The AfJEM blog
Uchunguzi means investigation in Swahili and provides a summary of some of the most recent international literature as presented in other leading journals, but with an emphasis on what is relevant to our continent
Uchunguzi is written by Dr. Ben W. Wachira, emergency physician at the Accident and Emergency Department, Aga Khan University, Nairobi, Kenya. Follow Ben on Twitter
Listen to the December 2017 journal watch and issue round-up podcast
Weight issues in kids
From: Wells M, Goldstein LN, Bentley A. The accuracy of emergency weight estimation systems in children-a systematic review and meta-analysis. Int J Emerg Med 2017;10(1):29
The safe and effective administration of fluids and medications during paediatric emergencies depends on an appropriately determined dose, based on body weight. Weight cannot often be measured in these circumstances and thus a convenient, quick and accurate method of weight estimation is required. This meta-analysis aimed to determine which paediatric weight estimation systems predicted weight in children most accurately. Using a percentage of estimations within 10% of actual weight (PW10) of 70% as a benchmark of acceptable accuracy, only the PAWPER tape and the Mercy method achieved acceptable accuracy, with parental estimates close behind. Using PW20, only the PAWPER tape (96.6%) and the Mercy method (95.3%) met the suggested acceptability criteria of a PW20 > 95%. The PW20s for the Broselow tape, parental estimates and a value calculated for pooled age-based formulas were 81.2, 87.1 and 65.0%, respectively. In their conclusion, the authors recommend that dual length- and habitus-based (two-dimensional) systems (Mercy method and the PAWPER tape) or parental estimates of weight should be used for weight estimation in children because of superior accuracy to other systems (high quality evidence) followed by the Broselow tape. Age-based formulas and healthcare provider guesses should not be used for weight estimation in children because of potential patient harm (high quality evidence).
WHO's quality dimensions in the EC
From: DeWulf A, Otchi EH, Soghoian S. Identifying priorities for quality improvement at an emergency Department in Ghana. BMC Emerg Med 2017;17(1):28
Healthcare quality improvement (QI) is a global priority. The World Health Organization (WHO) argues that expanding and integrating emergency services into existing primary care and public health systems is a priority for global healthcare service improvement. In 2016, the WHO defined quality based on six dimensions; efficacy, efficiency, accessibility, acceptability/patient centeredness, equitability, and safety. The aims of this study were to educate staff about the World Health Organization’s (WHO) definition of quality in healthcare, and to identify an initial focus for building an emergency centre (EC) QI program at a tertiary care hospital in Ghana. The authors conducted semi-structured interviews with EC staff using open-ended questions to probe their understanding and valuation of the six dimensions of quality defined by the WHO. Overall, accessibility was the highest ranked (61%) followed by efficacy, safety, and acceptability. Equity was ranked lowest though it was the second most frequently discussed dimension. Financial accessibility and hospital bed availability were the most common themes that emerged in relation to opportunities for improvement across other quality dimensions. These findings highlight the importance of understanding the perspectives of frontline healthcare workers which can help guide sustainable and meaningful change.
Low- and middle-income country nine-point trauma plan
From (not OA): Bachani AM, Botchey I, Paruk F, Wako D et al. Nine-point plan to improve care of the injured patient: A case study from Kenya. Surgery 2017; pii: S0039-6060(17)30389-6
Injury rates in low- and middle-income countries are among the greatest in the world, with >90% of unintentional injury occurring in these countries. The risk of death from injuries is six times more here than in high-income countries. This increased rate of injury is partly due to the lack of availability and access to timely and appropriate medical care for injured individuals. Kenya, like most low- and middle-income countries, has seen a 5-fold increase in injury fatalities throughout the past 4 decades, in large part related to the absence of a coordinated, integrated system of trauma care. The Bloomberg Global Road Safety Program (2010–2014) was a 10 country (including Kenya), multiple consortium partner effort, to decrease the mortality associated with road traffic injuries. In Kenya, in addition to efforts to improve road safety, there was also a focus on improving the care of the injured patient. This initiative included the development and implementation of the Trauma System Profile (TSP) tool using both qualitative and quantitative methods to understand the existing system and capabilities for the care of the injured patient in Kenya. Utilizing findings from the TSP, a review of the evidence base in the literature, and consultation with local and international stakeholders, the authors of this report developed and implemented the following 9-point plan to improve trauma care in Kenya;
What about the Family?
