Preparedness of healthcare facilities for a public health emergency in a Caribbean country

OBJECTIVE: To review basic, critical elements of emergency preparedness and response capacity in the healthcare system of Trinidad and Tobago. DESIGN AND METHODS: A descriptive study involving one major hospital and one randomly selected health centre in each Regional Health Authority (RHA). Responders were chosen by purposive sampling and structured face-to-face interviews were carried out. Data collection was undertaken using modified versions of two previously validated data collection tools. RESULTS: All 5 hospitals in each RHA and 4 of 5 health centres participated. Emergency response plans existed in all healthcare facilities reviewed; however plans were not regularly tested. An investigation team can be assembled in 24 hours and a patient referral system was in place in all hospitals. There appeared to be access to stockpiles in all facilities. There was a gap in ongoing infection control measures including the absence of regular personal protective equipment (PPE) training for staff. CONCLUSIONS: There was an urgent need for systematic rather than ad hoc measures for testing existing plans and staff training in their roles and responsibilities during an acute public health event should one occur. For infectious diseases with high case fatality rates such as avian influenza and Ebola, it is critical for front line staff to be aware of infection control measures including how to properly use PPE. Governments should take the opportunity of the Ebola outbreak in West Africa to utilize public health capacity to catalyse the systematic strengthening of core capacities for alert and response to meet their International Health Regulations (IHR) 2005 obligations.

Paediatric patients who attend the accident and emergency department: perspectives of parents- a qualitative study.

OBJECTIVE: To explore the perspectives of parents with non-urgent conditions who attend a Paediatric Emergency Department (ED) rather than a primary care facility or private health care provider. Study Design: A qualitative study using a semi-structured approach. SUBJECTS and METHODS: Demographic data were collected over a period of three months from 134 parents if children through a self administered questionnaire. Of these, 24 parents were interviewed to determine their reason for attending the ED: their knowledge of the health service and to explain their understanding of their child's illness. RESULTS: Five major factors were identified as influencing parents' decisions to attend the ED: age of the child, ease of access; confidence of staff in the facilities; perception that ED was more patient friendly and cost of private health care. While most parents were willing to initiate treatment for minor illnesses at home, many indicated they preferred the ED rather than the health centre if their child's acute illness was more severe. CONCLUSIONS: We found that the deterrents to seeking health care in the primary care setting included concerns about the competence of doctors and nurses in treating sick children and communicating with parents. In addition, insufficient paediatric clinics days, long waiting time and inadequate child friendly facilities were also named as barriers to accessing primary care health centres.

Emergency medical training for health promoters in Central and South America

Underserved regions in the developing world are challenging areas to provide emergency medical care. As populations in these often remote or isolated districts may have minimal access to regular health care, contacts with medical providers are frequently episodic and driven by an acute condition. Health promoters—practitioners who provide basic medical care and promote public health in numerous countries across Central and South America, Asia and Africa—help to fill this void. Typically, health promoters are certified through a formal training program in their country and come from the same population as the clients they serve, which helps them form a link between their community and the dominant health care system in the region (1-2). Access to health and social services in regions served by health promoters is usually minimal, resulting in high morbidity and mortality associated with preventable diseases. Health promoters strive to improve the overall health of these communities by supplementing and improving the curative, preventive, and promotional aspects of the existing health system.

Predictors of repeat visits to the emergency room by asthmatic children in primary care

BACKGROUND: Subsets of asthmatic children, particularly in the Caribbean, burden the health system through repeated emergency room (ER) visits. We examined children to determine predictors of repeated ER visits in Trinidad. Methods: Caregivers of 300 asthmatic children in primary healthcare in Trinidad reported on perceived factors of exacerbated wheeze requiring ER services. RESULTS: Prevalence of ER utilization in the past 12 months was 59.7 per cent and 40.3 per cent for repeated visits. Average age of wheezing onset was 2.8 (SD = 2.5) years. From the logistic regression analyses, independent predictors of repeat ER visits were mothers with a history of asthma (OR = 2.0, 95 per cent Cl = 1.0-4.0), exposure to perfumes/odors (OR = 2.4, 95 per cent Cl = 1.4-4.2), using inhaled corticosteroids (ICS) (OR = 2.2, 95 per cent Cl = 1.2-4.0), and young age group (1-5 vs. 13-16 years) (OR = 2.7, 95 per cent Cl = 1.1-6.4). More 1-5 year-olds (63.8 per cent) and 6-12-year-olds (60.2 per cent) wheezed in the dry and wet seasons, respectively (p = 0.04). Follow-up was poor (32.3 per cent), and disease management did not include educational interventions. CONCLUSIONS: Repeated ER use in pediatric asthma underscores a pressing need for health providers and caregivers to develop an asthma management plan noting the identified predictors to assist in reducing Trinidad's asthma burden.

