Implementation and outcomes of a comprehensive emergency care curriculum at a low-resource referral hospital in Liberia: A novel approach to application of the WHO Basic Emergency Care toolkit.

BACKGROUND: Emergency care is vital in low- and middle-income countries (LMICs) but many frontline healthcare workers in low-resource settings have no formal training in emergency care. To address this gap, the World Health Organization (WHO) developed Basic Emergency Care (BEC): Approach to the acutely ill and injured, a multi-day, open-source course for healthcare workers in low-resource settings. Building on the BEC foundation, this study uses an implementation science (IS) lens to develop, implement, and evaluate a comprehensive emergency care curriculum in a single emergency facility in Liberia. METHODS: A six-month emergency care curriculum consisting of BEC content, standardized WHO clinical documentation forms, African Federation of Emergency Medicine (AFEM) didactics, and clinical mentorship by visiting emergency medicine (EM) faculty was designed and implemented using IS frameworks at Redemption Hospital, a low-resource public referral hospital in Monrovia, the capital of Liberia. Healthcare worker performance on validated knowledge-based exams during pre- and post-intervention testing, post-course surveys, and patient outcomes were used to evaluate the program. RESULTS: Nine visiting EM physicians provided 1400 hours of clinical mentorship and 560 hours of didactic training to fifty-six Redemption Hospital staff over six-months. Median test scores improved 20.0% (p<0.001) among the forty-three healthcare workers who took both the pre- and post-intervention tests. Participants reported increased confidence in caring for medical and trauma patients and comfort performing emergency care tasks on post-course surveys. Emergency unit (EU)/Isolation unit (IU) mortality decreased during the six-month implementation period, albeit non-significantly. Course satisfaction was high across multiple domains. DISCUSSION: This study builds on prior research supporting WHO efforts to improve emergency care globally. BEC implementation over a six-month timeframe using IS principles is an effective alternative strategy for facilities in resource-constrained environments wishing to strengthen emergency care delivery.

Surgical antimicrobial prophylaxis among surgical patients: results from a retrospective observational study at a public hospital in Liberia.

BACKGROUND: Surgical antibiotic prophylaxis (SAP) is one of the most effective measures to prevent surgical site infections (SSIs). According to WHO SAP guidelines, SAP requires appropriate indication for administration and delivery of the antimicrobial agent to the operative site through intravenous administration within 60-120 min before the initial surgical incision is made. In Liberia, it is unknown how surgeons practice and there has been anecdotal observation of antibiotic overuse. OBJECTIVE: To elucidate baseline SAP compliance, particularly appropriate SAP use based on wound class and time of antibiotic administration. METHODS: An observational, cross-sectional study was conducted from November to December 2017. One-day training was provided on SAP/SSI to 24 health workers by the Ministry of Health and WHO. Following this training, surgical cases (general surgery and obstetrics and gynaecology (OB/GYN) underwent chart review with focus on time of SAP administration and appropriate SAP based on Centers for Disease Control and Prevention (CDC) wound classification. RESULTS: A total of 143 charts were reviewed. Twenty-nine (20.3%) cases showed appropriate prophylaxis through administrations of antibiotics 120 min before surgical incision, resulting in SAP compliance. One hundred and fourteen cases (79.7%) showed SAP noncompliance with timing of antibiotic administration. Of the OB/Gyn cases, 109 wounds were classified as Class I (clean) and one wound was classified as Class III (contaminated). For General Surgical cases, 32 wounds were classified as Class I and one as Class III. Of the 109 Class I OB/Gyn surgeries, 24 (22%) were appropriately given antibiotics based on the CDC wound guidelines while 78% were non-compliant with recommendations. Of the 32 Class I General surgery cases, 4 (12.5%) were compliant with antibiotics guidelines while 28 (87.5%) were not. CONCLUSION: Compliance with SAP is low. More studies need to be done to explore the contributing factors to this. Implementing mechanisms to achieve proper use of SAP is needed.

Emergency department antimicrobial use in a low-resource setting: results from a retrospective observational study at a referral hospital in Liberia.

OBJECTIVE: Data on antimicrobial use in low-income and middle-income countries (LMICs) remain limited. In Liberia, the absence of local data impedes surveillance and may lead to suboptimal treatment, injudicious use and resistance against antimicrobials. This study aims to examine antimicrobial prescribing patterns for patients in the emergency department (ED) of a large Liberian public hospital. Secondarily, this prescribing was compared with WHO prescribing indicators. DESIGN: Retrospective observational study. SETTING: An adult ED of a large public hospital in Monrovia, Liberia. PARTICIPANTS: A total of 1082 adult patients (>18 years of age) were recorded in the ED, from 1 January to 30 June 2019. MAIN OUTCOME MEASURES: Number, type and name of antimicrobials ordered per patient were presented as number and percentages, with comparison to known WHO prescribing indicators. Pearson χ2 tests were used to assess patient variables and trends in medication use. RESULTS: Of the total patients, 44.0% (n=476) were female and the mean age was 40.2 years (SD=17.4). An average of 2.78 (SD=2.02) medicines were prescribed per patient encounter. At least one antimicrobial was ordered for 64.5% encounters (n=713) and two or more antimicrobials for 35.7% (n=386). All antimicrobial orders in our sample used the generic name. Ceftriaxone, metronidazole and ampicillin were the most common and accounted for 61.2% (n=743) of antimicrobial prescriptions. The majority (99.9%, n=1211) of antimicrobials prescribed were from the WHO Essential Drugs List. CONCLUSION: This study is one of the first on ED-specific antimicrobial use in LMICs. We revealed a high rate of antimicrobial prescription, regardless of patient demographic or diagnosis. While empiric antimicrobial use is justified in certain acute clinical scenarios, the high rate from this setting warrants further investigation. The results of this study underscore the importance of ED surveillance to develop targeted antimicrobial stewardship interventions and improve patient care.

