Performance characteristics of a local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania.

BACKGROUND: A number of region-specific validated triage systems exist; however very little is known about their performance in resource limited settings. We compare the local triage tool and internationally validated tools among under-fives presenting to an urban emergency department in Tanzania. METHODOLOGY: Prospective descriptive study of consecutive under-fives seen at Muhimbili National Hospital (MNH), ED between November 2017 to April 2018. Patients were triaged according to Local Triage System (LTS), and the information collected were used to assign acuities in the other triage scales: Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), Manchester Triage Scale (MTS) and South African Triage Scale (SATS). Patients were then followed up to determine disposition and 24 h outcome. Sensitivity, specificity, positive and negative predictive values for admission and mortality were then calculated. RESULTS: A total of 384 paediatric patients were enrolled, their median age was 17 months (IQR 7-36 months). Using LTS, 67(17.4%) patients were triaged in level one, 291(75.8%) level 2 and 26 (6.8%) in level 3 categories. Overall admission rate was 59.6% and at 24 h there were five deaths (1.3%). Using Level 1 in LTS, and Levels 1 and 2 in other systems, sensitivity and specificity for admission for all triage scales ranged between 27.1-28.4% and 95.4-98% respectively, (PPV 90.3-95.3%, NPV 47.1-47.4%). Sensitivity for mortality was 80% for LTS, and 100% for the other scales, while specificity was low, yielding a PPV for all scales between 6.9 and 8%. CONCLUSION: All triage scales showed poor ability to predict need for admission, however all triage scales except LTS predicted mortality. The test characteristics for the other scales were similar. Future studies should focus on determining the reliability and validity of each of these triage tools in our setting.

Pre-referral stabilization and compliance with WHO guidelines for trauma care among adult patients referred to an urban emergency department of a tertiary referral hospital in Tanzania.

BACKGROUND: The outcomes of trauma are considered to be time dependent. Efficient and timely pre-referral stabilization of trauma patients has been shown to impact survival. Tanzania has no formal pre-hospital or trauma system. World Health Organisation has provided a set of standards for initial stabilization of trauma patients according to the level of the hospitals. We aimed to describe pre-referral stabilization provided to adult trauma patient referred to the national referral hospital and compliance with World Health Organisation guidelines. METHODS: This prospective observational cross-sectional study was conducted at the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH), between July 2017 and December 2017. Eligible patients were adults with head injury and extremity injury ≥18 years who were referred from a peripheral hospital and had a referral note. Research assistant enrolled patients using structured case report form clinical information, and initial stabilization received at the referring hospital. Primary outcome was the proportion of patients who had initial stabilization performed according to World Health Organisation recommendation. RESULTS: We enrolled 368 (29% of eligible patients), the median age was 34 years (Interquartile range 26-44 years), and 281 (76%) were male. Overall 69% of referred patients arrived at the EMD more than 24 h after injury. Of those enrolled, 50 (13.6%) patients had received at least one stabilization intervention prior to transfer to MNH. Among 206 patients with extremity injuries, splinting was inadequate or missing in all cases; No patients with head injury received cervical spine protection. Among patients referred from a health center, 26.9% received an initial stabilization, while stabilization procedures were administered to 13.2% of those from district hospitals, and 10% of those from regional hospitals. CONCLUSIONS: In this urban public emergency department in Tanzania, majority of trauma patients were referred from lower health facilities after 24-h of injury. Most did not receive initial trauma stabilization as recommended by the World Health Organisation guidelines. Future studies should identify barriers to pre-referral stabilization of adult trauma patients.

Mobile application adjunct to the WHO basic emergency care course: a mixed methods study.

OBJECTIVES: The WHO developed a 5-day basic emergency care (BEC) course using the traditional lecture format. However, adult learning theory suggests that lecture-based courses alone may not promote long-term knowledge retention. We assessed whether a mobile application adjunct (BEC app) can have positive impact on knowledge acquisition and retention compared with the BEC course alone and evaluated perceptions, acceptability and barriers to adoption of such a tool. DESIGN: Mixed-methods prospective cohort study. PARTICIPANTS: Adult healthcare workers in six health facilities in Tanzania who enrolled in the BEC course and were divided into the control arm (BEC course) or the intervention arm (BEC course plus BEC app). MAIN OUTCOME MEASURES: Changes in knowledge assessment scores, self-efficacy and perceptions of BEC app. RESULTS: 92 enrolees, 46 (50%) in each arm, completed the BEC course. 71 (77%) returned for the 4-month follow-up. Mean test scores were not different between the two arms at any time period. Both arms had significantly improved test scores from enrolment (prior to distribution of materials) to day 1 of the BEC course and from day 1 of BEC course to immediately after BEC course completion. The drop-off in mean scores from immediately after BEC course completion to 4 months after course completion was not significant for either arm. No differences were observed between the two arms for any self-efficacy question at any time point. Focus groups revealed five major themes related to BEC app adoption: educational utility, clinical utility, user experience, barriers to access and barriers to use. CONCLUSION: The BEC app was well received, but no differences in knowledge retention and self-efficacy were observed between the two arms and only a very small number of participants reported using the app. Technologic-based, linguistic-based and content-based barriers likely limited its impact.

Guillain-Barré syndrome associated with COVID-19 infection.

We are reporting a case of Acute Post-Infectious Flaccid paralysis also commonly known as Guillain-Barré Syndrome (GBS) in a patient with confirmed COVID-19 infection. GBS often occurs following an infectious trigger which induces autoimmune reaction causing damage to peripheral nerves. So far, only 8 cases have been described in association with COVID-19. This is the first to be described in Tanzania in an African Child, and probably the first in the continent. This report is presented for clinicians to be aware and for the medical fraternity to look into this unusual presentation which may shed some more light on possible pathways of the pathogenesis and clinical manifestations. We recommend that the presentation of GBS with acute respiratory distress should warrant extra precaution and a testing for COVID-19 especially when the symptoms of COVID-19 are protean.

