with a large sample size, stigma and mental health disorders negatively influenced parenting attitudes, whereas family and community acceptance were associated with adaptive parenting attitudes. Interventions to reduce stigmatization, augment acceptance, and improve maternal mental health may improve the long-term well-being of mothers and children from SVRPs.
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Affiliation(s)
- Shada A Rouhani
- Harvard Humanitarian Initiative, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts;
| | - Jennifer Scott
- Harvard Humanitarian Initiative, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of Women's Health and Departments of Obstetrics and Gynecology and
| | - Ashley Greiner
- Harvard Humanitarian Initiative, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Katherine Albutt
- Harvard Humanitarian Initiative, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michele R Hacker
- Harvard Medical School, Boston, Massachusetts; Departments of Obstetrics and Gynecology and Harvard School of Public Health, Boston, Massachusetts
| | - Philipp Kuwert
- Department of Psychiatry, HELIOS Hansehospital, University Medicine Greifswald, Stralsund, Germany; and
| | - Michael VanRooyen
- Harvard Humanitarian Initiative, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard School of Public Health, Boston, Massachusetts
| | - Susan Bartels
- Harvard Humanitarian Initiative, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts; Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Emergency Medicine, Queen's University, Ontario, Canada
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Aaronson EL, Marsh RH, Guha M, Schuur JD, Rouhani SA. Emergency department quality and safety indicators in resource-limited settings: an environmental survey. Int J Emerg Med 2015; 8:39. [PMID: 26520848 PMCID: PMC4628609 DOI: 10.1186/s12245-015-0088-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 04/17/2015] [Accepted: 10/16/2015] [Indexed: 11/16/2022] Open
Abstract
Background As global emergency care grows, practical and effective performance measures are needed to ensure high quality care. Our objective was to systematically catalog and classify metrics that have been used to measure the quality of emergency care in resource-limited settings. Methods We searched MEDLINE, Embase, CINAHL, and the gray literature using standardized terms. The references of included articles were also reviewed. Two researchers screened titles and abstracts for relevance; full text was then reviewed by three researchers. A structured data extraction tool was used to identify and classify metrics into one of six Institute of Medicine (IOM) quality domains (safe, timely, efficient, effective, equitable, patient-centered) and one of three of Donabedian’s structure/process/outcome categories. A fourth expert reviewer blinded to the initial classifications re-classified all indicators, with a weighted kappa of 0.89. Results A total of 1705 articles were screened, 95 received full text review, and 34 met inclusion criteria. One hundred eighty unique metrics were identified, predominantly process (57 %) and structure measures (27 %); 16 % of metrics were related to outcomes. Most metrics evaluated the effectiveness (52 %) and timeliness (28 %) of care, with few addressing the patient centeredness (11 %), safety (4 %), resource-efficiency (3 %), or equitability (1 %) of care. Conclusions The published quality metrics in emergency care in resource-limited settings primarily focus on the effectiveness and timeliness of care. As global emergency care is built and strengthened, outcome-based measures and those focused on the safety, efficiency, and equitability of care need to be developed and studied to improve quality of care and resource utilization. Electronic supplementary material The online version of this article (doi:10.1186/s12245-015-0088-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
| | - Moytrayee Guha
- Center for Clinical Excellence, Brigham and Women's Hospital, Boston, MA, USA.
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
| | - Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
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Greiner AL, Albutt K, Rouhani SA, Scott J, Dombrowski K, VanRooyen MJ, Bartels SA. Respondent-driven sampling to assess outcomes of sexual violence: a methodological assessment. Am J Epidemiol 2014; 180:536-44. [PMID: 25073471 DOI: 10.1093/aje/kwu149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Sexual violence is pervasive in eastern Democratic Republic of Congo (DRC). Survivors of sexual violence encounter numerous challenges, and women with a sexual violence-related pregnancy (SVRP) face even more complex sequelae. Because of the stigma associated with SVRP, there is no conventional sampling frame and, therefore, a paucity of research on SVRP outcomes. Respondent-driven sampling (RDS), used to study this "hidden" population, uses a peer recruitment sampling system that maintains strict participant privacy and controls and tracks recruitment. If RDS assumptions are met and the sample attains equilibrium, sample weights to correct for biases associated with traditional chain referral sampling can be calculated. Questionnaires were administered to female participants who were raising a child from a SVRP and/or who terminated a SVRP. A total of 852 participants were recruited from October 9, 2012, to November 7, 2012. There was rapid recruitment, and there were long referral chains. The majority of the variables reached equilibrium; thus, trends established in the sample population reflected the target population's trends. To our knowledge, this is the first study to use RDS to study outcomes of sexual violence. RDS was successfully applied to this population and context and should be considered as a sampling methodology in future sexual violence research.
