Uchunguzi | Journal Watch - March 2018

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 March 2018 journal watch and issue round-up podcast

---

Do you live close enough to be saved?
From: Ouma PO, et al. Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis. Lancet Glob Health. 2018;6(3):e342-e350

Emergency or acute conditions are becoming major contributors to mortality, contributing to 45% of mortality and 35% of disability in low- and middle-income countries. The African Federation for Emergency Medicine, through a series of consensus conferences, highlighted the need to integrate emergency care into health systems. Key towards addressing the challenges in emergency care is defining access to hospitals and highlighting populations most distal to these services. In this paper, the authors developed a spatial platform of 4,893 public hospitals across 48 countries and islands of sub-Saharan Africa, including Zanzibar to assess general population access to hospital care metrics in 2015. Geographical accessibility to emergency hospital care varied between countries, ranging from less than 25% of the population living within 2-h travel time of a public hospital in South Sudan to more than 90% in Nigeria, Kenya, Cape Verde, Swaziland, South Africa, Burundi, Comoros, São Tomé and Príncipe, and Zanzibar. Seven countries had less than 50% of the population living within a 2-h travel time of a public emergency care hospital: South Sudan, Mauritania, Eritrea, Niger, Sudan, Madagascar, and Chad.  The findings of this study highlight the fact that most countries are well below the benchmark set for 2030, with less than 80% of the population living within a 2-h travel time of emergency hospital care. Beyond just defining physical access, the definition of the scope, service provision capacities, laboratory capacities, and optimal catchment populations for emergency hospital care should be prioritised.

Ambulance use: Lessons from Ethiopia
From: Abebe Y, et al. Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia. BMC Emerg Med. 2018;18(1):7

Africa alone accounts for one-sixth of global road traffic deaths. It is estimated that 80% of road traffic deaths occur before patients even reach a hospital in low- and middle-income countries. Care by formally trained pre-hospital personnel and transport by equipped ambulances has advantages in certain time-sensitive and high-acuity scenarios. In sub-Saharan Africa, the precise populations receiving such pre-hospital care and transport remain ill-defined. To address this important research gap, researchers in Addis Ababa, Ethiopia performed retrospective chart review of all adult and pediatric patients arriving after road traffic collision (RTC) to Addis Ababa Burn Emergency and Trauma (AaBET) Hospital emergency department (ED) from August 22nd, 2015 to March 9th, 2016 (7 months). A total of 2,062 patients were evaluated after trauma in the ED, RTC accounting for 662 patients (32%). Over half of patients arrived with either high (13.1%) or moderate (42.2%) acuity mostly by ambulance (59.0%). Patients with high acuity were most likely to be referred (aOR 2.20, 95%CI 1.16–4.17), but were not more likely to receive ambulance transport (aOR 1.56, 95%CI 0.86–2.84) than those with low acuity. Nearly half (40.2%) of all patients were referred by ambulance despite having low acuity. Despite ambulance expansion in Addis Ababa, ambulance use among RTC patients remains heavily concentrated among those with low-acuity. Inter-facility referral appears a primary contributor to low-acuity ambulance use. This study highlights the importance of understanding which patients receive ambulance transport and may help identify opportunities for targeted resource allocation as these services are relatively expensive and remains scarce compared to other lower-resource approaches (e.g., modified motorcycles).

Resuscitation in Nigeria- Beyond clean water and vaccines
From: Zha Y, et al. Cardiopulmonary Resuscitation Capacity in Referral Hospitals in Nigeria: Understanding the Global Health Disparity in Resuscitation Medicine. J Natl Med Assoc. 2017

In high-income countries, cardiopulmonary resuscitation (CPR) is now standard of care that hospitals have the accessible and functional equipment, well-trained providers, and an organized response process. However, in low- and middle-income countries (LMICs), basic public health principles such as clean water and vaccination have been appropriately emphasized over time with the unfortunate consequence of neglecting the further development of hospital-based care. There is a paucity of data on the state of resuscitative services in LMICs, with a few studies highlighting the lack of infrastructure for the provision of resuscitation. In this survey, the researchers evaluated the resuscitation infrastructure, equipment, personnel, training, and clinical management in referral teaching hospitals across Nigeria. In total, 17 hospitals (82% public, 12% private, 6% public-private partnership), were included in the survey. Only 20% (3 out of 15) of hospitals had a cardiac arrest response team system, 21% (3/14) documented CPR events, and 21% (3/14) reviewed such events for education and quality improvement. Most basic supplies were sufficient in the ICU; (100% [15/15] availability of defibrillators, and 94% [16/17] of adrenaline) but were less available in other departments. While 67% [10/15] of hospitals had a resuscitation training program, only 27% [4/15] had at least half their physicians trained in basic life support. The most important finding from this research according to the authors that has the most cost-efficient solution is a need for quality improvement measures. The application of real-time resuscitation documentation coupled with structured meetings for continuous quality evaluation is low-cost, non-resource-intensive, and has the potential to identify opportunities for improvement, areas of dysfunction, and problems to be addressed in all aspects of the resuscitation process.

