Impact of sequential capacity building on emergency department organisational flow during COVID-19 pandemic: a quasi-experimental study in a low-resource, tertiary care centre.

INTRODUCTION: A quasi-experimental study was conducted to estimate the impact of sequential emergency department (ED) capacity building interventions on key performance indicators such as patients' length of stay (LOS) and wait time (WT) during the COVID-19 pandemic. This was achieved through augmenting personnel education and head count, space restructuring and workflow reorganisation. SETTING AND PARTICIPANTS: This study included 268 352 patients presenting from January 2019 to December 2020 at Indus Hospital and Health network Karachi, a philanthropic tertiary healthcare facility in a city of 20 million residents. A follow-up study was undertaken from January to December 2021 with 123 938 participants. PRIMARY AND SECONDARY OUTCOME MEASURES: These included mean and median ED-LOS and WT for participants presenting in different cohorts. The results of the pre-COVID-19 year 2019 (phase 0) were compared with that of the COVID-19 year, 2020 (phases 1-3 corresponding to peaks, and phase 4 corresponding to reduction in caseloads). The follow-up was conducted in 2021 to see the sustainability of the sequential capacity building. RESULTS: Phases 1, 2 and 3 had a lower mean adjusted LOS (4.42, 3.92 and 4.40 hours) compared with phase 0 (4.78 hours, p<0.05) with the lowest numbers seen in phase 2. The same held true for WT with 45.1, 23.8 and 30.4 min in phases 1-3 compared with 49.9 in phase 0. However, phase 4 had a higher LOS but a lower WT when compared with phase 0 with a p<0.05. CONCLUSION: Sequential capacity building and improving the operational flow through stage appropriate interventions can be used to off-load ED patients and improve process flow metrics. This shows that models created during COVID-19 can be used to develop sustainable solutions and investment is needed in ideas such as ED-based telehealth to improve patient satisfaction and outcomes.

Clinical Outcomes Following the Implementation of a Novel One-Year Training Program in Emergency Medicine in Karachi, Pakistan.

Background: Most Emergency Departments (EDs) in low- and middle-income countries (LMICs), particularly in Pakistan, are staffed by physicians not formally trained in Emergency Medicine (EM). As of January 2022, there were only 13 residency training programs in EM throughout all of Pakistan. Therefore, an intermediate solution-a one-year training program in EM-was developed to build capacity. Objective: To determine the impact of a novel training program in EM on clinical metrics and outcomes. Methods: The first cohort of a novel, one-year training program-the Certification Program in Emergency Medicine (CPEM)-completed the program in June 2019. The program consisted of two arms: CPEM-Clinical (CPEM-C), which included physicians from the Indus Hospital and Health Network (IHHN) ED; and CPEM-Didactic (CPEM-D), which included physicians from EDs across Karachi. Both groups participated in weekly conferences, such as didactics, small group discussions, workshops, and journal clubs. CPEM-C learners also received clinical mentorship from local and international faculty. Mortality, length of stay (LOS), and time-to-evaluation, as well as metrics in four key areas-patients at risk for cardiovascular disease/acute coronary syndrome, sepsis, respiratory illness, and intra-abdominal trauma-were assessed before and after the initial cohort at IHHN and compared with other groups in IHHN. Findings and Conclusions: More than 125,000 patients were seen from July to December 2017 (pre-CPEM) and July to December 2019 (post-CPEM). Overall, there were significant improvements in all clinical metrics and outcomes, with the exception of LOS and time-to-evaluation, and a trend toward improved mortality. In comparing CPEM graduates to other groups in IHHN ED, most metrics and outcomes significantly improved or trended toward improvement, including mortality. Implementation of a medium-duration, intensive EM training program can help improve patient care and the development of EM as a new specialty in lower-resource settings.

Patient perception regarding privacy and confidentiality: A study from the emergency department of a tertiary care hospital in Karachi, Pakistan.

