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 September 2017 journal watch and issue round-up podcast
Setting up a paediatric emergency unit 101
From: Molyneux EM, Langton J, Njiram’madzi J, et al. Setting up and running a paediatric emergency department in a hospital in Malawi: 15 years on. BMJ Paediatrics Open. 2017;1:e000014
In most African district hospitals, paediatric emergency medicine, outpatients and immunisation clinics are held simultaneously in one place and run by the same staff. Triage is minimal and the service is often left to the least trained and least supervised health workers. In 2001, the 1100-bedded Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, opened a purpose-built paediatric emergency care unit.
Since then, outpatients are seen in a separate building attached to the emergency department. The WHO course, Emergency Triage Assessment and Treatment, was taught to the nurses and clinical officers. Triaged patients are allocated to different areas depending on need with the very sick being managed straight away by a clinician or senior nurse. Non-urgent cases are sent to their local health centre which they had bypassed to come to the hospital. First-line investigations are done in the emergency unit and treatments, including blood transfusions, given so that there is no delay on the wards. As much as possible all children are stabilised before being taken to a ward. The timely management of patients has reduced delays that lead to unnecessary admissions, improved the care and patient flow of sick children. This review details 15 years of experience setting up and running a paediatric emergency department in a low-resource setting. This will hopefully encourage others to think about any such need in their own health unit and help them to develop what is best for their setting.
From: Opiro K, Wallis L, Ogwang M. Assessment of hospital-based adult triage at emergency receiving areas in hospitals in northern Uganda. Afri Health Sci. 2017;17(2):481-90
In sub-Saharan Africa, the burden of emergency conditions is high, with high mortality from these conditions. Emergency care services are also not well established mostly due to resource limitations and therefore health service resources must be used in a manner which does “the most for the most”. This is partly achieved using a triage system. An assessment of the practice of adult hospital-based emergency triage in hospitals in Northern Uganda was conducted through a descriptive cross-sectional study. Interestingly, only one of the six hospitals included in the study was found to have a formal local triage protocol in use. The other 5 hospitals had no formal triage guidelines and staff applied subjective “eye-ball” triage to judge on which patients needed emergency attention. Only two hospitals had an allocated emergency department, while in the other hospitals emergency triage was performed from the outpatient department and various hospital wards. Lack of training was identified as the major barrier, followed by variation of triage scales from one hospital to another and shortage of staff on duty to perform triage. This highlights the need for countries to develop one formal triage guideline that can be uniformly used in hospitals as well as in training institutions countrywide. Additionally, individual hospital needs to take initiative and formulate or adopt a triage protocol to be used locally and there is a need to scale up recruitment and training of health workers.
Paediatric injuries in Cape Town
From: Wesson HKH, Bachani AM, Mtambeka P, Schulman D, et al. Changing state of pediatric injuries in South Africa: An analysis of surveillance data from a Pediatric Emergency Department from 2007 to 2011. Surgery. 2017. [Epub ahead of print] - not open access
Paediatric injuries are associated with significant morbidity and mortality, especially in low- and middle-income countries. Data to characterize the cause and risk factors associated with childhood injuries in low- and middle-income countries are very scarce. This study describes the cause of paediatric injuries and their possible changes between 2007 and 2011 using hospital-based data in Cape Town, South Africa. In total, 14,915 injured children with 15,414 injuries presented to Red Cross War Memorial Children’s Hospital in the study period with a mean age of 5.01 ± 3.5 years. Common mechanisms of injury included falls (n = 6,036; 40%), road traffic injuries (n = 1,939; 13%), burns (n = 1,885; 12.6%), and assault (n = 640; 4.3%). Comparing 2011 to 2007, the incidence of road traffic injuries has decreased by 7% (P < .05) while burn injuries increased 11% (P <.05). Seventy-three percent (73%) of injuries that presented occurred in the informal settlements. This data highlights the need to collect more widespread data to strengthen the need for targeted interventions to address risk factors for paediatric injuries and hopefully reduce morbidity and mortality.
…and paediatric injuries in Egypt
From: Sobhy SA , El-Sayed HF, Fialaa IE, Ismail MT, et al. Characteristics and injury severity score of childhood injuries at emergency department of Suez Canal university hospital. http://dx.doi.org/10.5455/medscience.2017.06.8640 [Epub ahead of print]
Injury surveillance provides an understanding of the incidence, trends, and magnitude of injuries, and identifies specific populations that have a higher incidence of injuries. A cross-sectional analytic study at emergency department in Suez Canal University Hospital in Egypt targeted children aged ≤ 18 years who presented with an injury from June 2013 to April 2014. Of the total of 402 injured children, (47.2%) were aged 12-18 years. Motor car accidents had the highest Injury severity score (ISS) which was 29.2±2.6. Most of falls (66.1%) occurred in children aged less than 6 years. 26.2% of burn had permanent disability and ISS of burn was 14.5±1.3. Most of accidental poisoning (78.8%) occurred in children aged less than 6 years. About 85% of poisoning had no significant disability. Childhood intentional injury represented 5.7% of all injuries and had ISS of 8.5±7.7. Falls were the leading cause of injury-related hospitalizations and emergency department visits among children in Suez Canal University Hospital (29.4%), while motor vehicle traffic crashes are the leading cause of death (57%). Surveillance can help identify injuries on which to focus prevention efforts. Priority can be given to the most prevalent injury causes, those that show an increasing incidence, or those that affect a population of special interest, such as children.