From: Almaze J P B, De Beer J. Patient- and family-centred care practices of emergency nurses in emergency departments in the Durban area, KwaZulu-Natal, South Africa. S Afr J Crit Care 2017;33(2):59-65
Patient- and family-centred care (PFCC) is an approach to the planning, delivery and evaluation of healthcare that focuses on a mutually beneficial partnership between patients, families and healthcare professionals. Family members often find it a traumatic experience when a loved one is brought to the emergency centre (EC). They are not usually psychologically prepared for this event, as most of these are emergencies. This can result in role conflict, high levels of stress, interruption of normal routines and potential changes in relationships among family members. A PFCC approach in the EC recognises the needs of both the patient and family members. This approach is central to delivering effective care, including prompt assessment of family members’ needs, that not only reduces their stress and anxiety but also enhances the patient’s satisfaction with care. This paper describes PFCC practices of emergency nurses in the ECs in the Durban area of KwaZulu-Natal (KZN) Province, South Africa, with a particular focus on the status of PFCC in these ECs and challenges in providing PFCC in the EC. The authors conducted a descriptive survey among 44 emergency nurses from four ECs in the Durban area of KZN using an adapted Self-Assessment Inventory Tool. Most of the emergency nurses (84%) surveyed acknowledged the importance of family participation in patient care, 87% reported that family members were provided with information in a timely manner, and 77% indicated that they had the necessary skills to provide care to family members. The authors recommend that a family needs assessment be included as part of every EC patient’s assessment and there needs to be an evaluation of hospital policies and procedures for congruency with PFCC, especially in relation to family-witnessed resuscitation and invasive procedures to promote family participation in patient care. In addition, bereavement programmes to support staff in dealing with bereavement issues would be beneficial.
Publish or peril…peril
From: Bruijns SR, Maesela M, Sinha S, Banner M. Poor Access for African Researchers to African Emergency Care Publications: A Cross-sectional Study. West J Emerg Med 2017;18(6):1018-1024
Publications from the African region made up only 1.8% (829 of 46,901) of global emergency medicine (EM) publication output between 2010 and 2015; but this number is not representative of the relative size of the African continent, nor its relative higher burden of disease, morbidity and mortality compared to other world regions. This can be attributed, at least in part, to the cost of access (actual and cost-wise) to African emergency care publications which remains unknown. The aim of this retrospective, cross-sectional study was to describe access to African emergency care publications in terms of publisher-based access (open access or subscription) and alternate access (self-archived or author provided), as well as the cost of access. A sequential search strategy described access to each article in all emergency medicine publications included in Scopus between 2011 and 2015. The authors calculated mean article charges against the purchasing power parity index (used to describe out-of-pocket expense). Of the 666 publications from 49 journals included, 395 (59.3%) were open access. For subscription-based articles, 106 (39.1%) were self-archived, 60 (22.1%) were author-provided, and 105 (38.8%) were inaccessible. Mean article access cost was $36.44, and mean processing charge was $2,319.34. Using the purchasing power parity index, it was calculated that equivalent out-of-pocket expenditure for South African, Ghanaian and Tanzanian authors would respectively be $15.77, $10.44 and $13.04 for access, and $1,004.02, $664.36 and $830.27 for processing. Based on this, the corrected cost of a single-unit article access or process charge for South African, Ghanaian and Tanzanian authors, respectively, should be 2.3, 3.5 and 2.8 times lower than the standard rate for equitable out-of-pocket expenditure. Given the stark differences in emergency care resource requirements and availability between high-income countries and low- and middle-income countries, it is important that African emergency care research is both conducted and disseminated in accessible format within Africa.
Three is a crowd in the EC
From: Myers JG, Hunold KM, Ekernas K, et al. Patient characteristics of the Accident and Emergency Department of Kenyatta National Hospital, Nairobi, Kenya: a cross-sectional, prospective analysis. BMJ Open 2017;7(10):e014974
Data from resource-limited settings describing patients presenting for acute, emergent and urgent care, as well as the overall burden of disease in this setting is largely absent. This limits efforts to develop emergency care capacity despite the stochastic infectious disease patterns compounded by an increasing incidence of non-communicable diseases (NCDs) (such as heart disease and diabetes) and trauma (largely secondary to automotive accidents). This well-described ‘triple burden of disease’ was highlighted in the 2010 Global Burden of Disease (GBD) study. To continue to define the baseline burden of acute disease in resource-limited settings, this prospective observational study done over a three-month period in 2015 characterised the presenting complaint, medical conditions, diagnoses and disposition of patients seen in the emergency centre (EC) of Kenyatta National Hospital (KNH) in Nairobi, Kenya. Majority of the patients arrived by taxi or bus (39%) followed by walking (28%) and less by ambulance (17%). Thirty-five per cent of patients were diagnosed with NCDs, 24% with injuries and 16% with communicable diseases, maternal and neonatal conditions. Overall, head injury was the single most common final diagnosis and occurred in 32 (8%) patients. The most common patient reported mechanism for head injury was road traffic accident (39%). Though a comprehensive understanding of the acute care needs at Kenya’s largest referral centre is long overdue, this study still highlights the growing burden of injuries and NCDs—compounding the existing burden of communicable conditions, presenting for acute care in this setting.