Public access defibrillation in the Caribbean: the time has come

Recent technological advances in resuscitation equipment and procedures have opened the door for some developing countries to consider implementing early defibrillation programmes. This is particularly true in the Caribbean, where urbanisation is rapidly altering the nature of health problems, and public expectations of healthcare delivery is rapidly rising. However before an SCD victim in the Caribbean can expect to be rescued from a cardiac arrest there is much work to be done. 'Core ACLS' courses that emphasise the critical aspects of ACLS, coupled with widespread teaching programmes aimed at educating the general public about cardiovascular resuscitation, should be initiated. Before full advantage can be taken of recent technological advances, and emergency medical systems can become a reality in the Caribbean, a comprehensive approach to the introduction of resuscitative practices should be considered (AU)

Patient perception of the services of the accident and emergency department of the Queen Elizabeth Hospital, Barbados: a research project submitted in fulfillment of the requirement for the degree of Doctor of Medicine in Emergency Medicine of the University of the West Indies

On July 14th, 1990 the Accident and Emergency Department of the Queen Elizabeth Hospital was offically opened. This evolved from the previously known Casualty Department which was thought to be inadequate. Since its inception however, the new Department has undergone new problems, the major ones being:- medical and nursing staff shortages, long waiting and treatment times, abandonment of the elderly in the Department, equipment failure and delays in obtaining laboratory results. In view of these problems, a cross-sectional survey of 200 patients picked by random tables was conducted in the Accident and Emergency Department from August - November 1999. Patients were interviewed by telephone to determine their perception of the services offered. Results showed that despite the Department's shortcomings the majority of patients were overall satisfied with the services offered. However, recommendations have been put forward from the patients' comments to improve these services and make the Department more effective (AU)

Penetrating Injury to the Great Vessels: Case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.(AU)

Pre-hospital Emergency Medical Services, Phase I: Role of the Department of Community Health and Psychiatry

The Department of Community Health and Psychiatry was contracted by the Ministry of Health to assist with the implementation of a pilot programme in the Western Health Region to train fire fighters as basic level Emergency Medical Technicians (EMTs), and was responsible for its design, implementation and monitoring for first 18 months. The course was covered in 440 hours over a 10 week period, and included training in emergency medical response, driving an emergency medical vehicle, emergency medical despatching and inventory control. Of 76 fire fighters selected for training, 62 graduated, receiving Certificate of Merit from the Ministry of Health, Jamaica and were deployed into service on 17th April 1996. During the period 17 April to 31 December, 1996, the newly trained EMT's responded to 1,299 calls. Medical and surgical cases represented approximately 55 percent of all calls, followed by trauma (19 percent), motor vehicle accident (9 percent) and obstetric emergencies (8 percent). Between 15 percent and 20 percent of calls in Montego Bay and Negril involved tourists. This first group of EMT's has performed well and was well received by the communities and the persons who used the service.(AU)

Effect of basic prehospital trauma life support program on cognitive and trauma management skills

We tested the effectiveness of a basic prehospital trauma life support (PHTLS) program by assessing cognitive performance and trauma management skills among prehospital trauma personnel. Fourteen subjects who completed a standard PHTLS course (group I) were compared to a matched group not completing a PHTLS program (group II). Cognitive performance was assessed on 50-item multiple choice examinations, and trauma skills management was assessed with four simulated trauma patients. Pre-PHTLS multiple choice questionnaire scores were similar (45 +/- 9.4 percent vs. 48.4 +/- 8.9 percent for groups I and II respectively), but the post-PHTLS scores were higher in group I (80.4 +/- 5.9 percent) than in group II (52.6 +/- 4.9 percent). Pre-PHTLS simulated trauma patient performance scores (standardized to a maximum total of 20 for each station) were similar at all four stations for both groups, ranging from 7.9 to 10.4. The post-PHTLS scores were statistically significantly higher at all four stations for group II (range 8.0 - 11.1). The overall mean pre-PHTLS score for all four stations was 8.3 +/- 2.1 for group I and 8.8 +/- 2.0 (NS) for group II; the group I post-PHTLS mean score for the four stations was 17.1 +/- 2.7 (p < 0.05) compared to 9.1 +/- 2.3 for group II. Pre-PHTLS Adherence to Priority scores on a scale of 1 to 7 were similar (1.1 +/- 0.9 for group I and 1.2 +/- 1.0 for group II). Post-PHTLS group I Priority scores increased to 5.9 +/- 1.1. Group II (1.1 +/- 1.0) did not improve their post-PHTLS scores. The pre-PHTLS Organized Approach scores in the simulated trauma patients on a scale of 1 to 5 were 2.1 +/- 1.0 for group I and 1.9 +/- 1.2 for group II (NS) compared to 4.2 +/- 0.9 (p < 0.05) in group I and 2.0 +/- 0.8 in group II after PHTLS. This study demonstrates improved cognitive and trauma management skills performance among prehospital paramedical personnel who complete the basic PHTLS program.(Au)

The organisation of helicopter emergency services for the rescue of aircraft crash victims in the tropical forest

The purpose of this report was to describe lessons learned from experience in the tropical forest of Guyana and one helicopter rescue mission in that hostile environment. With previous data reported in the literature several guidelines for organizing these operations can be proposed. These rescue operations involve hoisting the victim to helicopter, medical treatment itself, and penetration into a hostile environment. Effectiveness and safety mandate that the physicians involved receive regular training in the techniques of helicopter evacuation, first aid, and survival. It is necessary to adapt conventional first aid kits for the purpose and to develop light and adequate survival equipment as listed exhaustively by the author.(AU)