Effectiveness of a Pediatric Emergency Medicine Curriculum in a Public Tanzanian Referral Hospital.

INTRODUCTION: The World Health Organization recently recognized the importance of emergency and trauma care in reducing morbidity and mortality. Training programs are essential to improving emergency care in low-resource settings; however, a paucity of comprehensive curricula focusing specifically on pediatric emergency medicine (PEM) currently exists. The African Federation for Emergency Medicine (AFEM) developed a PEM curriculum that was pilot-tested in a non-randomized, controlled study to evaluate its effectiveness in nurses working in a public Tanzanian referral hospital. METHODS: Fifteen nurses were recruited to participate in a two-and-a-half-day curriculum of lectures, skill sessions, and simulation scenarios covering nine topics; they were matched with controls. Both groups completed pre- and post-training assessments of their knowledge (multiple-choice test), self-efficacy (Likert surveys), and behavior. Changes in behavior were assessed using a binary checklist of critical actions during observations of live pediatric resuscitations. RESULTS: Participant-rated pre-training self-efficacy and knowledge test scores were similar in both control and intervention groups. However, post-training, self-efficacy ratings in the intervention group increased by a median of 11.5 points (interquartile range [IQR]: 6-16) while unchanged in the control group. Knowledge test scores also increased by a median of three points (IQR: 0-4) in the nurses who received the training while the control group's results did not differ in the two periods. A total of 1192 pediatric resuscitation cases were observed post-training, with the intervention group demonstrating higher rates of performance of three of 27 critical actions. CONCLUSION: This pilot study of the AFEM PEM curriculum for nurses has shown it to be an effective tool in knowledge acquisition and improved self-efficacy of pediatric emergencies. Further evaluation will be needed to assess whether it is currently effective in changing nurse behavior and patient outcomes or whether curricular modifications are needed.

Implementation of electronic medical records at an Emergency Medicine Department in Tanzania: The information technology perspective.

In 2015, the Emergency Medicine Department at Muhimbili National Hospital (MNH) installed and implemented the first Electronic Medical Record (EMR) tailored to the emergency centre (EC). The EMR deployed was designed for emergency centre use only (Emergency Department Information System (EDIS)) and linked with the existing EMR that focused on registration and billing. This very collaborative experience can be used as a reference to share the many lessons learnt by all, including hospital management, EC staff, private funders and EMR vendors. The IT Project Plan was developed to make sure steps were followed for EDIS implementation. This included the IT plan documents, specific user requirements, development of a Memorandum of Understanding and user manuals. Super key users were identified among the staff during the training and they helped to empower staff, consolidate knowledge and share the workload. Several challenges have been overcome, including when the power was not regulated so an automatic generator and uninterruptible power supply (UPS) devices installed to protect all computers. Providers were primarily a very novice group of computer users and many had little to no computer experience so were taught both basic computing skills and EDIS specific tasks. Trained staff were moved around the hospital and a lot of time was taken up training new staff, so discussion with hospital management led to retention of staff in the EC. Specific templates have been introduced to ensure adequate minimum documentation. However, even with these, clinical notes are often very brief and we are searching for further mechanisms to improve this. Hospitals in low-resource settings considering the implementation of an EMR should ensure that a comprehensive plan is in place that involves significant staff training, improvement of existing, or installation of new information technology systems, ongoing ICT support and funds for unforeseen issues and ongoing maintenance.

Development and Implementation of Short Courses to Support the Establishment of a Prehospital System in Sub-Saharan Africa: Lessons Learned from Tanzania.

BACKGROUND: Tanzania has no formal prehospital system. The Tanzania Ministry of Health launched a formal prehospital system to address this gap. The Muhimbili University of Health and Allied Sciences (MUHAS) was tasked by the Ministry of Health to develop and implement a multicadre/provider prehospital curriculum so as to produce necessary healthcare providers to support the prehospital system. We aim to describe the process of designing and implementing the multicadre/provider prehospital short courses. The lessons learned can help inform similar initiatives in low- and middle-income countries. METHODS: MUHAS collaborated with local and international Emergency Medicine and Emergency Medical Services (EMS) specialists to form the Emergency Medical Systems Team (EMST) that developed and implemented four short courses on prehospital care. The EMST used a six-step approach to develop and implement the curriculum: problem identification, general needs assessment, targeted needs assessment, goals and objectives, educational strategies, and implementation. The EMST modified current best EMS practices, protocols, and curricula to be context and resource appropriate in Tanzania. RESULTS: We developed four prehospital short courses: Basic Ambulance Provider (BAP), Basic Ambulance Attendant (BAAT), Community First Aid (CFA), and EMS Dispatcher courses. The curriculum was vetted and approved by MUHAS, and courses were launched in November 2018. By the end of July 2019, a total of 63 BAPs, 104 BAATs, 25 EMS Dispatchers, and 287 CFAs had graduated from the programs. The main lessons learned are the importance of a practical approach to EMS development and working with the existing government cadre/provider scheme to ensure sustainability of the project; clearly defining scope of practice of EMS providers before curriculum development; and concurrent development of a multicadre/provider curriculum to better address the logistical barriers of implementation. CONCLUSION: We have provided an overview of the process of designing and implementing four short courses to train multiple cadres/providers of prehospital system providers in Tanzania. We believe this model of curricula development and implementation can be replicated in other countries across Africa.