The Impact of Water Sanitation and Hygiene (WASH) Improvements on Hand Hygiene at Two Liberian Hospitals during the Recovery Phase of an Ebola Epidemic.

Fourteen years of civil war left Liberia with crumbling infrastructure and one of the weakest health systems in the world. The 2014-2015 Ebola virus disease (EVD) outbreak exposed the vulnerabilities of the Liberian health system. Findings from the EVD outbreak highlighted the lack of infection prevention and control (IPC) practices, exacerbated by a lack of essential services such as water, sanitation, and hygiene (WASH) in healthcare facilities. The objective of this intervention was to improve IPC practice through comprehensive WASH renovations conducted at two hospitals in Liberia, prioritized by the Ministry of Health (MOH). The completion of renovations was tracked along with the impact of improvements on hand hygiene (HH) practice audits of healthcare workers pre- and post-intervention. An occurrence of overall HH practice was defined as the healthcare worker practicing compliant HH before and after the care for a single patient encounter. Liberia Government Hospital Bomi (LGH Bomi) and St. Timothy Government Hospital (St. Timothy) achieved World Health Organization (WHO) minimum global standards for environmental health in healthcare facilities as well as Liberian national standards. Healthcare worker (HCW) overall hand hygiene compliance improved from 36% (2016) to 89% (2018) at LGH Bomi hospital and from 86% (2016) to 88% (2018) at St. Timothy hospital. Improved WASH services and IPC practices in resource-limited healthcare settings are possible if significant holistic WASH infrastructure investments are made in these settings.

Understanding the Predictors that Contribute to Liberian Health Care Workers Feeling Protected From Ebola While at Work.

OBJECTIVE: To assess Liberian health care workers' feelings around safety in returning to work in the setting of the Ebola virus disease outbreak of 2014-2015 after receiving infection prevention and control (IPC) training. METHODS: Academic Consortium Combating Ebola in Liberia (ACCEL) training surveys were done at 21 public, Liberian hospitals to understand health care workers' attitudes surrounding Ebola and whether they felt safe while at work based on multiple factors. Logistic regression was used for analysis. RESULTS: We found that health care workers feeling safe at work during the Ebola outbreak was primarily predicted by the number of IPC/Ebola trainings received pre-ACCEL interventions. Health care workers felt increasingly safer and motivated to return to work as trainings approached 3 (OR 8, p-value < 0.001); however, more than 3 trainings resulted in decreased safety and motivation. In addition, health care workers who reported washing their hands before and after patient contact were 3.4 times more likely to understand how to protect themselves from Ebola. CONCLUSIONS: These results help to better understand the utility of repeated trainings on health care worker practice attitudes and the importance of IPC policies within hospitals, such as hand hygiene promotion and education, when coordinating humanitarian efforts.

Abnormal urinalysis results are common, regardless of specimen collection technique, in women without urinary tract infections.

BACKGROUND: Voided urinalysis to test for urinary tract infection (UTI) is prone to false-positive results for a number of reasons. Specimens are often collected at triage from women with any abdominal complaint, creating a low UTI prevalence population. Improper collection technique by the patient may affect the result. At least four indices, if positive, can indicate UTI. OBJECTIVE: We examine the impact of voided specimen collection technique on urinalysis indicators of UTI and on urine culture contamination in disease-free women. METHODS: In this crossover design, 40 menstrual-age female emergency department staff without UTI symptoms collected urine two ways: directly in a cup ("non-clean") and midstream clean catch ("ideal"). Samples underwent standard automated urinalysis and culture. Urinalysis indices and culture contamination were compared. RESULTS: The proportion of abnormal results from samples collected by "non-clean" vs. "ideal" technique, respectively, were: leukocyte esterase (>trace) 50%, 35% (95% confidence interval for difference -6% to 36%); nitrites (any) 2.5%, 2.5% (difference -2.5 to 2.5%); white blood cells (>5/high-powered field [HPF]) 50%, 27.5% (difference 4 to 41%); bacteria (any/HPF) 77.5%, 62.5%, (difference -7 to 37%); epithelial cells (>few) 65%, 30% (difference 13 to 56%); culture contamination (>1000 colony-forming units of commensal or >2 species) 77%, 63% (difference -5 to 35%). No urinalysis index was positively correlated with culture contamination. CONCLUSION: Contemporary automated urinalysis indices were often abnormal in a disease-free population of women, even using ideal collection technique. In clinical practice, such false-positive results could lead to false-positive UTI diagnosis. Only urine nitrite showed a high specificity. Culture contamination was common regardless of collection technique and was not predicted by urinalysis results.