Improving trauma care in Trinidad and Tobago

Indentification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago. (AU)

Use by visitors of the services of the Queen Elizabeth Hospital, Barbados, W.I

This paper analyses data for 1990 culled from the medical records of the Queen Elizabeth Hospital, Barbados and examines the use of inpatient and emergency services by visitors to Barbados. The 473 visitors admitted represented 2.1 percent of all admissions. The records of 425 contained information on country of origin: 145 were from non-Caribbean and 280 from Caribbean countries. The distribution by country of non-Caribbean visitors was the same as that of regular tourist arrivals - the majority came from the USA, Canada and the UK. Caribbean visitors represented 14.4 percent of the tourists, but accounted for 65.9 percent of visitor admissions. Non-Caribbean visitors were 85.6 percent of tourists, but 34.1 percent of admissions. Young patients predominated among Caribbean, and older patients among non-Caribbean. Accidents, cardiovascular disease, alcohol-related illnesses and near drowning were commoner in the non-Caribbean visitors, while cancer and obstetrical/gynaecological problems were commoner in Caribbean visitors. Seven per cent of visitor admissions went to the Intensive Care Unit as against 0.15 percent of other patients. The average hospital stay of visitors was 11.7 days compared with 7.0 days for Barbadians. There were 898 visitors treated in the Accident and Emergency Department and the commonest problems were lacerations, abrasions and infections. The UK provided most of these patients. These data show that there is appreciable visitor use of the public health services. Non-Caribbean visitors use them because they fall ill on holiday, but many Caribbean visitors may come specifically for health care. The cost to the Barbadian health service is not insignificant: at the 1990 estimated bed-day cost of Bds$250, it represents a cost of Bds$1.1 million per annum to the Government for inpatient services alone, or 2 percent of total hospital costs. (AU)

The impact of the ATLS course on traffic accident mortality in Trinidad and Tobago

Advanced Trauma Life Support (ATLS) training of medical staff did not improve outcome of the trauma victim. Potential benefit of this course may have been masked by weak links in the trauma care chain such as pre-hospital care and in hospital investigative and therapeutic facilities. (AU)

A prospective analysis of 4,041 consecutive cases in a West Indian accident and emergency department - abstract

Information on arrival, attendance and discharge times, age, sex, diagnoses, outcome, trauma classification and procedures and investigations performed was recorded in a specially designed form in 4,041 consecutive cases attending the Port-of-Spain General Hospital Accident & Emergency (A & E) department over a two-week period and was prospectively analyzed; 468 patients were referred to health centres, 1, 397 (35 percent) were admitted, and 2,171 (54 percent) were seen and discharged; 83 percent of all cases were seen without prior referral. The average time before being seen by a doctor was 31 minutes and the maximum period spent by any patient (admission - discharge) was 5 hours and 42 minutes. Medical procedures (adult and paediatric), general and orthopaedic surgery accounted for 78.4 percent of all cases. The most commonly encountered diagnoses in these specialities were asthma, lacerations and upper limb fractures. Based on these findings, the efficiency of the A & E department may be improved by increasing screening at the primary care level, training A & E officers in high-volume specialities, supplementing casualty staff with a paediatrician during peak hours and providing 'ensuite' plaster room for minor orthopaedi trauma (AU)

Pre-hospital care in Barbados - abstract

Pre-hospital care in Barbados was completely re-organised in 1984 with international assistance. Training included a three-month course for 45 emergency medical technicians (EMTs) to the basic EMT level. The aim of this study was to review the operations of the Emergency Ambulance Service (EAS), now in its seventh year of operation. During the three-month period July - September 1991, the following information was taken from each call: time and allocation, time of arrival at the scene and the chief complaint. The EAS responded monthly to 1,142 calls from the various parishes. Distribution of calls closely followed that of the population. The majority of calls (66.4 percent) were genuine emergencies, with only 1.2 percent being crank calls. Emergency included asthmatics (12.5 percent), accidents (9.3 percent), violent injuries (6.1 percent), comatose patients (7.3 percent), seizures (5.1 percent) and 14 (0.4 percent) patients with cardiac arrest. The average response time for all calls was 20 minutes. This ranged from 13 minutes in the central parish of St. Michael, to 39 minutes in the northern district of St. Lucy, and 30 minutes in the eastern area of St. Philip. These findings highlight the need for satellite stations in the northern and eastern sides of the island. The wide range of emergencies identified also provides a useful base for reviewing the curriculum and introducing new protocols for pre-hospital care (AU)

Emergency room: profile of patients flow

The case notes of 1274 patients registered in the Emergency Room are reviewed. The vast majority 933 (73 percent) were treated and discharged and only 151 (12 percent) needed admission to the ward. A mean 182 patients were seen each day. Nearly 50 percent of the patients were children. For a population of 150,000 thew number of persons who attend the emergency room, is very high. The situation would benefit from increased emergency space and staff, increased training for staff and public health education with emphasis on prevention. (AU)