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O'Laughlin KN, Rouhani SA, Faustin ZM, Ware NC. Testing experiences of HIV positive refugees in Nakivale Refugee Settlement in Uganda: informing interventions to encourage priority shifting. Confl Health 2013; 7:2. [PMID: 23409807 PMCID: PMC3645965 DOI: 10.1186/1752-1505-7-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [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: 10/04/2012] [Accepted: 02/10/2013] [Indexed: 11/10/2022] Open
Abstract
Background Recent initiatives by international health and humanitarian aid organizations have focused increased attention on making HIV testing services more widely available to vulnerable populations. To realize potential health benefits from new services, they must be utilized. This research addresses the question of how utilization of testing services might be encouraged and increased for refugees displaced by conflict, to make better use of existing resources. Methods Open-ended interviews were conducted with HIV-infected refugees (N=73) who had tested for HIV and with HIV clinic staff (N=4) in Nakivale Refugee Settlement in southwest Uganda. Interviews focused on accessibility of HIV/AIDS-related testing and care and perspectives on how to improve utilization of testing services. Data collection took place at the Nakivale HIV/AIDS Clinic from March to July of 2011. An inductive approach to data analysis was used to identify factors related to utilization. Results In general, interviewees report focusing daily effort on tasks aimed at meeting survival needs. HIV testing is not prioritized over these responsibilities. Under some circumstances, however, HIV testing occurs. This happens when: (a) circumstances realign to trigger a temporary shift in priorities away from daily survival-related tasks; (b) survival needs are temporarily met; and/or (c) conditions shift to alleviate barriers to HIV testing. Conclusion HIV testing services provided for refugees must be not just available, but also utilized. Understanding what makes HIV testing possible for refugees who have tested can inform interventions to increase testing in this population. Intervening by encouraging priority shifts toward HIV testing, by helping ensure survival needs are met, and by eliminating barriers to testing, may result in refugees making better use of existing testing services.
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Affiliation(s)
- Kelli N O'Laughlin
- Brigham & Women's Hospital, 75 Francis Street, Boston, Massachusetts, 02115, USA.
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Shan L, Rouhani SA, Schut HA, Snyderwine EG. 2-Amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) modulates lactogenic hormone-mediated differentiation and gene expression in HC11 mouse mammary epithelial cells. Cell Growth Differ 2001; 12:649-56. [PMID: 11751460] [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] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
2-Amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) is a mammary gland carcinogen in cooked meat. Using the HC11 mouse mammary epithelial cell line, a well-characterized model for hormone-mediated differentiation, we examined whether PhIP altered the expression of genes regulated by lactogenic hormones dexamethasone, insulin, and prolactin (DIP). When HC11-Lux cells (stably transfected with a beta-casein promoter luciferase construct) were cultured in DIP-containing medium, PhIP (100 microM) enhanced luciferase activity 11-fold over that observed in DIP medium alone. The effect of PhIP on augmenting luciferase activity was observed only when lactogenic hormones were included in the medium. Expression of the endogenous beta-casein gene was also higher in HC11 cells treated with PhIP in hormone-enriched medium. With the increased expression of beta-casein gene, the level of phospho-signal transducer and activator of transcription 5A (phospho-STAT5A), the transcription factor regulating beta-casein gene expression, was elevated in PhIP-exposed HC11 cells. AG490, a Janus kinase 2 (JAK2)-specific inhibitor, blocked the effect of PhIP on beta-casein gene expression. PhIP-treated cells also showed higher expression of Bcl-2 and lower expression of Bax, consistent with a possible antiapoptotic action of PhIP. The findings indicate that PhIP modulates lactogenic hormone-mediated gene expression in mammary epithelial cells, apparently via enhanced phosphorylation of STAT5A. The findings have implications for a novel mechanism of action of the mammary gland carcinogen PhIP.
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Affiliation(s)
- L Shan
- Chemical Carcinogenesis Section, Laboratory of Experimental Carcinogenesis, Division of Basic Sciences, National Cancer Institute, NIH, Bethesda, MD 20892, USA
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