Background and Objective: Maintaining privacy and ensuring confidentiality with patients is paramount to developing an effective patient-provider relationship. This is often challenging in over-crowded Emergency Departments (EDs). This survey was designed to explore patients' perceptions on maintenance of privacy and confidentiality and their subsequent interactions with providers in a busy tertiary care hospital in Karachi. Methods: Trained nursing staff conducted structured interviews with 571 patients who presented to The Indus Hospital (TIH) ED from January to December 2020. All patients were 14 years of age or older, could speak and understand Urdu, and provide informed consent. Patients were asked about their perceptions of privacy and confidentiality in the ED and whether this affected their interactions with providers. Results: Respondents were primarily men (64%) under the age of 45 (62%) presenting for the first time (49%). The majority of patients felt that privacy and confidentiality were maintained, however 10% of patients reported that they had rejected examination due to privacy concerns and 15% of patients reported that they had changed or omitted information provided to a provider due to confidentiality concerns. There was correlation between privacy and confidentiality concerns and patient-provider interactions (p<0.0001). Conclusions: Despite the often over-crowded and busy environment of the ED, patients generally felt that privacy and confidentiality were maintained. Given the correlation between perception and behavior and the importance of an effective patient-provider relationship, particularly in the acute setting when morbidity and mortality is high, initiatives that focus on maintaining privacy and confidentiality should be pursued.

A 1-year training program in emergency medicine for physicians in Karachi, Pakistan: Evaluation of learner and program outcomes.

BACKGROUND: Pakistan has an underdeveloped and overburdened emergency care system, with most emergency departments (EDs) staffed by physicians not formally trained in emergency medicine (EM). As of January 2020, only nine Pakistani institutions were providing formal EM specialty training; therefore, a training program of shorter duration is needed in the interim. METHODS: The Certification Program in Emergency Medicine (CPEM) is a 1-year training program in EM consisting of two arms: CPEM-Clinical (CPEM-C), which includes physicians from The Indus Hospital (TIH) ED, and CPEM-Didactic (CPEM-D), including physicians from EDs across Karachi. Both groups participate in weekly conferences, including didactics, small-group discussions, workshops, and journal clubs. CPEM-C learners also receive clinical mentorship from visiting international and TIH EM faculty. Both groups were assessed with preprogram, midterm, and final examinations as well as on clinical skills. Additionally, both groups provided regular feedback on program content and administration. RESULTS: Twenty-five of the 32 initially enrolled learners completed the program in June 2019. Scores on a matched set of 50 questions administered in the pretest and final examination improved by an average of 15.1% (p < 0.005) for CPEM-C learners and 8.5% (p < 0.0005) for CPEM-D learners, with 93% of learners showing improvement. Clinical evaluations of CPEM-C and CPEM-D learners during the first and fourth quarters showed an average improvement of 1.1 out of 5 (p < 0.05) and 1.2 out of 9 (p < 0.0005) points, respectively. Learner evaluations of the program were overall positive. CONCLUSIONS: CPEM demonstrated significant improvement in test scores and clinical evaluations in both program arms. Evaluations also suggested that the program was well received. These data, along with CPEM's ability to train physicians from multiple institutions using low-cost, innovative educational strategies, suggest that it may be an effective, transferable mechanism for the expedited development of EM in Pakistan and countries where EM is developing as a specialty.

Inter-hospital communication and transfer practices during COVID-19 Pandemic in Karachi, Pakistan. A brief overview.

OBJECTIVE: To discuss the referral mechanisms established for safe and expeditious inter-facility transfer of COVID 19 positive patients to ensure their referrals through establishing proper communication channels. METHODS: Mobile phone and WhatsApp based groups, administrated by The Indus Hospital were established in April 2020. Through detailed reports and frequent communication, factors like bed and ventilator availability across these facilities are shared. Weekly reports through zoom meetings updating the key stake holders, discussion of problems faced and planning for the week ahead are also done. RESULT: The establishment of these groups has been successful in ensuring referral to and from The Indus Hospital to various healthcare facilities across Karachi using appropriate ambulance services. CONCLUSION: The development of referral mechanisms is the need of the day that has been highlighted through the COVID 19 pandemic. It is our hope that these mechanisms are sustained after the pandemic and result in improvement in patient outcome through proper referrals.