Prioritising children when they cannot prioritise themselves
From: Hansoti B, Hodkinson P, Wallis L. Prioritizing the Care of Critically Ill Children in South Africa: How Does SCREEN Perform Against Other Triage Tools? Pediatr Emerg Care 2017. [Epub ahead of print] - not open access
Key approaches to reducing childhood mortality through emergency care are centred on strategies to reduce delays in care that occur because critical illness is not recognized early. SCREEN (Sick Children Require Emergency Evaluation Now) is a simple subjective tool (relying on clinical discriminators) which can be implemented by health care workers without formal medical/nursing training. It was derived from the validated WHO IMCI danger signs. In addition to the danger signs, two further modifiers were added: (1) if the child is younger than two months because this group is at much higher risk of severe illness and (2) if the child had been seen in clinic/hospital in the last two days. It takes less than one minute to administer.
In comparison to other validated triage tools (Pediatric Early Warning Score (PEWS), Pediatric South African Triage Scale (PSATS) and the WHO Early Treatment and Triage Tool (ETAT)), SCREEN had a high sensitivity (100%–98.73%; P < 0.001) and specificity (64.41%–50.71%; P < 0.001) and can be executed by laypersons in less than 1 minute to identify critically ill children in low-resource settings, so that their care can be prioritised to avoid harmful delays.
Road traffic injuries in Lagos
From: Ibrahim NA, Ajani AWO, Mustafa IA, Balogun RA, et al. Road traffic injury in Lagos, Nigeria: assessing prehospital care. Prehosp Disaster Med. 2017;32(4):424-430 - not open access
Injuries are the third most important cause of overall deaths globally with one-quarter resulting from road traffic crashes. Majority of these deaths occur before arrival in the hospital and can be reduced with prompt and efficient prehospital care. This retrospective review was conducted in Lagos, Nigeria to assess the effectiveness of prehospital care, especially the role of Lagos State Ambulance Service (LASAMBUS) in providing initial care and transportation of the injured to the hospital. A total of 23,537 patients seen at the Surgical Emergency Room (SER) of the Lagos State University Teaching Hospital (LASUTH) from January 1, 2012 to December 31, 2014 were included in the study. Among them, 16,024 (68.1%) had trauma. Road traffic crashes were responsible in 5,629 (35.0%) of trauma cases. Passengers constituted 42.0% of the injured, followed by pedestrians (34.0%). Four wheelers were the most frequent vehicle type involved (54.0%), followed by motor cycles (30.0%). Relatives brought 55.4%, followed by bystanders (21.4%). Only 2.3% had formal prehospital care and were brought to the hospital by LASAMBUS. They also had significantly shorter arrival time. Like many low- and middle-income countries, increasing the number of ambulance points on the highways and other major roads requires resources that may not be readily available. Training selected groups in the community and uniformed personnel who are likely to be first-responders in basic first-aid may be a more feasible and cost-effective measure to improve prehospital care in this setting. The target group could be commercial vehicle drivers, teachers, the police, fire fighters, and road safety personnel.
…and road traffic injuries in Kenya
From: Botchey IM Jr, Hung YW, Bachani AM, Saidi H, et al. Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital. Surgery. 2017 [Epub ahead of print] - not open access
In Kenya, injury is the second leading cause of death after HIV and AIDS. There has been a 5-fold increase in both road fatalities and nonfatal casualties due to road traffic crashes during the past four decades. In January 2014, researchers implemented an electronic data collection system to provide data on the patterns of injuries at Kenyatta National Hospital (KNH), a level six, 2,000 bed, public teaching hospital and the largest referral hospital in the country. Prospective data on all patients presenting at the emergency department who had at least one injury was collected between January 2014 and June 2015. A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years) and the leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥ 60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity. Trauma registries are a useful source of data for quantifying the burden of injuries and patient outcomes in low- and middle-income countries (LMICs). Understanding the burden of injury and the process of care is imperative for reviewing the quality of care, designing quality improvement processes, and appropriate interventions and changes in policy to decrease the burden of injury. However, the long-term implementation of prospective trauma registries in LMICs should be based on sustainable and cost-effective instruments. Engagement of the stakeholders as well as local funding of data collection are crucial for long-term sustainability.