EMS: Plan B
From: Delaney PG, et al. Lay First Responder Training in Eastern Uganda: Leveraging Transportation Infrastructure to Build an Effective Prehospital Emergency Care Training Program. World J Surg. 2018

Road traffic injuries (RTIs) kill 1.2 million people and injure or disable between 20 million and 50 million people a year (with more than 90% of those deaths occurring in LMICs). According to the WHO, by 2030, traffic injuries will account for 3.6% of total deaths in the world compared to just 0.8% for malaria, translating to an urgent need for functional emergency medical systems. In fact, 45% of all deaths and 36% of the disease burden that occur in low-income countries are potentially addressed by prehospital emergency medical services. In response, lay first responder programs have been launched in several places without formal prehospital care systems. The aim of this study was to create a sustainable and efficient prehospital lay first responder program specifically in a rural setting. The researchers trained one hundred and fifty-four motorcycle taxi riders in first aid in rural Uganda and provided them with a first aid kit following WHO guidelines for basic first aid. Post-implementation incident report forms were collected from the trained providers after each patient encounter over 6 months and follow-up interviews were conducted with 110 of 154 trainees, 9 months post-training. Impressively, improvements were demonstrated across all five major first aid categories: bleeding control (56.9 vs. 79.7%), scene management (37.6 vs. 59.5%), airway and breathing (43.4 vs. 51.6%), recovery position (13.1 vs. 43.4%), and victim transport (88.2 vs. 94.3%). From the incident report findings, first responders treated 250 victims (82.8% RTI related) and encountered 24 deaths (9.6% of victims). Of the first aid skills, bleeding control and bandaging was used most often (55.2% of encounters). Lay first responders provided transport in 48.3% of encounters. Of 110 lay first responders surveyed, 70 of 76 who had used at least one skill felt ‘‘confident’’ in the care they provided.  The findings provide a scalable alternative for LMICs to develop a prehospital care system composed of lay first responders and existing transport organizations.

Now we can measure quality emergency care in LMIC
From: Broccoli MC, et al. Defining quality indicators for emergency care delivery: findings of an expert consensus process by emergency care practitioners in Africa. BMJ Glob Health 2018;3:e000479

In low- and middle-income countries (LMICs), the need for quality emergency care has never been greater. It is estimated that 54% of worldwide morbidity and mortality can be attributed to emergency conditions. Quality assessment of emergency care delivery is the essential foundation for improvement of care provision. Measurable indicators for the provision of emergency care in LMICs are lacking; the quality of such care delivered at health facilities in these settings has yet to be addressed. The African Federation for Emergency Medicine (AFEM) scientific committee through a multiphase expert consensus process identified, ranked and refined a minimum set of context-appropriate clinical quality indicators for facility-based emergency care that were pragmatic, measurable and centred around current health priorities. The consensus working group selected seven conditions (trauma, sepsis, acute respiratory compromise, shock, altered mental status, pain and obstetric bleeding) that address nearly 75% of mortality in the African region to prioritise during indicator development, and the final product at the end of the multiphase study was a list of 76 indicators. The proposed minimum set of clinical quality indicators for facility-based emergency care in Africa provide a common language by which to facilitate intranational and international comparison and bring us one step closer to measuring quality emergency service delivery in low-resourced settings and lead to enhanced quality and safety of care provided.

A framework for emergency care development in sub-Saharan Africa - we need data
 From: Bitter CC, et al. What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda. BMJ Open 2018;8:e019024

 ​Lack of information regarding the most frequently used procedural skills and the resources required to care for acutely ill and injured patients hinders the development of emergency care delivery and training in low-resource settings. This study describes the resources and clinical skills used to care for a large, longitudinal cohort of patients seen at the Karoli Lwanga Hospital Emergency Department (ED) in rural Uganda from November 2009 through February 2015. From 26 710 patient visits, procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound. Such information is vital to inform training and protocols, emergency care formulary development and checklists of useful laboratory resources and diagnostic imaging modalities to define a framework for emergency care development in sub-Saharan Africa (SSA).